ANXIETY DISORDERSANXIETY DISORDERS

Yard. Doç. Dr. Berfu Yard. Doç. Dr. Berfu AkbaşAkbaş

A diffuse, unpleasant, vague sensation of A diffuse, unpleasant, vague sensation of apprehension, often accompanied by apprehension, often accompanied by autonomic symptoms; palpitations, autonomic symptoms; palpitations, perspiration, headache, tightness in the perspiration, headache, tightness in the chest, mild stomach discomfort, chest, mild stomach discomfort, restlessness, dizziness, diarrhea, tremors, restlessness, dizziness, diarrhea, tremors, urinary frequency, hesitancy.urinary frequency, hesitancy.

Normal Anxiety : advantageous response to a Normal Anxiety : advantageous response to a threatening situationthreatening situation

Pathological Anxiety: inappropriate response to a Pathological Anxiety: inappropriate response to a given stimulus.given stimulus.

Fear: A response to a known, external, definite Fear: A response to a known, external, definite threatthreat

Epidemiology: Epidemiology: women life-time prevalence: % 30.5women life-time prevalence: % 30.5 Men : % 17.7Men : % 17.7 Autonomic Nervous SystemAutonomic Nervous System Neurotransmitters: Neurotransmitters: Norepinephrine, serotonin, GABANorepinephrine, serotonin, GABA Neuroanatomy:Locus cereleus, raphe Neuroanatomy:Locus cereleus, raphe

nuclei, limbic system, temporal lobesnuclei, limbic system, temporal lobes Genetics:Genetics:

Anxiety DisordersAnxiety Disorders

Panic DisorderPanic Disorder Specific PhobiaSpecific Phobia Social PhobiaSocial Phobia Posttraumatic Stress Disorder ( PTSD Posttraumatic Stress Disorder ( PTSD

)) Acute Stress DisorderAcute Stress Disorder Generalized Anxiety DisorderGeneralized Anxiety Disorder

PANIC DISORDER PANIC DISORDER Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-

6%6% DSM 5 CRITERIA FOR PANIC DISORDERDSM 5 CRITERIA FOR PANIC DISORDER 1- Recurrent unexpected panic attacks1- Recurrent unexpected panic attacks 2- Persistent concern about having 2- Persistent concern about having

additional attacksadditional attacks 3- Worry about its consequences ( going 3- Worry about its consequences ( going

crazy..)crazy..) 4- Significant change in behaviour4- Significant change in behaviour 5- Panic attacks are not due to a substance 5- Panic attacks are not due to a substance

or a medical condition or another mental or a medical condition or another mental disorder disorder

PANIC ATTACKPANIC ATTACK 4 or more of the following symtoms:4 or more of the following symtoms: * palpitations* palpitations * sweating* sweating * trembling or shaking* trembling or shaking * shortness of breath* shortness of breath * feeling of choking* feeling of choking * chest pain* chest pain * nausea or abdominal discomfort* nausea or abdominal discomfort * feeling dizzy, lightheaded, faint* feeling dizzy, lightheaded, faint * derealization- depersonalization* derealization- depersonalization * fear of losing control or going crazy* fear of losing control or going crazy * fear of dying* fear of dying * numbness or tingling sensations* numbness or tingling sensations * chills or hot flushes* chills or hot flushes

MEDİCAL CONDITIONS THAT CAN MIMIC A PANIC MEDİCAL CONDITIONS THAT CAN MIMIC A PANIC ATTACKATTACK

Angina pectorisAngina pectoris ArrithmiasArrithmias COPDCOPD Temporal lobe epilepsyTemporal lobe epilepsy Pulmonary EmbolismPulmonary Embolism AsthmaAsthma HyperthyroidismHyperthyroidism HypoglycemiaHypoglycemia PheochromacytomaPheochromacytoma

COURSE AND PROGNOSISCOURSE AND PROGNOSIS Onset: early adulthoodOnset: early adulthood %30-40%30-40→long term symptom free→long term symptom free %50→mild symptoms%50→mild symptoms %10-20→significant symptoms%10-20→significant symptoms

%40-80→depression develops%40-80→depression develops %20-40→alcohol adn substance dependance%20-40→alcohol adn substance dependance

TREATMENT:TREATMENT: Benzodiazepines ( alprazolam, lorazepam )Benzodiazepines ( alprazolam, lorazepam ) SSRISSRI’’s ( paroxetine, sertraline, citalopram )s ( paroxetine, sertraline, citalopram ) Cognitive behaviour therapyCognitive behaviour therapy

SPECIFIC PHOBIASSPECIFIC PHOBIAS

SPECIFIC PHOBIASPECIFIC PHOBIA A phobia is defined as an irrational fear that A phobia is defined as an irrational fear that

produces conscious avoidance of the fearred produces conscious avoidance of the fearred subject, activity or situation.subject, activity or situation.

