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Anxiety Disorders New Insights. Dr.R.V.S.N.Sarma., M.D., M.Sc., Consultant Physician visit : www.drsarma.in. ANXIETY. What is anxiety ?. 􀂾􀂾It is a mood-state with 􀂾􀂾Marked Negative effects 􀂾􀂾Bodily symptoms of tension 􀂾􀂾Apprehensions about future

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Anxiety disorders new insights l.jpg

Anxiety Disorders New Insights

Dr.R.V.S.N.Sarma., M.D., M.Sc.,

Consultant Physician

visit : www.drsarma.in



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What is anxiety ?

  • 􀂾􀂾It is a mood-state with

  • 􀂾􀂾Marked Negative effects

  • 􀂾􀂾Bodily symptoms of tension

  • 􀂾􀂾Apprehensions about future

  • Its consequence is ‘worry’


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What is physiological worry ?

  • 􀂾 Worry is a normal response to stressful

    situations limited to particular situations

  • Should not exceed the duration of event

  • Should not spread to other topics

  • 􀂄 Excessive worry should not be seen

    as a normal response, as part of one’s

    personality


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What is pathological worry ?

  • 􀂾􀂾It is a component of anxiety

  • 􀂾􀂾Negative emotional thoughts, images

  • 􀂾􀂾Uncontrollable and they occur in sequence

  • 􀂾􀂾Concern about future threats and danger

  • Their frequency and intensity are more


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What do people worry about ?

  • 􀂾􀂾Real problems that could be potentially

    solved, but are not acted on

  • 􀂄 Real problems that probably cannot be

    solved (at least not by the individual), but

    can be coped with

  • 􀂄 “Imagined problems” that do not yet exist

    and probably will never exist

  • 􀂄 Worry about worry and its consequences


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Pathological v/s normal anxiety

  • 􀂾􀂾 Autonomous responses

  • 􀂾􀂾 Greater intensity

  • 􀂾􀂾 Longer duration

  • 􀂾􀂾 Behavior significantly affected

  • Stressor may be minimal or absent


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Origin of anxiety

  • 􀂾􀂾Protective response

  • 􀂾􀂾Normal/protective anxiety

  • Fear and pathological anxiety

  • Common underlying neuro-physiology

  • 􀂾 Two categories of fear/anxiety

    • Acute and

    • Chronic


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Negative effects of worry

Unreasonable fear

Anxiety Disorder

Panic Disorder

Substance abuse

Depression


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What cause Anxiety Disorders ?

  • 􀂾􀂾No single cause

  • 􀂄 Several possible causes

    􀂄 genetics, other biological factors

    physiology, infection, injury, trauma

    􀂄 temperament, life experiences

    􀂄 upbringing, family, school, peers,

    society in general, Doctors in particular

    stress - chronic or acute



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Importance of Anxiety Disorders

  • 􀂾􀂾Accurate Dx and Rx of anxiety

    disorders is essential

  • Reduction of secondary psychiatric

    conditions

    • Depression

    • Substance abuse problems


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Anxiety Disorders - DSM-IV

Generalized Anxiety

Disorder (GAD)

2. Panic Disorder (PD)

with Agoraphobia (AG)

3. PD sans Agoraphobia

4. Specific Phobia (SP)

5. Social Phobia (SoP)

6. Obsessive Compulsive

Disorder (OCD)

7. Post traumatic Stress

Disorder (PTSD)

8. Acute Stress Disorder

9. SAD, CAD (ASD)

10. Substance-Induced

Anxiety disorder (SIAD)

11. Anxiety disorder due

some medical illness

Dual Diagnosis Disorders


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Prevalence of Anxiety Disorders

Kessler et al. Arch Gen Psychiatry. 1995;52:1048.

Kessler et al. Arch Gen Psychiatry. 1994;51:8.


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Sex differences in Anxiety Disorders

Are women more ‘Nutty’ ?


