ANXIETY DISORDERS By Professor Dr Mostafa ElSaadani WHAT
ANXIETY DISORDERS By Professor Dr: Mostafa El-Saadani
WHAT ARE ANXIETY DISORDERS? • The most prevalent group of psychiatric conditions They are common conditions. Prevalence rate ranges from 2% to 13%. Female to male ratio is about 1. 5: 1. They are underdiagnosed & undertreated. Psychotic features are absent.
Anxiety Disorders • They are mostly caused by an interaction between genetic predisposition & external stressors or traumas; leading to appearance of different disorders. This means that anxiety and related disorders are illnesses NOT weakness of personality nor weakness of religious beliefs. • The main difference between physiological fear & anxiety and related disorders is the presence of significant distress & impairment in activities & relations.
Nosology Anxiety disorders include: • • • Generalized anxiety disorder (GAD). Specific phobia. Social anxiety disorder (social phobia). Panic disorder. Agoraphobia. Separation anxiety disorder. Selective mutism. Substance/ medication induced anxiety disorder. Anxiety disorder due to another medical condition.
Anxiety Disorders: Nosology • According to Diagnostic & statistical manual of mental disorders-fifth edition (DSM-5) , that was issues in 2013, they are grouped and differentiated into (3) main categories: • I. Anxiety disorders. • II. Obsessive compulsive & other related disorders. • III. Trauma- & stressor- related disorders. • (N. B Comorbidities between different types of anxiety disorders are common. • Also, comorbidities between depressive symptoms (or disorders) and different types of anxiety disorders are common.
Anxiety Disorders: Nosology • II. Obsessive-compulsive & other related disorders: • Obsessive compulsive disorder (OCD). • Body dysmorphic disorder. • Hoarding disorder. • Trichotillomania (hair pulling with sense of tension). • Excoriation disorder (skin picking disorder). • Substance/ medication induced obsessive-compulsive & other related disorders. • Obsessive-compulsive & other related disorders due to another medical condition.
Anxiety Disorders: Nosology • • III. Trauma- & stressor- related disorders: Posttraumatic stress disorder (PTSD). Acute stress disorder (ASD). Adjustment disorder.
1. Generalized anxiety disorder • This disorder is characterized by excessive anxiety and worry for 6 months or more. Anxiety and worry are associated with at least 3 of the following symptoms: • Restlessness or feeling on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance • The disorder causes significant distress & impairment in activities & relations. (but delusions are extremely rare) • “N. B although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder”.
2. Specific phobia: • Exposure to certain neutral objects provokes immediate & marked fear. That's why the patient always tries to avoid these objects. This marked fear is out of proportion to the actual danger. • Objects that can provoke this fear can be animals (e. g. cats), environmental (e. g. heights) or blood - injuries (e. g. needles). • The disorder causes significant distress & impairment in activities & relations. • Differential diagnoses have to be excluded.
3. Social anxiety disorder (social phobia): • Exposure to social situations (as talking or eating in front of others) provokes immediate & marked fear. That's why the patient always tries to avoid these situations. • This marked fear is out of proportion to the actual danger. • The disorder causes significant distress & impairment in activities & relations. • Differential diagnoses have to be excluded.
4. Panic disorder: • Recurrent episodes of panic attacks. A panic attack is a sudden onset of intense fear or discomfort, usually reaching a peak within 10 minutes. Attacks are associated with a group of systemic symptoms, including at least 4 of the following: • • Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Shortness of breath or feeling of smothering Choking sensation Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint
4. Panic disorder: • Derealization (i. e. , feeling of unreality) or depersonalization (i. e. , being detached from oneself) • Fear of losing control or going crazy • Fear of dying • Paresthesias (i. e. , numbness or tingling sensations) • Chills or hot flashes • Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attack resulting in significant behavioral changes (e. g. , avoiding situations or locations) and worry about the implications of the attack or its consequences (e. g. losing control, going crazy, dying). The disorder causes significant distress & impairment in activities & relations.
5. Agoraphobia: (Agora = Market) • Exposure to 2 or more of the following (using public transportation, being in open spaces, closed places, standing in line or in crowd & being outside the home alone) provokes immediate & marked fear. • The patient always tries to avoid these situations because of thoughts that is escape might be difficult. • This marked fear is out of proportion to the actual danger. • The duration of suffering is 6 months or more. • The disorder causes significant distress & impairment in activities & relations. • Differential diagnoses have to be excluded.
