Anxiety disorders in adults 2005

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Anxiety disorders in adults 2005

  1. 1. ANXIETY DISORDERS IN CHILDREN & ADULTS THEORY DIAGNOSIS TREATMENT
  2. 2. Pharmacological response to medications designed to treat anxiety disorders is NOT evidence or proof of ETIOLOGY.
  3. 3. FEAR VERSUS ANXIETY <ul><li>FEAR </li></ul><ul><li>OBJECTIVE </li></ul><ul><li>PAST EXPERIENCE WITH STRESSOR </li></ul><ul><li>KNOWN PROBALITY OF HARM </li></ul><ul><li>ANXIETY </li></ul><ul><li>SUBJECTIVE </li></ul><ul><li>FUTURE ORIENTED </li></ul><ul><li>UNKNOWN HOW ONE WILL BE HARMED </li></ul>
  4. 4. NORMAL VERSUS ABNORMAL ANXIETY <ul><li>LEVEL OF ANXIETY </li></ul><ul><li>SOME LEVEL OF ANXIETY NECESSARY TO CREATE MOTIVATION </li></ul><ul><li>HIGH LEVELS OF ANXIETY RESULT IN INTERFERENCE WITH PERFORMANCE </li></ul><ul><li>HIGH LEVELS OF ANXIETY RESULT IN HIGH LEVEL OF COGNITIVE & PHYSIOLOGICAL AROUSAL </li></ul>
  5. 5. NORMAL VERSUS ABNORMAL ANXIETY <ul><li>JUSTIFICATION </li></ul><ul><li>ANY LEVEL OF ANXIETY WOULD BE CONSIDERED ABNORMAL IF NO RATIONAL JUSTIFICATION EXISTS FOR THE SITUATION TO TRIGGER ANXIETY. </li></ul><ul><li>PERCEPTION OF THE EVENT AS THREATENING TO THE INDIVIDUAL’S SAFETY IS KEY . </li></ul>
  6. 6. NORMAL VERSUS ABNORMAL ANXIETY <ul><li>INTERFERENCE IN FUNCTIONING </li></ul><ul><li>ANXIETY IS ABNORMAL IF IT CAUSES ANY </li></ul><ul><li>IMPAIRMENT IN FUNCTIONING IN ANY LIFE AREA: </li></ul><ul><li>(1) SOCIAL </li></ul><ul><li>(2) OCCUPATIONAL </li></ul><ul><li>(3) PHYSICAL </li></ul><ul><li>(4) RECREATIONAL </li></ul>
  7. 7. PREVALENCE & INCIDENCE OF ANXIETY DISORDERS <ul><li>MOST COMMON MENTAL DISORDER IN UNITED STATES. </li></ul><ul><li>15%-TO-17% OF ADULT POPULATION SUFFER FROM 1 OR MORE ANXIETY DISORDERS. </li></ul><ul><li>23 MILLION HAVE ONE FORM OF THE 6 ANXIETY DISORDERS </li></ul><ul><li>5% -TO-10% OF SCHOOL AGE CHILDREN HAVE AN ANXIETY RELATED DISORDER. </li></ul>
  8. 8. PREVALENCE & INCIDENCE OF ANXIETY DISORDERS <ul><li>26% SUFFER FROM 2 OR MORE INDEPENDENT ANXIETY DISORDERS. </li></ul><ul><li>19% SUFFER FROM ONLY 1 ANXIETY DISORDER. </li></ul><ul><li>55% SUFFERED FROM MULTIPLE DISORDERS, ONE OF WHICH HELPED CAUSE THE OTHERS. </li></ul>
  9. 9. ANXIETY DISORDERS <ul><li>Generalized Anxiety Disorder </li></ul><ul><li>Panic Disorder </li></ul><ul><li>Obsessive-Compulsive Disorder </li></ul><ul><li>Post-Traumatic Stress Disorder </li></ul><ul><li>Specific Phobia </li></ul><ul><li>Social Phobia </li></ul><ul><li>Agoraphobia w/o Panic Attacks </li></ul><ul><li>Agoraphobia with Panic Attacks </li></ul>
  10. 10. ANXIETY DISORDERS <ul><li>Anxiety Disorder Due to a General Medical Condition </li></ul><ul><li>Substance Induced Anxiety Disorder </li></ul><ul><li>Anxiety Disorder NOS </li></ul><ul><li>Mixed Anxiety-Depressive Disorder </li></ul>
  11. 11. GENERALIZED ANXIETY DISORDER THEORY DIAGNOSIS TREATMENT
  12. 12. Epidemiology of Generalized Anxiety Disorder <ul><li>One-year prevalence rate is approximately 3% of adults. </li></ul><ul><li>Life-time prevalence rate approximately 5%. </li></ul><ul><li>25% of GAD patients present with comorbid condition: </li></ul><ul><li>Depression </li></ul><ul><li>Panic Disorder </li></ul><ul><li>Substance abuse </li></ul><ul><li>Hypochondriasis </li></ul><ul><li>Personality Disorder </li></ul>