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Spectrum of Anxiety Disorders

http://www.nimh.nih.gov/publicat/anxiety.cfm


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What is Gen. Anxiety Disorder ?

  • Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long.

  • The “What if?” disorder

  • Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress.


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Domains of anxiety

  • 􀂾􀂾Physical

  • 􀂾􀂾Affective

  • 􀂾􀂾Cognitive

  • 􀂾􀂾Behavioral


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Physical domain

  • 􀂾􀂾 Anorexia

  • 􀂾􀂾 Butterflies in stomach

  • 􀂾􀂾 Chest pain/tightness

  • 􀂾􀂾 Diaphoresis

  • 􀂾􀂾 Dry mouth

  • 􀂾􀂾 Dyspnoea

  • 􀂾􀂾 Faintness

  • 􀂾􀂾 Flushing

  • 􀂾􀂾 Hyperventilation

  • 􀂾􀂾 Light-headedness

  • 􀂾􀂾 Muscle tension

  • 􀂾􀂾 Nausea, Vomiting

  • 􀂾􀂾 Pallor

  • 􀂾􀂾 Palpitations

  • 􀂾􀂾 Paresthesias

  • 􀂾􀂾 Sexual dysfunction


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Physical domain contd..

  • 􀂾􀂾 Headache

  • 􀂾􀂾 Shortness of breath

  • 􀂾􀂾 Stomach pain

  • 􀂾􀂾 Tachycardia

  • 􀂾􀂾 Tremulousness

  • 􀂾􀂾 Urinary frequency

  • 􀂾􀂾 Diarrhea


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Affective domain

  • 􀂾􀂾 Edginess

  • 􀂾􀂾 Uneasiness

  • 􀂾􀂾 Terror

  • 􀂾􀂾 Panic


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Behavioral domain

  • 􀂾􀂾 Triggers many responses

  • 􀂾􀂾 Behavioral in nature

  • 􀂾􀂾 Concerned with diminishing

  • 􀂾􀂾 And even avoiding the distress


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Regulation of locus ceruleus

  • 􀂾􀂾Alpha-noradrenergic auto receptors

  • 􀂾􀂾Serotonin receptors

  • 􀂾􀂾GABA-benzodiazepine receptors

  • 􀂾􀂾Opiate receptors

  • Dopamine receptors



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Generalized Anxiety Disorder -GAD

Restlessness or feeling keyed up or on edge,

Being easily fatigued,

Difficulty concentrating or mind going blank,

Irritability,

Muscle tension,

Sleep disturbance

Pathological anxiety, which is

  • excessive, chronic and

  • typically interferes with their ability to function in normal daily activities.

  • GAD is distinguished from Phobic anxiety – as it is not triggered by a specific object

Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events. The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms


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Case # 1

  • Ms. D has a chief c/o “worrying about everything” for the last year. She also c/o frequent headaches, fatigue and insomnia secondary to the anxiety.

  • These symptoms have worsened to the point where she has been distracted and making mistakes at work.


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GAD – Mr. Fisc

Worry that is

  • 􀂄 Excessive, uncontrollable

  • 􀂄 Frequent, multiple topics (not only onetime)

  • 􀂄 More than one day out of two

    3 out of 6 other associated physical symptoms

  • 􀂄 Muscle tension, Restlessness

  • 􀂄 Fatigued easily, Irritability

  • 􀂄 Sleep disturbance, Concentration difficulty


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Acute fear state

  • 􀂾􀂾Response to life-threatening danger

  • 􀂾􀂾Terror, helplessness,

  • Sense of impending disaster/doom

  • 􀂾􀂾Urgency to flee or seek safety

  • 􀂾􀂾Sympathetic/Nor-adrenergic activation

  • 􀂾􀂾Located in locus ceruleus

  • 􀂾 Corresponds to panic attacks


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Agoraphobia

  • Anxiety in situations where escape might be

    difficult (or embarrassing) or help might not be

    available in the event of having a panic attack or

    panic-like symptoms

  • Situations are avoided or endured with marked

    distress

  • May not leave home or may need a companion

  • Can occur with and without panic disorder



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Social Phobia

  • Marked, persistent fear of social or performance

    situations where a person is exposed to unfamiliar

    situations or people or possible scrutiny by others.

