Download anxiety disorders

ANXIETY DISORDERS
CEMRE YILMAZ
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Separation anxiety disorder
Selective mutism
Specific phobia
Social anxiety disorder ( social phobia)
Panic disorder
Agorophobia
Generalized anxiety disorder (GAD)
Post-traumatic stress disorder
• Cogu cocukluk caginda baslar.
• K:%25 E:%15
• Huzursuzluk, gerginlik, tedirginlik, sıkıntı, daralma
• Dikkatini toplayamama ve bir konu üzerine
yoğunlaşamama
• Çabuk yorulma, uyku bozuklukları, kolay
irkilme, tetikte olma
• Baş ağrısı, baş dönmesi, başta uyuşma ve
sersemlik hissi
• Kulaklarda uğuldama, çınlama, görme
bulanıklıkları
FEAR NETWORK
• Amygdala
• Insula
• Anterior cingulate cortex
NEUROCHEMISTRY
*Neurotransmitters
• GABA underactivity
• 5HT dysfunction
• Noradrenaline dysfunction
• Dopamine dysfunction
*Neuropeptides
• CCK
• NPY
• OT/AVP
*Neuroendocrine
• HPA axis overactivity
Generalized Anxiety
Disorder
Generalized Anxiety
Disorder
• Persistent, prominent , exaggerated worry about
everyday events and problems
• Feeling on edge , free floating anxiety
• Muscle tension
• tension headache
• Restlessness , irritability
• Difficulty concentrating, initial insomnia
• Autonomic symptoms :palpitations, sweating ,
tremors, dry mouth
• Nausea, abdominal discomfort, numbness, hot
flushes
Generalized Anxiety
Disorder
• 9% (Turkiye: 5-6%)
• diagnosis peaks middle age and declines the later
years of life
• Median age at onset: 30
• More in developed countries
• More frequently in females
• Early onset = more comorbidity
• Comorbidities: other anxiety disorders , depression ,
substance use disorders
• 110 million disability days per year in the U.S.
Generalized Anxiety
Disorder
DSM5:
*Excessive anxiety and worry about several events or activities
most days of the week for at least six months
*The individual finds it difficult to control the worry.
* At least three of the following symptoms (with at least some
symptoms having been present for more days than not for the
past 6 months);
• Restlessness or feeling keyed up or on edge.
• Being easily fatigued.
• Difficulty concentrating or mind going blank.
• Irritability.
• Muscle tension.
• Sleep disturbance
Generalized Anxiety
Disorder
* Anxiety or worry that causes you significant distress
or interferes with your daily life
*The disturbance is not attributable to the
physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition
(e.g., hyperthyroidism).
*The disturbance is not better explained by another
mental disorder
Generalized Anxiety
Disorder
*DD
• Pheochromocytoma
• Hyperthyroidism
• Substance induced anxiety disorder
• Social anxiety disorder
• OCD
• Posttraumatic stress disorder
• Depressive , bipolar , psychotic disorders
Generalized Anxiety
Disorder
Treatment
* Psychotherapy
 cognitive behavioral therapy
*Antidepressants :
SSRI
Escitalopram (cipram)
 Paroxetine(paxil,pexeva)
SNRI
 Duloxetine (cymbalta)
 Venlafaxine(effexor XR)
*Buspirone
*Benzodiazepines
Panic Disorder
Panic Disorder
*Episodes of panic attacks
• Acute onset of severe anxiety with no obvious
trigger (out of blue)
• Symptoms usually peak within minutes.
• Autonomic symptoms : palpitations , sweating ,
tremors, dry mouth
• Feeling of choking , difficulty breathing , abdominal
discomfort , dizziness, hot flushes , cold chills
• Fear of dying , fainting , going crazy
Panic Disorder
• Often starts in the late teens
• More frequently in females
• Increased risk
family history
major life stress
smoking or excessive caffeine intake
history of childhood physical or sexual abuse
Panic Disorder
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*DSM
*frequent, unexpected panic attacks. (at least four of the followings)
Palpitations, pounding heart, or accelerated heart rate.
Sweating.
Trembling or shaking.
Sensations of shortness of breath or smothering.
Feelings of choking.
Chest pain or discomfort.
Nausea or abdominal distress.
Feeling dizzy, unsteady, light-headed, or faint.
Chills or heat sensations.
Paresthesias
Derealization (feelings of unreality) or depersonalization (being detached from
one
self).
Fear of losing control or “going crazy.”
Fear of dying.
*At least one of the attacks has been followed by one month or more of ongoing
worry about having another attack
Panic Disorder
*The disturbance is not attributable to the
physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition
(e.g., hyperthyroidism, cardiopulmonary disorders).