  13. 13. Epidemiology of Generalized Anxiety Disorder <ul><li>Half of pts presenting for treatment report onset in childhood or adolescence. </li></ul><ul><li>In children, Over-anxious Disorder of Childhood </li></ul><ul><li>Gender ratio is approximately 2-to-1 females </li></ul><ul><li>Course of disorder is CHRONIC but fluctuates & often WORSENS during periods of stress. </li></ul><ul><li>familial association </li></ul>
  14. 14. PSYCHOANALYTIC EXPLANATION OF GAD & PANIC DISORDERS <ul><li>INTERNAL CONFLICTS ARE SOURCE OF BOTH DISORDERS </li></ul><ul><li>UNCONSCIOUS IMPULSES THREATEN EXPRESSION </li></ul><ul><li>ANXIETY IS ALARM THAT DEFENSES ARE ABOUT TO BREAK DOWN. </li></ul><ul><li>SINCE NO FOCUS FOR DEFENSE, ANXIETY SYMPTOMS ARE RESULT OF UNSUCCESSFUL DEFENSE AGAINST ANXIETY PROVOKING IMPULSES . </li></ul>
  15. 15. COGNITIVE THEORY OF GENERALIZED ANXIETY DISORDER <ul><li>Beck (1991) - People with GAD constantly make unrealistic assumptions that they are in imminent danger : </li></ul><ul><li>a. ANY STRANGE SITUATION SHOULD BE REGARDED AS DANGEROUS . </li></ul><ul><li>b. A SITUATION OR PERSON IS UNSAFE UNTIL PROVEN SAFE. </li></ul><ul><li>c. IT IS ALWAYS BEST TO ASSUME THE WORST . </li></ul><ul><li>d. MY SECURITY & SAFETY DEPEND ON ANTICIPATING & PREPARING MYSELF AT ALL TIMES FOR ANY POSSIBLE DANGER. </li></ul>
  16. 16. GABA & ANXIETY DISORDERS <ul><li>Research points to a problem in feedback system can cause fear or anxiety to go unchecked (Lloyd, 1992). </li></ul><ul><li>GABA is released to exert inhibitory action on excitatory activity of neurons. </li></ul><ul><li>A second site on GABA A receptor binds with benzodiazepines. </li></ul><ul><li>People with GAD may have ongoing problems with anxiety feedback system. </li></ul>
  17. 17. GABA A Receptor with Binding Sites
  18. 18. GABA & GENERALIZED ANXIETY DISORDER
  19. 19. GABA & ANXIETY DISORDERS <ul><li>Brain supplies of GABA too low. </li></ul><ul><li>May have too few GABA A receptors. </li></ul><ul><li>GABA A receptors do not readily bind neurotransmitter. </li></ul><ul><li>Brain may be releasing an excess of other chemicals reducing GABA activity at receptor sites. </li></ul>
  20. 20. ASSESSMENT OF GAD <ul><li>SCREENING TOOLS </li></ul><ul><li>Anxiety Screening Questionnaire (15 items) </li></ul><ul><li>Primary Care Evaluation of Mental Disorders </li></ul><ul><li>(PRIME-MD) </li></ul><ul><li>Hamilton Anxiety & Depression Scale </li></ul><ul><li>Beck Anxiety Scale </li></ul><ul><li>Center for Epidemiological Studies Depression Scale </li></ul><ul><li>(CESD) </li></ul><ul><li>Hospital Anxiety & Depression Scale </li></ul>
  21. 21. ASSESSMENT OF GAD <ul><li>INTERVIEWING QUESTIONS: </li></ul><ul><li>“ During the past 4 weeks, have you been bothered by feeling worried, tense, or anxious MOST of the time?” </li></ul><ul><li>“ Are you frequently tense, irritable, and have trouble sleeping?” </li></ul><ul><li>If either answered YES, further investigation is warranted. </li></ul>