  • The individual fears acting in an embarrassing or

    humiliating way.

  • The Person recognizes fear as excessive.

  • Exposure causes anxiety symptoms or panic

  • Situations are avoided or endured with anxiety


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Specific Phobias

Marked and persistent fear that is excessive or unreasonable,

cued by the presence or anticipation of a specific object or

situation (e.g., flying, heights, animals, receiving an injection,

seeing blood).

Exposure to the phobic stimulus almost invariably provokes an

immediate anxiety response, which may take the form of a

Panic Attack.

The person recognizes that his/her fear is excessive or

unreasonable. The phobic situation is avoided or else is

endured with intense anxiety or distress


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Specific Phobias - Examples

  • Acrophobia fear of heights

  • Agoraphobia fear of open places

  • Claustrophobia fear of enclosed places

  • Ailurophobia fear of cats

  • Cynophobia fear of dogs

  • Pathophobia fear of disease

  • Mysophobia fear of dirt and germs

  • Arachnophobia fear of spiders

  • Hematophobia fear of blood

  • Xenophobia fear of strangers

Better-halfophobia fear of wife



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Panic Attack – DSM IV

􀂾 Palpitations

Sweating

Trembling or shaking

Shortness of breath

Feeling of choking

Chest pain or discomfort

Nausea or abd. distress

8. Feeling dizzy, fainty

9. Derealization (feelings of unreality)

10. Fear of going crazy

11. Fear of dying

12. Paresthesias

13. Chills or hot flushes

􀂾􀂾A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes


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Case # 2

Mrs. B c/o a long h/o episodes of anxiety, SOB, racing heart, sweating, CP, and fears that she is having a MI and will die. These last 30 minutes and are unexpected. She c/o anxiety while in malls and traveling alone to new places for fear of having another attack. Despite a negative w/u, she still worries about having a MI during an attack.


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Panic Disorder with Agoraphobia

  • Recurrent unexpected panic attacks: anxiety

    associated with at least four physical and/or

    cognitive symptoms cognitive symptoms

  • At least 1 month of worry about having additional

    attacks or the consequences of an attack (losing

    control, having a heart attack, “going crazy”).

  • Agoraphobia


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Panic Disorder – Chest pain

  • Chest pain is a common symptom of panic attacks

  • 22 – 70% of panic attacks are associated with CP

  • 18 – 25% of all patients with chest pain have PD

  • Rates of PD higher among cardiology outpatients with chest pain.

  • Such patients undergo expensive cardiac workups, but their PD remains undiagnosed & untreated.


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Obsessive Compulsive Disorder - OCD

Obsessions

  • Recurrent and persistent thoughts, impulses, or images

    that are experienced during the disturbance, as intrusive

    and inappropriate, and cause marked anxiety or distress.

  • The thoughts, impulses, or images are not simply

    excessive worries about real life problems.

  • The person attempts to ignore or suppress such thoughts impulses or to neutralize them with some other thought or action.

  • The person recognizes that the obsessive thoughts,

    impulses, or images are a product of his or her own mind


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Obsessive Compulsive Disorder -OCD

Compulsions

  • Repetitive behaviors (e.g., hand washing, ordering,

    checking) or mental acts (e.g., praying, counting, repeating

    words silently)

  • He/she is driven to perform in response to an obsession,

  • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event

  • But, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive.


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Obsessive Compulsive Disorder -OCD

  • Putamen

  • Globus Pallidus

  • Caudate Nucleus

  • Thalamus

  • Orbital frontal

    cortex



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Post traumatic Stress Disorder- PTSD

Experiential requirements

  • The person has experienced a life-threatening

    event and has responded with intense fear,

    hopelessness or horror.

