BEHAVIORAL SCIENCE

IzBen C. Williams, MD, MPHInstructor

Lecture # 12

ANXIETY, SOMATOFORM and

FACTITIOUS DISORDRES,

and MALINGERING

Anxiety DisordersDefinition: Anxiety is abnormal fear that is out of

proportion to any external stimulus Fear is a normal reaction to a known,

external source of dangerThe physiologic manifestations of anxiety

(qv), are similar to those of fear Anxiety is essentially unconscious

symptom formation in response to stress

Anxiety DisordersDefinition: Anxiety Disorder: A chronic condition

characterized by an excessive and persistent sense of apprehension, with physical symptoms such assweating, palpitations, irritability, muscle

tension, restlessness, GI and urinary disturbances,

It is essentially, unconscious symptom formation in response to stress

Anxiety Disorders

“The Scream”

Edvard Munch

The Vise

.

Anxiety DisordersDefinition: The boundary between normal and

pathologic anxiety cannot be drawn with great precision or confidence.

However, it is generally agreed that when anxiety substantially impairs work style or social adjustment, careful assessment is indicated, and treatment is likely to be worthwhile.

Anxiety DisordersTypes of Anxiety disorders:

Phobic disorder (specific and social)Panic disorderObsessive compulsive disorderPosttraumatic stress disorderGeneralized anxiety disorder

Anxiety DisordersI. Phobic Disorder:Def.: A phobia is a type of anxiety disorder, characterized by a persistent, intense and irrational fear and avoidance of a situation or object, to which the sufferer commits great lengths in avoiding, disproportional to any actual danger posed.

Anxiety DisordersI. Phobic Disorder:There are different types of phobias. Agoraphobia: (one of the most familiar) the

fear of being in public places, often stems from panic disorder as a result of trying to avoid places that have triggered past panic attacks.

Social phobia: is characterized by an undue fear of embarrassment in social situations; sometimes accompanied by panic attacks

Anxiety DisordersI. Phobic Disorder: (cont’d) Specific Phobias: Excessive or irrational fear in

response to the presence or anticipation of a specific object or situation (eg. Height, spiders, blood) Subtypes:

Animal type Natural environment type Blood-injection-injury type Situational type Other type (illness phobia, space phobia

Anxiety DisordersII. Panic Disorder:Panic attacks are unprovoked , sudden episodes

of anxiety that usually reach their peak within a few minutes and subside within an hour.

A sense of dread, which is the most prominent psychological symptom may be masked by, or seem to be in reaction to, the physical symptoms that frequently accompany panic attacks: palpitations, chest pain, sweating, dyspnea, tremors, dizziness, ……..

Anxiety DisordersII. Panic Disorder:Panic disorder: consists of recurrent panic

attacks characterized by sudden apprehension or fear and usually accompanied by autonomic arousal that is not a reaction to physical exertion, a life-threatening situation, a substance , a medical factor, or another disorder

May be accompanied by agoraphobia

Anxiety DisordersIII.Obsessive-Compulsive Disorder:Symptoms include persistent, intrusive, recurrent

ideas, thoughts, feelings, images, or impulses (obsessions), which are experienced as senseless and repugnant and which the patient tries to ignore or resist.

Repetitive stereotyped physical and mental actions (compulsions), which the patient recognizes as senseless and tries to resist, nay also occur

Compulsions are performed with a subjective sense of necessity

Anxiety DisordersIV. Post Traumatic Stress Disorder: describes……A syndrome of distress, re-experiencing, avoidance,

and arousal that develops after exposure to events or circumstances that involved actual death or injury or a threat to the physical integrity of oneself or others and that evoked intense fear, helplessness, or horror

Symptoms may appear immediately after the trauma or may be delayed

Symptoms of excessive arousal include insomnia, angry outbursts, difficulty concentrating, exaggerated startle response

Anxiety DisordersIV. Post Traumatic Stress Disorder:Treatment involves:

Discussion of the trauma as a means of achieving retroactive mastery

At times, confrontation of the perpetrators can help Group therapy often very helpful Adjunctive techniques (eg biofeedback) and

medication (esp. SSRIs and Carbamazepine)

Anxiety DisordersV. Generalized Anxiety Disorder:Symptoms include:

At least six months of unrealistic worry about a number of life circumstances accompanied by at least 3 of 6 additional symptoms of anxiety, including, insomnia irritability, restlessness, easy fatigability, difficulty concentrating, muscle tension

Treatment:Benzodiazepines, buspirone, and

antidepressants are drugs used. Relaxation training, hypnosis, biofeedback and related treatments are also useful

Anxiety Disorders

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Anxiety DisordersAcute Stress Disorder (ASD).A traumatic event defined exactly as for PTSD,

produces anxiety or arousal, avoidance, re-experiencing, and acute or delayed dissociative symptoms

ASD begins within one month of the event and lasts up to 4 weeks

This may be followed by PTSD

Anxiety DisordersIllnesses that cause anxiety:Before investigating a psychological cause of anxiety, it is important to exclude the possibility of physical disordersCardiovascular disordersPulmonary disordersDisorders of the endocrine system and metabolismTumorsNeurologic disordersInfectionsDrug related disorders