  22. 22. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Treatment options – Most efficaciously treated by combination of CBT & Pharmacotherapy </li></ul><ul><li>Cognitive-Behavior Therapy </li></ul><ul><li>Reframing </li></ul><ul><li>Cognitive Restructuring </li></ul><ul><li>Identifying Anxiety Triggers </li></ul><ul><li>Cognitive Rehearsal </li></ul><ul><li>Stress-Inoculation </li></ul>
  23. 23. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy </li></ul><ul><li>SSRI </li></ul><ul><li>Paroxetine (Paxil) only FDA for GAD </li></ul><ul><li>Fluoxetine (Prozac) </li></ul><ul><li>Sertraline (Zoloft) </li></ul><ul><li>Citalopram (Celexa) </li></ul><ul><li>Fluvoxamine (Luvox) </li></ul><ul><li>See Table 11.4 in Kaplan & Saddock for dosing. </li></ul>
  24. 24. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy – SSRI </li></ul><ul><li>Advantages of SSRI </li></ul><ul><li>Few side effects </li></ul><ul><li>Not addictive/dependence liability </li></ul><ul><li>Treats co-morbid depression </li></ul><ul><li>Once daily dosing </li></ul><ul><li>Low sedation effect </li></ul>
  25. 25. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy – SSRI </li></ul><ul><li>Disadvantages of SSRI </li></ul><ul><li>Patient does not experience symptom attentuation with single dose </li></ul><ul><li>Several weeks to full therapeutic effects </li></ul><ul><li>Gastrointestinal and Sexual side-effects common </li></ul>
  26. 26. TREATMENT OF GAD IN PRIMARY CARE <ul><li>SNRI Venaflaxine Hydrochloride (Effexor XR) </li></ul><ul><li>Approved by FDA </li></ul><ul><li>Reduces symptoms of: </li></ul><ul><li>anxious mood </li></ul><ul><li>excessive motor tension </li></ul><ul><li>restlessness </li></ul><ul><li>insomnia </li></ul><ul><li>irritablility </li></ul><ul><li>poor concentration </li></ul>
  27. 27. TREATMENT OF GAD IN PRIMARY CARE <ul><li>SNRI Venaflaxine Hydrochloride (Effexor XR) </li></ul><ul><li>Common side effects: </li></ul><ul><li>asthenia somnolence </li></ul><ul><li>nausea tremor </li></ul><ul><li>constipation abnormal ejaculation/orgasm </li></ul><ul><li>Patient does not experience symptom attentuation with single dose </li></ul><ul><li>Several weeks to full therapeutic effects. </li></ul>
  28. 28. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Nonbenzodiazepine agent – Buspirone (Buspar) </li></ul><ul><li>It is a 5-HT 1A receptor partial agonist. </li></ul><ul><li>More effective in reducing cognitive symptoms than somatic symptoms of GAD. </li></ul><ul><li>Less addictive potential associated with its use. </li></ul><ul><li>Indicated if patient has co-morbid substance use disorder. </li></ul>
  29. 29. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Nonbenzodiazepine agent – Buspirone (Buspar) </li></ul><ul><li>Patients who had used benzodiazepines are not likely to respond to Buspirone. </li></ul><ul><li>Lack or absence of anxiolytic effects (muscle relaxation & sense of well being) may be contributing factor. </li></ul><ul><li>Effects take 2-to-3 weeks to become evident. </li></ul>
  30. 30. Treatment of GAD <ul><li>BENZODIAZEPINES </li></ul><ul><li>ALPRAZOLAM XANAX </li></ul><ul><li>CHLORDIAZEPOXIDE LIBRIUM </li></ul><ul><li>CLONAZEPAM KLONOPIN </li></ul><ul><li>CLORAZAPATE TRANZENE </li></ul><ul><li>DIAZEPAM VALIUM </li></ul><ul><li>LORAZEPAM ATIVAN </li></ul><ul><li>OXAZEPAM SERAX </li></ul><ul><li>PRAZEPAM CENTREX </li></ul>
