Anxiety Disorders by Dr Sarma

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Information about Anxiety Disorders by Dr Sarma

Published on December 17, 2008

Author: aSGuest6903


Anxiety Disorders New Insights : Anxiety Disorders New Insights Dr.R.V.S.N.Sarma., M.D., M.Sc., Consultant Physician visit : Slide 2: ANXIETY Slide 4: What is anxiety ? ????It is a mood-state with ????Marked Negative effects ????Bodily symptoms of tension ????Apprehensions about future Its consequence is ‘worry’ Slide 5: What is physiological worry ? ?? Worry is a normal response to stressful situations limited to particular situations Should not exceed the duration of event Should not spread to other topics ?? Excessive worry should not be seen as a normal response, as part of one’s personality Slide 6: What is pathological worry ? ????It is a component of anxiety ????Negative emotional thoughts, images ????Uncontrollable and they occur in sequence ????Concern about future threats and danger Their frequency and intensity are more Slide 7: What do people worry about ? ????Real problems that could be potentially solved, but are not acted on ?? Real problems that probably cannot be solved (at least not by the individual), but can be coped with ?? “Imagined problems” that do not yet exist and probably will never exist ?? Worry about worry and its consequences Slide 8: Pathological v/s normal anxiety ???? Autonomous responses ???? Greater intensity ???? Longer duration ???? Behavior significantly affected Stressor may be minimal or absent Slide 9: Origin of anxiety ????Protective response ????Normal/protective anxiety Fear and pathological anxiety Common underlying neuro-physiology ?? Two categories of fear/anxiety Acute and Chronic Slide 10: Negative effects of worry Unreasonable fear Anxiety Disorder Panic Disorder Substance abuse Depression Slide 12: What cause Anxiety Disorders ? ????No single cause ?? Several possible causes ?? genetics, other biological factors physiology, infection, injury, trauma ?? temperament, life experiences ?? upbringing, family, school, peers, society in general, Doctors in particular stress - chronic or acute Slide 13: What cause Anxiety Disorders ? Slide 14: Importance of Anxiety Disorders ????Accurate Dx and Rx of anxiety disorders is essential Reduction of secondary psychiatric conditions Depression Substance abuse problems Slide 15: Generalized Anxiety Disorder (GAD) 2. Panic Disorder (PD) with Agoraphobia (AG) 3. PD sans Agoraphobia 4. Specific Phobia (SP) 5. Social Phobia (SoP) 6. Obsessive Compulsive Disorder (OCD) 7. Post traumatic Stress Disorder (PTSD) 8. Acute Stress Disorder 9. SAD, CAD (ASD) 10. Substance-Induced Anxiety disorder (SIAD) 11. Anxiety disorder due some medical illness Anxiety Disorders - DSM-IV Dual Diagnosis Disorders Prevalence of Anxiety Disorders : Prevalence of Anxiety Disorders Kessler et al. Arch Gen Psychiatry. 1995;52:1048. Kessler et al. Arch Gen Psychiatry. 1994;51:8. Slide 17: Sex differences in Anxiety Disorders Are women more ‘Nutty’ ? Slide 18: Spectrum of Anxiety Disorders Slide 20: What is Gen. Anxiety Disorder ? Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long. The “What if?” disorder Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress. Slide 21: Domains of anxiety ????Physical ????Affective ????Cognitive ????Behavioral Slide 22: Physical domain ???? Anorexia ???? Butterflies in stomach ???? Chest pain/tightness ???? Diaphoresis ???? Dry mouth ???? Dyspnoea ???? Faintness ???? Flushing ???? Hyperventilation ???? Light-headedness ???? Muscle tension ???? Nausea, Vomiting ???? Pallor ???? Palpitations ???? Paresthesias ???? Sexual dysfunction Slide 23: Physical domain contd.. ???? Headache ???? Shortness of breath ???? Stomach pain ???? Tachycardia ???? Tremulousness ???? Urinary frequency ???? Diarrhea Slide 24: Affective domain ???? Edginess ???? Uneasiness ???? Terror ???? Panic Slide 25: Behavioral domain ???? Triggers many responses ???? Behavioral in nature ???? Concerned with diminishing ???? And even avoiding the distress Slide 26: Regulation of locus ceruleus ????Alpha-noradrenergic auto receptors ????Serotonin receptors ????GABA-benzodiazepine receptors ????Opiate receptors Dopamine receptors The amygdala and locus ceruleus : The amygdala and locus ceruleus Slide 28: Generalized Anxiety Disorder -GAD Pathological anxiety, which is excessive, chronic and typically interferes with their ability to function in normal daily activities. GAD is distinguished from Phobic anxiety – as it is not triggered by a specific object Restlessness or feeling keyed up or on edge, Being easily fatigued, Difficulty concentrating or mind going blank, Irritability, Muscle tension, Sleep disturbance Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events. The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms Slide 29: Case # 1 Ms. D has a chief c/o “worrying about everything” for the last year. She also c/o frequent headaches, fatigue and insomnia secondary to the anxiety. These symptoms have worsened to the point where she has been distracted and making mistakes at work. Slide 30: Worry that is ?? Excessive, uncontrollable ?? Frequent, multiple topics (not only onetime) ?? More than one day out of two 3 out of 6 other associated physical symptoms ?? Muscle tension, Restlessness ?? Fatigued easily, Irritability ?? Sleep disturbance, Concentration difficulty