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ANXIETY DISORDERS

No Need to Panic

Monday, February 23, 2015

PANIC DISORDER BY DR. HISHAM AFANEH

Definition of Anxiety
From the German word Angst.
It is indistinguishable From fear except
as to cause.
It is the same Experience of dread and
foreboding

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

:-Definition of anxiety
:-Except that it drives
Unknown internal stimulus
Inappropriate to the reality of an external
stimulus
Concerned with a future stimulus

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Normal versus Pathological anxiety


Normal fear and anxiety serve a useful
function, that is, they protect us from danger.
Such anxiety make sense of identity and meaning of the
life

Pathological anxiety, the fear and anxiety


result in dysfunction and distress.

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

In psychiatry
Anxiety Disorders:
- Separate clinical
entities
- Not secondary to
organic causes
- Functional (no
demonstrable CAUSE)

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Anxiety disorders are


characterized by:
persistent fear and anxiety
that
occurs too often,
is
too severe,
and is
triggered too easily or lasts too long.
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Cont.
Behavior :
-IF anxiety impairs coping.
- IF normal function is disrupted.
- IF avoidance or withdrawal behavior occurs.
.. It is IF A pathologic nature .

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Definition of subtypes
Generalized anxiety disorder (GAD)

symptoms of anxiety are persistent

Varying little from one situation to another

Phobic anxiety disorder

- Symptoms are episodic but associated with defined circumstances

Panic disorder
- Symptoms are episodic not
circumstances

Monday, Februa
ry 23, 2015

associated with defined

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic disorder

Named after Pan, the Greek god of


nature

Monday, February 23, 201


5

PANIC DISORDER BY DR. HISH


AM AFANEH

Panic disorder

Monday, Februa
ry 23, 2015

Criteria of panic attack


Epidemiology
Risk Factors
Differential diagnosis
Treatment

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic disorder
Cardiac neurosis
Da Costa's Syndrome
Effort Syndrome
Nervous syndrome
Neurocirculatory
Asthenia
Soldier's heart

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

:DEFINITION OF PANIC ATTACK


Periodic short bouts of panic
Sudden feelings of terror that occur suddenly and
without warning ,without any cause or precipitation
The Attacks occur in 50%-75% of cases during non REM sleep
( night panic) in addition to day occurrence

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic attacks
Onset
Most can recall the precise date ,time, nature and circumstances of the first
panic attack

Course
Frequency of attacks vary considerably between;
Few attacks in a life time.
Daily attacks for months ,then disappear and reappear.

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic attacks
Duration

From seconds to minutes in most


cases, rarely it persists for hours
followed by exhaustion or
headaches and sometimes long
sleep.

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic Attack criteria


The abrupt onset of an episode of intense fear or
discomfort, which peaks in approximately 10 minutes, and
includes at least four of the following symptoms:

A feeling of imminent danger or doom

The need to escape


Palpitations
Sweating
Trembling
Shortness of breath or a smothering
feeling
A feeling of choking
Chest pain or discomfort
Monday, February 23, 2015

Nausea or abdominal discomfort


Dizziness or lightheadedness
A sense of things being unreal,
depersonalization
A fear of losing control or "going crazy"
A fear of dying
Tingling sensations
Chills or hot flushes

PANIC DISORDER BY DR. HISHAM


AFANEH

There are three types of Panic Attacks

1. Unexpected - the attack "comes out of the blue"


without warning and for no discernable reason.
2. Situational - situations in which an individual
always has an attack, for example, upon entering a
tunnel.
3. Situationally Predisposed - situations in which
an individual is likely to have a Panic Attack, but
does not always have one. An example of this
would be an individual who sometimes has attacks
while driving.