  31. 31. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy – Benzodiazepines </li></ul><ul><li>Advantages </li></ul><ul><li>Therapeutic effect in single dose </li></ul><ul><li>Time to full therapeutic effect in days. </li></ul><ul><li>Anxiolytic effect of medications helps reduce somatic symptoms of GAD </li></ul>
  32. 32. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy – Benzodiazepines </li></ul><ul><li>Disddvantages </li></ul><ul><li>Impaired alertness & motor performance </li></ul><ul><li>High addictive or dependence liability </li></ul><ul><li>Does not treat co-morbid depression </li></ul><ul><li>Requires several doses per day </li></ul><ul><li>High sedation effect </li></ul><ul><li>Memory impairment </li></ul>
  33. 33. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy – Benzodiazepines </li></ul><ul><li>Most common clinical mistake is to routinely continue treatment INDEFINITELY. </li></ul><ul><li>Treatment may be minimum of 6 months-to-1 year so consideration of other medications who seem warranted. </li></ul><ul><li>Start treatment with benzodiazepine & buspirone & taper off benzodiazepine when buspirone reaches maximum effect ( 2-to-3 weeks). </li></ul>
  34. 34. PANIC DISORDER THEORY DIAGNOSIS TREATMENT
  35. 35. Epidemiology of Panic Disorder <ul><li>One-year prevalence rate is approximately 1.5% of adults. </li></ul><ul><li>Life-time prevalence rate approximately 3.5%. </li></ul><ul><li>Panic Disorder patients present with comorbid condition: </li></ul><ul><li>Major Depression GAD </li></ul><ul><li>Substance abuse OCD </li></ul><ul><li>Specific Phobia Agoraphobia </li></ul><ul><li>Social Phobia PTSD </li></ul>
  36. 36. Epidemiology of Generalized Anxiety Disorder <ul><li>Typically onset between adolescence & mid-30’s. </li></ul><ul><li>Females 3X more likely to have PD with agoraphobia </li></ul><ul><li>Males 2X more likely to have PD W/O agoraphobia </li></ul><ul><li>Course of disorder is CHRONIC but waxing & waning. </li></ul><ul><li>1 st degree biological relatives are 8 times more likely to develop panic disorder. </li></ul><ul><li>If onset before age 20, 20 times more likely </li></ul>
  37. 37. NOREPINEPHERINE & PANIC DISORDERS <ul><li>Research has focused upon abnormal norepinepherine activity in locus coeruleus. </li></ul><ul><li>Function of locus coeruleus is to send messages to amygdala (limbic system) that is known to trigger emotional reactions. </li></ul><ul><li>Studies have indicated that locus coerulus is involved in activating certain behaviors such as increased vigilance. </li></ul>
  38. 38. NOREPINEPHERINE & PANIC DISORDERS <ul><li>Over-activity in nordrenergic system has been linked to panic disorder. </li></ul><ul><li>Stimulation of locus coerulus in both animal & human studies trigger panic symptoms. </li></ul><ul><li>Noradrenergic over-activity may be result of fewer GABA A receptor sites and lower GABA levels in occipital cortex of panic disorder patients. (Malizia, 1998; Goddard, 2001) </li></ul>
  39. 39. NOREPINEPHERINE & PANIC DISORDERS <ul><li>Anti-depressant drugs act to restore appropriate norepinepherine activity in locus coerulus & helps to reduce symptoms of disorder. </li></ul><ul><li>80% will experience some significant improvement. </li></ul><ul><li>40% reach full recovery or improve markedly; 20% show NO improvement . </li></ul>
