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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-Definition: Vague, subjective, nonspecific feeling of uneasiness, tension, apprehension, & sometimes dread or impending doom.
-Symptoms:hypertension, tachycardia, muscle hypertonia, hyperactivity, irritability.
-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.
*Predisposing factors: (2)
-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 & 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.
-Pt. is usually alert & not confused (Some pts. describe a state of clouded consciousness).
-Onset is sudden & recovery is sudden & complete.
-Recurrence is rare.
-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. 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. 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 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 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.
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.