SS - Psych - 03 - Anxiety Disorders

7/30/2019 SS - Psych - 03 - Anxiety Disorders

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Pioneer Batch Class of 2012

MODULE Psychiatry DATE February 3, 2010

TOPIC Anxiety Disorders LECTURER Dr. Luz Katigbak

Page 1 of7 Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

OUTLINE:I. AnxietyII. Epidemiology of Anxiety in the PhilippinesIII. Anxiety from the Failure to Cope

IV. Medical Illnesses mimicking Anxiety DisordersV. Anxiety Mimicking Medical IllnessesVI. Drugs that Cause Anxiety

ANXIETY DISORDERSVII. Panic DisorderVIII. Specific Phobia and Social PhobiaIX. Obsessive-Compulsive DisorderX. Post Traumatic Stress Disorder

XI. Acute Stress DisorderXII. Generalized Anxiety Disorder

XIII. Etiology and Treatment

a. Biologicalb. Psychosocial

XIV. Take it Easy

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I. Anxiety

AnxietyA diffuse, unpleasant, vague sense of apprehension, often

accompanied by symptoms, i.e., headache, perspiration,tightness in the chest, mild stomachAn alerting signal

It warns us of impending danger and enables us to take

measures to deal with a threatAdaptive, lifesaving quali ty

Normal anxietya univeral experienceIt is adaptive and is a lifesaving quality

An accompaniment of growth, of changeExamples

o For a child, separation from parents

o First day of school; first dateo News of chronic or terminal illnesso If theres a new or novel situation we are facing, we have a

sense of feeling anxious

Pathological anxiety

Indications when you should seek professional help:

Evident to patients families, friends, clinicianBased on patients internal states, behavior and level offunctioningthe person himself who is anxious is uncomfortable. He does not feel

well.

An inappropriate response to a given stimulus by virtue ofintensity or durationA persons reaction is not proportionate to a situation

o Ex. The pre-schooler has been going to the class for thepast 6 months, but he still has not yet adjusted

Fear vs Anxiety

Fear also an alerting signal; a response to a stimulus thatis known, external, or a definite threatAnxiety - a response to a threat that is unknown, threat,

internal

Diagnostic approach to anxiety symptomsMedical assessment

o Anxiety disorder due to ________(hypertension/PTB/drug induced)

Psychosocial assessment

o Why do you think you are so anxious?If you ask them when it started

o You would find out that there were external stressors

present

Self-regulationo Relaxation exercises, breathing exercises,

meditation

Medicationo Therapy treats problems; medication treats

symptoms

II. Epidemiology of Anxiety in the Philippines

Prevalence of Psychiatric Disorders in the Philippines Condition Prevalence

Anxiety 14.3

Panic 5.6

Depression

Among chronically-ill medical patientsMood 32

Anxiety

16

Somatoform disorder 11

Probable alcohol abuse 8

Overall 48- Most prevalent is mood disorders

o Depressive The idea of being sick, activities will be

limited, medical imbalance

Prevalence in the Primary Care setting60% of patients with psychiatric conditions

Anxiety: 5th most common diagnosisPanic disorder:

o 6-12% in PCP practice (primary care practice)

o 10-14% in Cardiology

Anxiety in the Medical Setting

- The hospitalized patient encounters internal and externaldangers:Assaults in the body

o Youll have injections, blood extractions

Atmosphere of illness, pain and deatho Synonymous to not knowing what is going to happen

Separation from loved ones and familiar surroundings

Uncertainty about his illnessThe implications of the illness in his capacity to work andmaintain social and family relationship


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III. Anxiety from the Failure to Cope

- gives a sense of fear and vulnerability

Factors:

Personality features with brittleness or tendency to regressin the face of threat

o This kind of personality, these are the ones who are not very

flexible, they are very rigid

Suddenness of the onset of threatUnavailability of familial or other social support

Feelings of aloneness or abandonmentMeaning of the illness or injury

o Could not be comprehended

The patient becomes frightened, trembles, cannot sleep,repeatedly seeks attention and reassurance, complains of

excessive pain, becomes disruptive

IV. Medical Illness Mimicking Anxiety Disorder

- 5-42% of anxiety symptoms have underlying medical illness- Primarily, there is medical illness but presents as anxiety disorders

