Download Anxiety

Anxiety Disorders
By
Salina Chan, R3
2013
Anxiety & Related Disorders
 Generalized anxiety disorder
 Social Anxiety disorder
 Panic attacks
 Panic disorder
 Agoraphobia
 Specific Phobias
 Acute stress reaction
 PTSD
 OCD
Anxiety Disorders
 Some terms and general applications…
 “Marked” = intense or severe
 Avoid triggers or endure them with intense fear or
anxiety
 Anxiety in children = crying, tantrums, freezing,
clinging or shrinking
 Remember, it’s only a disorder when causes sig
adverse impact on important areas of functioning
 r/o secondary to substances or medical condition
Generalized Anxiety Disorder
WATCHERS
 Worry, and
 Anxiety excessive about a number of activities
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6 months
3/6 symptoms below (1 only for children)
Tension
Concentration
Hyperarousal
Energy (fatigue)
Restlessness
Sleep problems
Generalized Anxiety Disorder
 Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for > 6 months, about a
number of events or activities (e.g. work, school
performance)
 Difficult to control, i.e. can’t put off and focus on task at
hand
 3 of the 6 possible associated symptoms
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Restlessness/keyed up/on edge
Easily fatigued
Difficulty concentration/mind going blank
Irritability
Muscle tension
Sleep disturbance
Generalized Anxiety Disorder
 More worries = more likely GAD
 Worries about everyday, routine life circumstances,
e.g.
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job responsibilities
health
finances
health of family members
misfortune to their children
minor matters, e.g. chores
Generalized Anxiety Disorder
Generalized Anxiety Disorder
 MSE:
 Appearance variable
 Speech can be rapid
 Thought form can be trailing, blocking, tangential,
overinclusive
 “What if” phrases
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d/t inability to tolerate uncertainty of future events
Social Anxiety Disorder (Social Phobia)
 Marked fear or anxiety about one or more social
situations in which the individual is exposed to
possible scrutiny by others
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Having a conversation
Meeting unfamiliar people
Being observed
Performing in front of others
Social Anxiety Disorder (Social Phobia)
 Fears will act in a way or
show anxiety that will be
negatively evaluated,
e.g.:
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Humiliating
Embarrassing
Lead to rejection
Offend others
 Judged as:
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Anxious
Weak
Crazy
Stupid
Boring
Intimidating
Dirty
unlikable
Social Anxiety Disorder (Social Phobia)
 MSE
 Appearance may show
poor eye contact, rigid
body posture, agitation
(e.g. rubbing hands,
tense), blushing
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Blushing = hallmark
physical response of SAD
 Affect may be shy &
withdrawn
 Speech may be overly
soft voice
 Thought content
 Concerns about being
judged:
How they look
 What they say
 being embarrassed
 embarrassing others
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Public speaking
Grocery lines
Talking on phone
Poverty/blocking: b/c
stress of interview causes
thought blocking
Social Anxiety Video
 http://www.youtube.com/watch?v=gmEJEfy5f50
(37:08 – 39:39)
Panic Attack
 An abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes, and during
which time > 4 of the following symptoms occur…
Panic Attack
 STUDENTS FEAR Cs
 Sweating
 Trembling or shaking
 Unsteadiness/dizziness/faint/lightheaded
 Depersonalization/derealization
 Excessive heart rate, palpitations, or pounding heart
 Nausea/Abdominal distress
 Tingling/Numbness
 Shortness of breath or smothering
 FEAR of dying, losing control, going crazy
 Chest Pain, Chills, Choking
Panic Attack
 4 Head
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Dizzy/unsteady/lighthead
ed/faint
Derealization/depersonali
zation
Fear losing control/crazy
Fear dying
 4 Chest
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SOB
Heart
Chest pain
 4 Hands
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Trembling/shaking
Chills/heat
sweating
Paresthesias
 1 GI
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Nausea/abdominal
distress
Panic Attack Differential
 Generalized anxiety d/o
 Depressive d/o
 Social anxiety d/o
 Bipolar d/o
 Panic disorder
 Personality d/o
 Specific phobia
 Psychotic d/o
 OCD
 Medical causes
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Hyperthyroidism, cardiac,
resp, gastro
 Substance-induced
Panic Disorder
 Recurrent, unexpected
panic attacks
 > 1 month of:
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Persistent concern/worry
about more attacks or
their consequences
OR
Change in behaviour
related to the attacks
Panic Disorder Video
 http://www.youtube.com/watch?v=Ii2FHbtVJzc
Agoraphobia
 Marked fear or anxiety about > 2 of following
situations
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Using public transportation
Being in open spaces
Being in enclosed spaces
Standing in line or being in a crowd
Being outside of the home alone
 Fears or avoids these b/c of thoughts that escape
might be difficult or help might not be available in
event of developing panic-like symptoms or other
incapacitating or embarrassing symptoms
Specific Phobias
 Marked fear or anxiety
about a specific object or
situation
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Persistent (> 6 months)
Out of proportion to the
actual danger
Nearly every time
 Types of Phobia: BEAST
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Blood/Injection/Injury
Environment, natural
(heights, storms)
Animal/Insect
Situational (airplane,
closed spaces)
Things, other (loud noise,
clowns, vomiting)
Trauma-Related Disorders
Acute Stress Reaction
 Exposure to actual or threatened death, serious
injury, or sexual violation in > 1 of the following ways
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Directly experiencing the traumatic event
Witnessing, in person, the event as it occurred to others
Learning that the event occurred to close family/friends (must
be violent/accidental)
Experienced repeated or extreme exposure to aversive details
of the traumatic event
 > 9 symptoms that last 3 days – 1 month
 Precursor to PTSD
Post-Traumatic Stress Disorder (PTSD)
A. Traumatic event
1.
