ANXIETY DISORDER

Elmeida Effendy Psychiatric Department Medical Faculty USU

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DSM- IV-TR
1. Panic disorder with or without

agoraphobia 2. Agoraphobia with or without panic disorder 3. Specific phobia 4. Social phobia 5. Obsessive-compulsive disorder 6. Posttraumatic stress disorder 7. Acute stress disorder 8. Generalized anxiety disorder

Panic Disorder & Agoraphobia

An acute intense attack of anxiety

accompanied by feelings of impending doom is known as panic disorder The anxiety is characterized by discrete periods of intense fear that can vary from several attacks during one day to only a few attacks during a year Patients with panic disorder present with a number of comorbid conditions, most commonly agoraphobia, which refers to a fear of or anxiety regarding places from which escape might be difficult
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DSM-IV-TR Criteria for Panic Attack

A discrete period of intense fear or

discomfort,in which four (or more) of the following symptoms developed abruptly & reached a peak within 10 minutes : 1.palpitations, pounding heart, or accelerated heart beat 2. sweating 3. trembling or shaking 4. sensations of shortness of breath or smothering 5. feeling of choking 6.chest pain or discomfort

 7. nausea or abdominal distress

8. feeling dizzy, unsteady, lightheaded or

faint 9. derealization (feelings of unreality) or depersonalization ( being detached from one self) 10. fear of losing control or going crazy 11. fear of dying 12. paresthesias ( numbness or tingling sensations) 13. chills or hot flushes

 The DSM-IV-TR contains 2 diagnostic criteria for

panic disorder, one without agoraphobia and the other with agoraphobia, but both require the presence of panic attacks Panic attacks can occur in mental disorders other than panic disorder, particularly in specific phobia, social phobia & PTSD Unexpected panic attacks occur at any time & are not associated with any identifiable situational stimulus, but panic attacks need not be unexpected Attacks in patients with social & specific phobias are usually expected or cued to a recognized or specific stimulus
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 Some panic attacks do not fit easily into

the distinction between unexpected & expected, and these attacks are referred to as situationally predisposed panic attacks

DSM- IV- TR Criteria for Agoraphobia

A. Anxiety about being in places or

situations from which escape might be difficult(or embarassing)or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge & traveling in a bus, train or automobile
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 B. The situations are avoided (e.g., travel is

restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic like symptoms, or require the presence of a companion C. The anxiety or phobic avoidance is not better accounted for by another mental disorder , such as social phobia (e.g., avoidance limited to social situations because of fear of embarassment), specific phobia (e.g., avoidance limited to a single situation like elevators), obsessive compulsive disorder ( avoidance of dirt), posttraumatic stress disorder ( avoidance of stimuli associated with a severe stressor) or separation anxiety

Specific Phobia & Social Phobia

Phobia : an excessive fear of a specific object,

circumstance or situation Specific phobia : strong, persisting fear of an object or situation Social phobia :strong, persisting fear of situations in which embarassment can occur The diagnosis of both specific & social phobia requires the development of intense anxiety, even to the point of panic, when exposed to the feared situations
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Specific Phobia
More common than social phobia

May anticipate harm, such as being bitten by a

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dog, may panic at thought of losing control if they fear being in an elevator The peak age of onset for the natural environment type & blood-injection-injury-type : 59 years Onset for situational type (except fear of heights): mid 20s The feared objects & situations in specific phobia (listed in descending frequency of appearance) are animals, storms, heights, illness, injury &

Social Phobia= Social Anxiety Disorder

Have excessive fears of humiliation or

embarassment in various social settings, such as speaking in public, urinating in public rest room (shy bladder) &speaking to a date

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Obsessive Compulsive Disorder (OCD)

Represented by a diverse group of symptoms

that include intrusive thoughts, rituals, preoccupation & compulsions These recurrent obsessions or compulsions cause severe distress to the person The obsessions or compulsions are time consuming & interfere significantly with the persons normal routine, occupational functioning, usual social activities or relationships A patient with OCD may have an obsession, a compulsion or both
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 Obsession : a recurrent & intrusive thought,

feeling, idea or sensation Compulsion : a behavior Specifically, a compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding A patient with OCD realizes the irrationality of the obsession & experiences both the obsession & the compulsion as ego-dystonic (unwnted behavior)

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OCD has 4 major symptom pattern :

1. Contamination

2. Pathological doubt
3. Intrusive thoughts 4. Symmetry

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Obsessions
Contamination

Pathological doubt
Somatic Need for symmetry Aggressive Sexual Other Multiple obsessions

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Compulsions
Checking

Washing
Counting Need to ask or confess Symmetry and precision Hoarding Multiple comparisons

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Treatment
Pharmacotherapy : SSRI, clomipramine

Behavior therapy : desensitization,thought

stopping,flooding,implosion therapy & aversive conditioning Psychotherapy

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Posttraumatic Stress Disorder (PTSD)& Acute Stress Disorder

Condition marked by the development of

symptoms after exposure to traumatic life events The person reacts to this experience with fear & helplessness, persistently relives the event, & tries to avoid being reminded of it PTSD :The symptom must last for more than a month after the event & must significantly affect important areas of life, such as family & work Acute stress disorder : occurs earlier than PTSD; within 4 weeks of the event, & remits within 2days to 4 weeks
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 The stressors causing both acute stress disorder

& PTSD are sufficiently overwhelming to affect almost anyone They can arise from experiences in war, torture, natural catatstrophes, assault, rape & serious accidents, for example, in cars & in burning buildings The DSM-IV-TR diagnostic criteria for PTSD specify that the symptoms of experiencing, avoidance & hyperarousal must have lasted more than 1 month ;acute : if the symptoms have lasted less than 3 months, chronic : if the symptoms have lasted than 3 months or more
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Clinical Features of PTSD

Painful reexperiencing of the event, a pattern of

avoidance & emotional numbing, fairly constant hyperarousal The disorder may not develop until months or even years after the event The mental status examination often reveals feelings of guilt, rejection & humiliation Patients may also describe dissociative states & panic attacks, illusions & hallucinations may be present
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Treatment
Pharmacotherapy : SSRI : sertraline, paroxetine

Psychotherapy : psychodynamic psychotherapy,

crisis intervention with support, education & development of coping mechanism & acceptance of the event

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Generalized Anxiety Disorder

Excessive anxiety & worry about several events

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or activities for most days during at least 6- month period The worry is difficult to control and is associated with somatic symptoms, such as muscle tension, irritability, difficulty sleeping & restlessness Anxiety is not focused on features of another axis I disorder, not caused by substance use or a general medical condition& does not occur only during a mood or psychiatric disorder Anxiety is difficult to control, is subjectively distressing & produces impairment in important areas of a persons life

DSM-IV_TR Diagnostic Criteria for Generalized Anxiety Disorder

A. Excessive anxiety & worry occurring more

days than not for at least 6 months, about a number of events or activities (such as work or school performance) B. The person finds it difficult to control the worry

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 C. The anxiety & worry are associated with 3 or

more of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months)
1. restlessness or feeling keyed up or on edge 2. being easily fatigue 3. difficulty concentrating or mind going blank 4. irritability 5. muscle tension 6. sleep disturbance ( difficulty falling or staying

asleep, or restless unsatisfying sleep)

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 D. The focus of the anxiety & worry is not

confined to features of an axis I disorder E. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning The disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder or a pervasive developmental disorder

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