Chapter 5 anxiety and related disorders
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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.

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CHAPTER 5 Anxiety and Related Disorders

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Chapter 5 anxiety and related disorders

CHAPTER 5Anxiety and Related Disorders

-Definition: Vague, subjective, nonspecific feeling of uneasiness, tension, apprehension, & sometimes dread or impending doom.

-Symptoms:hypertension, tachycardia, muscle hypertonia, hyperactivity, irritability.

Chapter 5 anxiety and related disorders

-Common disorders that have anxiety symptoms:

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.

Chapter 5 anxiety and related disorders

*Predisposing factors: (2)

1-Hereditary factors:

-Average of anxiety in identical twins: >50%.

2- Age:

-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)

Types of anxiety according to level

Types of anxiety (according to level)

  • Mild anxiety:

    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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

  • Panic Attack:

    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

1 phobias

1. Phobias

-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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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).


Chapter 5 anxiety and related disorders


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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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.

2 post traumatic stress disorder ptsd

2-Post Traumatic Stress Disorder (PTSD)

-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.

Chapter 5 anxiety and related disorders

-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.

Chapter 5 anxiety and related disorders

-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).

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders



Tofranil( Imipramine), Inderal ( Propanolol).



-Cognitive-behavioral approach:

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.

Chapter 5 anxiety and related disorders

3-Relation training & desensitization by building a hierarchy of stressful moments & relaxation.

4-Social support & involving family & friends in caring & understanding pt.'s condition.

3 acute stress disorder

3-Acute Stress Disorder

  • The same condition of PTSD, but the period to have the Sx is 2 days-1 month.

4 generalized anxiety disorder

4-Generalized Anxiety Disorder

-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:

1- Restlessness

2- Easily to be fatigued

3- Irritability

4- Difficulties in concentration

5- Muscle tension

6- Sleep disturbances


Chapter 5 anxiety and related disorders


-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.

5 obsessive compulsive disorder

5- Obsessive Compulsive Disorder

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.

Chapter 5 anxiety and related disorders


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).

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders



-Anfranil(Clomipramin): Drug of choice (6-12months).

2-Behavioral therapy:

-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.

3-Psychodynamicpsychoanalytic therapy:

-Aims to help pt. get insight into his aggressive impulses & strengthens ego to deal with aggression in mature ways.

6 somatororm disorders

6-Somatororm Disorders

-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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders


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).

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders


-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).

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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.

Chapter 5 anxiety and related disorders

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:

Sensory symptoms:

Anesthesia or loss of sensation in a part of body or one half of body.

Hysterical deafness.

Loss of olfactory or taste senses.

Hysterical blindness.

Chapter 5 anxiety and related disorders


-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.

Chapter 5 anxiety and related disorders


-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.

Chapter 5 anxiety and related disorders


-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.

Chapter 5 anxiety and related disorders

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).

Chapter 5 anxiety and related disorders

Course & 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.

Comparison b w somatization hypochondriasis

Comparison b/w Somatization & Hypochondriasis

7 dissociative disorders

7-Dissociative Disorders

-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.

Chapter 5 anxiety and related disorders

-Usually pt. is aware of memory loss.

-Pt. is usually alert & not confused (Some pts. describe a state of clouded consciousness).

-Onset is sudden & recovery is sudden & complete.

-Recurrence is rare.

Chapter 5 anxiety and related disorders


-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.

Chapter 5 anxiety and related disorders

B. 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.

Chapter 5 anxiety and related disorders

-When fugue is over, pt. 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.

Chapter 5 anxiety and related disorders

C. Multiple 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.

->in females.

-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.

Chapter 5 anxiety and related disorders

-Each 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.

-Chronic disorder.


-Poor if onset is early & if >2 personalities.

Chapter 5 anxiety and related disorders


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.

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