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anxiety disorder
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Elmeida EffendyPsychiatric Department
Medical FacultyUSU
ANXIETY DISORDER
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DSM- IV-TR 1. Panic disorder with or without
agoraphobia2. Agoraphobia with or without panic
disorder3. Specific phobia4. Social phobia5. Obsessive-compulsive disorder6. Posttraumatic stress disorder7. Acute stress disorder8. Generalized anxiety disorder
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Panic Disorder & AgoraphobiaAn acute intense attack of anxiety
accompanied by feelings of impending doom is known as panic disorder
The anxiety is characterized by discrete periods of intense fear that can vary from several attacks during one day to only a few attacks during a year
Patients with panic disorder present with a number of comorbid conditions, most commonly agoraphobia, which refers to a fear of or anxiety regarding places from which escape might be difficult
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DSM-IV-TR Criteria for Panic AttackA discrete period of intense fear or
discomfort,in which four (or more) of the following symptoms developed abruptly & reached a peak within 10 minutes :
1.palpitations, pounding heart, or accelerated heart beat
2. sweating3. trembling or shaking4. sensations of shortness of breath
or smothering5. feeling of choking6.chest pain or discomfort4
7. nausea or abdominal distress8. feeling dizzy, unsteady,
lightheaded or faint9. derealization (feelings of
unreality) or depersonalization ( being detached from one self)
10. fear of losing control or going crazy
11. fear of dying12. paresthesias ( numbness or
tingling sensations)13. chills or hot flushes
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The DSM-IV-TR contains 2 diagnostic criteria for panic disorder, one without agoraphobia and the other with agoraphobia, but both require the presence of panic attacks
Panic attacks can occur in mental disorders other than panic disorder, particularly in specific phobia, social phobia & PTSD
Unexpected panic attacks occur at any time & are not associated with any identifiable situational stimulus, but panic attacks need not be unexpected
Attacks in patients with social & specific phobias are usually expected or cued to a recognized or specific stimulus
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Some panic attacks do not fit easily into the distinction between unexpected & expected, and these attacks are referred to as situationally predisposed panic attacks
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DSM- IV- TR Criteria for AgoraphobiaA. Anxiety about being in places or
situations from which escape might be difficult(or embarassing)or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge & traveling in a bus, train or automobile
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B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic –like symptoms, or require the presence of a companion
C. The anxiety or phobic avoidance is not better accounted for by another mental disorder , such as social phobia (e.g., avoidance limited to social situations because of fear of embarassment), specific phobia (e.g., avoidance limited to a single situation like elevators), obsessive compulsive disorder ( avoidance of dirt), posttraumatic stress disorder ( avoidance of stimuli associated with a severe stressor) or separation anxiety disorder (e.g., avoidance of leaving home or relatives)
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Specific Phobia & Social PhobiaPhobia : an excessive fear of a specific
object, circumstance or situationSpecific phobia : strong, persisting fear of
an object or situationSocial phobia :strong, persisting fear of
situations in which embarassment can occur
The diagnosis of both specific & social phobia requires the development of intense anxiety, even to the point of panic, when exposed to the feared situations
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Specific PhobiaMore common than social phobiaMay anticipate harm, such as being bitten by a
dog, may panic at thought of losing control if they fear being in an elevator
The peak age of onset for the natural environment type & blood-injection-injury-type : 5-9 years
Onset for situational type (except fear of heights): mid 20s
The feared objects & situations in specific phobia (listed in descending frequency of appearance) are animals, storms, heights, illness, injury & death
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Social Phobia= Social Anxiety DisorderHave excessive fears of humiliation or
embarassment in various social settings, such as speaking in public, urinating in public rest room (‘shy bladder”) &speaking to a date
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Obsessive Compulsive Disorder (OCD)Represented by a diverse group of symptoms
that include intrusive thoughts, rituals, preoccupation & compulsions
These recurrent obsessions or compulsions cause severe distress to the person
The obsessions or compulsions are time –consuming & interfere significantly with the person’s normal routine, occupational functioning, usual social activities or relationships
A patient with OCD may have an obsession, a compulsion or both
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Obsession : a recurrent & intrusive thought, feeling, idea or sensation
Compulsion : a behaviorSpecifically, a compulsion is a conscious,
standardized, recurrent behavior, such as counting, checking, or avoiding
A patient with OCD realizes the irrationality of the obsession & experiences both the obsession & the compulsion as ego-dystonic (unwanted behavior)
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OCD has 4 major symptom pattern :1. Contamination2. Pathological doubt3. Intrusive thoughts4. Symmetry
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ObsessionsContaminationPathological doubtSomaticNeed for symmetryAggressiveSexualOtherMultiple obsessions
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CompulsionsCheckingWashingCountingNeed to ask or confessSymmetry and precisionHoardingMultiple comparisons
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TreatmentPharmacotherapy : SSRI, clomipramineBehavior therapy : desensitization,thought
stopping,flooding,implosion therapy & aversive conditioning
Psychotherapy
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Posttraumatic Stress Disorder (PTSD)& Acute Stress DisorderCondition marked by the development of
symptoms after exposure to traumatic life eventsThe person reacts to this experience with fear &
helplessness, persistently relives the event, & tries to avoid being reminded of it
PTSD :The symptom must last for more than a month after the event & must significantly affect important areas of life, such as family & work
Acute stress disorder : occurs earlier than PTSD; within 4 weeks of the event, & remits within 2days to 4 weeks
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The stressors causing both acute stress disorder & PTSD are sufficiently overwhelming to affect almost anyone
They can arise from experiences in war, torture, natural catatstrophes, assault, rape & serious accidents, for example, in cars & in burning buildings
The DSM-IV-TR diagnostic criteria for PTSD specify that the symptoms of experiencing, avoidance & hyperarousal must have lasted more than 1 month ;acute : if the symptoms have lasted less than 3 months, chronic : if the symptoms have lasted than 3 months or more
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Clinical Features of PTSDPainful reexperiencing of the event, a
pattern of avoidance & emotional numbing, fairly constant hyperarousal
The disorder may not develop until months or even years after the event
The mental status examination often reveals feelings of guilt, rejection & humiliation
Patients may also describe dissociative states & panic attacks, illusions & hallucinations may be present
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Treatment
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Pharmacotherapy : SSRI : sertraline, paroxetine
Psychotherapy : psychodynamic psychotherapy, crisis intervention with support, education & development of coping mechanism & acceptance of the event
Generalized Anxiety Disorder
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Excessive anxiety & worry about several events or activities for most days during at least 6- month period
The worry is difficult to control and is associated with somatic symptoms, such as muscle tension, irritability, difficulty sleeping & restlessness
Anxiety is not focused on features of another axis I disorder, not caused by substance use or a general medical condition& does not occur only during a mood or psychiatric disorder
Anxiety is difficult to control, is subjectively distressing & produces impairment in important areas of a person’s life
DSM-IV_TR Diagnostic Criteria for Generalized Anxiety Disorder
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A. Excessive anxiety & worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
B. The person finds it difficult to control the worry
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C. The anxiety & worry are associated with 3 or more of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months)1. restlessness or feeling keyed up or on
edge2. being easily fatigue3. difficulty concentrating or mind going
blank4. irritability5. muscle tension6. sleep disturbance ( difficulty falling or
staying asleep, or restless unsatisfying sleep)
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D. The focus of the anxiety & worry is not confined to features of an axis I disorder
E. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
The disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder or a pervasive developmental disorder