Anxiety

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Anxiety

  1. 1. Dr. Aftab Asif Associate Professor Department of Psychiatry Anxiety Disorders
  2. 2. NORMAL ANXIETY & PATHOLOGICAL TYPES OF ANXIETY     <ul><li>Behavior </li></ul><ul><li>Ability to function </li></ul><ul><li>  Assessment by patient, friend & clinician </li></ul><ul><li>Neuropsychiatric Evaluation </li></ul>
  3. 3. ANXIETY DISORDER <ul><li>  Panic disorder (with or </li></ul><ul><li>with out agoraphobia) </li></ul><ul><li>Specific phobia </li></ul><ul><li>Special phobia </li></ul><ul><li>Generalized anxiety disorder </li></ul><ul><li>Obsessive-compulsive disorder </li></ul><ul><li>Acute stress disorder </li></ul><ul><li>Posttraumatic stress disorder </li></ul><ul><li>  Anxiety disorder due to medical condition </li></ul><ul><li>Substance-induced anxiety disorder </li></ul>
  4. 4.      PSYCHOANALYTIC THEORIES: <ul><li>   “ Anxiety around ego to take defensive action against the pressure from within” </li></ul>
  5. 5. MAJOR CATEGORIES: <ul><li>Depending on the nature of the feared consequences </li></ul><ul><li>Id or impulse anxiety </li></ul><ul><li>Separation anxiety </li></ul><ul><li>Castration anxiety </li></ul><ul><li>Superego anxiety </li></ul>
  6. 6.    BEHAVIOURAL THEORIES: <ul><li>Conditioned response to a specific environmental stimuli. </li></ul><ul><li>Regular food Contaminated food Allergy Desensitization </li></ul>
  7. 7. BIOLOGICAL THEORIES: <ul><li>Biological events precede the psychological conflict </li></ul><ul><li> Autonomic nervous system Stimulation of ANS- like </li></ul><ul><li>Cardiovascular – tachycardia </li></ul><ul><li>Muscular – headache </li></ul><ul><li>Gastrointestinal – diarrhoea </li></ul><ul><li>Respiratory – tachypnea </li></ul>
  8. 8. NEUROTRANSMITTER: <ul><li>Norepinephrine </li></ul><ul><li>Serotonin </li></ul><ul><li>GABA </li></ul>
  9. 9. Norepinephrine: Locus Ceruleus Pons     Limbic system Cerebral cortex Brainstem Spinal cord   Stimulation Fear
  10. 10. <ul><li> - Adrenergic agonist </li></ul><ul><li>(Isoproternol) </li></ul><ul><li>  </li></ul><ul><li> 2 - Adrenergic antagonist (yohimbine) </li></ul><ul><li>= Increased pain attacks </li></ul><ul><li>  </li></ul><ul><li>Clonidine (catapres) = Reduced pain attacks </li></ul>
  11. 11. SEROTONIN: <ul><li>Raphe nuclei in rostral brainstem </li></ul><ul><li>Cerebral cortex </li></ul><ul><li>Limbic system </li></ul><ul><li>Amygdala </li></ul><ul><li>Hippocampus </li></ul><ul><li>Hypothalamus </li></ul><ul><li>Some drug involved with serotonin reduce the anxiety level. </li></ul>
  12. 12. GABA <ul><li>Benzodiazepine inhance </li></ul><ul><li>The level of GABA reduced anxiety </li></ul><ul><li>Benzodiazepine severe panic attacks </li></ul><ul><li>antogonist (flumazenil) </li></ul>
  13. 13. BRAIN – IMAGING STUDY: <ul><li>CT/MRI --- some </li></ul><ul><li>increase in the size </li></ul><ul><li>of cerebral ventricles. </li></ul><ul><li>MRI – specific defect </li></ul><ul><li>in the tight temporal lobe. </li></ul><ul><li>PET/SPECT/EEG – </li></ul><ul><li>Abnormalities in frontal cortex. </li></ul>
  14. 14. GENETIC STUDIES: <ul><li>50% relatives </li></ul><ul><li>have panic </li></ul><ul><li>attacks </li></ul>
  15. 15. NEUROANATOMICAL CONSIDERATIONS: <ul><li>Limbic system </li></ul><ul><li>Increased concentration </li></ul><ul><li> of GABA </li></ul><ul><li>Cerebral cortex </li></ul><ul><li>Frontal cerebral cortex </li></ul><ul><li>Connected with Parahippocampal cingulated gyrus hypothalamus </li></ul><ul><li>Production of anxiety </li></ul>
  16. 16. DIFFERENT DISORDER VARIES <ul><li>Wide range of medical conditioning: </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Hypoparathyroidism </li></ul><ul><li>Vit B12 deficiency </li></ul><ul><li>Cardiac arrythmias </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>83 % of cardiomyopathy patient awaiting cardiac transplantation have panic disorder. </li></ul><ul><li>25 % Parkinson’s disease hare panic attacks </li></ul><ul><li>25 % of chronic obstructive pulmonary disease (COPD) have panic attacks </li></ul>
  17. 17. <ul><ul><li>Amphetamine </li></ul></ul><ul><ul><li>Cocaine </li></ul></ul><ul><ul><li>Caffeine </li></ul></ul>Substance Induced Anxiety Disorder