  40. 40. LOCUS COERULUS & PANIC DISORDER
  41. 41. ASSESSMENT OF PANIC DISORDER <ul><li>SCREENING TOOLS </li></ul><ul><li>Anxiety Screening Questionnaire (15 items) </li></ul><ul><li>Primary Care Evaluation of Mental Disorders </li></ul><ul><li>(PRIME-MD) </li></ul><ul><li>Hamilton Anxiety & Depression Scale </li></ul><ul><li>Beck Anxiety Scale </li></ul><ul><li>Center for Epidemiological Studies Depression Scale </li></ul><ul><li>(CESD) </li></ul><ul><li>Hospital Anxiety & Depression Scale </li></ul><ul><li>Panic Disorder Self-Test (www.adaa.org) </li></ul>
  42. 42. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Cognitive Behavior Therapy </li></ul><ul><li>Stress-inoculation </li></ul><ul><li>Reframing </li></ul><ul><li>Cognitive Restructuring </li></ul><ul><li>Relaxation Training </li></ul><ul><li>Progressive Relaxation </li></ul><ul><li>Deep breathing </li></ul><ul><li>Positive Imagery </li></ul>
  43. 43. TREATMENT OF GAD IN PRIMARY CARE <ul><li>Pharmacotherapy </li></ul><ul><li>SSRI </li></ul><ul><li>Paroxetine (Paxil) only FDA for GAD </li></ul><ul><li>Fluoxetine (Prozac) </li></ul><ul><li>Sertraline (Zoloft) </li></ul><ul><li>Citalopram (Celexa) </li></ul><ul><li>Fluvoxamine (Luvox) </li></ul><ul><li>See Table 11.4 in Kaplan & Saddock for dosing. </li></ul>
  44. 44. Pharmacotherapy of Panic Disorder <ul><li>SSRI </li></ul><ul><li>Paroxetine (Paxil) </li></ul><ul><li>Fluvoxamine (Luvox) </li></ul><ul><li>Sertraline (Zoloft) </li></ul><ul><li>DOSE </li></ul><ul><li>5-10 mg start </li></ul><ul><li>20-60 mg maintenance </li></ul><ul><li>12.5 mg start </li></ul><ul><li>50-125 mg maintenance </li></ul><ul><li>12.5 – 25 mg start </li></ul><ul><li>100-150 mg maintenance </li></ul>
  45. 45. Pharmacotherapy of Panic Disorder <ul><li>TCA </li></ul><ul><li>Clomipramine (Anafrinil) </li></ul><ul><li>Imipramine (Tofranil) </li></ul><ul><li>DOSE </li></ul><ul><li>5-12.5 mg start </li></ul><ul><li>50-125 mg maintenance </li></ul><ul><li>10-12.5 mg start </li></ul><ul><li>150-500 mg maintenance </li></ul>
  46. 46. Pharmacotherapy of Panic Disorder <ul><li>Benzodiazepines </li></ul><ul><li>Alprazolam (Xanax) </li></ul><ul><li>Clonazepine (Klonopin) </li></ul><ul><li>Lorazepam (Ativan) </li></ul><ul><li>DOSE </li></ul><ul><li>.25-.5 mg tid start </li></ul><ul><li>.5-2 mg tid maintenance </li></ul><ul><li>.25 -.5 mg bid start </li></ul><ul><li>.5-2 mg bid maintenance </li></ul><ul><li>25 -.5 mg bid start </li></ul><ul><li>.5-2 mg bid maintenance </li></ul>
  47. 47. OBESSIVE-COMPULSIVE DISORDER THEORY DIAGNOSIS TREATMENT
  48. 48. OBSESSIONS <ul><li>INTRUSIVE THOUGHTS WISHES THAT CANNOT BE IGNORED, DISMISSED OR RESISTED. </li></ul><ul><li>COMMON THEMES : </li></ul><ul><li>CONTAMINATION ORDERLINESS </li></ul><ul><li>VIOLENCE SEXUALITY </li></ul>
  49. 49. COMPULSIONS COMMON FORMS <ul><li>These behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive: </li></ul><ul><li>cleaning hand washing </li></ul><ul><li>ordering checking </li></ul><ul><li>touching counting </li></ul><ul><li>repeating words silently praying </li></ul>
  50. 50. COMMOM OBSESSIONS & COMPULSIONS