- Medical Causes of Anxietyo Neurological problems

o Endocrine problemso Cardiologic problemso Rheumatoid collagen problemso Chronic infection problems

o Intoxication or withdrawal from alcohol or druguse most commonWhat are the symptoms: cold sweats, tremors, nausea,irritability, palpitations

Other Medical Causes of AnxietyRespiratory:

o COPDo Pulmonary embolismo Asthmao Hypoxiao Pulmonary edema

Cardiovascularo Angina pectoriso Arrythmia

Endocrineo Hyperthyroidismo Hypoglycemiao

PheochromocytomaMetabolico Hypercalcemiao Hyperkalemia

o Hyponatremia

Suspect a Medical cause if:Onset of anxiety symptoms occur after 35 years old

o Anxiety disorder usually occur before 35 yo

Lack of personal or family history of anxiety disordero Strong genetic link for anxiety disorder

Absence of significant life events exacerbating anxietyLack of avoidance behaviorPoor response to standard anti-anxiety

V. Anxiety Mimicking Medical Illness

Most patients usually end up with systemic specialists

Three most common symptomso Cardiacpalpitations, chest pain

o GIdiarrhea, nausea, dyspepsiao Neurologicdizziness, headache

Predominance of physical symptomso You cannot correlate the symptoms

Absence of affective, cognitive and behavioral components

Physical symptoms of AnxietyRespiratory

o Chest pressure

o Chokingo Sighingo Dyspnea

Autonomic

o Dry mouto Sweatingo Headaches

o Hot flashesCardiovascular

o Tachycardiao Palpitations

o Chest paino Faintness

Musculoskeletal

o Aches and painso Twitchingo Stiffness

GU

o Frequencyo Urgencyo Sexual dysfunctiono Menstrual problems

GIo Swallowingo Abdominal paino Nausea

o Irritable bowelNeurologic

o Dizziness

o Tremoro Tingling sensation

VI. Drugs that Cause Anxiety

Just to caution you that the medicines that we give to our patients could

harm them. We should weigh the risk vs benefits. You might cause them

more harm that cure

Stimulants

SympathomimeticsDrug withdrawal

Anticholinergics


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DopaminergicsMiscellaneous

o Baclofen

o Cycloserineo Hallucinogenso Indomethacin

ANXIETY DISORDERS

VII. Panic Disorder

Same as the symptoms in anxiety disorder

Panic attack discrete period of intense fear of discomfort,characterized by the following symptoms developing abruptlyand reaching a peak in 10 minutesSignificant change in behavior

o Because of so much worry of going in to attack, they refrain from

going out, they withdraw from people, cant go to work

Symptoms:

o Palpitations, pounding, or accelerated heart rateo Sweatingo Trembling or shaking

o Sensations of shortness of breath or smotheringo Feeling of chokingo Chest pain or discomforto Nausea or abdominal distress

o Feeling dizzy, unsteady, lightheaded, or fainto Derealization ( feeling of unreality) or

depersonalization (feelings of being detached fromoneself)

o Fear of losing control or going crazyo Fear of dyingo Paresthesias (Numbness or tingling sensations)o Chills or hot flushes

DSM IV-TR Criteria for Panic Disorder

Recurrent unexpected panic attacksAt least one of the attacks has been followed by at least 1 month of

one or more of the following:I. Persistent concern about having additional panic attacksII. Worry about the implications of the attack or its

consequences

III. A significant change in behavior related to the attacksPresence or absence of agoraphobia

The panic attacks are not due to the direct physiologic effects of asubstance (e.g., a drug of abuse, a medication) or a general medicalcondition (e.g., hyperthyroidism).

The panic attacks are not better accounted for by another mentaldisorder.