5-10% ( most common anxiety disorder )5-10% ( most common anxiety disorder ) Early beginningEarly beginning Animals ( ailurophobia-cats, cynophobia-dogs)Animals ( ailurophobia-cats, cynophobia-dogs) Natural enviroment( storms,acrophobia-height)Natural enviroment( storms,acrophobia-height) Blood-injection-injuryBlood-injection-injury Situational ( elevators, airoplane )Situational ( elevators, airoplane ) Other ( mysophobia-germs,nasophobia-illness, Other ( mysophobia-germs,nasophobia-illness,

death)death) Treatment:Treatment: Exposure therapyExposure therapy benzodiazepinesbenzodiazepines

SOCIAL PHOBIASOCIAL PHOBIA 3-13%, teens3-13%, teens hyperactivation of the amygdala and insula in fMRI A marked fear of social or performance situations in A marked fear of social or performance situations in

which the person is exposed to unfamiliar people. The which the person is exposed to unfamiliar people. The individual fears that he will act in a way that will be individual fears that he will act in a way that will be humiliating or embarrassing.humiliating or embarrassing.

Exposure to the feared social situation provokes Exposure to the feared social situation provokes anxiety which may take the form of panic attackanxiety which may take the form of panic attack

The person recognizes that the fear is excessive or The person recognizes that the fear is excessive or unreasonable.unreasonable.

The feared social or performance situations are The feared social or performance situations are avoidedavoided

Treatment:Treatment: SSRISSRI’’s, benzodiazepiness, benzodiazepines Behavioral and cognitive therapyBehavioral and cognitive therapy

GENERALIZED ANXIETY DISORDERGENERALIZED ANXIETY DISORDER Prevalance: ~ % 5Prevalance: ~ % 5 More likely to occur in people with «behavioral More likely to occur in people with «behavioral

inhibition»inhibition» Excessive anxiety and worry about a number of Excessive anxiety and worry about a number of

events or activities.events or activities. Anxiety and worry is associated with at least 3 of the Anxiety and worry is associated with at least 3 of the

followings: restlessness, being easily fatiqued, followings: restlessness, being easily fatiqued, difficulty in concentrating, irritability, muscle tenion, difficulty in concentrating, irritability, muscle tenion, sleep disturbance.sleep disturbance.

Treatment:Treatment: Cognitive and behavioral therapyCognitive and behavioral therapy SSRISSRI’’s, benzodiazepiness, benzodiazepines

1. Feeling nervous, anxious, or on edge

0 1 2 3

2. Not being able to stop or control worrying

0 1 2 3

3. Worrying too much about different things

0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still

0 1 2 3

6. Becoming easily annoyed or irritable

0 1 2 3

7. Feeling afraid as if something awful might happen

POSTRAUMATIC STRESS DISORDERPOSTRAUMATIC STRESS DISORDER Develops after a person sees, is involved in or hears Develops after a person sees, is involved in or hears

of an extreme traumatic stressor. The persons of an extreme traumatic stressor. The persons response involves intense fear, helplessness or response involves intense fear, helplessness or horror.horror.

The event is persistantly reexperienced as images, The event is persistantly reexperienced as images, flashbacks, thoughts, dreams.flashbacks, thoughts, dreams.

Intense psychological distress at exposure to cues Intense psychological distress at exposure to cues that symbolize or resemble the eventthat symbolize or resemble the event

Persistance avoidance of the stimuli and numbing of Persistance avoidance of the stimuli and numbing of general responsivenessgeneral responsiveness

Sleep disturbances, irritability, hypervigilance, Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle difficulty concentrating, exaggerated startle responseresponse

1 week-30 years1 week-30 years

ACUTE STRESS DISORDERACUTE STRESS DISORDER Develops after a person sees, is involved in or Develops after a person sees, is involved in or

hears of an extreme traumatic stressor. The hears of an extreme traumatic stressor. The persons response involves intense fear, persons response involves intense fear, helplessness or horrorhelplessness or horror

A subjective sense of numbing, detachment, A subjective sense of numbing, detachment, absence of emotionsabsence of emotions

Derealization, depersonalization,Derealization, depersonalization, Dissociative amnesiaDissociative amnesia The event is persistantly reexperienced as The event is persistantly reexperienced as

images, flashbacks, thoughts, dreamsimages, flashbacks, thoughts, dreams Sleep disturbances, irritability, hypervigilance, Sleep disturbances, irritability, hypervigilance,

difficulty concentrating, exaggerated startle difficulty concentrating, exaggerated startle responseresponse

PharmacotherapyPharmacotherapy Benzodiazepines: GABA A agonistBenzodiazepines: GABA A agonist SSRISSRI’’ss TCITCI’’ss MAO inhibitorsMAO inhibitors B- adrenergic receptor antagonists B- adrenergic receptor antagonists

( propranolol( propranolol AntihistaminicsAntihistaminics Buspirone ( HT1a agonist)Buspirone ( HT1a agonist) Ca channel blockersCa channel blockers

ANXIETY DISORDER DUE TO A GENERAL MEDICAL ANXIETY DISORDER DUE TO A GENERAL MEDICAL CONDITIONCONDITION

Thyroid disorders ( hyper-hypothyroidism )Thyroid disorders ( hyper-hypothyroidism ) HypoglycemiaHypoglycemia Neurological Disorders ( MS, epilepsy, CVD, Neurological Disorders ( MS, epilepsy, CVD,

Parkinson)Parkinson) AnemiaAnemia Cardiomyopathies, hypoxia, cardiac arrytmiasCardiomyopathies, hypoxia, cardiac arrytmias SLE, RA, PANSLE, RA, PAN ALCOHOL – DRUG WITHDRAWALALCOHOL – DRUG WITHDRAWAL caffeinecaffeine