ANXIETY DISORDERS 1
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ANXIETY DISORDERS 1ANXIETY DISORDERS 1
AHMAD ALHADI, MDPsychiatrist and Psychotherapist
KSU, KKUH
AHMAD ALHADI, MDPsychiatrist and Psychotherapist
KSU, KKUH
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IntroductionIntroduction
• Normal vs Abnormal
• GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1).
• OCD (Part 2).
• Acute & PTSD, Adjustment Dis., Grief (Part 3).
• Normal vs Abnormal
• GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1).
• OCD (Part 2).
• Acute & PTSD, Adjustment Dis., Grief (Part 3).
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ABNORMAL ANXIETY NORMAL ANXIETY
Out of proportion
body responses > External trigger
Many – severe – prolonged & interfere with life.
GAD-Panic-PhobiasAcute &PTSD- …etc
Proportional to the trigger (time & severity).
External trigger > body responses.
few - not severe - not prolonged & minimal effect on life .
Trait (character) State (situational)
1-Apprehension
2- Attention
3- Features
4- Types
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Anxiety DisordersAnxiety Disorders
THREAT COPING
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Features of AnxietyFeatures of Anxiety Physical PsychologicalNeuro:
ENT:
CVS & CHEST:
GI:
Genito-urin.:
SKIN:
MSS:
Apprehension + hypervigilance
Excessive worries + anticipation
Difficulty concentrating
Feeling of restlessness
Sensitivity to noise
Sleep disturbance
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Vicious cycle of panic attackVicious cycle of panic attack
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Any Anx Dis
Specific Phobia
Social Phobia
PTSD
Any Mood dis
MDD
Bipolar Dis
0 5 10 15 20 25
MaleFemale
Mental Disorders among Adults (18 and older), in the past year (2001)
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William R Yates, Anxiety Disorders: Multimedia 2010
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William R Yates, Anxiety Disorders: Multimedia 2010
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Fear networkFear network
Fear network centered in the Amygdala which has interaction with :• Hippocampus, hypothalamic and brainstem sites (observed signs of fear
responses)
Neuroanatomical Hypothesis of Panic Disorder, Revised, Jack M,2004
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Anxiety DisordersAnxiety Disorders
1. Generalized Anxiety Disorder (GAD)
2. Panic Disorder
3. Agoraphobia
4. Specific Phobia
5. Social Phobia.
6. Obsessive Compulsive Disorder (OCD)
7. Post Traumatic Stress Disorder (PTSD), Acute Stress Disorder
1. Generalized Anxiety Disorder (GAD)
2. Panic Disorder
3. Agoraphobia
4. Specific Phobia
5. Social Phobia.
6. Obsessive Compulsive Disorder (OCD)
7. Post Traumatic Stress Disorder (PTSD), Acute Stress Disorder
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Criteria: 6 months duration – most of the time Excessive worries about many events : ( routine themes, Difficult to control or relax, not
productive, expect terrible events if not worry, worry about not being worried or when everything is going well in pt’s life).
Multiple physical & psychological features. Significant impairment in function. Not due to GMC , substance abuse or other axis I psychiatric disorder.
Criteria: 6 months duration – most of the time Excessive worries about many events : ( routine themes, Difficult to control or relax, not
productive, expect terrible events if not worry, worry about not being worried or when everything is going well in pt’s life).
Multiple physical & psychological features. Significant impairment in function. Not due to GMC , substance abuse or other axis I psychiatric disorder.
Generalized Anxiety DisorderGeneralized Anxiety Disorder
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Associated features:
panic attacks (episodes of short severe anxiety). Sadness +/- weeping Overconcerned about body functions (heart,
brain,...)
MSE : Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking Sweating. Difficulty in inhalation.
Associated features:
panic attacks (episodes of short severe anxiety). Sadness +/- weeping Overconcerned about body functions (heart,
brain,...)
MSE : Tense posture, excessive movement e.g. hands (tremor) & head, excessive blinking Sweating. Difficulty in inhalation.
Generalized Anxiety DisorderGeneralized Anxiety Disorder
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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.
Co-morbidity is high ( panic d, depression, substance abuse…etc).
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.
Co-morbidity is high ( panic d, depression, substance abuse…etc).
Generalized Anxiety DisorderGeneralized Anxiety Disorder
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90.4% of persons with GAD met criteria for another psychiatric disorder over the course of their lifetime. 90.4% of persons with GAD met criteria for another psychiatric disorder over the course of their lifetime.
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D Dx : Anxiety due to other physical problems:
anemia –hyperthyroidism – hypoglycemia-BA - Rx – sub. Abuse.
Psychotic disorders. Depressive disorders. Panic disorder.Hypochondriasis.Mixed anxiety & depressive disorder. Adjustment disorder with anxious mood. Normal reaction to stress.
D Dx : Anxiety due to other physical problems:
anemia –hyperthyroidism – hypoglycemia-BA - Rx – sub. Abuse.
