Download Anxiety Disorders by Dr Sarma

Anxiety Disorders
New Insights
Dr.R.V.S.N.Sarma., M.D., M.Sc.,
Consultant Physician
visit : www.drsarma.in
What is anxiety ?
􀂾􀂾It is a mood-state with
􀂾􀂾Marked Negative effects
􀂾􀂾Bodily symptoms of tension
􀂾􀂾Apprehensions about future

Its consequence is ‘worry’
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
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
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
Pathological v/s normal anxiety
 􀂾􀂾 Autonomous responses
 􀂾􀂾 Greater intensity
 􀂾􀂾 Longer duration
 􀂾􀂾 Behavior significantly affected

Stressor may be minimal or absent
Origin of anxiety
 􀂾􀂾Protective response
 􀂾􀂾Normal/protective anxiety

Fear and pathological anxiety

Common underlying neuro-physiology
 􀂾 Two categories of fear/anxiety
 Acute and
 Chronic
Negative effects of worry
1. Unreasonable fear
2. Anxiety Disorder
3. Panic Disorder
4. Substance abuse
5. Depression
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
What cause Anxiety Disorders ?
Importance of Anxiety Disorders
 􀂾􀂾Accurate Dx and Rx of anxiety
disorders is essential

Reduction of secondary psychiatric
conditions
 Depression
 Substance abuse problems
Anxiety Disorders - DSM-IV
1. 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
Lifetime Prevalence (%)
Prevalence of Anxiety Disorders
27
24
21
18
15
24.9
14
12
9
6
3
0
6.8
5.7
4.7
1.6
Any Anxiety
Disorder
Social
Anxiety
Disorder
PTSD
Generalized
Anxiety
Disorder
Panic
Disorder
OCD
Kessler et al. Arch Gen Psychiatry. 1995;52:1048.
Kessler et al. Arch Gen Psychiatry. 1994;51:8.
Sex differences in Anxiety Disorders
Are women more ‘Nutty’ ?
Spectrum of Anxiety Disorders
SpecPHOB
SocPHOB
PTSD
GAD
Percent
OCD
AGORAPH
PANIC D
0
1
2
3
4
5
http://www.nimh.nih.gov/publicat/anxiety.cfm
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.
Domains of anxiety
􀂾􀂾Physical
􀂾􀂾Affective
􀂾􀂾Cognitive
􀂾􀂾Behavioral
Physical domain
 􀂾􀂾 Anorexia
 􀂾􀂾 Hyperventilation
 􀂾􀂾 Butterflies in stomach  􀂾􀂾 Light-headedness
 􀂾􀂾 Chest pain/tightness
 􀂾􀂾 Muscle tension
 􀂾􀂾 Diaphoresis
 􀂾􀂾 Nausea, Vomiting
 􀂾􀂾 Dry mouth
 􀂾􀂾 Pallor
 􀂾􀂾 Dyspnoea
 􀂾􀂾 Palpitations
 􀂾􀂾 Faintness
 􀂾􀂾 Paresthesias
 􀂾􀂾 Flushing
 􀂾􀂾 Sexual dysfunction
Physical domain contd..
 􀂾􀂾 Headache
 􀂾􀂾 Shortness of breath
 􀂾􀂾 Stomach pain
 􀂾􀂾 Tachycardia
 􀂾􀂾 Tremulousness
 􀂾􀂾 Urinary frequency
 􀂾􀂾 Diarrhea
Affective domain
 􀂾􀂾 Edginess
 􀂾􀂾 Uneasiness
 􀂾􀂾 Terror
 􀂾􀂾 Panic
Behavioral domain
 􀂾􀂾 Triggers many responses
 􀂾􀂾 Behavioral in nature
 􀂾􀂾 Concerned with diminishing
 􀂾􀂾 And even avoiding the distress
Regulation of locus ceruleus
 􀂾􀂾Alpha-noradrenergic auto receptors
 􀂾􀂾Serotonin receptors
 􀂾􀂾GABA-benzodiazepine receptors
 􀂾􀂾Opiate receptors

