Ch 57 - Anxiety Disorder.pptx

7/29/2019 Ch 57 - Anxiety Disorder.pptx

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ANXIETY DISORDER

Jeny Rose Quiblat, MD


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ANXIETY

Fearful emotion accompanied by certain physicalsymptoms

perceived as a subjective feeling of heightenedtension and diffuse uneasiness


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SUBCLASSESOF ANXIETY DISORDER

Panic Disorder

Phobic

obsessive-compulsive

Generalized anxiety disorder post-traumatic stress

social phobia

atypical anxiety


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PANIC DISORDER

recurrent episodes of intense

apprehension

Fear

terror

accompanied by at least four particular symptoms, all ofwhich reach a peak within 10 minutes.

Attacks are followed by the fear of having additional

episodes


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PANIC DISORDER

key distinguishing feature of panic disorder is theepisodic and recurrent nature of the panic attacks

2 types Panic Disorder with Agoraphobia

Panic Disorder without Agoraphobia


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PANIC DISORDER

onset of panic disorder is generally between theages of 17 and 30 years

It is often precipitated by stressful life events.

familial, with up to 40% of first-degree relatives alsobeing affected

50% to 90% risk of having a major depressiveepisode at some point in their lifetime


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CRITERIAFOR PANIC ATTACK

A period of intense fear or discomfort in which 4symptoms developed abruptly and reached a peakperiod of 10 minutes.

Dyspnea palpitations,

chest pain choking or smothering

Dizziness paresthesias, diaphoresis,

trembling or shaking, chills or hot flashes,

nausea or abdominal distress,

fears of dying, going crazy or losing control during anattack


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CRITERIAFOR PANIC ATTACK

at least one of the attacks must be followed by 1month of persistent concern about having additionalattacks, worry about the implications of the attackor its consequences


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THREE STAGESINTHE DEVELOPMENTOFPANIC DISORDER

Stage 1 : Initial acute panic attack or cluster ofattack Described as the worst experience in their life, after one or a

series of life events overwhelm their coping mechanisms

Stage 2

Panic attacks increase in frequency

phobias develop

anticipatory anxiety and avoidance behavior develop medical care seeking dramatically increases for

somatic complaint


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THREE STAGESINTHE DEVELOPMENTOFPANIC DISORDER

Stage 3: Agoraphobia

fear of the marketplace

Fear of being in places or situation from which escape indifficult , embarrassing in the event of panic attack


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PANIC DISORDER W/O AGORAPHOBIA

The following two conditions are present:

recurrent unexpected panic attacks;

at least one of the attacks has been followed by amonth (or more) of persistent concern about having

additional attacks, worry about the implications of the attacks or their

consequences

a significant change in behavior related to the attacks.


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PANIC DISORDER W/O AGORAPHOBIA

Agoraphobia is not present.

The panic attacks are not a result of the direct

effects of a substance or a general medical

The anxiety is not better accounted for by anothermental disorder


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PANIC DISORDER WITH AGORAPHOBIA

The following two conditions are present:

recurrent unexpected panic attacks;

at least one of the attacks has been followed by amonth (or more) of persistent concern about having

additional attacks, worry about the implications of the attacks or their

consequences

a significant change in behavior related to the attacks.


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PANIC DISORDER WITH AGORAPHOBIA

Agoraphobia is present.

The panic attacks are not a result of the direct

effects of a substance or a general medical

The anxiety is not better accounted for by anothermental disorder


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COMPONENTSOF PANIC DISORDER

Cognitive

Worry

Sense of foreboding

Sense of impending doom or dread

Tendency to be inattentive, distractible

Sense of unreality

Rumination

Loss of control


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Affective

Isolation

Anxiety or nervousness

Secondary depression

Irritability

Social

Dependency

Vocational limitations


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Somatic

Tachycardia

Hyperventilation

Diaphoresis

Dizziness or syncope

Flushing

Muscle tension

Tremulousness

Restlessness


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a phobic disorder is the persistent andirrational fear of a specific object, activity, orsituation that results in a compelling desire to

avoid the dreaded object, activity, or situation.

The fear is recognized by the individual asexcessive or unreasonable in proportion to theactual danger of the situation, object, or activity


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Specific Phobia Social Phobia


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A specific phobia involves a persistentirrational fear and compelling desire to avoidan object or a situation.

Common among women

Peak of onset :5-9 yrs for natural environment

type and blood inj type Peak of onset :mid 20s for situational type


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fears are related to most social situations

(e.g., initiating conversations, dating,participating in small groups, attending

parties). has its onset during the teenage years

Onset can occur after a humiliating incident orsituation


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GENERALIZED ANXIETY DISORDER

Generalized anxiety disorder is excessive worry forat least 6 months.

The person finds it difficult to control the worry.

Panic disorder, major depression, alcohol abuse,and organic causes need to be ruled out.