  18. 18. Mixed anxiety/depression disorder <ul><li>A </li></ul>D D A A D A D
  19. 19. PANIC DISORDER <ul><li>Epidemiology: </li></ul><ul><li>Life time prevalence </li></ul><ul><li>1.5 to 3 % - panic disorder </li></ul><ul><li>  4 % - panic attacks </li></ul><ul><li>  Women Men </li></ul><ul><li>2-3 1 </li></ul><ul><li>Mitral valve prolapse </li></ul><ul><li>      Mid systolic dick on cardiac auscultation </li></ul><ul><li>     Prolapse of one of the mitral valve leaflets </li></ul><ul><li>     Heterogenous </li></ul>
  20. 20. DRUGS USED FOR THE TREATMENT OF PANIC DIAORDER. Nausea, diarrhea, anxiety/nervousness, sexual dysfunction somnolence 60 mg 20-40 mg 10 mg Paroxetine Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 60 mg 20-40 mg 10 mg Fluoxetine Dry mouth, drowsiness, nausea, anxiety/nervousness, othostatic hypotension, myoclonus, hypotension, myoclonus, hypertensive 90 mg 30-90 mg 15 mg twice daily Pheneizine Dry mouth, blurred vision, constipation, urinary hesitancy, othostasis, somnolence, anxiety, sexual dysfunction 150 mg 50-100 mg 25 mg at bedtime Imipramine CommonS. Effect Max. Dosage Daily Dosing Range Starting Dosage Drug
  21. 21. Somnolence, ataxia, memory problems, physical dependence, withdrawal reactions 6 mg/day 1.5-4.0 mg 0.25-0.5 mg twice daily Clonazepam Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 6 mg/day 1.5-4.0 mg 0.25-0.5 mg 3times daily Alprazolam Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 60 mg 25-150 mg 25 mg Sertraline
  22. 22. PHOBIC DISORDERS <ul><li>“ A marked and persistent </li></ul><ul><li>fear that is excessive at </li></ul><ul><li>unreasonable, cued by </li></ul><ul><li>the presence or anticipation </li></ul><ul><li>of a specific object or </li></ul><ul><li>situation.” </li></ul>
  23. 23. SPECIFIC TYPES: <ul><li>Animal type </li></ul><ul><li>if the fear is cued by : </li></ul><ul><li>Animals or insects </li></ul><ul><li>Natural environment type: </li></ul><ul><li>Storms, heights or water </li></ul><ul><li>Blood-injection - injury type: </li></ul><ul><li>Situational type : </li></ul><ul><li>Public transportation, tunnels, bridges, elevatos, flying, driving, peak in childhood or in mid 20s </li></ul>
  24. 24. SOCIAL PHOBIA: <ul><li>Exposed to unfamiliar people </li></ul><ul><li>or to possible scrutiny by others. </li></ul><ul><li>EPIDIMIOLOGY: </li></ul><ul><li>Phobic disorder – 5-10 % in </li></ul><ul><li>general population </li></ul><ul><li>Social phobia – 3 % </li></ul>
  25. 25. TREATMENT: <ul><li>Pharmacological Treatment: </li></ul><ul><li>Benzodiazepine </li></ul><ul><li> -blockers </li></ul><ul><li>Antidepressants. </li></ul><ul><li>Psychotherapy: </li></ul><ul><li>Behavior or Cognitive behavior therapy </li></ul>
  26. 26. GENERALIZED ANXIETY DISORDER (GAD) <ul><li>Excessive anxiety and </li></ul><ul><li>worry for at least 6months. </li></ul><ul><li>SYMPTOMS: </li></ul><ul><li>Restlessness or feeling </li></ul><ul><li>keyed up, on edge </li></ul><ul><li>Difficulty concentration or mind going blank </li></ul><ul><li>  Irritability </li></ul><ul><li>Muscle tension </li></ul><ul><li>  Sleep disturbance </li></ul>
  27. 27. EPIDIMIOLOGY: <ul><li>  Early adult life. </li></ul><ul><li>  Commonly in women </li></ul><ul><li>  More frequently in general </li></ul><ul><li>Medical practice than in Psychiatry </li></ul><ul><li>  High rate of comorbidity </li></ul><ul><li>  Symptoms of hyperarousal </li></ul><ul><li>  Do not recognize themselves as having psychiatric illness </li></ul>
  28. 28. DIFFERENTIAL DIAGNOSIS: <ul><li>Major depression </li></ul><ul><li>OCD </li></ul><ul><li>Panic disorder </li></ul><ul><li>Somatoform disorder </li></ul><ul><li>Paranoid </li></ul><ul><li>Eating disorder </li></ul><ul><li>Hyper thyroidism </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Diabetes </li></ul><ul><li>Drugs </li></ul><ul><li>Mitral valve prolapse </li></ul><ul><li>      </li></ul>
  29. 29. TREATMENT: <ul><li>Pharmacological treatment: </li></ul><ul><li>Benzodiazepine </li></ul><ul><li>Buspirone(serotonin 1 A receptor partial agonist) </li></ul><ul><li>TCA </li></ul><ul><li>SSRI </li></ul><ul><li>Psychotherapy: </li></ul><ul><ul><ul><ul><li>Cognitive – behavior therapy . </li></ul></ul></ul></ul><ul><li>  </li></ul>
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