Psychotic disorders. Depressive disorders. Panic disorder.Hypochondriasis.Mixed anxiety & depressive disorder. Adjustment disorder with anxious mood. Normal reaction to stress.
Generalized Anxiety DisorderGeneralized Anxiety Disorder
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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
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
Generalized Anxiety DisorderGeneralized Anxiety Disorder
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Rule out common physical reasons. Explain the nature of the illness & symptoms. Reassure that symptoms are not due to a
physical disease. Reduction of caffeine intake. Draw attention to psychological factors (connect
with his affect). Behavioral Therapies (CBT, Relaxation training,
Meditation….). Short course(2/52) BDZ e.g. lorazepam. Long term Rx: SSRI-SNRI-TCA- buspirone
Rule out common physical reasons. Explain the nature of the illness & symptoms. Reassure that symptoms are not due to a
physical disease. Reduction of caffeine intake. Draw attention to psychological factors (connect
with his affect). Behavioral Therapies (CBT, Relaxation training,
Meditation….). Short course(2/52) BDZ e.g. lorazepam. Long term Rx: SSRI-SNRI-TCA- buspirone
Generalized Anxiety DisorderGeneralized Anxiety Disorder
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PANICPANIC
Any Qs?Any Qs?
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!! تخّي لVideo 1
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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 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 concerns about another attack or implications of the attack or changes in behavior.
3- Not due to other disorders
Panic Disorder: Disorder with specific
criteria: 1- unexpected recurrent
panic attacks (+/- situationally bound).
2- one month period (or more) of persistent concerns about another attack or implications of the attack or changes in behavior.
3- Not due to other disorders
Panic DisorderPanic Disorder
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SpontaneousEssential to diagnose
Panic Disorder
Occur on anticipationOr immediately on exposure
to the triggere.g. specific phobia
can be ass./with panic disorder
Exposure is likely but not
always trigger them e.g. social phobia
Panic Attacks
Unexpected Situationally bound
Situationally predisposed
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Epidemiology
Women > men
Prevalence : 1– 3 %
Age at onset :
20 --- 35 years
Epidemiology
Women > men
Prevalence : 1– 3 %
Age at onset :
20 --- 35 years
Etiology
Genetic predisposition Disturbance of
neurotransmitters
NE & 5 HT
in the locus ceruleus
(alarm system
in the brain ) Behavioral conditioning Mitral valve prolapse
2x ?..% not increased in Echo. MVP
Etiology
Genetic predisposition Disturbance of
neurotransmitters
NE & 5 HT
in the locus ceruleus
(alarm system
in the brain ) Behavioral conditioning Mitral valve prolapse
2x ?..% not increased in Echo. MVP
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Course & Prognosis
With treatment : good
Some pts recover within weeks even with no treatment.
Others have chronic fluctuating course.
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
Management
Rule out physical causes.
Support & reassurance
Relaxation & CBT Medications:
BNZ
SSRIs
TCAs
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PHOBIA SPHOBIA S
Any Qs So far?Any Qs So far?
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Phobic Disorders Irrational excessive fear ± panic attack on exposure + avoidance or endured with +++ discomfort
Phobic Disorders Irrational excessive fear ± panic attack on exposure + avoidance or endured with +++ discomfort
Agoraphobia Social Specific
1(Away from home, 2)Crowded places, or 3)confinement (in-closed spaces e.g. bridges or in-closed vehicles ( e.g. bus) *where it is difficult or embarrassing to
escape or get help .*Anxiety about
fainting and / or loss of control
Functional impair.
Embarrassment when observed
performing badly or showing anxiety features) e.g. speaking in
public , leading prayer serving guests
*Functional impair.
Objects or situations e.g. blood ex.
dental clinic hospital
airplane (height) animals
insects thunder
storms closed spaces/lifts
darkness
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VIDEO 2&3VIDEO 2&3
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Agoraphobia Social Specific
Epidemiology:F : M = 2 : 1Prevalence : 2–10%.Onset : 20–35 y.
Etiology:Personality predis.Psychosocial trigger.
Treatment :CBT with graded exp.Medications :Either; SSRIs, TCAs, orMAOIs +/- BNZ
Epidemiology:M : F = ? Cultural F.prevalence : 3-13%only 10 % come.
Etiology: Genetic predis. (shyness)psychosocial (shame – criticism)
Treatment:CBT, Ass. T. & SSTMedications :PRN : B-blockers, BNZSSRIs , MAOIs , or TCA
Epidemiology:F>M common in children
Etiology :? Modeling cont. of childhood fearsConditioning.Genetics (blood phobia)
Treatment :Behavior therapy: ERP+/- B blockers / BNZ
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• Video 4 (therapy)• Video 4 (therapy)
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• Normal vs Abnormal
• GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1).
• OCD (Part 2).
• Acute & PTSD, Adjustment Dis., Grief (Part 3).
• Normal vs Abnormal
• GAD, Panic Dis., Agoraphobia, Social Phobia, Specific Phobia (Part 1).
• OCD (Part 2).
• Acute & PTSD, Adjustment Dis., Grief (Part 3).
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Thank you