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ANXIETY DISORDERS CEMRE YILMAZ • • • • • • • • 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 • • • • • • • • • • • • • • *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 • • • • • *DD Agoraphobia Panic disorders GAD Major depressive disorder Body dysmorphic disorder Social Phobia • • • • *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 • • • • *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 • • • • • 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.