anxiety disorders

the experience of anxiety generalized anxiety disorder panic disorder phobias obsessive-compulsive disorder posttraumatic stress disorder treating anxiety disorders

the experience of anxiety

anxiety involves worry, fear, apprehension, intrusive thoughts, physical symptoms, and feelings of tension. It often seems to have an automatic quality that comes more from within the individual than from situational factors. It is normal for people to experience anxiety when faced with stressful, threatening situations, but it is abnormal to feel strong, chronic anxiety in the absence of an obvious cause. (However “normal” may vary with level of consciousness.)

common anxiety symptoms and self descriptions indicative of high anxiety symptoms

• Nervousness, jitteriness • Tension • Feeling tired • Dizziness • Frequency of urination • Heart palpitations • Feeling faint • Breathlessness • Sweating • Trembling • Sleeplessness • Difficulty in concentrating • hypervigilance

pathological anxiety epidemiology

• Anxiety disorders make up one of the most common groups of psychiatric disorders.

• the national co morbidity study reported that one in four persons met the diagnostic criteria for at least one anxiety d/o • Women (30.5 percent lifetime prevalence) are more likely to have an anxiety d/o than are men (19.2 percent lifetime prevalence). • Finally. The prevalence of anxiety d/o decreases with higher socioeconomic status.

• Prevalence of anxiety

d/o Disorder percent(1yr prevalence)

Any anxiety d/o 13.3

Generalized anxiety d/o 2.8

Panic d/o Phobic d/o 8.0

Obsessive-compulsive d/o Posttraumatic stress d/o 1.7

2.3

3.6

Source: National Institute of Mental Health

self- descriptions

• “ I am often bothered by the thumping of my heart.” • “ little annoyances get on my nerves and irritate me.” • “ I often suddenly become scared for no good reason.” • “ I worry continuously, and that gets me down.” • “ I frequently get spells of complete exhaustion and fatigue” • “ it is always hard for me to make up my mind.” • “ I always seem to be dreading something.” • “ I feel nervous and high-strung all the time.” • “ I often feel I can’t overcome my difficulties.” • “ I feel constantly under strain.”

Psychological sciences psychological theories

each theory has both conceptual and practical usefulness in treating anxiety d/o

psychoanalytic theories behavioral theories existential theories

biological sciences

• • • A range of biologically based sensitivities may exist among persons with the symptoms of anxiety disorders.

•

Autonomic nervous system

system concerned with visceral activities ) (functional division of the nervous : stimulation of the ANS may cause peripheral manifestations of anxiety cardiovascular and/or gastrointestinal.

•

Neurotransmitters

(chemical product of the NS that makes possible the movement of the nerve impulse across the synapse) :norepinephrine, serotonin,and y-aminobutyric acid (GABA) are the three major neurotransmitters associated with anxiety. Brain- imaging studies: CT, MRI, PET, SPECT, EEG.

Genetic studies

Neuroanatomical considerations: limbic system, and cerebral cortex.

generalized anxiety disorder

at least 6-months. hypervgilance.

300.02

A person with GAD experiences vague but intense concerns and fearfulness that persist over a long period The symptoms include motor tension, autonomic reactivity, apprehension about the future, and durations as long as 20 years.

prolonged use of drugs can have significant side effects.

The distinction between GAD and normal anxiety is emphasized by the use of the words “excessive and “difficult to control” in the criteria and by the specification the symptoms cause significant impairment or distress.

clinical features of GAD

1.

2.

3.

Excessive anxiety and worry occurring for at least 6 months and affecting many areas of a person’s life.

Inability to control worry The presence of 3 or more of the following symptoms( only one type of symptom is required for DSM-IV in the diagnosis of children): a. restlessness; feeling on edge b. being easily fatigue c. difficulty concentrating; mind goes blank d. irritability e. muscle tension f. sleep disturbance( difficulty falling or staying asleep; unsatisfying sleep) 4. Considerable distress or impairment in social, occupational, or other important areas of life.

treatment for GAD

• Psychotherapy Cognitive-behavioral:cognitive address patient’s hypothesized cognitive distortions directly, and behavioral approaches address somatic symptoms directly. (relaxation and biofeedback).

supportive: offers patient’s reassurance and comfort, although its long-term efficacy is doubtful.

