CHAPTER 5 Anxiety and Related Disorders. -Definition: Vague , subjective, nonspecific feeling of uneasiness, tension, apprehension, & sometimes dread or impending doom. -Symptoms: hypertension, tachycardia, muscle hypertonia, hyperactivity, irritability.
-Definition: Vague, subjective, nonspecific feeling of uneasiness, tension, apprehension, & sometimes dread or impending doom.
-Symptoms:hypertension, tachycardia, muscle hypertonia, hyperactivity, irritability.
1- Neurotic Disorders: Hysterical Disorder, Depression, PTSD.
2- Psychotic Disorders: Major depressive disorder, Schizophrenia.
3- Organic Disorders: Hyperthyrodism, Athersoclerosis, Hypoglycemia, Post-concussion, Menopause, Pre-menstruation.
-Average of anxiety in identical twins: >50%.
-Anxiety increases in Children (Immature nervous system).
-Anxiety increases in Elderly (Atrophic nervous system).
Sx in pediatric: phobia in night, phobia from strangers, animals, older children, being alone, nightmares, urinal or fecal incontinence, walking during sleeping.
Sxin adolescent: unsuitability, irritability, social embarrassment esp. when facing or meeting the other sex, guilty feeling, anxious about genital area, being very shy, speech stutter.
Sxin in Adulthood:DECREASE.
Sxin in elderly:INCREASE(regarding dz., death)
a. Physiologic:V/S normal, minimal muscle tension, pupils normal, constricted.
b. Cognitive:perceptual field is broad
-Thought may be random but controlled.
c. Emotional/Behavioral:relative comfort &safety, relaxed, calm appearance &voice.
**Habitual behaviors occur here.
2. Moderate Anxiety:
a. Physiologic:V/S normal or slightly elevated, Tension experienced, may be uncomfortable.
b. Cognitive:alert; perception narrowed, focused (Optimum state for solving & learning), Attentive.
c. Emotional/ Behavioral:Readiness & challenge (energize), engage in competitive activity & learn new skills, voice & facial expression concerned.
3. Severe Anxiety: symptoms
a. Physiologic: Fight or flight, autonomic N. system excessively stimulated (highly increase in v/s, diaphoresis, urine urgency & frequency, diarrhea, dry mouth, decrease appetite, dilated pupil), muscles rigid, tension, decrease heating & pain sensation.
b. Cognitive / perceptual:Perceptual field greatly narrowed, problem solving: difficult, automatic behavior, selective attention (focus on one detail).
c. Emotional/Behavioral: Feels threatened, seem or feel depressed, becomes very disorganized or withdrawn, may close eyes to shut out environment.
Definition: A discrete period of intense fear or discomfort in which four or more of the following Sxdeveloped abruptly and reached a peak within10 minutes.
3-Trembling or shaking
4-Sensations of shortness of breath
5-Feeling of shocking
6-Chest pain or discomfort
7-Nausea or abdominal distress
8-Feeling dizzy, unsteady or Faint
9-Realization of losing control
10-Fear of dying
12-Chills or hot flashes
-Pt. experiences panic attack in response to particular situations or learns to avoid situations that evoke panic attack.
-Phobia results even pt. knows that it won’t happen & no danger if exposed to situation.
-Even pt. knows that very well he/she can’t control phobia and doesn’t confront internal conflict but convert it into external Sx.
Types of phobias:
1-Agoraphobia: Anxiety about being in places or situations from which escape may be difficult (or embarrassing) or in which help might not be readily available in event of unexpected panic attack.
-This includes: fear of being alone, being in crowded area or standing in a line, being, on a bridge, traveling in a bus; becomes in need to have a companion.
2- Social phobia: fear from being under observation from others, which may lead to avoiding social need.
-Usually accompanied with low self-esteem (evaluation and fear of criticism).
Course & prognosis:
-Usually starts in late childhood & early adolescence.
-May become chronic & decreases after midlife.
-Rarely that disorder is severe &interfere with vocational performance because of avoidance.
-Addiction (Alcohol, anti-anxiety).
1-Drugs: anti-anxiety or anti-depression.
Behavioral psychotherapy: with drugs in severe cases by Gradual Desensitizationby exposing him to the fear object gradually and could be accompanied by some drugs or relaxation training or Flooding: by exposing pt. suddenly to fear object in reality or imagination.
Insight psychotherapy: To make pt. understand the cause phobia & secondary gain symptoms, role of resistance and this will make him able to find methods more acceptable to control anxiety with motivating pt. to be exposed to phobia situation.
