Anxiety Disorders ByDr. Ahmed Albehairy, M.D Consultant Psychiatry
Concept of Anxiety- Definition ( normal anxiety ?).- Anxiety vs. Fear.- Components: . Emotional . . Cognitive anticipation , memory. . Behavioral. . Somatic- Pathogenesis of Anxiety (Bio – Psycho- Social approach).- Stress – related anxiety.
Stress – Related anxiety.Stressors Body Change Adapted Body Response
Forms of anxiety- Developmental ( separation – social anxiety ).- State.- Trait( BPD- Narcissistic- Avoidant- Passive aggressive – Depressant PD).
Forms of anxietysymptoms ( emotional, somatic, cognitive, and behavioral)- Acute stress reaction. - Impulse control.- GAD. - OCD.- SAD. - Impulse control.- Simple phobia. - PTSD.- Panic . - Premature ejaculation.- Agoraphobia - Burn out.
EtiologyBio : ++symp tone, inc NA, dec, REM latency, like MD, dec GABA.++/_ 5HTINC in temporal lobe, hyperfrontality in OCD++ of LC.Changes in CRF and sP and Ckinin.Psycho: freud, cognitive errors.Social: learning theory,Genetic
Epidemiology of anxiety- Most of them 1-3%- GAD 3-8%- GAD, PTSD,PHOBIA== M:F =1:2- OTHERS M:F == 1:1- PANIC,GAD, OCD == HIGH CONC.MONZ
• PANIC ATTACK attacks (ie, Panic disorder is characterized by recurrent panic periods of intense fear of abrupt onset peaking in intensity within 10 min). Four of the following must be present for a panic attack:• Palpitations, pounding heart, or accelerated heart rate• Sweating• Trembling or shaking• Shortness of breath or dyspnea• Sensation of choking• Chest pain or discomfort• Nausea or abdominal distress• Feeling dizzy, unsteady, lightheaded, or faint• Derealization or depersonalization• Fear of losing control or going crazy• Fear of dying• Paresthesias• Chills or hot flashes• Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with panic disorder.
GAD• Generalized anxiety disorder is characterized by excessive anxiety and worry. Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the following symptoms:• Restlessness or feeling keyed-up or on edge• Being easily fatigued• Difficulty concentrating or mind going blank• Irritability• Muscle tension• Sleep disturbance• Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder
OCD• OCD is characterized by obsessions or compulsions. Obsessions or compulsions must be recognized as unreasonable or excessive and must cause marked distress.• Obsessions include all of the following: – Recurrent and persistent thoughts, impulses, or images that are intrusive and knowingly inappropriate and cause anxiety or distress – Obsessions are very discomforting and can include fear of losing control and harming someone close to the patient, such as his or her child. – Patient commonly knows he or show wont act on the obsessions, but it will still cause significant distress. – Obsessions may be hidden by the patient for fear of being called "crazy." – Thoughts, impulses, or images that are not simply excessive worries about real-life problems – Attempts are made to ignore or suppress thoughts. – Thoughts, impulses, or images are recognized as being the product of the mind and not imposed from an outside force.• Compulsions include the following: – Repetitive behaviors, such as handwashing, ordering, and checking, that people feel are driven and must be carried out and occur to such an extreme that a persons ability to function is impaired. – Behaviors or mental acts are done to reduce distress or anxiety.
Social phobia• Marked and persistent fear of social or performance situations to the extent that a persons ability to function at work or in school is impaired.• Exposure to social or performance situation always produces anxiety.• Fear/anxiety recognized as excessive• Social or performance situations are avoided or endured with intense anxiety.• Avoidance behavior, anticipation, or distress in the feared social or performance setting produces significant impairment in functioning.
PTSD• PTSD is a severe trauma that is experienced that includes (1) actual or threatened death or serious injury or threat to personal integrity of self or others and (2) responses that include intense fear, helplessness, or horror. (Life-threatening experiences and the attendant loss of control are key elements.)• Persistent reexperience of the event occurs by at least 1 of the following: – Recurrent and intrusive recollections – Recurrent distressing dreams/nightmares – Feelings of reliving traumatic event, ie, flashbacks – Intense psychologic distress with internal or external cues to the trauma – Physiological reactivity on exposure to trauma cues• Persistent avoidance of stimuli of trauma and numbing/avoidance behavior demonstrated by at least 3 of the following: – Avoidance of thoughts or conversation related to the trauma – Avoidance of activities, places, or people related to the trauma – Amnesia for important trauma-related events – Decreased participation in significant activities – Feeling detached or estranged from others – Restricted affect – Foreshortened sense of the future• Persistent symptoms of increased arousal demonstrated by 2 or more of the following: – Difficulty staying or falling asleep – Irritability or anger outbursts – Difficulty concentrating – Hypervigilance – Exaggerated startle response• Although not a diagnostic feature, suicidal and homicidal ideation have been associated with PTSD.
D.DM.D, SCHIZOPHRENIA,BIPI,ADJUST,SUBSTANCE RELATED,DEMENTIA,ANGINA,HYPERVENTILATION,HYPOGLY CEMIA,CARCINOID S
Management of anxiety disorders- Self help : - prepare your body and mind for the situation . - focus on the moment. - enjoy the moment. - avoid self judgment during the act. - dont judge what happened or about to happen.
Management of anxiety disorders supportive, insight oriented. Psychotherapy – CBT. Relaxation – breathing tech. 8-12 sessions. group therapy
Common Side Effect of AntidepressantsTCA : dry mouth, constipation, drowsiness, orthostatic hypotension, weight gain,,++ IOP.Bupropion, seizure, agitation,insomnia.Trazodone: sedation, priapism.SSRI: insomnia, agitation, headache, nausea. Fluxetine ( akathesia). Paroxetine , dry mouth.Venlafaxine: hypertension, nausea.Mirtazepine: wt gain and sedation.MAOI --- TYRMINE, SSRI,LETHALITY : TCA OVERDOSE, serotenorgig syndrome
Hot Items in Choosing medications in DepressionPsychotic dep--- AP +AD, ECTMelancholic ----- AD + ECT( REC)Atypical ---------- SSRISeasonal -------- AD + phototherapyPostpartum ------ ? BAD, in hospital
Hot Items in Choosing medications in Depressionrisk Lower moderate higherBreast feeding TCA, Amoxipen, MAOI, Flupenthexol mianserine, VENLAFAXINE mirtazepine, SSRI, trazodoneCVS SSRI,Mianserine, MAOI, TCA, mirtazepine, venlafaxine trazodonediabetus SSRI,TRAZODON FLUXETINE, MAOI E, VENLAFAXINE MIANSERIN E, MIRTAZEPIN E, TCA
Hot Items in Choosing medications in Depressionrisk Lower moderate higherOLD AGE VENLAFAXINE, MAOI, TCA MIRTAZEPINE, SSRI, MIANSERINE, VENLAFAXINE TRAZODONEPREGNAN ?// TRYPTOPHAN TCA,MAOI,MECY RTIZAPINE,V ENLAFAXINE, MIANSERINERENAL MIANSERINE,TCA,TR SSRI,MIRTEZ VENLAFAXINE, AZODONE,TRYPTOP APINE,MAOI, FLUXETINE HAN DULEXTINE