6. Obsessive-compulsive disorder (OCD): • Obsessions: Recurrent, persistent & usually unwanted thoughts, urges or images. The patient knows that they are a product of his/her mind (Egodystonic). Their presence cause marked distress. The patient tries to ignore or stop them, but it is not easy to reach this goal. • Compulsion: Repetitive behaviors (e. g. handwashing) or mental acts (e. g, counting) as a response & as a trial to stop obsessions. • Obsessions & compulsions are time consuming (taking more than one hour per day). The disorder causes significant distress & impairment in activities & relations. Differential diagnoses have to be excluded.
7. Posttraumatic stress disorder (PTSD): • Exposure to a severe stressor such as combat violence, sexual assault, physical assault, near death experience or witnessed death of a loved one. • The stressor can be experienced directly, witnessed directly or indirect • (hearing of exposure of a close relative to severe trauma). • In addition to the trauma exposure, diagnosis of PTSD requires symptoms in 4 symptom domains for more than one month: • Intrusion: Intrusive memories, flashbacks (patient feels or acts as if traumatic events" were recurring), nightmares
7. Posttraumatic stress disorder (PTSD): • • • This name was coined after Vietnam War Avoidance: Avoidance of trauma-related cues, thoughts or feelings Negative cognition and mood: Memory impairment of the trauma, self-blame, negative evaluation of self Alteration of arousal and reactivity: Insomnia, hypervigilance, irritable or aggressive behavior The disorder causes significant distress & impairment in activities & relations. "N. B. If the condition started immediately after trauma and persisted for at least 3 days up to a month; the condition is called acute stress disorder (ASD). If the condition started or persisted after one month, so the condition is named Posttraumatic stress disorder (PTSD)".
Differential diagnosis: • In all types of anxiety and related disorders, we have to exclude: • Other types of anxiety disorders. • Other types of mental disorders (e. g. if the patient c/o fear of insects; as these insects are advanced tools to withdraw his/her thoughts from his mind, so the patient is suffering from psychosis not phobia). • Substance/ medication induced anxiety & related disorders (e. g. cannabis induced). • Anxiety & related disorders due to another medical condition (e. g. hyperthyroidism, pheochromocytoma, Caushing’s disease, myocardial infarction, hypoxemia, hypoglycemia).
Investigations: • Investigations to exclude differential diagnosis (e. g. CBC, LFTs, TFTs, lipid profile, increased cortisol (Caushing disease), increased adrenaline (Pheochromocytoma), or urine screaming for illicit drugs). • Investigations for psychopharmacological treatment initiation or follow up (e. g. serum Na level for patients starting to receive medical treatment for fear of hyponatremia that may occur as a side effects for these drugs (especially SSRIs). • (N. B choice of investigations if needed depends on the clinical assessment).
Prognosis: • Generally, most of the cases of different types of anxiety and related disorders show significant improvement with treatment. • Absence of comorbid substance use disorder, comorbid depression & presence of good social support usually lead to better prognosis.
Treatment: • Psychotherapy: – - It's the main line of treatment for mild cases. In moderate & severe cases; better results are reached with combination of psychopharmacological & psychotherapeutic intervention than psychopharmacological intervention alone. • Methods commonly used are relaxation techniques, systemic desensitization (in phobias), stop technique and exposure & response prevention (in OCD). •
Treatment • Psychopharmacology: – Needed for moderate & severe cases – The start of clinical improvement needs about 2 -8 weeks (4 -12 weeks for OCD). • The least duration of treatment is 12 months while the patient is free of Symptoms. Stoppage of medication before 12 months increases the likelihood of relapse "i. e. return of symptoms again". • Psychopharmacological intervention is NOT harmful. They WON'T cause addiction "except for benzodiazepines if used for a prolonged period".
Treatment • 1. Antidepressants: • a) Selective serotonin reuptake inhibitors (SSRIs): • - Drugs of this group are (fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram & escitalopram) • - The usual side effects that can occur are nausea, headache, and initial irritability, insomnia or somnolence sexual side effects and hyponatremia. • b) Other antidepressants: • Tricyclic antidepressants (TCAs): as clomipramine for (OCD). • Serotonin Noradrenaline reuptake inhibitors (SNRIs): as venlafaxine. • Trazodone: for treatment of insomnia & initial irritability at starting of SSRIs
Treatment • 2. Other medications: • a. Benzodiazepines (minor tranquilizers): • b. Propranolol: for social anxiety occurring only in definite situations (e. g. exam phobia) and (some cases of PTSD with palpitations). Propranolol can be given just an hour before this situation; if there is no contraindication (. e. g. bronchial asthma). • Hospitalization: Usually, it isn't needed except in certain situations like: 1. Suicidal attempts. 2. severe panic attacks. 3. Observation & investigations of Differential diagnosis (e. g. substance use disorder) 4. Presence of comorbid conditions like severe comorbid depression.