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Case video

Panic attack and Occupational Therapy.flv

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Diagnostic Criteria: Panic Disorder


DSM-IV criteria

Recurrent unexpected panic attacks


A month or more of at least one of the
following after an attack:
Persistent concern about having more
attacks.
Worry about the implications or cause of
attack.
Significant change in behavior related to
attack.
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Diagnostic Criteria:
Panic Disorder
Absence or presence of agoraphobia
Panic attacks not due to substance or
another mental disorder
Various symptoms present with attacks

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Agoraphobia
Fear of the marketplace (agora) = fear of public areas
(stores, theater, public transport), fear of being away
from safe places (home)
Hypothesis: almost exclusively a complication
of panic
Patient afraid of being caught somewhere
having a panic attack, where escape would be
difficult/impossible

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Facts Panic Disorder

3.5% lifetime prevalence


More common in females 2:1
Age typically 20s to 40s, risk may decrease with age
Rates are similar across studies conducted in different
nations (e.g., US, Switzerland, Puerto Rico, far East)
except for lower rates in one Taiwan study

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Primary models for


understanding Panic
Disorder

Monday, February 23,


2015

PANIC DISORDER BY DR. HISHAM


AFANEH

Biological model

Some evidence of a genetic predisposition

Abnormal norepinephrine activity

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Biological model for understanding Panic Disorder Cont

genetics :-Some evidence for


24% of identical twins (Monozygotic)
11% of fraternal twins (Dizgotics)
Disorder runs in families
10

times more likely in biological relatives of those with


panic disorder (genetic vs. environmental factors?)

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Biological model for understanding Panic Disorder Cont

Redmund: that he could stimulate a


norepinephrine rich area of the brain and
cause panic attacks in monkeys.
Bourin: Induced panic attacks in humans by
injecting them with drugs which affect
norepinephrine levels.
Evidence that other neurotransmitters may
also play a role.
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Cognitive Behavioral Model


for understanding Panic Disorder
Cognitive: anxiety sensitivity =
A misunderstanding of bodily functions (sympathetic arousal)
Intense focus on body sensations (biological predisposition?)
Assess those sensations illogically (out of control/dangerous)
Interpret them as harmful

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

How panic works.


Thinking about
going where
you previously
had a panic
attack

The panic vicious


circle:
spiralling out of
control
Short of breath
Chest pain, etc

Frightened and petrified

Im going to pass out

Im dying

Panic Disorder: Risk Factors

Statistically associated with heart condition known


as mitral valve prolapse (MVP), which does not
rule out Axis I diagnosis of panic disorder
Caffeine and stimulant medications frequently
increase panic attack frequency

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic Disorder: Risk Factors,contd


Depression a risk factor for
isolated panic attacks
15-35% of all depressed
patients
- Risk for committing suicide
15%
Alcoholism
- 20-40% of all panic patients

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

DIFERENTIAL
DIAGNOSIS
MEDICAL CONDITIONS
1. Acute myocardial infarction
- in pure panic attacks patient doesn't
experience crushing chest pain

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

DIFERENTIAL DIAGNOSIS
2. Catecholamine secreting tumors
( pheochromcytoma)
Severe Abdominal or Back pain
Hypertensive response to smoking
Malignant hypertensive episodes
Sweating in the chest and back
while in panic in soles , palms and
forehead
Splitting headache
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

DIFERENTIAL
DIAGNOSIS
3. Substance Abuse :
Cocaine.
Marijuana
Alcohol
Opiates

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

DIFERENTIAL
DIAGNOSIS
4.Hypoglycemia:Extremely rarely cause panic
attacks
5. Caffeine:More than 700mg may cause
panic attacks , also patient with
panic disorder may aggravate
with one cup of coffee.
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

What You Can Do


Assessment
Intervention

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Assessment
Physical exam and baseline lab investigations should be
performed before initiation of pharmacological treatment
Regularly monitor weight changes and adverse effects of
medication, including sexual dysfunction

Monday, February 23, 2015

PANIC DISORDER BY DR. HISH


AM AFANEH

Assessment
Explore the possibility of physical causes for
emotional symptoms
A physical exam should be part of the
assessment when new symptoms are present
Look for a history that does not fit
Review personal and family history carefully
Be suspicious if the onset of the disorder is
late in life

Monday, February 23, 2015

PANIC DISORDER BY DR. HISH


AM AFANEH

Assessment
Be suspicious if there is a history of
recent onset of headaches, loss of
function, unusual perceptions (tingling,
dissociation, visual disturbances, or
hallucinations- especially visual, olfactory,
or tactile)
Drugs, drugs, drugs.

