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Anxiety & Phobias
Normal vs. Abnormal anxiety
Anxiety Disorders:
1- GAD
2-Panic disorder
3- Agoraphobia
4- Social phobia
5- Specific phobia 6- Acute & PTSD
7- OCD
NORMAL ANXIETY ABNORMAL
ANXIETY
1-Apprehension Proportional to the
trigger
( time & severity).
2- Attention
Out of proportion
<
External trigger > body
responses.
3- Features
few - not severe - not
prolonged & minimal
effect on life .
4- Types
Trait (character)
& state (situational)
Many – severe –
prolonged
& interfere with life.
GAD-Panic-Phobias
Acute &PTSD- …etc
Features of anxiety
Psychological
Apprehension+ hypervigilance
Physical
CNS:
ENT:
Excessive worries+ anticipation
Difficulty concentrating
CVS & CHEST:
Feeling of restlessness
GI:
Sensitivity to noise
GUT & RS:
SKIN:
Sleep disturbance
MSS:
Generalized Anxiety Disorder
Criteria:
6 months duration – most of the time
Excessive worries about many events
Multiple physical & psychological features
Difficult to control
Significant impairment in function
Not due to GMC , substance abuse or other
axis I psychiatric disorder
Associated features:
panic attacks (episodes of short severe anxiety).
Sadness +/- weeping
Overconcern about body functions (heart, brain,...)
MSE :
Tense posture, excessive movement
e.g. hands (tremor) & head, excessive blinking
Sweating
Difficulty in inhalation.
Epidemiology:
women > men
Prevalence : 3 – 5 %.
Age of onset vary , range : 20 – 55 years.
Pt. usually consults medical
(non-psychiatric) specialties,
and / or faith-healers first.
D Dx :
Normal reaction to stress.
Anxiety due to physical problems:
anemia –hypothyroidism - BA - Rx – sub. A.
Panic disorder.
Adjustment disorder with anxious mood.
Somatization disorder.
Hypochondriasis.
Mixed anxiety & depressive disorder.
Depressive disorders.
Psychotic disorders.
Course & Prognosis
If not properly treated :
chronic, fluctuating & worsens with stress.
Secondary depression .
Possible physical complications: e.g. HTN,DM.IHD
Poor Prognostic Factors:
•
Very severe symptoms
•
Personality problems
•
Uncooperative patient.
• Derealization
Management of GAD
• Rule out common physical causes.
• Explain the nature of the illness & symptoms.
• Reassure that symptoms are not due to a
physical disease.
• Draw attention to psychological factors.
• Cognitive-Behavioral Treatment (CBT).
• Short course(2/52) BDZ e.g. lorazepam.
• Long term Rx: SSRI-SNRI-TCA-
Panic Disorder
Panic attack :
• a symptom not a disorder.
• episodic sudden intense fear
( of dying, going mad, or loosing
self-control).
• Can be part of many disorders:
panic disorder, GAD, phobias,
sub. Abuse
acute & PTSD
3 types:
1- unexpected
2- situationally bound
3- situationally predisposed
Panic Disorder:
Disorder with specific
criteria:
1- unexpected recurrent
panic attacks
(+/- situationally bound).
2- one month period (or
more) of persistent
concern about another
attack or implication of the
attack.
3- Not due to other disorders
Panic Attacks
Unexpected
Spontaneous
Essential to diagnose
Panic Disorder
Situationally bound
Occur on anticipation
Or immediately on exposure
to the trigger
e.g. specific phobia
can be ass./with
panic disorder
Situationally predisposed
Exposure is likely but
not
always trigger them
e.g. social phobia
Epidemiology
Etiology
Genetic predisposition
Women > men
Prevalence : 1– 3 %
Age at onset :
20 --- 35 years
Disturbance of
neurotransmitters
NE & 5 HT
in the locus ceruleus
( alarm system
in the brain )
Behavioral
conditioning
Mitral valve prolapse 2x ?
Course & Prognosis
With treatment : good
Some pts recover within
weeks even with no
treatment.
Others have chronic
fluctuating course.
Management
Rule out physical causes.
Support & reassurance
Relaxation & CBT
Medications:
BNZ
SSRIs
TCAs
Phobic Disorders
Irrational excessive fear on exposure + avoidance
Specific
Social
Agoraphobia
Objects or situations
e.g. blood ex.
dental clinic
hospital
airplane (height)
animals
insects
thunder
storms
closed spaces/lifts
darkness
Embarrassment
when observed
performing
e.g. speaking in
public,
leading prayer
serving guests
Sweating / tremor
palpitation / SOB
Functional impair.
Crowded places
difficult to
escape :
fainting/ vomiting
diarrhea
e.g. mosques
main roads
public transport
malls / markets
airports /queues
Functional impair.
Specific
Epidemiology:
M=F
common in children
Etiology :
? Modeling
cont. of childhood fears
Treatment :
behavior therapy: exp.
+ / - B- blockers / BNZ
Social
Epidemiology:
M : F = ? Cultural F.
prevalence : 3 - 13 %.
only 10 % come .
Etiology: genetic
predis. ( shyness )
psychosocial (shame
– criticism ).
Treatment:
CBT, Ass. T. & SST
Medications :
PRN : B-blockers,BNZ
SSRIs , MAOIs , or
TCA
Agoraphobia
Epidemiology:
F:M=2:1
Prevalence : 2 – 10%.
Onset : 2o – 35 y.
Etiology:
Personality predis.
Psychosocial trigger.
Treatment :
CBT with graded exp.
Medications :
Either; SSRIs, TCAs, or
MAOIs +/- BNZ
Anxiety & Phobias
Normal vs. Abnormal anxiety
Anxiety Disorders:
1- GAD
2-Panic disorder
3- Agoraphobia
4- Social phobia
5- Specific phobia 6- Acute & PTSD
7- OCD