ANXIETY DISORDER

Elmeida EffendyPsychiatric DepartmentMedical FacultyUSUANXIETY DISORDER1

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Anxiety disorders : abnormal states in which the most striking features are mental & physical symptoms of anxiety which are not caused by organic brain disease or another psychiatric disorderAnxiety disorders are divided as follows :Generalized anxiety disorder; which anxiety is unvarying & persistentPhobic anxiety disorder; anxiety is intermittent & arises in particular circumstances Panic disorder : anxiety is intermittent & unrelated to particular circumstances

Classification of Anxiety DisordersICD 10F 4. Anxiety disordersF 40 Phobic anxiety disordersAgoraphobia

Social phobiaSpecific phobiaF 41 Other anxiety disordersPanic disorderGeneralized anxiety disorderMixed anxiety & depressive disorder

DSM IV Anxiety disorders

Agoraphobia without a history of panic disorderPanic disorder with agoraphobiaSocial phobiaSpecific phobia

Panic disorder without agoraphobiaGeneralized anxiety disorder

DSM- IV-TR 1. Panic disorder with or without agoraphobia2. Agoraphobia with or without panic disorder3. Specific phobia4. Social phobia5. Obsessive-compulsive disorder6. Posttraumatic stress disorder7. Acute stress disorder8. Generalized anxiety disorder4

Panic Disorder & AgoraphobiaAn acute intense attack of anxiety accompanied by feelings of impending doom is known as panic disorderThe anxiety is characterized by discrete periods of intense fear that can vary from several attacks during one day to only a few attacks during a yearPatients with panic disorder present with a number of comorbid conditions, most commonly agoraphobia, which refers to a fear of or anxiety regarding places from which escape might be difficult5

DSM-IV-TR Criteria for Panic AttackA discrete period of intense fear or discomfort,in which four (or more) of the following symptoms developed abruptly & reached a peak within 10 minutes :1.palpitations, pounding heart, or accelerated heart beat2. sweating3. trembling or shaking4. sensations of shortness of breath or smothering5. feeling of choking6.chest pain or discomfort6

7. nausea or abdominal distress8. feeling dizzy, unsteady, lightheaded or faint9. derealization (feelings of unreality) or depersonalization ( being detached from one self)10. fear of losing control or going crazy11. fear of dying12. paresthesias ( numbness or tingling sensations)13. chills or hot flushes7

The DSM-IV-TR contains 2 diagnostic criteria for panic disorder, one without agoraphobia and the other with agoraphobia, but both require the presence of panic attacksPanic attacks can occur in mental disorders other than panic disorder, particularly in specific phobia, social phobia & PTSDUnexpected panic attacks occur at any time & are not associated with any identifiable situational stimulus, but panic attacks need not be unexpectedAttacks in patients with social & specific phobias are usually expected or cued to a recognized or specific stimulus8

Some panic attacks do not fit easily into the distinction between unexpected & expected, and these attacks are referred to as situationally predisposed panic attacks9

DSM- IV- TR Criteria for AgoraphobiaA. Anxiety about being in places or situations from which escape might be difficult(or embarassing)or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge & traveling in a bus, train or automobile10

B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic like symptoms, or require the presence of a companionC. The anxiety or phobic avoidance is not better accounted for by another mental disorder , such as social phobia (e.g., avoidance limited to social situations because of fear of embarassment), specific phobia (e.g., avoidance limited to a single situation like elevators), obsessive compulsive disorder ( avoidance of dirt), posttraumatic stress disorder ( avoidance of stimuli associated with a severe stressor) or separation anxiety disorder (e.g., avoidance of leaving home or relatives)11

Specific Phobia & Social PhobiaPhobia : an excessive fear of a specific object, circumstance or situationSpecific phobia : strong, persisting fear of an object or situationSocial phobia :strong, persisting fear of situations in which embarassment can occurThe diagnosis of both specific & social phobia requires the development of intense anxiety, even to the point of panic, when exposed to the feared situations12

Specific PhobiaMore common than social phobiaMay anticipate harm, such as being bitten by a dog, may panic at thought of losing control if they fear being in an elevatorThe peak age of onset for the natural environment type & blood-injection-injury-type : 5-9 yearsOnset for situational type (except fear of heights): mid 20sThe feared objects & situations in specific phobia (listed in descending frequency of appearance) are animals, storms, heights, illness, injury & death13

Social Phobia= Social Anxiety DisorderHave excessive fears of humiliation or embarassment in various social settings, such as speaking in public, urinating in public rest room (shy bladder) &speaking to a date14

Obsessive Compulsive Disorder (OCD)Represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupation & compulsionsThese recurrent obsessions or compulsions cause severe distress to the personThe obsessions or compulsions are time consuming & interfere significantly with the persons normal routine, occupational functioning, usual social activities or relationshipsA patient with OCD may have an obsession, a compulsion or both15