Insight-oriented: focuses on uncovering conflicts and identifying ego strengths.

substance-induced anxiety disorder 293.84

• The disorder is the direct result of a toxic substance. Including drugs of abuse, medication, poison, and alcohol, among others.

• The DSM-IV diagnostic criteria for substance-induce anxiety disorder require the presence of prominent anxiety, panic attacks, obsessions, or compulsions. The guidelines state that the symptoms should have develop during the use of of the substance or within a month of the cessation of substance use. The structure of the diagnosis includes specification of the substance (e.g. cocaine), specification of the appropriate state during the onset (e.g., intoxication), and mention of the specific symptom pattern (e.g., panic attacks).

Panic disorder

.

• Panic Disorder is an illness in which a person

experiences sudden, sometimes unexpected rushes of intense fear or discomfort accompanied by a number of distressing physical sensations.

• The panic attack, the core feature of panic

disorder, strikes suddenly, often in familiar places where there is seemingly nothing to be afraid of.

• But when the attack comes, it comes as if there

were a real threat, and the body reacts accordingly. Panic disorder is often accompanied by agoraphobia, the fear of being alone in public places (such as supermarkets), particularly places from which a rapid exit would be difficult in the course of a panic attack.

• In addition to agoraphobia, other phobias and

obsessive-compulsive disorder can coexist with panic disorder.

Panic d/o: Panic attacks

• The term panic attack denotes an abrupt surge of intense anxiety rising to a peak that either is cued by the presence, or thoughts, of particular stimuli or that occurs without obvious cues and is spontaneous and unpredictable. During these episodes, the person experiences the urge to flee, or the feeling that they need to escape. The symptoms may be misdiagnose as a serious medical condition (M.I.).

• It is known that the d/o typically begins when its victims are in their 20s. Often a serious event, will trigger the first attack. Women are two to three times more likely to be affected than men. 3 million Americans will experience panic disorders sometime in their lives.

Criteria for panic attack

• 1.

2.

3.

4.

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: is not codable disorder.

Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering 5.

6.

7.

8.

Feeling of choking Cheat pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint 9.

Derealization (feelings or unreality) or depersonalization (being detached from oneself) 10. Fear of losing control or going crazy 11. Fear of dying 12. Paresthesias 13. Chills or hot flashes

treatment for panic disorder

Can consist of taking a medication to adjust the chemicals in your body-just as you might take medicine to correct a thyroid imbalance or any other hormonal imbalance. two major categories of medication that have been shown to be safe and effective in the treatment of panic disorder are antidepressants and benzodiazepines. Another treatment is cognitive behavior therapy (CBT), which focuses on reducing the person’s fears of panic symptoms and assisting the person to resume avoided activities. The combination of medication and psychotherapy appears to be more effective than either treatment alone.

agoraphobia

DSM-IV-TR includes diagnoses for panic disorder with and without agoraphobia and also for agoraphobia without history of panic disorder.

patients with agoraphobia avoid situations in which it would be difficult to obtain help. They prefer to be accompanied by someone in crowded stores, closed-in spaces (tunnels, bridges, and elevators) and closed-in vehicles (subways, buses, and airplanes) severely affected patients may refuse to leave the house. Agoraphobic individuals are often clinging and dependent.

Diagnostic criteria for:

• A.

B.

Panic disorder with agoraphobia 300.21

Both (1) and (2) The presence of agoraphobia • A.

B.

C.

D.

Agoraphobia without history of panic disorder 300.22

The presence of agoraphobia related to fear of developing panic-like symptoms Criteria have never been met for panic disorder The disturbance is not due to the direct physiological effects of a substance or a general medical condition If an associated general medical condition is present, the fear described in criterion A is clearly in excess of that usually associated with the condition.

phobias

• People who have phobias have fears related to specific objects, people, or situations. • Phobias often develop gradually or begin with a generalized anxiety attack. • Phobias are common disorders that affect women about twice as frequently as men. Phobias often begin before adulthood and are likely to become chronic. • Phobias can be grouped into three main types: specific phobias, social phobias, and agoraphobia.

examples for five categories of phobias

Separation fear

Crowds Traveling alone Being alone at home

Animal fears

Mice Rats Insects

Nature fears

Mountains The ocean Cliffs, heights

social fears

eating with strangers being watched while writing being watched while working

mutilation fears

open wounds surgical operations blood

Specific phobias 300.29

• Most commonly occurring type of phobia. This group includes miscellaneous irrational fears such as intense fear of a certain type of animal or of being in an enclosed place. Specific phobias may arise from an earlier frightening or anxiety-producing situation that involved the type of person or situation that later became associated with the phobia. Procedures that use the classical conditioning approach of pairing the phobic stimulus with nonanxiety response are often used successfully to treat specify phobias.