  51. 52. ASSESSMENT OF OCD <ul><li>SCREENING TOOLS </li></ul><ul><li>Yale-Brown Obsessive Compulsive Scale (YBOCS) </li></ul><ul><li>Anxiety Screening Questionnaire (15 items) </li></ul><ul><li>Primary Care Evaluation of Mental Disorders </li></ul><ul><li>(PRIME-MD) </li></ul><ul><li>Hamilton Anxiety & Depression Scale </li></ul><ul><li>Beck Anxiety Scale </li></ul><ul><li>Center for Epidemiological Studies Depression Scale </li></ul><ul><li>(CESD) </li></ul><ul><li>Hospital Anxiety & Depression Scale </li></ul>
  52. 53. PSYCHOANALYTIC VIEW OF OBSESSIVE-COMPULSIVE DISORDER <ul><li>OCD develops when child comes to fear his own ID impulses & uses EDMs as counter-thoughts or compulsive actions to lessen resulting anxiety. </li></ul><ul><li>Three ego-defenses are common in OCD: </li></ul><ul><li>isolation - isolates & disowns undesirable/unwanted thoughts & experiences them as intrusions </li></ul><ul><li>undoing - Individual engages in acts that implicitly cancel out their undesirable impulses. </li></ul><ul><li>reaction formation - Takes on lifestyle that directly opposes their unacceptable impulses. </li></ul>
  53. 54. SEROTONIN & OBSESSIVE-CONPULSIVE DISORDER <ul><li>Serotonin plays role in operation of orbital region & caudate nuclei. </li></ul><ul><li>Low levels of serotonin disrupts functioning. </li></ul><ul><li>Research has found: </li></ul><ul><li>Reducing serotonin activity results in an increase of OCD symptoms. </li></ul><ul><li>Low levels of serotonin are related to high levels of OCD symptoms. </li></ul><ul><li>Increasing serotonin levels reduces symptoms . </li></ul>
  54. 58. PHOBIC DISORDERS: SPECIFIC PHOBIA SOCIAL PHOBIA AGORAPHOBIA THEORY DIAGNOSIS TREATMENT
  55. 59. SPECIFIC PHOBIA <ul><li>A. Marked & persistent fear that is excessive or unreasonable, cued by presence or anticipation of a specific object or situation. </li></ul><ul><li>B. Exposure to phobic stimulus almost invariably provokes an immediate anxiety response </li></ul><ul><li>C. Person recognizes that the fear is excessive or unreasonable. </li></ul>
  56. 60. SPECIFIC PHOBIA <ul><li>. </li></ul>Animal Type Natural Environment Type (heights, storms, water) Blood Injection Injury type Situational Type (airplanes, elevators, enclosed places)
  57. 61. AGE OF ONSET OF PHOBIA
  58. 62. PSYCHOANALYTIC MODEL OF PHOBIC REACTIONS <ul><li>PHOBIAS ARE EXPRESSIONS WISHES/ FEARS WHICH ARE UNACCEPTABLE TO EGO </li></ul><ul><li>UNCONSCIOUS CONFLICT IS DISPLACED TO EXTERNAL OBJECT OR SITUATION </li></ul><ul><li>PHOBIA IS LESS THREATENING TO PERSON THAN THE RECOGNITION OF THE UNCONSCIOUS IMPULSE </li></ul>
  59. 63. PSYCHOANALYTIC MODEL OF PHOBIC REACTIONS <ul><li>PHOBIA IS ONLY A SYMPTOM OF UNDERLYING CONFLICT. </li></ul><ul><li>LEVEL OF PHOBIC FEAR INDICATES STRENGTH OF CONFLICT. </li></ul><ul><li>ONCE UNDERLYING CONFLICT IS DISPLACED ONTO EXTERNAL SITUATION, CONFLICT CAN BE CONTROLLED SIMPLY THROUGH AVOIDANCE. </li></ul>
  60. 64. SOCIAL PHOBIA <ul><li>LIFE TIME PREVALENCE 11% MALES </li></ul><ul><li>15% FEMALES </li></ul><ul><li>ONSET IN ADOLESCENCE </li></ul><ul><li>COMMON IN FAMILIES WHO : </li></ul><ul><li>USE SHAME AS CONTROL TECHNIQUE </li></ul><ul><li>STRESS IMPORTANCE OF OPINIONS OF OTHERS </li></ul>