Obsession : a recurrent & intrusive thought, feeling, idea or sensationCompulsion : a behaviorSpecifically, a compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoidingA patient with OCD realizes the irrationality of the obsession & experiences both the obsession & the compulsion as ego-dystonic (unwanted behavior)16

OCD has 4 major symptom pattern :1. Contamination2. Pathological doubt3. Intrusive thoughts4. Symmetry17

ObsessionsContaminationPathological doubtSomaticNeed for symmetryAggressiveSexualOtherMultiple obsessions18

CompulsionsCheckingWashingCountingNeed to ask or confessSymmetry and precisionHoardingMultiple comparisons19

TreatmentPharmacotherapy : SSRI, clomipramineBehavior therapy : desensitization,thought stopping,flooding,implosion therapy & aversive conditioningPsychotherapy20

Posttraumatic Stress Disorder (PTSD)& Acute Stress DisorderCondition marked by the development of symptoms after exposure to traumatic life eventsThe person reacts to this experience with fear & helplessness, persistently relives the event, & tries to avoid being reminded of itPTSD :The symptom must last for more than a month after the event & must significantly affect important areas of life, such as family & workAcute stress disorder : occurs earlier than PTSD; within 4 weeks of the event, & remits within 2days to 4 weeks21

The stressors causing both acute stress disorder & PTSD are sufficiently overwhelming to affect almost anyoneThey can arise from experiences in war, torture, natural catatstrophes, assault, rape & serious accidents, for example, in cars & in burning buildings The DSM-IV-TR diagnostic criteria for PTSD specify that the symptoms of experiencing, avoidance & hyperarousal must have lasted more than 1 month ;acute : if the symptoms have lasted less than 3 months, chronic : if the symptoms have lasted than 3 months or more22

Clinical Features of PTSDPainful reexperiencing of the event, a pattern of avoidance & emotional numbing, fairly constant hyperarousalThe disorder may not develop until months or even years after the eventThe mental status examination often reveals feelings of guilt, rejection & humiliationPatients may also describe dissociative states & panic attacks, illusions & hallucinations may be present23

Treatment24Pharmacotherapy : SSRI : sertraline, paroxetinePsychotherapy : psychodynamic psychotherapy, crisis intervention with support, education & development of coping mechanism & acceptance of the event

Generalized Anxiety Disorder25Excessive anxiety & worry about several events or activities for most days during at least 6- month periodThe worry is difficult to control and is associated with somatic symptoms, such as muscle tension, irritability, difficulty sleeping & restlessnessAnxiety is not focused on features of another axis I disorder, not caused by substance use or a general medical condition& does not occur only during a mood or psychiatric disorderAnxiety is difficult to control, is subjectively distressing & produces impairment in important areas of a persons life

Generalized anxiety disorder3 characteristic featuresWorry & apprehension :worries are widespread & not focused on a specific issueMotor tension : restlessness, trembling, inability to relax, headacheAutonomic hyperactivity :sweating, palpitations, dry mouth, epigastric discomfort, dizziness

Other psychological symptoms of GAD :irritability, poor concentration, sensitivity to noise, poor memoryOther motor symptoms of GAD :aching & stiffness in musclesAutonomic symptoms can be grouped according to systems of the body as follows :Gastrointestinal :dry mouth, difficulty in swallowing, epigastric discomfort, excessive wind, borborygmi, frequent loose motionsRespiratory : feeling of construction in the chest,difficulty in inhaling, & the consequences of hyperventilation

Cardiovascular :feeling of discomfort over the heart, palpitations, awareness of missed beats & throbbing in the neckGenitourinary : frequency & urgency of micturition, failure of erection, lack of libido, menstrual discomfortNervous system :tinnitus, feeling of blurring of vision, dizziness, prickling sensations

EtiologyStressful events; involving threatGenetic causesPersonality ;a persistent tendency to anxietyPsychoanalytic theoriesby a particular way of dealing with painful emotions intrapsychic conflicts which generate anxiety when the ego is overwhelmed by excitation from any of 3 sources :i) outside the world (realistic anxiety); ii) the instinctual level of id : love, anger & sex (neurotic anxiety) iii) the superego (moral anxiety)

Psychological responses to stressful eventsConditioning theoriesCognitive theories

DSM-IV_TR Diagnostic Criteria for Generalized Anxiety Disorder31A. Excessive anxiety & worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)B. The person finds it difficult to control the worry

32C. The anxiety & worry are associated with 3 or more of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months)1. restlessness or feeling keyed up or on edge2. being easily fatigue3. difficulty concentrating or mind going blank4. irritability5. muscle tension6. sleep disturbance ( difficulty falling or staying asleep, or restless unsatisfying sleep)