  • The person’s response to the event occurred more

    than 4 weeks after it was experienced and lasted

    more than one month.

  • The traumatic event is persistently re experienced

    in several ways, e.g., by intrusive recollections,

    dreams, illusions, hallucinations, or flashbacks.



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Post traumatic Stress Disorder- PTSD

Behavioral requirements

  • Thought avoidance, related-activities and/or

  • People-avoidance behavior,

  • Feelings of detachment,

  • Blunted affect,

  • Sense of doom

  • Insomnia,

  • Irritability,

  • Hyper vigilance,

  • Exaggerated startle response


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Post traumatic Stress Disorder- PTSD

Subdivisions

  • Acute – when PTSD is diagnosed between 1 and 3

    months after the event occurs it is called acute

  • Chronic - when PTSD continues longer than 3

    months, it is considered chronic and long term

  • Delayed Onset PTSD-this term is used to describe

    those cases where the symptoms do not occur

    immediately after the experience, but, rather,

    months or years later


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Case # 3

Mr. A witnessed a friend die in a MVA six weeks ago and c/o frequent nightmares of the accident, poor sleep, fears of driving, anxiety around highways, anhedonia and decreased affection highways, towards his girlfriend. His girlfriend also notes that he has been very irritable and startles easily since the accident.


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Post traumatic Stress Disorder- PTSD

  • 􀂾􀂾Exposure to a traumatic event

  • 􀂾􀂾Response involving intense fear,

  • Helplessness and horror

  • 􀂾􀂾Re-experiencing of the traumatic event

  • Avoidance of stimuli/psychological numbing

  • 􀂾􀂾Increased arousal

  • 􀂾􀂾Symptoms greater than 1 month



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Medical conditions causing anxiety

  • 􀂾􀂾Endocrine conditions

  • 􀂾􀂾Cardiovascular conditions

  • 􀂾􀂾Respiratory conditions

  • 􀂾􀂾Metabolic conditions

  • 􀂾􀂾Neurological conditions


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Substances causing anxiety

  • 􀂾􀂾Alcohol Alcohol

  • 􀂾􀂾Amphetamines

  • 􀂾􀂾Caffeine

  • 􀂾􀂾Cannabis

  • 􀂾􀂾Cocaine

  • 􀂾􀂾Hallucinogens

  • 􀂾􀂾Inhalants

  • 􀂾􀂾Phencyclidine

Substances that cause

anxiety (withdrawal)

  • 􀂾􀂾Alcohol

  • 􀂾􀂾Cocaine

  • 􀂾􀂾Sedatives

  • 􀂾􀂾Hypnotics

  • 􀂾􀂾Anxiolytics


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Medications causing anxiety

  • Anesthetics

  • Analgesics

  • Sympathomimetics

  • Bronchodilators

  • Anti-cholinergics

  • 􀂾Insulin

  • Thyroid hormones

  • Oral contraceptives

  • Antihistamines

  • Anti-parkinsonians

  • 􀂾Corticosteroids

  • Antihypertensives

  • Cardiovascular drugs

  • Anticonvulsants


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Anxiety Disorders

Current Management Strategies


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Management of Anxiety Disorders

  • 􀂾 Pharmacotherapy (Medications)

  • Psycho-analytic therapy – PT

  • Behavior Therapy - BT

  • Cognitive Behavior Therapy – CBT

  • Computer therapy - CT

  • 􀂾 Virtual Realty – VR

  • Mood GYM



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How do anxiolytics act ?

