ANXIETY DISORDER

Jeny Rose Quiblat, MD

ANXIETY

Fearful emotion accompanied by certain physical symptoms

perceived as a subjective feeling of heightened tension and diffuse uneasiness

SUBCLASSES OF ANXIETY DISORDER

Panic Disorder Phobic obsessive-compulsive Generalized anxiety disorder post-traumatic stress social phobia atypical anxiety

PANIC DISORDER

recurrent episodes of intense

apprehension Fear terror accompanied by at least four particular symptoms, all of which reach a peak within 10 minutes.

Attacks are followed by the fear of having additional episodes

PANIC DISORDER

key distinguishing feature of panic disorder is the episodic and recurrent nature of the panic attacks 2 types
Panic Disorder with Agoraphobia Panic Disorder without Agoraphobia

PANIC DISORDER

onset of panic disorder is generally between the ages of 17 and 30 years It is often precipitated by stressful life events. familial, with up to 40% of first-degree relatives also being affected

50% to 90% risk of having a major depressive episode at some point in their lifetime

CRITERIA FOR PANIC ATTACK

A period of intense fear or discomfort in which 4 symptoms developed abruptly and reached a peak period of 10 minutes.

Dyspnea palpitations, chest pain choking or smothering Dizziness paresthesias, diaphoresis, trembling or shaking, chills or hot flashes, nausea or abdominal distress, fears of dying, going crazy or losing control during an attack

CRITERIA FOR PANIC ATTACK

at least one of the attacks must be followed by 1 month of persistent concern about having additional attacks, worry about the implications of the attack or its consequences

THREE STAGES IN THE DEVELOPMENT OF PANIC DISORDER

Stage 1 : Initial acute panic attack or cluster of attack

Described as the worst experience in their life, after one or a series of life events overwhelm their coping mechanisms

Stage 2
Panic attacks increase in frequency phobias develop anticipatory anxiety and avoidance behavior develop medical care seeking dramatically increases for somatic complaint

THREE STAGES IN THE DEVELOPMENT OF PANIC DISORDER

Stage 3: Agoraphobia

fear of the marketplace Fear of being in places or situation from which escape in difficult , embarrassing in the event of panic attack

PANIC DISORDER

W/O AGORAPHOBIA

The following two conditions are present:

recurrent unexpected panic attacks; at least one of the attacks has been followed by a month (or more) of persistent concern about having additional attacks, worry about the implications of the attacks or their consequences a significant change in behavior related to the attacks.

PANIC DISORDER

W/O AGORAPHOBIA

Agoraphobia is not present. The panic attacks are not a result of the direct effects of a substance or a general medical The anxiety is not better accounted for by another mental disorder

PANIC DISORDER

WITH AGORAPHOBIA

The following two conditions are present:

recurrent unexpected panic attacks; at least one of the attacks has been followed by a month (or more) of persistent concern about having additional attacks, worry about the implications of the attacks or their consequences a significant change in behavior related to the attacks.

PANIC DISORDER

WITH AGORAPHOBIA

Agoraphobia is present. The panic attacks are not a result of the direct effects of a substance or a general medical The anxiety is not better accounted for by another mental disorder

COMPONENTS OF PANIC DISORDER

Cognitive
Worry Sense of foreboding Sense of impending doom or dread Tendency to be inattentive, distractible Sense of unreality Rumination Loss of control

COMPONENTS OF PANIC DISORDER

Affective

Isolation Anxiety or nervousness Secondary depression Irritability

Social
Dependency Vocational limitations

COMPONENTS OF PANIC DISORDER

Somatic
Tachycardia Hyperventilation Diaphoresis Dizziness or syncope Flushing Muscle tension Tremulousness Restlessness

a phobic disorder is the persistent and irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the dreaded object, activity, or situation.

The fear is recognized by the individual as excessive or unreasonable in proportion to the actual danger of the situation, object, or activity

Specific Phobia Social Phobia

A specific phobia involves a persistent irrational fear and compelling desire to avoid an object or a situation.

