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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 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 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. 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 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 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.: Humiliating Embarrassing Lead to rejection Offend others Judged as: 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agitation (e.g. rubbing hands, tense), blushing Blushing = hallmark physical response of SAD Affect may be shy & withdrawn Speech may be overly soft voice Thought content Concerns about being judged: How they look What they say being embarrassed embarrassing others Public speaking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 Dizzy/unsteady/lighthead ed/faint Derealization/depersonali zation Fear losing control/crazy Fear dying 4 Chest SOB Heart Chest pain 4 Hands Trembling/shaking Chills/heat sweating Paresthesias 1 GI 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 Hyperthyroidism, cardiac, resp, gastro Substance-induced Panic Disorder Recurrent, unexpected panic attacks > 1 month of: 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 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 Persistent (> 6 months) Out of proportion to the actual danger Nearly every time Types of Phobia: BEAST 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 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) 2. Avoidance and emotional numbing (3/7) 3. 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 SSRI , e.g. Cipralex 30mg Setraline 150-200mg SNRI Venlafaxine: 250-300mg Desvenlafaxine: 100mg 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 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: 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 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 Gold standard Antipsychotics: alone or as adjuvant txn E.g. Seroquel 400-500mg, Risperidone 1-2mg Psychotherapy CBT