Anxiety disorders Dr. Eman Abahussain psychiatry consultant,kkuh,kauh.
Normal vs. Abnormal anxiety Anxiety Disorders: 1- GAD 2-Panic disorder 3- Agoraphobia 4- Social phobia 5- Specific phobia 6- Acute & PTSD 7- OCD
fear: is a response to a known external definite threat Anxiety: is a response to a threat that is unknown internal vague or conflictual.
Generalized Anxiety Disorder Criteria: 6 months duration – most of the time Excessive worries about many events Multiple physical & psychological features Difficult to control Significant impairment in function Not due to GMC , substance abuse or other axis I psychiatric disorder
: COMORBIDITY: 50-90% other mental disorders. Epidemiology: women > menPrevalence : 3 – 5 %. Age of onset vary , range : 20 – 55 years. Pt. usually consults medical (non-psychiatric) specialties, and / or faith-healers first. MSE : Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking Sweating Difficulty in inhalation.
DDx : Normal reaction to stress. Anxiety due to physical problems: anemia –hyperhyroidism - BA - Rx – sub. A. Panic disorder. Adjustment disorder with anxious mood. Somatization disorder. Hypochondriasis. Mixed anxiety & depressive disorder. Depressive disorders. Psychotic disorders.
Course & Prognosis chronic, fluctuating & worsens with stress. it may cause Secondary depression . Poor Prognostic Factors: • Very severe symptoms • Personality problems • Uncooperative patient.
Management of GAD • Rule out common physical causes. • Explain the nature of the illness & symptoms. • Reassure that symptoms are not due to a physical disease. • Draw attention to psychological factors. • Cognitive-Behavioral Treatment (CBT). • Short course(2/52) BDZ e.g. lorazepam. • Long term Rx: SSRI-SNRI-TCA - 6 months after initial response to treatment,(NICE guidelines),few studies examine relapse prevention .
Panic Disorder Panic attack : • a symptom not a disorder. • Can be part of many disorders: panic disorder, GAD, phobias, sub. Abuse acute & PTSD • It is adiscreate period of intense fear or discomfort,in which 4 of the anxiety symptoms developed abruptly and reached apeak within 10 min .
Symptoms of panic attack: • Palpitation • Sweating • Trembling • Shortness of breath • Feeling of choking • Chest pain • Feeling dizzy • Fear of dying • paresthesias
Panic Disorder: Disorder with specific criteria: 1- unexpected recurrent panic attacks (+/- situationally bound). 2- one month period (or more) of persistent concern about having another attack or worry about the implications of the attack, or change in behavior related to the attacks. 3- Not due to other disorders
Epidemiology Women > men Prevalence : 1– 3 % Age at onset : 20 --- 35 years Etiology Genetic predisposition Disturbance of neurotransmitters NE & 5 HT in the locus ceruleus ( alarm system in the brain ) Behavioral conditioning
Prognosis: • 30-40% became symptoms free • 50%have mild symptoms • 10-20%continue to have significant symptoms
Management Rule out physical causes. Support & reassurance CBT: cognitive therapy( instructions about a patient false beliefs and information about panic attack) behavioral therapy (relaxation, breathing training, in vivo exposure) Medications: BNZ , SSRIs, TCAs Treatment should continue for 12 months or more.
OCD • 1-obsessions: • Recurrent persistent intrusive thoughts impulses or images from his own mind, that cause marked distress and anxiety, pt tries to suppress them with some other thoughts or actions. • 2-compulsions: • Repetitive behaviors or mental acts that pt feels driven to do . • 3- they are excessive or unreasonable • 4- cause marked distress or time consuming or interfer with function.
:Main themes -Contamination & washing - pathological doubt, Checking & counting Ablution, prayers… -intrusive thoughts: Images of aggression , Self- harm ,Sexual act. -symmetry, and slowness -other symptoms: religious obsessions
Epidemiology Males = Females Lifetime prevalence = 2-3 % Mean age of onset = 20 – 25 yeas
Course and prognosis: the course is usually long but variable ,some have fluctuating course and others constant one. 20-30%have significant improvement 40-50% moderate improvement. 20-40%remain ill or even worse.
D D • Anxiety, panic and phobia. • Depressive disorders. • Hypochondriasis • Schizophrenia. • Organic mental disorders. • OCPD: perfectionism, orderliness…
Treatment Pharmacobehavioral : 1- Pharmacological: - SSRIs : fluoxetine - paroxetine clomipramine Duration of treatment 12 months and more. 2- Behavioral : exposure & response prevention others
Prognosis Good p. Factors Bad p. Factors • Non – severe • No OCPD • Depressed / anxious mood • Compliance with T • Family support • very – severe • OCPD • No Depressed / anxious mood • Non- Compliance with treatment. • No Family support