Re-experiencing event (1/5)
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Avoidance and emotional numbing (3/7)
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Arousal increased (2/7)
B. Unable to function
C. Month or more
Post-Traumatic Stress Disorder (PTSD)
 Traumatic event
 person experienced, witnessed
 actual or threatened serious injury, death, or threat to
physical integrity of self or other
 Person experienced intense helplessness, fear, and horror
 Re-experiencing event (1/5)
 intrusive thoughts, nightmares, flashbacks, or recollection of
traumatic memories and images.
 Avoidance and emotional numbing (3/7)
 detachment from others; flattening of affect; loss of interest; lack of
motivation; and persistent avoidance of activity, places, persons, or
events associated with the traumatic experience
 Unable to function
 Symptoms are distressing and cause significant impairment in
social, occupational, and interpersonal functioning
 Arousal increased (2/7)
 usually manifested by startle reaction, poor concentration, irritable
mood, insomnia, and hypervigilance
Post-Traumatic Stress Disorder (PTSD)
“Doc, I’ve got Anxiety!”
 Anxiety d/o
 Bipolar d/o
 Depressive d/o
 Psychotic d/o
 Sleep d/o
 Substance use d/o
Social Anxiety Disorder Differential
 Normative shyness
 Major depressive disorder
 Agoraphobia
 Body dysmorphic disorder
 Panic disorder
 Delusional disorder
 Generalized anxiety
 Autism spectrum disorder
disorder
 Separation anxiety disorder
 Specific phobias
 Selective mutism
 Personality disorder
 Other mental disorders,
e.g. Scz, eating d/o
 Other medical conditions
 Oppositional defiant
disorder
Anxiety Disorders – Treatment
 Rule out medical conditions (VINDICATE)
 TSH, pheochromocytoma, hypoglycemia, arrythmia, asthma
 Lifestyle
 eat well, exercise, socialize, relaxation
 Psychotherapy
 CBT, EMDR
 Meds
 Antidepressants, B-Blockers (must cross BBB)
 Benzodiazepines & Antipsychotics
Medications
 Antidepressants: Use higher doses than for
depression, e.g. ~50% more
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SSRI , e.g.
Cipralex 30mg
 Setraline 150-200mg
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SNRI
Venlafaxine: 250-300mg
 Desvenlafaxine: 100mg
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Mirtazapine: 30-45mg
Buspirone: 30mg
Trazadone: 50 to 400 mg
Medications
 Beta-blockers
 Social Performance anxiety
 Benzodiazepines
 Clonazepam, Ativan
 Short-term or PRN use
 Good to use when starting SSRIs to minimize activating effects
 Antipsychotics
 Seroquel: PRN or regular doses
Medications
Psychotherapy
 Details after this lecture
 Cognitive Behavioural
Therapy
 Eye movement
desensitization and
reprocessing
Obsessive-Compulsive Disorder
Q: What is an Obsession?
 A: Recurrent and persistent thoughts, impulse or
images
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Experienced as intrusive and inappropriate
Cause marked anxiety and distress
Not just worries about real life problems
The person tries to ignore or suppress them
Recognized as being part of their own mind
Q: What is a Compulsion?
 A: Repetitive behaviours or mental acts that a person
feels has to be done:
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In response to an obsession
According to rules that have to be applied rigidly
 Aimed at preventing or reducing distress or
preventing a dreaded event or situation
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Excessive or not connected in a realistic way in what is trying
to be prevented
Obsessive – Compulsive Disorder
 Obsessions AND/OR Compulsions
 Pt recognizes are unreasonable
 Cause marked distress, are time consuming
(>1hr/day) or interfere with functioning
Treatment
 Medications
 SSRI
 TCA: Clomipramine
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Gold standard
Antipsychotics: alone or as adjuvant txn
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E.g. Seroquel 400-500mg, Risperidone 1-2mg
 Psychotherapy
 CBT