33D. The focus of the anxiety & worry is not confined to features of an axis I disorderE. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioningThe disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder or a pervasive developmental disorder

Diagnostic conventionsDSM- IV & ICD 10 require the presence of similar symptoms for diagnosis of GAD but they require different durations for these symptoms.DSM-IV requires that symptoms have been present for 6 monthsICD 10 has the less stringent requirement that symptoms should have been present for most days for at least several weeks at a time & usually several months

TreatmentCounsellingCognitive behavioral therapyDrugs

DSM 5Separation Anxiety Disorder (190)Selective Mutism (195)Specific Phobia (197)Specify if:AnimalNatural environmentBlood-injection-injuryFear of bloodFear of injections and transfusionsFear of other medical careFear of injurySituationalSocial Anxiety Disorder (Social Phobia) (202)Specify if: Performance onlyPanic Disorder (208)Panic Attack Specifier (214)Agoraphobia (217)Generalized Anxiety Disorder (222)Substance/Medication-Induced Anxiety Disorder (226)Note: See the criteria set and corresponding recording procedures forsubstance-specific codes and ICD-9-CM and ICD-IO-CM coding.Specify if: With onset during intoxication. With onset during withdrawal.With onset after medication use293.84 (F06.4) Anxiety Disorder Due to Another Medical36

Social Anxiety Disorder (Social Phobia) (202)Specify if: Performance onlyPanic Disorder (208)Panic Attack Specifier (214)Agoraphobia (217)Generalized Anxiety Disorder (222)37

Substance/Medication-Induced Anxiety Disorder (226)Note: See the criteria set and corresponding recording procedures forsubstance-specific codes and ICD-9-CM and ICD-IO-CM coding.Specify if: With onset during intoxication. With onset during withdrawal.With onset after medication use

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293.84 (F06.4) Anxiety Disorder Due to Another Medical Condition (230)300.09 (F41.8) \ Other Specified Anxiety Disorder (233)300.00 (F41.9) Unspecified Anxiety Disorder (233)Obsessive-Compulsive and Related Disorders39

Obsessive-Compulsive and Related Disorders (235)

The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated:^Specify if: With good or fair insight. With poor insight. With absent insight/delusional beliefsObsessive-Compulsive Disorder^ (237)Specify if: Tic-relatedBody Dysmorphic Disorder^ (242)Specify if: With muscle dysmorphiaHoarding Disorder^ (247)Specify if: With excessive acquisitionTrauma- and Stressor-Related Disorders (265)313.89 (F94.1)313.89 (F94.2)309.81 (F43.10)308.3 (F43.0)Reactive Attachment Disorder (265)Specify if: PersistentSpecify current severity: SevereDisinhibited Social Engagement Disorder (268)Specify if: PersistentSpecify current severity: SeverePosttraumatic Stress Disorder (includes Posttraumatic StressDisorder for Children 6 Years and Younger) (271)Specify whether:40

Trichotillomania (Hair-Pulling Disorder) (251)Excoriation (Skin-Picking) Disorder (254)Substance/Medication-Induced Obsessive-Compulsive andRelated Disorder (257)Note: See the criteria set and corresponding recording procedures forsubstance-specific codes and ICD-9-CM and ICD-IO-CM coding.Specify if: With onset during intoxication. With onset during withdrawal.With onset after medication usesymptoms. With skin-picking symptomsOther Specified Obsessive-Compulsive and Related Disorder(263)Unspecified Obsessive-Compulsive and Related Disorder (264)

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Obsessive-Compulsive and Related Disorder Due to AnotherMedical Condition (260)Specify if: With obsessive-compulsive disorder-like symptoms. Withappearance preoccupations. With hoarding symptoms. With hairpullingOther Specified Obsessive-Compulsive and Related DisorderUnspecified Obsessive-Compulsive and Related Disorder42

Trauma- and Stressor-Related Disorders (265)Reactive Attachment Disorder (265)Specify if: PersistentSpecify current severity: SevereDisinhibited Social Engagement Disorder (268)Specify if: PersistentSpecify current severity: SeverePosttraumatic Stress Disorder (includes Posttraumatic StressDisorder for Children 6 Years and Younger) (271)Specify whether: With dissociative symptomsSpecify if: With delayed expressionAcute Stress Disorder (280)43

Adjustment Disorders (286)Specify whether:309.0 (F43.21) With depressed mood309.24 (F43.22) With anxiety309.28 (F43.23) With mixed anxiety and depressed mood309.3 (F43.24) With disturbance of conduct309.4 (F43.25) With mixed disturbance of emotions and conduct309.9 (F43.20) Unspecified309.89 (F43.8) Other Specified Trauma- and Stressor-Related Disorder (289)

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