Prevalence is 6% in primary care, affecting twiceas many women as men.


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The anxiety and worry are associated with at leastthree of the following six symptoms

1. Restlessness or feeling keyed up or on edge

2. Becoming easily fatigued3. Difficulty concentrating or the mind goingblank

4. Irritability

5. Muscle tension6. Sleep disturbance


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The anxiety, worry, or physical symptoms causeclinically significant distress or impairment in social,occupational, or other important areas offunctioning.

The disorder is not the result of the direct effects ofa substance or a general medical condition


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POST TRAUMATIC STRESS DISORDER

experienced or witnessed a severe catastrophicevent that involved actual or threatened death orserious injury to oneself or others.

They frequently reexperience the event throughdreams or feelings that the event is recurring andmay have panic attacks during these flashbacks.


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CRITERIAFOR POST TRAUMATIC STRESSDISORDER

The person has been exposed to a traumatic eventin which both of the following conditions have beenmet

The person has experienced, witnessed, or been

confronted with an event or events that involve actual orthreatened death or serious injury or a threat to thephysical integrity of oneself or others.

The person's response involved intense fear,helplessness, or horror


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The traumatic event is persistently reexperienced inat least one of the following ways

Recurrent recollections of the event, including images,thoughts, or perceptions.

Recurrent distressing dreams of the event.

Acting or feeling as though the traumatic event wererecurring


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The traumatic event is persistently reexperienced in atleast one of the following ways

Intense psychological distress at exposure to internal or

external cues that symbolize or resemble an aspect ofthe traumatic event.

Physiologic reactivity on exposure to internal or externalcues that symbolize or resemble an aspect of thetraumatic event.


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Persistent avoidance of stimuli associated with thetrauma and numbing of general responsiveness(not present before the trauma at least 3 of thefollowing


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Efforts to avoid thoughts, feelings, or conversations

associated with the trauma Efforts to avoid activities, places, or people that arouse

recollections of the trauma

Inability to recall an important aspect of the trauma

Markedly diminished interest or participation in significantactivities

Feeling of detachment or estrangement from others

Restricted range of affect

Sense of a foreshortened future


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Persistent symptoms of increased arousal (notpresent before the trauma), as indicated by at leasttwo of the following:

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response


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The duration of the disturbance is longer than 1month.

The disturbance causes clinically significantdistress or impairment in social, occupational, or

other important areas of functioning.


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HISTORY The history is probably the single best diagnostic

tool in the workup of an anxious patient, whetherthe anxiety is of an acute or chronic nature.

The history taking process should be sufficientlyopen-ended and unhurried to elicit informationabout the patient's concerns and fears, current life

situation, family and other support systems, andconcurrent medical problems.


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PHYSICAL EXAMINATION

The patient looks worried and acts tense.

Increased motor activity is often evident,

Facial muscles may show twitching or tics.

Breathing is often rapid and superficial and, unsteady voice, strained facies, grinding of teeth,

dilated pupils

tremor of hands, flushing and excessive

perspiration, and labile hypertension.


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MANAGEMENT

Prerequisites for the Physician

Adequate Workup

Treatment Based on Cause

Development of a Therapeutic Plan his plan usually entails a series of office visits on a

regular basis over time and may require specifictherapeutic interventions,

provides the physician opportunity to reassess the

effectiveness and progress of management p


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Education

Building Support Mechanisms

Members of the extended family and friends arefrequently helpful in this respect

It is often useful to involve other family members indevelopment of the therapeutic plan.


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PANIC DISORDER

Pharmacologic therapy, once effective, should befollowed by gradual reexposure to the situationsthat were being avoided.

Start with a selective serotonin reuptake inhibitor(SSRI) or tricyclic antidepressant such asimipramine at a low dosage and then increase untilepisodes cease.


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PANIC DISORDER

first-line treatment of choice for panic disordershould be SSRIs.

paroxetine, sertraline, fluoxetine, citalopram, andfluvoxamine

Started at a low doasge Increased dosage by 5mg until panic attacks

disappear

Common S.E: Jitteriness, nausea headache


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PHOBIC DISORDERS

desensitization,

the patient learns a relaxation technique and then, whilein a relaxed state, is exposed to a gradual hierarchy ofstimuli (through imagery or in vivo) that approaches the

phobic object or situation For agoraphobia, evidence from two studies has

shown that imipramine in combination withexposure enhances the effects of exposure


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POST-TRAUMATIC STRESS DISORDER

SSRIs are effective in civilians but not veterans,whereas imipramine and monoamine oxidaseinhibitors (MAOIs) are effective in veterans.

Cognitive-behavioral therapy and eye movementdesensitization therapy have been shown to beeffective.

The combination of antidepressant medication andpsychotherapy may be optimal therapy.

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Ch 57 - Anxiety Disorder.pptx