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ANXIETY DISORDERS Dr nasirian

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Anxiety disorders are among the most prevalent mental disorders in the general population. Nearly 30 million persons are affected in the United States, with women affected nearly twice as frequently as men.

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Anxiety disorders are associated with significant morbidity and often are chronic and resistant to treatment.

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(1) panic disorder with or without agoraphobia (2) agoraphobia with or without panic disorder (3) specific phobia (4) social phobia (5) obsessive-compulsive disorder (OCD) (6) posttraumatic stress disorder (PTSD) (7) acute stress disorder (8) generalized anxiety disorder

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Fear versus Anxiety Fear is a response to a known, external, definite, or nonconflictual threat; anxiety is a response to a threat that is unknown, internal, vague, or conflictual.

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Symptoms of Anxiety

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Obsessive-Compulsive Disorder Epidemiology Comorbidity: (major depressive disorder, social phobia,alcohol use disorders, generalized anxiety disorder, specific phobia, panic disorder, eating disorders, and personality disorders,Tourette's disorder,Tic)

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Etiology Biological Factors Neurotransmitters Serotonergic System Noradrenergic System Neuroimmunology Brain-Imaging Studies Genetics

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Nonpsychiatric Clinical Specialists Likely to See Obsessive-Compulsive Disorder Patients: Dermatologist Family practitioner Oncologist, infectious disease internist Neurologist Neurosurgeon Obstetrician Plastic surgeon Dentist

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DSM-IV-TR Diagnostic Criteria for Obsessive-Compulsive Disorder Either obsessions or compulsions: Obsessions as defined by ; recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress the person attempts to ignore or suppress such thoughts, or to neutralize them with some other thought or action the person recognizes that the obsessional thoughts, impulses are a product of his or her own mind

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Compulsions as defined by repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation.

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At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. The obsessions or compulsions cause: marked distress, are time-consuming (take more than 1 hour a day), or significantly interfere with the person's normal functioning, or relationships

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Differential Diagnosis Medical Conditions Tourette's Disorder Other Psychiatric Conditions

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Course and Prognosis Treatment Pharmacotherapy Behavior Therapy Psychotherapy Other Therapies(psychosurgery,ECT)

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Posttraumatic Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: the person experienced, was confronted with an event or threatened death or serious injury, or a threat to the physical integrity of self or others the person's response involved intense fear, helplessness, or horror.

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reexperience: recurrent and intrusive distressing recollections of the event recurrent distressing dreams of the event acting or feeling as if the traumatic event were recurring intense psychological distress at exposure to internal or external cues physiological reactivity on exposure to internal or external cues

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Persistent avoidance efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings)

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Persistent symptoms of increased arousal difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response

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Duration of the disturbance is more than 1 month. Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more With delayed onset

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Epidemiology Etiology Stressor Risk Factors Psychodynamic Factors Cognitive-Behavioral Factors Biological Factors

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Treatment Pharmacotherapy Psychotherapy

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Generalized Anxiety Disorder Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The person finds it difficult to control the worry.

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The anxiety and worry are associated with three (or more) of the following six symptoms restlessness being easily fatigued difficulty concentrating or mind going blank irritability muscle tension sleep disturbance

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Epidemiology Comorbidity Etiology Treatment

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Phobias The term phobia refers to an excessive fear of a specific object, or situation. Phobias are classified based on the nature of the feared object or situation, and DSM-IV-TR recognizes three distinct classes of phobia: Agoraphobia,specific phobia, and social phobia.

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Specific Phobia Approximately 10 percent of individuals in the United States meet criteria for specific phobia. The condition is more commonly diagnosed in females than males.

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specific phobia often co-occurs with other anxiety or mood disorders. comorbid disorders tend to cause more impairment than specific phobia and because individuals with isolated specific phobia are rarely seen in the clinic. Impairment associated with specific phobia typically manifests as restricted social or professional activities.

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subtypes of specific phobias: animal type, natural environment type, blood-injury type, Situational type other

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Specific phobia exhibits a bimodal age of onset, with a childhood peak for animal phobia, natural environment phobia, and blood-injury phobia and an early adulthood peak for other phobias, such as situational phobia.

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The severity of the condition is believed to remain relatively constant.

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Social phobia A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

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The person recognizes that the fear is excessive or unreasonable. The feared social or performance situations are avoided or else are endured with intense anxiety or distress. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships.

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prevalence estimates of social phobia vary widely, from 2 to approximately 15 percent. Like specific phobia, social phobia exhibits a female preponderance, although the sex ratio in the clinic may be more equal.

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Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: palpitations, or accelerated heart rate sweating trembling or shaking

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sensations of shortness of breath feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint

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derealization (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going crazy fear of dying paresthesias (numbness or tingling sensations) chills or hot flushes

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Panic disorder recurrent unexpected panic attacks at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: persistent concern about having additional attacks worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, going crazy ) a significant change in behavior related to the attacks

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Differential Diagnosis endocrinological disorders, including both hypo- and hyperthyroid states, hyperparathyroidism Pheochromocytomas Episodic hypoglycemia associated with insulinomas

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seizure disorders, vestibular dysfunction, neoplasms, Substance disorders of the cardiac and pulmonary systems, including arrhythmias, chronic obstructive pulmonary disease, and asthma

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Clues that a medical etiology underlies panic-like symptoms include: the presence of atypical features such as ataxia, alterations in consciousness, or bladder dyscontrol; the onset of panic disorder relatively late in life; or physical signs or symptoms indicative of a medical disorder.

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The lifetime prevalence of panic disorder is in the 1 to 4 percent range. Panic disorder typically has its onset in late adolescence or early adulthood. exhibit a fluctuating course, with varying levels of persistence over the lifespan.

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Approach to Treatment Medical Evaluation Choosing a Treatment Modality Medications for Anxiety in Predictable Situations -Adrenergic Receptor Antagonists, Benzodiazepines

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Medications for Chronic Recurrent or Unpredictable Anxiety SSRIs SNRIs TCA MAOIs others

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