Common among women Peak of onset :5-9 yrs for natural environment type and blood inj type Peak of onset :mid 20s for situational type

fears are related to most social situations (e.g., initiating conversations, dating, participating in small groups, attending parties). has its onset during the teenage years

Onset can occur after a humiliating incident or situation

GENERALIZED ANXIETY DISORDER

Generalized anxiety disorder is excessive worry for at least 6 months. The person finds it difficult to control the worry.

Panic disorder, major depression, alcohol abuse, and organic causes need to be ruled out. Prevalence is 6% in primary care, affecting twice as many women as men.

GENERALIZED ANXIETY DISORDER

The anxiety and worry are associated with at least three of the following six symptoms 1. Restlessness or feeling keyed up or on edge 2. Becoming easily fatigued 3. Difficulty concentrating or the mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance

GENERALIZED ANXIETY DISORDER

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disorder is not the result of the direct effects of a substance or a general medical condition

POST TRAUMATIC STRESS DISORDER

experienced or witnessed a severe catastrophic event that involved actual or threatened death or serious injury to oneself or others. They frequently reexperience the event through dreams or feelings that the event is recurring and may have panic attacks during these flashbacks.

CRITERIA FOR POST TRAUMATIC STRESS DISORDER

The person has been exposed to a traumatic event in which both of the following conditions have been met

The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury or a threat to the physical integrity of oneself or others. The person's response involved intense fear, helplessness, or horror

CRITERIA FOR POST TRAUMATIC STRESS DISORDER

The traumatic event is persistently reexperienced in at least one of the following ways
Recurrent recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting or feeling as though the traumatic event were recurring

The traumatic event is persistently reexperienced in at least one of the following ways Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

CRITERIA FOR POST TRAUMATIC STRESS DISORDER

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma at least 3 of the following

Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of a foreshortened future

CRITERIA FOR POST TRAUMATIC STRESS DISORDER

Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:

Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

CRITERIA FOR POST TRAUMATIC STRESS DISORDER

The duration of the disturbance is longer than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

HISTORY

The history is probably the single best diagnostic tool in the workup of an anxious patient, whether the anxiety is of an acute or chronic nature.
The history taking process should be sufficiently open-ended and unhurried to elicit information about the patient's concerns and fears, current life situation, family and other support systems, and concurrent medical problems.

PHYSICAL EXAMINATION
The patient looks worried and acts tense. Increased motor activity is often evident, Facial muscles may show twitching or tics. Breathing is often rapid and superficial and, unsteady voice, strained facies, grinding of teeth, dilated pupils tremor of hands, flushing and excessive perspiration, and labile hypertension.

MANAGEMENT
Prerequisites for the Physician Adequate Workup Treatment Based on Cause Development of a Therapeutic Plan

his plan usually entails a series of office visits on a regular basis over time and may require specific therapeutic interventions, provides the physician opportunity to reassess the effectiveness and progress of management p

Education Building Support Mechanisms

Members of the extended family and friends are frequently helpful in this respect It is often useful to involve other family members in development of the therapeutic plan.

PANIC DISORDER

Pharmacologic therapy, once effective, should be followed by gradual reexposure to the situations that were being avoided. Start with a selective serotonin reuptake inhibitor (SSRI) or tricyclic antidepressant such as imipramine at a low dosage and then increase until episodes cease.

PANIC DISORDER

first-line treatment of choice for panic disorder should be SSRIs.

paroxetine, sertraline, fluoxetine, citalopram, and fluvoxamine Started at a low doasge Increased dosage by 5mg until panic attacks disappear Common S.E: Jitteriness, nausea headache

PHOBIC DISORDERS

desensitization,

the patient learns a relaxation technique and then, while in a relaxed state, is exposed to a gradual hierarchy of stimuli (through imagery or in vivo) that approaches the phobic object or situation

For agoraphobia, evidence from two studies has shown that imipramine in combination with exposure enhances the effects of exposure

POST-TRAUMATIC STRESS DISORDER

SSRIs are effective in civilians but not veterans, whereas imipramine and monoamine oxidase inhibitors (MAOIs) are effective in veterans. Cognitive-behavioral therapy and eye movement desensitization therapy have been shown to be effective.

The combination of antidepressant medication and psychotherapy may be optimal therapy.