  • GABA and Glycine are inhibitory neurotransmitter

  • Serotonin and Noradrenaline are excitatory

  • Anxiety is increased excitatory transmitters

  • BZNs increase GABA and increase inhibition

  • SSRI decrease the serotonin levels and ↓excitation

  • TCAs act by ↓both serotonin and noradrenaline




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Different strategies of therapy

  • Behavior therapy

    • Desensitization

    • Behavior modification

    • Behavioral activation

  • Cognitive therapy

    • Rational-emotive therapy

    • Beck’s cognitive therapy

  • Newer approaches

    • Mindfulness meditation

    • Acceptance and commitment therapy

    • Dialectical Behavior Therapy (BPD)


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    Cognitive Behaviour Therapy - CBT

    • CBT is a method used to treat anxiety

    • Recognition of “distorted thinking,”

    • “Cognitive restructuring.”

    • It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder.


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    CBT – Obstacles - Restructuring

    • Hopelessness

    • Self-criticism

    • Fear of getting worse

    • Shame and embarrassment

    • Partial exposure

    • Blaming other people

    • Low motivation

    • Looking for complex solution

    • Depressing ruminations

    • There must be an easier way


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    Computer Therapy

    • Pts areashamed to seek help, and may fear the consequences at work and home.

    • Therapy is expensive and beyond the reach of many patients.

    • Computer therapy is very cheap and available by comparison.


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    Computer Therapy – Softwares

    • Fearfighter - for phobia/panic

    • Cope - for depression/anxiety

    • Balance - for GAD

    • BTSteps - for OCD

      These are PC based in a CD-Rom

      or phone based or Web-based



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    Virtual Reality - VR

    • VR therapy via SD (Systematic Desensitization) is becoming very popular.

    • SD is a process of gradually introducing a disturbing stimulus (e.g. view from a high place) in otherwise pleasant surroundings.

    • This process gradually suppresses the anxiety response.


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    Virtual Reality – VR - Advantages

    • Patients often have difficulty imagining the stimulus themselves.

    • They are often afraid of experiencing it directly – which may also be expensive and time-consuming.

    • VR affords patient privacy and confidentiality during treatment.

    • Very good for phobias


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    Virtual Reality – VR - Imagination

    • “Projection in time” – rationally reconstructing the future

    • “De-catastrophizing an image” – modifying a disturbing image

    • “Image modeling and substitution” –interrupting a negative train of images

    • “Covert conditioning” – subtle conditioning using imagined rather than real stimuli


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    Virtual Reality – VR - Hutchworld

    • Hutchworld is a virtual community attached to the Hutchison Cancer Research Center.

    • Designed to provide social support for cancer patients and their families.

    • Based on Microsoft’s Vworld’s system.


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    Mood GYM on the Internet

    • Few GPs are trained in CBT

    • Clinical psychologists are expensive

    • Young people are not easily reached

    • They may not want them – embarrassment

    • The web is accessible, convenient and popular

      with young people.

    • Deliver CBT via internet – 5 modules


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    Mood GYM Modules

    5 Modules - analysis and results

    • Essentials of CBT with examples and interactive exercises

    • Warpy Thoughts Questionnaire, Identifying dysfunctional thoughts. Methods to contest such thoughts

    • Other methods for overcoming warpy thoughts

    • Life Event Stress, Relaxation, meditation, music Pleasant Events Schedule, parental style

    • Simple problem solving, responses to relationship break-up



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    Take home points

    • 􀂾􀂾Anxiety disorders are very common

    • 􀂾􀂾Just as fevers these are of different types

    • 􀂾􀂾Accurate Dx. and Rx. by GP is essential

    • 􀂾􀂾Depression and substance abuse potential

    • Minimum of six weeks to see Rx effect

    • Prolonged Rx. is necessary 6 m or more

    • Drug Rx is only a small part of management

    • SSRI, TCAs, BZNs, MAOIs, ß-blockers etc.

    • CBT, Computer treatment, VRs, Mood GYM


    Thank you all visit us at www drsarma in l.jpg

    Thank You AllVisit us at : www.drsarma.in

    This is sponsored by Torrent –

    Makers of Clonotril (Clonazepam)