  61. 65. SOCIAL PHOBIA <ul><li>CAN BE DIVIDED INTO 3 TYPES: </li></ul><ul><li>PERFORMANCE </li></ul><ul><li>LIMITED INTERACTIONAL </li></ul><ul><li>GENERALIZED </li></ul>
  62. 66. SOCIAL PHOBIA <ul><li>PERFORMANCE </li></ul><ul><li>EXCESSIVE ANXIETY OVER ACTIVITIES </li></ul><ul><li>PLAYING INSTRUMENT </li></ul><ul><li>SPEAKING IN PUBLIC </li></ul><ul><li>EATING IN RESTAURANT </li></ul><ul><li>USING PUBLIC RESTROOM </li></ul>
  63. 67. <ul><li>LIMITED INTERACTIONAL </li></ul><ul><li>EXCESSIVE FEAR ONLY IN SPECIFIC SOCIAL or VOCATIONAL SITUATIONS </li></ul><ul><li>ex. INTERACTING WITH AUTHORITY FIGURE </li></ul><ul><li>GOING OUT ON A DATE </li></ul>SOCIAL PHOBIA
  64. 68. SOCIAL PHOBIA <ul><li>GENERALIZED </li></ul><ul><li>EXTREME ANXIETY DISPLAYED IN MOST SOCIAL SITUATIONS </li></ul><ul><li>MAY RESULT IN AVOIDANCE OF ALL SOCIAL INTERACTION </li></ul>
  65. 69. AGORAPHOBIA <ul><li>Anxiety about being in places or situations from which: </li></ul><ul><li>escape might be difficult (or embarrassing) </li></ul><ul><li>OR </li></ul><ul><li>help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic like symptoms. </li></ul>
  66. 70. AGORAPHOBIA <ul><li>Agoraphobic fears typically involve characteristic clusters of situations that include: </li></ul><ul><li>being outside home alone </li></ul><ul><li>being in a crowd or standing in line </li></ul><ul><li>being on bridge </li></ul><ul><li>traveling in bus, train, or automobile . </li></ul>
  67. 71. AGORAPHOBIA <ul><li>LIFE TIME PREVALENCE 5% OF MALES & 12% OF FEMALES. </li></ul><ul><li>DEVELOPS IN 50% OF PANIC DISORDERS </li></ul><ul><li>FAMILY & TWIN STUDIES INDICATE 3-TO-5 TIMES GREATER RISK FOR PANIC DISORDER/ AGORAPHOBIA THAN IN GENERAL POPULATION </li></ul>
  68. 72. <ul><li>AFFECTS 1/2 OF VICTIMS BY AGE 8 </li></ul><ul><li>SOME MAY HAVE BEEN BORN WITH TENDENCY TOWARDS EXTREME SHYNESS </li></ul><ul><li>1-IN-5 DEMONSTRATED CONSISTENT FEAR & DISTRESS IN NOVEL SITUATIONS AS EARLY AS 8 WEEKS OF AGE. </li></ul><ul><li>DISORDER THOUGHT TO OCCUR MORE OFTEN IN FEMALES BUT MALES </li></ul>POST-TRAUMATIC STRESS DISORDER IN CHILDREN
  69. 73. POST-TRAUMATIC STRESS DISORDER <ul><li>MUST EXPERIENCE TRAUMATIC EVENT </li></ul><ul><li>INTRUSIVE RE-EXPERIENCING OF EVENT </li></ul><ul><li>(DREAMS, FLASHBACKS, IMAGES, </li></ul><ul><li>THOUHGTS, RECOLLECTIONS) </li></ul><ul><li>AVOIDANCE OF STIMULI ASSOCIATED WITH EVENT </li></ul>
  70. 74. PERCENTAGE OF INDIVIDUALS DX WITH PTSD
  71. 75. POST-TRAUMATIC STRESS DISORDER <ul><li>NUMBING OF RESPONSIVENESS TO THE WORLD & RESTRICTION OF AFFECT </li></ul><ul><li>SYMPTOMS OF INCREASED AROUSAL </li></ul><ul><li>EXAGGERATED STARTLE REACTION </li></ul><ul><li>HYPERVIGILANCE </li></ul><ul><li>DIFFICULTY CONCENTRATING </li></ul><ul><li>INSOMINIA </li></ul><ul><li>NIGHTMARES </li></ul>
  72. 76. POST-TRAUMATIC STRESS DISORDER <ul><li>PTSD can occur at any age even childhood. </li></ul><ul><li>In young people, the response may be expressed as agitated behavior. </li></ul><ul><li>Most young people with PTSD avoid things that remind them of what happened. </li></ul><ul><li>Many have physical symptoms as well, such as startling easily. </li></ul>