The panic disorder can be with or without agoraphobiaThis is not a diagnosis. Just a specifier

Agora means market

an anxiety about being in places or situations from which escape

might be difficult or embarrassing; or in which help may not beavailable in the event of having an unexpected or situationallypredisposed panic attack or panic-like symptomsExamples:

Being alone outside the homeBeing in a crowd

On a bridgeTraveling

EpidemiologyLifetime prevalence 1-4%Women 2-3x more affected than men

Recent history of divorce or separationAge: 25 years

Co-morbidity

Depressive disorderSuicidality

Agoraphobia, other phobias, OCD

VIII. Specific Phobia and Social Phobia

Phobia an excessive fear of a specific object, circumstance orsituationFear in phobia is characterized as marked and persistent,

excessive and unreasonable, and provokes an immediate anxietyresponseThe person recognizes that the fear is excessive or unreasonable= He has Insight about his condition

Epidemiology5-10% of the population

Most common mental disorder among women2nd most common among men

6 months prevalence: 5-10%Peak age of onset:

o Natural environment and blood-injection injury type:

5-9 yearso Situational type: mid-20s

Descending frequency: animals, storms, heights, illness, injury,

deathSubstance abuse most common in men

Acrophobia heights. Claustrophobia closed spaces

Exposure to the phobic situation almost always invariably provokes an

immediate anxiety response which usually take the form of a panicattack

The phobic situation is either avoided or endured with intense anxietyor distress

Social phobia fear of one or more social performance situations in

which the person is exposed to unfamiliar people or to possiblescrutiny

Fear embarrassing and humiliating


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IX. Obsessive-Compulsive Disorder

Essential features: presence of obsessions or compulsionsObsessions repetitive thoughts. Compulsions repetitive actions

Severe enough to cause marked distress; time consuming;

interfere significantly with the persons normal routine An individual with OCD may have either an obsession or acompulsion, or bothOCD different from OC personality disorder and people with OC traits

ObsessionA recurrent and persistent thought, impulse, or image;experienced as intrusive or inappropriate and which cause

marked anxiety or distressThese are not simply excessive worries about real-life problemsThe individual attempts to suppress or neutralize them with

some other thought or actionThe individual recognizes them as a product of ones mind

CompulsionRepetitive behavior or mental act that the person is driven to

perform in response to an obsessionThe behavior is aimed at preventing or reducing distress or

preventing dreaded event or situationHowever the behavior is not realistically connected with whatthey are designed to neutralize or prevent, and are clearly

excessive

Epidemiology:Lifetime prevalence: 2-3%

4th most common psychiatric diagnosisAmong adults, men = women; among adolescents, boys > girls

Mean age of onset: 20 years

Co-morbidityMajor depression: 67% (the issue is control, so if we cant

control everything, then it causes depression)

Social phobia: 25%Alcohol use disorders, generalized anxiety disorder, specific

phobia, panic disorder, eating disorders, personality disordersTourettes disorder; 5-7%

Symptom patternsContamination fear of dirt, dust, microbesPathological doubtyou left the gas/window open

Intrusive thoughtsSymmetryroommates who would get furious if you touch their books

Other symptom patterns: religious obsessions, compulsivehoarding

X. Post Traumatic Stress Disorder

A syndrome which develop after the person has been exposed to

a traumatic event in which the following were present:o The person experienced, witnessed, or was confronted

with an event that involved actual or threatened deathor serious injury

Even if he did not witnessed or experienced the

traumatic experience but was presented with it (e.g. in

the news) he could still develop PTSD

o The persons response involved intense fearhelplessness, or horror

The traumatic event is frequently re-experienced in various wayso Nightmares, flashbacks, avoidance of stimuli

Persistent avoidance of stimuli associated with the trauma aswell as numbing of general responsiveness

o Psychotic components, hypervigilance

Persistent symptoms of increased arousal

The duration of the disturbance is more than 1 monthExamples:

o Ondoy, 911, etc

EpidemiologyLifetime incidence: 9-15%

Lietime prevalence: 8%10-12% among women; 5-6% among menMost prevalent in young adults