3- Simple phobia (isolated phobia) (specific phobia) :
-Includes specifies conditions:
1-Claustrophobia: Fear of closed places.
2-Mysophobia: fear of dirt, germs and contamination.
3-Acrophobia: fear of heights.
4-Zoophobia: fear of animals.
5-Aqua phobia (or hydrophobia): fear of water.
6-Nectrophobia: fear of darkness.
7-Pyrophobia: fear of fire.
8-Hematophobia: fear of blood.
9-Necrophobia: fear of dead bodies.
10-Xenophobia: fear of strangers.
11-Astrophobia: fear of lightening.
Course & prognosis:
-Beginning of simple phobias is varied.
-Zoophobia starts in childhood.
-Hematophobia often starts in adolescence or early adulthood.
-Acrophobia often starts in the fourth decade.
-Most of other phobias that start in childhood disappear without treatment.
-Disability results from simple phobias is slight if avoidance was easy as zoophobia, but disability is increasing if stimulus is common, spread & not avoidable as fear of riding cars for student.
-Pt. must have experienced traumatic event prior to onset of Sx.
-Pt. may have experienced event, witnessed it, or have been confronted with event that involved actual or threatened death or serious injury.
-Event should be outside range of usual human experience.
-Pt. response: intense fear, helplessness or horror.
-Pt. will have Sx from 1-3 months (Acute) or 3-6 months(Chronic)
- Event cause this disorder could be:
1-Natural: Earthquakes, volcans.
2-Man-made: Rape, Torture.
-PTSD could happen in one individual or more among group.
-Pt. will have the following Sx:
1-Re-experiencing the event:
a. Recurrent dreams of the event.
b. Sudden acting or feeling as if traumatic event was recurring (including sense of re-living the experience, illusions, hallucinations).
2-Persistent avoidance of stimuli associated with trauma.
3-Persistent Sxof increased arousal (difficulty to sleep, irritability, concentration).
Course & prognosis:
-May occur in any age after event (1wk-30 yrs).
-Sx: fluctuating & become severe during stressful events.
-Acute PTSD lasts for <3 months but it could become chronic (>3 months).
-30% of pts. with PTSD recovers, 40%slight symptoms, 20%moderate symptoms,10% become worse.
-Prognosis is conditioned by: rapid onset, good pre-morbid functioning & good social support.
-Complications:social phobia disturbance in relations with others guilty feeling that may lead to suicide.
Tofranil( Imipramine), Inderal ( Propanolol).
1-Building good relationship with pt.
2-Cognitive appraisal of event & explaining to pt. effect of stress on human being & that symptoms are a normal outcome to an abnormal situation.
3-Relation training & desensitization by building a hierarchy of stressful moments & relaxation.
4-Social support & involving family & friends in caring & understanding pt.'s condition.
-Excessive worry & anxiety about 2 or >of life conditions:
Worry of a child of being dying or exposing to any harm (in fact no danger at all).
-3 or more of the following sxwill appear:
2- Easily to be fatigued
4- Difficulties in concentration
5- Muscle tension
6- Sleep disturbances
-May start in any age but is >in 20s& 30s.
-Mainly chronic & may continue for life.
-Complication: is panic attack.
-other complication: addiction because of self-treatment.
1-Drugs: should decrease prescribed anti-anxiety as possible (because disorder is chronic).
2-Psychotherapy:Rx of choice.
a-Psychoanalytic psychotherapy: through long-term insight.
b-Behavioral psychotherapy: focuses on desensitization with entrance to cognitive therapy aims to stop conditioning in addition to relaxation & modifying behavior.
1-Obsession:undesirable but persistent thought or idea forced into consciousness & can’t be erased or dismissed, thought may be trivial or morbid. Always distressing or anxiety provoking.
2-Compulsion: unwanted urge to perform act or ritual contrary to pt.'s ordinary conscious wishes or standards.
-Uncontrolled & done to relieve extreme tension.
-Obsession produces anxiety managed by compulsive act.
3-Obsession compulsion:repetitive acts or rituals to release tension or relieve anxiety.
-Pt. carries out these acts even if he recognizes that they are inappropriate or foolish.
a. Endless hand washing.
b. Checking re-checking doors if they're locked.
c. Elaborate dressing rituals.
-Pt. is trying to resist this, but because of long period of disorder, resistance may decrease.
-As a result, pt. will have much difficulties in social r/s.
-Pt. is neurotic (because pt. believes that these ideas are not true & silly).
Course & prognosis:
-Usually starts in adolescence.
-Chronic disorder & pt. may not present to psychiatrist for 5-10 years.