*The disturbance is not better explained by another
mental disorder
Panic Disorder
Treatment
*Psychotherapy
*Antidepressants :
SSRI
 fluoxetine(prozac)
 Paroxetine(paxil , pexeva)
 Sertraline (zoloft)
SNRI
venlafaxine hydrochoride (effexor XR)
*Benzodiazepines
alprazolam (xanax)
Specific Phobias
• Marked fear or anxiety about a specific object or
situation
• Lasting for 6 months or more
• Predictable ( in contrast to panic disorder)
• Escape-avoidance
• %7-9 in USA
• Mostly after a traumatic event
Social Phobia
Social Phobia
• Marked fear or anxiety about social situations
• The social situation almost always provoke fear or
anxiety.
• Lasting for 6 months or more
• Fear of being the focus of attention
• %2-5
• Age of onset : 8-15
• Avoidance of social situations :similar to schizoid
personality or negative symptoms of schizophrenia
• Not being employed is a strong predictor for
persistence of social anxiety disorder
Social Phobia
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*DD
Agoraphobia
Panic disorders
GAD
Major depressive disorder
Body dysmorphic disorder
Social Phobia
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*Treatment
Psychotherapy
Antidepressants
Benzodiazepines
Beta blockers
Agoraphobia
Agoraphobia
*Marked fear or anxiety about two(or more) of the following five
situations:
• Using public transportation ( automobiles, buses, trains, ships, planes).
• Being in open spaces ( parking lots, marketplaces, bridges).
• Being in enclosed places ( shops, theaters, cinemas).
• Standing in line or being in a crowd.
• Being outside of the home alone.
*The individual fears or avoids these situations because of thoughts that
escape might be difficult or help might not be available in the event of
developing panic-like symptoms or other incapacitating or
embarrassing symptoms (fear of falling in the elderly; fear of
incontinence)
*The fear, anxiety or avoidance is persistent, typically lasting for 6 months
or more
*The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Agoraphobia
• Early 20s
• Heritability for agoraphobia is 61%. Of the various
phobias, agoraphobia has the strongest and most
specific association with the genetic factor that
represents proneness to phobias.
• More than one-third of individuals with agoraphobia
are completely homebound and unable to work.
Agoraphobia
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*DD
Social phobia
Panic disorder
PTSD
Major depressive disorder
Agoraphobia
*Treatment
Psychotherapy
 cognitive behavioral therapy
*Antidepressants :
SSRI
paroxetine(paxil,pexeva)
fluoxetine (prozac)
Tricyclic antidepressants
Monoamine oxidase inhibitors
*Benzodiazepines
xanax, niravam, klonopin
Post-traumatic Stress
Disorder
• Post-traumatic stress disorder (PTSD) is a mental
health condition that's triggered by a terrifying
event — either experiencing it or witnessing it.
Symptoms may include flashbacks, nightmares and
severe anxiety, as well as uncontrollable thoughts
about the event.
• Major physical/ sexual assault , traffic accident ,
natural disasters , terrorism
• Flashbacks , nightmares
• Other features: emotional numbing, insomnia ,
irritability , misuse of alcohol ,
depersonalization/derealization
Post-traumatic Stress
Disorder
*Risk Factors
• Prior exposure to traumas
• Family history of anxiety disorders
• Personality traits ( anxious , avoidant , perfectionist)
• Female gender
• Social , financial difficulties
Post-traumatic Stress
Disorder
*Traumatic events
• Being threatened with a weapon
• Witnessing another person being killed or injured
• Involved in a life-threatening accident
• Combat exposure (typically in young male frontline
soldiers)
• Victim of sexual assault
• Civil war , invasion
• Earthquake
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First episode of schizophrenia
Dementia
Delirium (esp alcohol withdrawal )
Unipolar depression
Mixed states of bipolar disorder
*Note that many patients have more than 1 anxiety
disorder
First episode of acute
anxiety
• Potential abuse of substances ( cocaine ,
amphetamine)
• Atypical presentation of MI (nausea , vomiting)
• Supraventricular tachycardia
• Hypoglycemia
• Pheochromocytoma (headache, high HR , BP,
sweating)
• Atypical seizures
Cognitive Behavioral
Therapy
• Attempts to correct maladaptive cognitions and
behaviours
• Specific phobias are the easiest to treat
• Disorders like PTSD are much more difficult to treat
Pharmacotherapy
Overview
• For all anxiety disorders (except simple phobias) SSRI
is usually the first-line medication
fluoxetine (prozac)
escitalopram (cipram)
• Benzodiazepines should not prescribe for more than
2 weeks. May be useful in simple phobias
(diazepam)
• Beta blockers may be useful for somatic symptoms
of anxiety such as tachycardia and tremors
Prognosis
• Tedaviye baslandiktan sonraki 3 yil icinde %50si
remisyona ugrar.
• Bunlarin 1/3u ise 3 yil icinde relaps yapar.