Single, divorced, widowed, socially withdrawn, lowsocioeconomic levelSeverity, duration, proximity to exposure most common risk

factor

XI. Acute Stress Disorder

Just like in PTSD, the person has been exposed to a traumatic

event, the conditions of which are similarExperiencing of the same signs and sypmtomsThe duration lasts for a min. of 2 days and max. of 4 weeks, and

occurs within 4 weeks of traumatic event

XII. Generalized Anxiety Disorder

Excessive anxiety and worry more days than not for at least 6monthsDifficult to control the worry

3 or more of the following:o Restlessnesso Easily fatiguedo Difficulty concentrating

o Irritabilityo Muscle tensiono Sleep disturbance

EpidemiologyAnxious for as long as they can rememberFirst seek consult in their 20s

Only 1/3 seek psychiatric treatment

Goals of Anxiolytic Treatment:Assuage anxiety and tensionLessen physical symptoms

Induce a state of well-being


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XIII. Etiiology and Treatment

A. Biological

Autonomic nervous systemB-adrenergic receptor (propranolol for social phobia

o Sweating, palpitation

Neurotransmitters:Beta adrenergic receptor antagonist (propranolol), alpha-2receptor agonist (clonidine)

Norepinephrineo Chronic symptoms characteristic of inc. noradrenergic

function

o Poorly regulated noradrenergic systemo Stimulation of locus ceruleus

CRHo Hypothalamic levels of CRH inc by stress, activation of

HPA axis, increase release of cortisol; excessive andsustained cortisol secretion causes hypertension,osteoporosis, immunosupression, insulin resistance,dyslipidemia, cardiovascular disease

SerotoninGABA

Brain imaging studies:Cerebral asymmetryAbnormality in the frontal cortex, occipital, temporal areas in

anxiety DO; parahippocampal gyrus in panic DOCaudte nucleus in OCDInc. activity in the amygdala in PTSD

Genetic studies

Neuroanatomical considerations

o Limbic system: Increased activity in the septohippocampal

pathway and anxiety

Cingulate gyrus and OCDo Cerebral cortex

Frontal and temporal cortex

i. Tricyclic antidepressants (TCAs)

- Clomipramine, imipramine, nortriptyline

Advantages:

o Single daily doseo Antidepressant effecto No abuse potentialo Well studied

o Effectiveo Generics available

Disadvantageso Delayed onseto Anticholinergic side-effectso Postural hypotensiono Weight gaino Sexual side-effects

o Initial stimulationo Dangerous in overdose

ii. Selective Serotonin Reuptake Inhibitors

- Fluoxetine (Prozac), fluvoxamine, paroxetine, sertraline,venlafaxine, citalopram, escitalopram

Advantages:o Effectiveo Benign side-effect

o Safetyo No dependence issueso Once a day dosing

Disadvantageso Delayed onset of action (2-4 weeks, sometimes even 4-6

weeks)

o Early anxiogenic effecto Sexual side effects

o Usually requires dose titration

iii. Benzodiazepines

- Alprazolam, bromazepam, clonazepam, diazepam,clorazepate

Advantages:o Rapid onseto Effectiveo Well-tolerated

o General anti-anxiety effectso Safe in overdose

Disadvantages

o Withdrawal reactiono Sedationo Multiple daily dosingo Abuse potential with history of abusingo Poor antidepressant effect

B. Psychosocial

Psychoanalyticalo Anxiety as result of psychic conflict between

unconscious sexual or aggressive wishes and

corresponding threats from the superego or externalrealityPsychodynamic therapy

o Goal: increase anxiety tolerance

Behavioral theorieso Anxiety is a conditioned response to a specific

environmental stimuluso Social learning: anxious parents, anxious child

o Biofeedback

o Behavior therapy

Systematic desensitizationRelaxation training

Hierarch constructionDesensitization of the stimulus

Therapeutic graded exposure Flooding

Participant modelinganxious parentbreeds an anxious child

Exposure to stimuli presented invirtual reality


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XIV. Take It Easy

POST-TRAUMATIC STRESS DISORDER

OBSESSIVE-COMPULSIVE DISORDER

GENERALIZED ANXIETY DISORDER

PANIC DISORDER


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G7: G7ood Luck! G7od bLess!

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SS - Psych - 03 - Anxiety Disorders