  73. 77. PTSD IN CHILDREN ETIOLOGICAL FACTORS <ul><li>Certain PREMORBID personality profiles & attitudes are more likely to develop PTSD. </li></ul><ul><li>Pre-morbid personality or psychological difficulties are associated with increase risk & more severe ASD & PTSD symptoms: </li></ul><ul><li>poor interpersonal relationships </li></ul><ul><li>external locus of control </li></ul><ul><li>pessimism </li></ul>
  74. 78. ETIOLOGICAL FACTORS <ul><li>NATURE & QUALITY OF SOCIAL SUPPORT SYSTEM </li></ul><ul><li>Person with a strong social support system after a traumatic event less likely to develop an extended disorder. </li></ul><ul><li>If feels loved/accepted/valued, will be more likely to recover. </li></ul><ul><li>Societal support for appears to be important in lessening severity & duration of symptoms. </li></ul>
  75. 79. ETIOLOGICAL FACTORS <ul><li>DEGREE OF EXPOSURE & SUBJECTIVE EXPERIENCE OF THREAT PLAYS CRITICAL ROLE IN DEVELOPMENT OF PTSD & ASD. </li></ul><ul><li>DURATION OF THE EXPOSURE </li></ul><ul><li>LEVEL OF INVOLVEMENT </li></ul><ul><li>SALIENCE </li></ul><ul><li>DEGREE OF HARM EXPERIENCED </li></ul>
  76. 80. MIXED ANXIETY & DEPRESSION <ul><li>SHARED SYMPTOMS </li></ul><ul><li>EXCESSIVE WORRY </li></ul><ul><li>MOTOR TENSION </li></ul><ul><li>EASY FATIGABILITY </li></ul><ul><li>DIFFICULTY CONCENTRATING </li></ul><ul><li>SOMATIC COMPLAINTS </li></ul>
  77. 81. MIXED ANXIETY & DEPRESSION <ul><li>ANXIETY </li></ul><ul><li>SHORTNESS OF BREATH </li></ul><ul><li>CHEST PAIN </li></ul><ul><li>NERVOUSNESS </li></ul><ul><li>IRRITABILITY </li></ul><ul><li>BURNING STOMACH </li></ul><ul><li>DIFFICULTY FALLING ASLEEP </li></ul><ul><li>DEPRESSION </li></ul><ul><li>DEPRESSED MOOD </li></ul><ul><li>ANHEDONIA </li></ul><ul><li>WEIGHT LOSS OR GAIN </li></ul><ul><li>SUICIDAL THOUGHTS </li></ul><ul><li>EARLY MORNING AWAKENING </li></ul>
  78. 82. MEDICATIONS THAT REDUCE ANXIETY <ul><li>AZASPIRONES </li></ul><ul><li>BUSPRIONE BUSPAR </li></ul><ul><li>BETA BLOCKERS </li></ul><ul><li>PROPANOLOL INDERAL </li></ul><ul><li>ATENOLOL TENORMIN </li></ul>
  79. 83. ANXIETY DISORDERS IN PRIMARY CARE: GUIDELINES <ul><li>RECOGNIZE ANXIETY AS CAUSE OF PT’s PRESENTING SYMPTOMS: </li></ul><ul><li>LOOK FOR MULTIPLE SYMPTOMS </li></ul><ul><li>GREATER # OF PHYSICAL SYMPTOMS, MORE LIKELY ANXIETY D/O PRESENT </li></ul><ul><li>GREATER # OF SOMATOFORM SYMPTOMS, MORE LIKELY ANXIETY D/O PRESENT </li></ul>
  80. 84. ANXIETY DISORDERS IN PRIMARY CARE: GUIDELINES <ul><li>RECOGNIZE ONLY A SMALL NUMBER OF PT’S WITH ANXIETY SYMPTOMS ARE A RESULT OF GENERAL MEDICAL CONDITION. </li></ul><ul><li>LOOK FOR ANXIETY IN OTHER LIFE AREAS </li></ul><ul><li>LOOK FOR TRIGGERS OR AVOIDANCE </li></ul><ul><li>(TIME/PLACE/SETTING/CONTEXT) </li></ul><ul><li>LOOK FOR MULTIPLE SYMPTOMS </li></ul><ul><li>LOOK FOR SOMATOFORM SYMPTOMS </li></ul><ul><li>EPIDEMIOLOGY = APPEARS IN YOUNGER PT--> </li></ul><ul><li>LESS RISK FOR ILLNESS </li></ul>
  81. 85. ANXIETY DISORDERS IN PRIMARY CARE: GUIDELINES <ul><li>A SIGNIFICANT # OF PT’S WITH ANXIETY SYMPTOMS HAVE CO-MORBID PSYCHIATRIC DISORDERS. </li></ul><ul><li>26% SUFFER FROM 2 OR MORE INDEPENDENT ANXIETY DISORDERS. 55% SUFFERED FROM MULTIPLE DISORDERS, ONE OF WHICH HELPED CAUSE THE OTHERS. </li></ul><ul><li>MAJOR DEPRESSION </li></ul><ul><li>SUBSTANCE DEPENDENCE/ ABUSE </li></ul>

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