Treatment • ECT (Electroconvulsive therapy): • Generally, the response of anxiety & related disorders is poor for ECT. However, ECT can be used for treating suicidal attempts or severe comorbid depression.
MCQs 1 -Delusion is rarely seen in: a. Depression b. Schizophrenia c. Anxiety d. Mania 2 -Twenty yr old female develops sudden episodic palpitation, tremors, fear of impending doom. Diagnosis is a. Panic disorder c. Social phobia c. Generalized Anxiety disorder d. Agoraphobia
MCQs 3 -Which is the treatment of choice for OCD? a. Exposure and response prevention b. Psychoanalysis c. Flooding d. Modeling 4 -The following is False about panic disorder : a. Symptoms begin unexpectedly or out of the blue b. Physical symptoms like tremors, tachycardia and psychological symptoms like hyperarousal, fear of impending doom can be seen c. Sudden onset of symptoms precipitated by some fearful event or stimuli d. It is important to look for medical conditions like hyperthyroidism, hypoglycemia, phaeochromocytoma, cardic disorders before diagnosing panic disorder
MCQs 5 -A middle age person complains of fear of leaving home fear of travelling alone and fear of being in crowd. He develops marked anxiety with palpitations and sweating if he is in these situations. he often avoids public transport to go his work place. the most likely diagnosis is a. GAD b. Personality disorder c. Schizophrenia d. Agarophobia 6 -Systematic Desensitization is most suitable treatment for the treatment of a. Phobia b. OCD c. Hysteria d. Hypochondriasis
MCQs 7 - Housebound Housewife syndrome is associated with: a. Depression b. OCD c. Agoraphobia d. Somatoform Disorder 8 -. A 25 year old female presents with 2 year history of repetitive, irresistible thoughts of contamination with dirt associated with repetitive hand washing. She reports these thoughts to be her own and distressing; but is not able to overcome them along with medications. She is most likely to benefit from which of the following therapies? a. Exposure and response prevention b. Systematic desensitization c. Assertive training d. Sensate focus
MCQs 9 - An obsession has following symptoms Except: a. Irrational thoughts b. Ego syntonic thoughts c. Ego dystonic thoughts d. Intrusive thoughts 10 -. Which of the following is seen in phobic anxiety states? a. Derealization b. La belle indifference c. Incongruity of affect d. Delusion of bodily change 11 - OCD responds better to a) Imipramine b) Clomipramine c) Amytryptiline d) Nortryptiline
MCQs 12 - Which war saw the coining of the term Post-traumatic Stress disorder (PTSD)? a. Gulf War b. Vietnam War c. Operation Enduring Freedom d. World War II 13 -. A 17 -year-old girl blushes, stammers, and feels completely foolish when one of her classmates or a teacher asks her a question. She sits at the back of the class hoping not to be noticed because she is convinced that the other students think she is unattractive and stupid. What is the possible diagnosis: a. Social anxiety disorder b. PTSD c. Agoraphobia c. GAD
MCQs 14 - Two years after she was saved from her burning house, a 32 -year-old woman continues to be distressed by recurrent dreams and intrusive thoughts about the event. What is the possible diagnosis: a. GAD b. Acute stress disorder c. PTSD d. Phobic disorder 15 - A Vietnam veteran startles, starts hyperventilating & palpitations whenever he hears a sharp noise. What is the most suitable medication for his condition: a. SSRIs b. Tricyclic antidepressant c. Propranolol d. Antipsychotic
MCQs 16 - A talented 21 -year-old violinist’s musical career is in jeopardy because he becomes acutely anxious whenever he is asked to play in front of an audience. What is the most suitable medication for his condition: a. SSRIs b. Tricyclic antidepressant c. Propranolol d. Antipsychotic 17 -. A 34 -year-old secretary climbs 12 flights of stairs every day to reach her office because she is terrified by the thought of being trapped in the elevator. She has never had any traumatic event occur in an elevator; nonetheless, she has been terrified of them since childhood. Which of the following is the most likely diagnosis? a. Social phobia b. Performance anxiety c. Generalized anxiety disorder d. Specific phobia e. Agoraphobia
MCQs 18 - Fear restricted to a particular object, situation and place is known as a. Anxiety b. Conversion disorder c. Phobia d. OCD 19 -Twenty Eight year old female who lost her son in a natural disaster Tsunami, 2 months later she started having flashbacks, hyper-arousals, intrusive images of the event. What is the probable diagnosis? a. PTSD b. Dissociative disorder c. Acute stress disorder d. Depressive episode 20 - Selective Serotonin Reuptake Inhibitors (SSRIs) are not indicated in a. Mania b. GAD c. OCD d. PTSD
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