• Criteria A (excessive fear) and B (stimulus exposure) • In specific phobia the panic attack is situationally bound to the specific phobic stimulus. Specify type.

• Treatment: exposure therapy(therapist desensitize pt. by using a series of gradual, self-paced exposures to the phobic stimuli, and they teach pt.’s various techniques to deal with anxiety, including relaxation, breathing control, and cognitive approaches. Pharmacotherapy may also benefit.

Social phobias (social anxiety disorder) 300.23

• Intense and incapacitating fear and embarrassment when dealing with others characterize social phobias. Fear of blushing when in a social situation and fear of eating when others are present are two social phobias that are especially difficult to treat successfully.

Treatment:

• Psychotherapy for the generalized type of social phobia usually involves a combination of behavioral and cognitive methods, including retraining, desensitization, rehearsal during sessions, and a range of homework assignments.

Obsessive-compulsive disorder 300.3

• People affected by an obsessive-compulsive d/o are unable to control their preoccupation with specific ideas or are unable to prevent themselves from repeatedly carrying out a particular act or series of acts that affect their ability to carry out normal activities. • Obsessive behavior is the inability to stop thinking about a particular idea or topic. The topic of these thoughts is often felt by the person involved to be unpleasant and shameful. • Compulsive behavior is the need to perform certain behaviors over and over. Many compulsions deal with counting, ordering, checking, touching and washing.

OCD DSM-IV-TR CRITERIA

• Criteria for obsessive-compulsive disorder include having recurrent and persistent thoughts, impulses, or images that are not simply general worries and real-life problems. • Patients recognize that the unwanted thoughts and rituals are the products of their minds, but distress persist and personal routines are seriously disrupted.

OCD symptoms patterns

• The presentation of obsessions and compulsions is heterogeneous in adults and in children and adolescents. The symptoms of an individual patient may overlap with time, but OCD has four major symptoms patterns.

1. Contamination- the fear object is often hard to avoid (e.g. feces, urine, dust, or germs)accompanied by compulsive avoidance. patients usually believe that the contamination is spread from object to object or person to person.

2. pathological doubt-often implies some danger of violence (e.g. forgetting to turn off the stove or not locking the door)followed by a compulsion of checking. The pt.’s always feel guilty about having forgotten or committed something. 3. Intrusive thoughts- repetitious thoughts of a sexual or aggressive act that is reprehensible to the pt. without compulsions.

OCD-symptoms patterns

4. Symmetry- the fourth most common patterns is the need for symmetry or precision, which can lead to a compulsion of slowness.

5. Other symptom patterns- religious obsessions and compulsive hoarding are common in patients with OCD. Trichotilomania (compulsive hair pulling) and nail niting may be compulsions related to OCD.

Cognitive therapist seek to help patients become aware of their excessive sense of responsibility as a step toward overcoming obsessions and compulsions.

Posttraumatic stress disorder 309.81 (PTSD)

• PTSD may occur after an extreme stress such as a

natural disaster, a serious accident, or participation in a battle or other war-related situations.

•

PTSD symptoms vary widely but may include recurrent dreams, flashbacks, impaired concentration, and emotional numbing. T

• hose experience PTSD after a stressful experience are

likely to have had previous histories of psychological disorder.

• The emotional disorder that often arises after a trauma such as war, assault, natural disaster, or death of a loved one is

posttraumatic stress disorder(PTSD)

. According to the DSM-IV-TR, a person with • PTSD must have been exposed to some event during which he/she feels fear, helplessness, or horror. • • Then, the person continues to reexperience the event through memories, reenactments, nightmares, or flashbacks. Cues that remind the person of the event are avoided and emotional responsiveness is numbed. • Often such individuals are chronically overaroused, easily startled, and quick to anger. With PTSD, the alarm response is a true alarm, meaning that it occurs in response to real threat or danger.