-About 30% of pts.: good improvement, 30-40%: mild improvement, & the rest: chronic or worse.
-Some pts. may have depression, suicide or addiction.
-Anfranil(Clomipramin): Drug of choice (6-12months).
-Effective in 60-70% of pts.(may be Rx of choice).
-Techniques used:Desensitization, thought stopping, flooding & implosion therapy.
Aversive conditioning:means giving a painful shock or loud noise when thought occurs.
-Some use response preventing as: forcibly stopping pt. from responding to obsession.
-Aims to help pt. get insight into his aggressive impulses & strengthens ego to deal with aggression in mature ways.
-Focusing is physical sxin absence of clinically significant organic disease.
A-Body Dysmorphic Disorder
-Preoccupation with imagined defect in appearance.
-Slight anomaly: concern is excessive.
-Significant distress or impairment in social or occupational functioning.
-Preoccupation is not better accounted for by another mental disorder.
Course & prognosis:
-Starts in adolescence, 20’s or 30’s, stays constantly & may have result of social & vocational disability.
-Complication: Plastic surgeries without any need.
-Pts. refuse psychotherapy despite their severe suffering & insist on having plastic surgeries so it is important for plastic surgeon to refer them to psychiatrist or psychologist.
-Meds. may relief Sx(anti-anxiety, anti-depression).
-Long-term psychotherapy is recommended.
B- Pain disorder
-Clinical presentation of pain in 1 or > anatomical sites.
-Pain is severe to warrant clinical attention &causes major impairment in 1 or > areas of functioning.
-Psychological factors play important role in onset, severity exacerbation, or maintenance of pain.
-Acute: less than 6 months (duration).
-Chronic: more than 6 months (duration).
Course & prognosis:
-In female double than males.
-Increase at 4th& 5th decade & b/w poor persons.
Drugs: Giving analgesics or narcotics is not useful (?addiction).
-Anti-depressant can be given: (Elatrol) or (Prozac).
-Anxiolotics or analgesics usually not effective.
Psychotherapy:Important that therapist helps pt. recognize psychogenic origin of pain.
-Explain to pt. how person state of mind affects how much pain he can feel.
-Relaxation technique, sports exercice.
-Sometimes, admission to hospital is needed to control feeling of pain (behavioral, cognitive & group psychotherapy may be used).
C- Somatization Disorder
-Frequently seeking & obtaining medical Rx for multiple clinically significant somatic complaints.
-Complaints must begin before 30 & cannot be explained by any medical disorder or direct effects of substance.
-Multiple sclerosis pt. would not be dxed by somatization.
-Differentiated from medical conditions if:
-Involvement of multiple organ systems (GI, neurological..).
-Sxexhibit early onset & chronic course, without development of physical signs or structural abnormalities.
-Absence of clinical (laboratory) abnormalities.
Course & prognosis:
-Females > males.
-Less occurrence if high social class, more among poor & illiterate persons.
-Starts before 30.
-Increase among first-degree relatives.
-Chronic & pt. is rarely free of sx or for medical seeking.
-Long & empathic r/s with one therapist.
-Using meds. is not recommended but anti-depressant or anxiolytics can be used symptomatically if anxiety or depression is present (?addiction).
D-Conversion Disorder(Hysterical neurosis, Conversion Type):
-Loss or change in beady functioning that can’t be explained by any medical disorder, & occurs in response to psychological stress.
-In females > males.
-Usually starts in adolescence or young adulthood.
-Medical exams do not reveal physical abnormality.
-Pt. is not conscious of producing sx.
-Histrionic personality pt: more exposed than others.
-Could happen if exposed to great stress.
-Loss or change can give sensory/motor sxor both.
Motor sx:Abnormal tremors, jerky movements.
* Note: hysterical conversion tremors: it is irregular & disappears if attention moved to another subject, etc…
-It differs from tremor in anxiety.
-Hysterical aphonia: Pt. can’t speak, but can understand what is said.
* Note: to differentiate, ask pt. to cough, if he does so, means vocal cords ok & is hysterical.
Comparison b/w organic & hysterical paralysis:
Tics: involuntary movement increases in embarrassing situations.
Hysterical comas:like normal sleep, doesn’t respond to stimuli, needs care for urination & defecation, usually needs hospitalization, used to escape from reality.
Hysterical fits: differ from organic epilepsy as following:
Anesthesia or loss of sensation in a part of body or one half of body.
Loss of olfactory or taste senses.
-Duration is brief.
-Starts & stops abruptly.
-Tends to recur.
-Prognosis is poor if secondary gain is high.