Monday, February 23, 2015

PANIC DISORDER BY DR. HISH


AM AFANEH

Baseline Lab Investigations

Complete blood count (CBC)

Fasting glucose
Electrolytes
Liver enzymes
Serum bilirubin
Serum creatinine

Monday, February 23, 2015

Urinanalysis
Urine toxicology for
substance use

24-hour creatinine clearance


(if history of renal disease)

Thyroid stimulating hormone

Electrocardiogram (>40 years or if


indicated)

Pregnancy test (if relevant)


Prolactin

PANIC DISORDER BY DR. HISH


AM AFANEH

TREATMENT
IN Emergency Department
Most cases the attack exhausts itself within minutes
but if it persists An injectable form of
benzodiazepines can be used

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Panic Disorder: Initial Therapy


First line

Second line

Citalopram, escitalopram, fluoxetine,


fluvoxamine, paroxetine, sertraline,
venlafaxine XR
Clomipramine,

imipramine, mirtazapine, benzodiazepines (e.g.,


alprazolam,clonazepam, lorazepam, diazepam)
adjunctive clonazepam

Bupropion, divalproex, gabapentin, moclobemide, olanzapine, adjunctive

Third line

pindolol, phenelzine, risperidone, quetiapine

Buspirone, trazodone, propranolol,


Not
recommended carbamazepine
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

How to Alleviate Panic Attacks

Monday, Februa
ry 23, 2015

How to Help S omeone Having a Panic Attack2.flv

PANIC DISORDER BY DR
. HISHAM AFANEH

Treatment of
hyperventilation ..
Rebreathing
- An immediate treatment is to

rebreathe expired air from bag in


order to increase the concentration of
CO2 in alveolar air
As an effective way of demonstrating
the connection between symptoms
and hyperventilation

Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

Cognitive therapy

The two major foci of cognitive therapy for panic


disorder are :Instruction regarding the patient's false beliefs
( patient's tendency to misinterpret mild bodily sensations
as indicative of impending panic attack, doom or death)

Monday, Februa
ry 23, 2015

Information regarding panic attacks


( when they occur , are time limited and not lifethreatening)

PANIC DISORDER BY DR
. HISHAM AFANEH

Behavioral and Cognitive Therapy

Monday, Februa
ry 23, 2015

Teaches patient to react differently to situations and


bodily sensations that trigger anxiety
Teaches patient to understand how thinking patterns
that contribute to symptoms
Patients learn that by changing how they perceive
feelings of anxiety, the less likely they are to have
them
Examples: Hyperventilating, writing down list of
top fears and doing one of them once a week,
spinning in a chair until dizzy; after awhile patients
learned to cope with the negative feelings associated
with them and replace them with positive ones

PANIC DISORDER BY DR
. HISHAM AFANEH

Strategies to reduce anxiety

Monday, February 23, 2015

PANIC DISORDER BY DR. HISH


AM AFANEH

Breathing exercises

Produce slow deep breathing


Prevent hyperventilation
Prevent excessive blowing off of CO2

How to Alleviate Panic Attacks

Monday, February 23, 2015

How to Do Breathing Exercis es 3.flv

PANIC DISORDER BY DR. HISH


AM AFANEH

Meditation
Cultivates calmness to create a sense
of control over life
Practice: Sit quietly in a position
comfortable to you and take a few
deep breaths to relax your muscles,
next choose a calming phrase (such
as om or that with great
significance to you), silently repeat
the word or phrase for 20 minutes
Monday, Februa
ry 23, 2015

PANIC DISORDER BY DR
. HISHAM AFANEH

How to Do Breathing Exercis es

Monday, Februa
ry 23, 2015

Breathing Exercis es with Enchanting.flv

PANIC DISORDER BY DR
. HISHAM AFANEH

Self Love
The most important holistic treatment of all
Laugh: be able to laugh at yourself and with others;
increases endorphin levels and decreases stress
hormones
Let go of frustrations
Do not judge self harshly: dont expect more from
yourself than you do others
Accept your faults

Monday, February 23, 2015

PANIC DISORDER BY DR. HISH


AM AFANEH

Questions?

Monday, February 23, 2015

PANIC DISORDER BY DR. HISH


AM AFANEH

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