Dopamine receptors
The amygdala and locus ceruleus
Generalized Anxiety Disorder -GAD
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
1. Restlessness or feeling
keyed up or on edge,
2. Being easily fatigued,
3. Difficulty concentrating
or mind going blank,
4. Irritability,
5. Muscle tension,
6. Sleep disturbance
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
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.
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
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
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
Agoraphobia
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
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
Specific Phobias - Examples
 Acrophobia
fear of heights
 Agoraphobia
fear of open places
 Claustrophobia
fear of enclosed places
 Ailurophobia
fear of cats
 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
 Cynophobia
fear of dogs
PAN – The Greek God
Panic Attack – DSM IV
1. 􀂾 Palpitations
8. Feeling dizzy, fainty
2. Sweating
9. Derealization (feelings of
unreality)
3. Trembling or shaking
4. Shortness of breath
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abd. distress
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
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.
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
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.
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
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.
Obsessive Compulsive Disorder -OCD
 Putamen
 Globus Pallidus
 Caudate Nucleus
 Thalamus
 Orbital frontal
cortex
Post traumatic Stress Disorder- PTSD
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.
Post traumatic stress disorder PTSD
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
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
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.
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
Separation Anxiety Disorder - SAD
Medical conditions causing anxiety
 􀂾􀂾Endocrine conditions
 􀂾􀂾Cardiovascular conditions
 􀂾􀂾Respiratory conditions
 􀂾􀂾Metabolic conditions
 􀂾􀂾Neurological conditions
Substances causing anxiety
 􀂾􀂾Alcohol Alcohol
Substances that cause
 􀂾􀂾Amphetamines
anxiety (withdrawal)
 􀂾􀂾Caffeine
 􀂾􀂾Alcohol
 􀂾􀂾Cannabis
 􀂾􀂾Cocaine
 􀂾􀂾Cocaine
 􀂾􀂾Sedatives
 􀂾􀂾Hallucinogens
 􀂾􀂾Hypnotics
 􀂾􀂾Inhalants
 􀂾􀂾Anxiolytics
 􀂾􀂾Phencyclidine
Medications causing anxiety
 Anesthetics
 Oral contraceptives
 Analgesics
 Antihistamines
 Sympathomimetics
 Anti-parkinsonians
 Bronchodilators
 􀂾Corticosteroids
 Anti-cholinergics
 Antihypertensives
 􀂾Insulin
 Cardiovascular drugs
 Thyroid hormones
 Anticonvulsants
Anxiety Disorders
Current Management Strategies
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
Drug Rx. of Anxiety Disorders
Clonazepam
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
Drug Rx. of Anxiety Disorders
Disorder
First Choice
2nd Choice Short (p.r.n)
GAD
BZNCZ, CDZ, ALZ
Beta-blockers
Buspirone
BZNTCAClomipramine ALZ, CZ, LZ
Add on
Carbamazp
Panic
Disorder
Paroxetine/
Citalopram
Phobias
Beta-blockers
SSRIs
BZNALZ, CZ
MAOI
OCD
Clomipramine
Fluoxetine
CDZ
Buspirone
PTSD
TCAImipra, Amytrp
SSRI- FLX
Sertaline, CP
BZN
MAOI
MAOI Phenelzine
Comparison of Benzodiazepines
BZN
Sedation Anxiolytic Half life
Lipid solu
Dose
Diazepam
+++
+
20-80 h
High
5 mg od
Alprazolam
+
+++
6-20 h
Low
0.5 mg qid
Clonazapam
++
+++
22-50 h
Low
0.5 mg bid
Lorazepam
++
++
10-20 h
Med
1 mg tid
+
+
7-30 h
Med
15 mg bid
Chlordiazepx
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)
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.
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
Computer Therapy
 Pts are ashamed 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.
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
MENTAL OUTSIDE
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.
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
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
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.
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
Mood GYM Modules
5 Modules - analysis and results
1. Essentials of CBT with examples and interactive
exercises
2. Warpy Thoughts Questionnaire, Identifying
dysfunctional thoughts. Methods to contest
such thoughts
3. Other methods for overcoming warpy thoughts
4. Life Event Stress, Relaxation, meditation, music
Pleasant Events Schedule, parental style
5. Simple problem solving, responses to
relationship break-up
Web stats summary
Sessions
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
This is sponsored by Torrent –
Makers of Clonotril (Clonazepam)