Anxiety DisordersPsychological components of anxiety:Many patients display anxiety symptoms

that don’t meet the criteria for specific disorders:

Situational anxietyAnxiety about deathAnxiety about mutilation, loss of prowess or

attractivenessAnxiety about loss of self esteemSeparation anxiety

Anxiety DisordersPsychological components of anxiety:Many patients display anxiety symptoms

that don’t meet the criteria for specific disorders:

Stranger anxietyAnxiety about loss of controlAnxiety about dependency Anxiety about intimacyAnxiety about being punishedSignal anxiety

Anxiety DisordersThe organic basis of anxiety:Neurotransmitters involved in the

development of anxiety include:Gamma-aminobutyric acid (GABA)Serotonin Norepinephrine

Anxiety DisordersThe organic basis of anxiety:Brain areas likely involved in anxiety:

The locus ceruleus (site of noradrenergic neurons)

Raphe nucleus (site of serotonergic neurons)

Caudate nucleus (role in OCD)Temporal cortexFrontal cortex

Anxiety DisordersThe organic basis of anxiety:

Anxiety Disorders.

Anxiety DisordersThe organic basis of anxiety:Organic causes of anxiety symptoms

include:XS caffeine intake, Substance abuseHyperthyroidismVit B₁₂ deficiencyHypo or hyperglycemiaPulmonary disease, Cardiac arrhythmiaPheochromocytoma (adrenal medullary

tumor)

Anxiety DisordersTreatment of anxiety disorders:A. Psychotherapy

Effective in situational anxiety and anxiety related to identifiable intra-psychic conflict. May be facilitated by medication and behavioral techniques

B. Behavior therapyEffective in phobias; anticipatory, situational, and

generalized anxiety; some forms of panic, OCD

C. Pharmacotherapy: Broadly effective in anxiety disorders

Anxiety DisordersTreatment of anxiety disorders:A. Psychotherapy

Supportive therapySupport of defenses Reality testingAdviceAdaptive behavior

Expressive psychotherapyClarification, confrontation, interpretation

Anxiety DisordersTreatment of anxiety disorders:B. Behavior therapy

i. Systematic desensitizationii. Graduated in vivo exposureiii. Panic control therapyiv. Response preventionv. Stop thinkingvi. Adjunctive behavioral techniques (relaxation

techniques, hypnosis, biofeedback)

Anxiety DisordersTreatment of anxiety disorders:C. Psychopharmacology

i. Benzodiazepines – the most effective anxiolytics. Uses: panic anxiety, generalized and situational anxiety, insomnia.

ii. Heterocyclic antidepressants: (used in Panic disorder, GAD, OCD, PTSD, insomnia

iii. MAO inhibitors: in atypical depression with reverse vegetative symptoms, but also in panic and social phobia

iv. Buspirone (BuSpar): is a non-benzodiazepine anxiolytic; it is a partial agonist of serotonin receptor; no sedation, no dependence. Not use with MAO (fatal serotonin syndrome)

Anxiety DisordersTreatment of anxiety disorders:C. Psychopharmacology

v. Barbiturates: to be avoided in treating anxiety or insomnia

vi. Antihistamines: diphenhydramine (Benadryl)

vii. Neuroleptics: psychotic features, personality disorders

viii.β-blocking agents: eg propanalol. Not as predictably effective but useful

Somatoform DisordersSomatoform disorders:

The essential feature of these disorders is the presence of symptoms that suggest a physical cause, including pain, but the symptoms can't be traced back to any physical cause and they are not the result of substance abuse or another mental disorder

Somatoform DisordersSomatoform disorders:

a. Somatization disorder: Multiple physical symptoms recurring over a period of several years and are either unrelated to an identifiable physical disorder, or grossly in excess of physical findings

b. Conversion disorder: Loss or alteration of physical functioning that suggests physical disorder, but which instead is apparently an expression of psychologic conflict or need

Somatoform DisordersSomatoform disorders:

c. Somatoform Pain Disorder: essentially same as conversion disorder with physical pain being the primary symptom.

d. Hypochondriasis: The fear of having, or the belief that one has, a serious physical illness.

e. Body Dysmorphic Disorder: Preoccupations with imagined defect(s) in one’s physical appearance, that is out of proportion to any physical characteristic or abnormality

Somatoform DisordersTreatment include:

Individual and group psychotherapy, with strategies such asEstablishing a good therapeutic relationship Providing a multidisciplinary approach

including other medical professionalsIdentifying and decreasing social difficulties

on which the symptoms may ‘feed’Anxiolytic and antidepressant agents,

hypnosis, behavioral relaxation therapy

Factitious DisordersFeigning illness: A factitious disorder is a condition in which a

person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms

Patients feign mental or physical illness, or actually induce physical illness in themselves or others for:Psychological gain (as in factitious disorder)Tangible gain (as in malingering)

Factitious DisordersFeigning illness:

Patients with factitious disorder often have some medical knowledge or have worked in the health field

Feigned symptoms commonly includeAbdominal pains, fever, blood in the urine,

induction of tachycardia, skin lesions and seizures