*Primary gain: Gain achieved by converting anxiety to somatic sx(symbolic of unconscious conflict).
*Secondary gain: Gain achieved by sx, pt. pain relieved from work or gets attention &sympathy from family by taking sick role.
-Exclude organic disease by physical exam.
-Telling pt. that he has no physical problems & sxare psychological stress &will disappear if pt. expresses his feelings.
-Amytal: may be used to produce a state of relaxation &re-experience trauma which enable pt. to talk freely about her troubles.
-6major criteria associated with disorder:
1-Pt is preoccupied with fears of having-or idea of having serious medical disorder based on his/her interpretation.
2-Misinterpretation of bodily sxpersists despite appropriate medical evaluation & reassurance.
3-Pt’s preoccupation with Sxis not as intense or distorted as in body dysmorphic disorder.
4-Preoccupation causes clinically significant distress or impairment in social, occupational, or major areas of functioning.
5-Duration of disturbance at least 6 months.
6-Condition is not better accounted for by another anxiety disorder, somatization disorder, or major depressive episode (Pt. may show sxof anxiety or depression).
Course impairment in social, occupational, or major areas of functioning.& prognosis:
-Mostly starts in 20’s.
-1/3 of pts. don’t improve & social/vocation disturbed.
-Males & female: equal.
-Exclude any organic factor.
-Invasive procedure should be avoided.
-Psychotherapy:preferred treatment even pt. resists this therapy (may accept it by a physician).
-Group psychotherapy: Rx of choice (pt.’s social support & interaction can improve their condition).
-Drugs not used unless depression/anxiety present.
-Disruption in usually integrated functions of consciousness, memory, identity & perception of environment.
A. Dissociative Amnesia
-1or > episodes of inability to recall important personal information(traumatic or stressful nature); too extensive to be explained by ordinary forgetting.
-Disturbance doesn’t occur during Dissociative Identity Disorder.
-Not due to substance effects or general medical condition.
-Most common in females.
-Usually pt. is aware of memory loss. impairment in social, occupational, or major areas of functioning.
-Pt. is usually alert & not confused (Some pts. describe a state of clouded consciousness).
-Onset is sudden & recovery is sudden & complete.
-Recurrence is rare.
Rx: impairment in social, occupational, or major areas of functioning.
-It is important to differentiate psychogenic amnesia from organic amnesia ( CVA,P.C, etc..).
-Amytal interview: Pt. is given short or medium acting barbiturates as Amytal IV & in a state of alleged consciousness pt. is helped to remember.
-Hypnosis: Under hypnosis, pt. is relaxed & in a somnolent state in which inhabitations are weekend, & repressed memories can be reached.
-Psychotherapy: After repressed memory is reached psychotherapy helps pt. resolve conflicts.
B impairment in social, occupational, or major areas of functioning.. Dissociative Fugue
-Sudden, unexpected travel away from one’s home or place of work, with inability to recall one’s past.
-Confusion about personal identity or assumes new identity, which may be partial (filling in the blanks).
-Disturbance doesn’t occur in context of a dissociative identity disorder, & is not due to effects of a substance or to a general medical condition.
-When fugue is over, pt. impairment in social, occupational, or major areas of functioning.remembers all he had forgotten but forgets what happened during fugue.
-Course is usually short.
-Pt. recovers suddenly & completely to find himself in a strange place.
-Recurrence is rare.
-No Rx is required if duration is short.
-Hyposis & Amytal interview maybe used to help pt. remember his identity.
C. Multiple impairment in social, occupational, or major areas of functioning.Personality Disorder (Dissociative Identity Disorder)
-2 or > personalities (each complete & integrated).
-At any time, pt. is dominated by one personality & unaware of presence of other personalities.
-Mostly occur in adolescence or early adulthood.
-Predisposing factor: severe physical/sexual abuse in childhood.
-Epilepsy is found in 25% of pts.
-EEG shows difference in activity in different personalities in the same pt.
-Each impairment in social, occupational, or major areas of functioning.personality is integrated & differ in mood, attitude, name, etc…
-Usually each personality doesn’t recognize presence of other personalities (Sometimes one of them knows about the other).
-Pt. may find himself in strange place or hearing voices inside him or another person taking control over him.
-Poor if onset is early & if >2 personalities.
Rx impairment in social, occupational, or major areas of functioning.:
Psychotherapy: Helps pt. resolve conflict & childhood memories.
-Helps in communication b/w different personalities to reintegrate pt.
-Hypnosis: Helps in confirming Dx by enhancing memories & resolving deep conflicts.