GAD – Mr. Fisc Slide 32: Acute fear state ????Response to life-threatening danger ????Terror, helplessness, Sense of impending disaster/doom ????Urgency to flee or seek safety ????Sympathetic/Nor-adrenergic activation ????Located in locus ceruleus ?? Corresponds to panic attacks Slide 33: Agoraphobia Anxiety in situations where escape might be difficult (or embarrassing) or help might not be available in the event of having a panic attack or panic-like symptoms Situations are avoided or endured with marked distress May not leave home or may need a companion Can occur with and without panic disorder Slide 34: Agoraphobia Slide 35: Social Phobia Marked, persistent fear of social or performance situations where a person is exposed to unfamiliar situations or people or possible scrutiny by others. The individual fears acting in an embarrassing or humiliating way. The Person recognizes fear as excessive. Exposure causes anxiety symptoms or panic Situations are avoided or endured with anxiety Slide 36: Specific Phobias Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a Panic Attack. The person recognizes that his/her fear is excessive or unreasonable. The phobic situation is avoided or else is endured with intense anxiety or distress Slide 37: Specific Phobias - Examples Acrophobia fear of heights Agoraphobia fear of open places Claustrophobia fear of enclosed places Ailurophobia fear of cats Cynophobia fear of dogs Pathophobia fear of disease Mysophobia fear of dirt and germs Arachnophobia fear of spiders Hematophobia fear of blood Xenophobia fear of strangers Better-halfophobia fear of wife Slide 39: PAN – The Greek God Slide 40: Panic Attack – DSM IV ?? Palpitations Sweating Trembling or shaking Shortness of breath Feeling of choking Chest pain or discomfort Nausea or abd. distress 8. Feeling dizzy, fainty 9. Derealization (feelings of unreality) 10. Fear of going crazy 11. Fear of dying 12. Paresthesias 13. Chills or hot flushes ????A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes Slide 41: Case # 2 Mrs. B c/o a long h/o episodes of anxiety, SOB, racing heart, sweating, CP, and fears that she is having a MI and will die. These last 30 minutes and are unexpected. She c/o anxiety while in malls and traveling alone to new places for fear of having another attack. Despite a negative w/u, she still worries about having a MI during an attack. Slide 42: Panic Disorder with Agoraphobia Recurrent unexpected panic attacks: anxiety associated with at least four physical and/or cognitive symptoms cognitive symptoms At least 1 month of worry about having additional attacks or the consequences of an attack (losing control, having a heart attack, “going crazy”). Agoraphobia Slide 43: Panic Disorder – Chest pain Chest pain is a common symptom of panic attacks 22 – 70% of panic attacks are associated with CP 18 – 25% of all patients with chest pain have PD Rates of PD higher among cardiology outpatients with chest pain. Such patients undergo expensive cardiac workups, but their PD remains undiagnosed & untreated. Slide 45: Obsessive Compulsive Disorder - OCD Obsessions Recurrent and persistent thoughts, impulses, or images that are experienced during the disturbance, as intrusive and inappropriate, and cause marked anxiety or distress. The thoughts, impulses, or images are not simply excessive worries about real life problems. The person attempts to ignore or suppress such thoughts impulses or to neutralize them with some other thought or action. The person recognizes that the obsessive thoughts, impulses, or images are a product of his or her own mind Slide 46: Obsessive Compulsive Disorder -OCD Compulsions Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) He/she is driven to perform in response to an obsession, The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event But, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive. Slide 47: Obsessive Compulsive Disorder -OCD Putamen Globus Pallidus Caudate Nucleus Thalamus Orbital frontal cortex Slide 49: Post traumatic Stress Disorder- PTSD Slide 50: Post traumatic Stress Disorder- PTSD Experiential requirements The person has experienced a life-threatening event and has responded with intense fear, hopelessness or horror. The person’s response to the event occurred more than 4 weeks after it was experienced and lasted more than one month. The traumatic event is persistently re experienced in several ways, e.g., by intrusive recollections, dreams, illusions, hallucinations, or flashbacks. Slide 51: Post traumatic stress disorder PTSD Slide 52: Post traumatic Stress Disorder- PTSD Behavioral requirements Thought avoidance, related-activities and/or People-avoidance behavior, Feelings of detachment, Blunted affect, Sense of doom Insomnia, Irritability, Hyper vigilance, Exaggerated startle response Slide 53: Post traumatic Stress Disorder- PTSD Subdivisions Acute – when PTSD is diagnosed between 1 and 3 months after the event occurs it is called acute Chronic - when PTSD continues longer than 3 months, it is considered chronic and long term Delayed Onset PTSD-this term is used to describe those cases where the symptoms do not occur immediately after the experience, but, rather, months or years later Slide 54: Case # 3 Mr. A witnessed a friend die in a MVA six weeks ago and c/o frequent nightmares of the accident, poor sleep, fears of driving, anxiety around highways, anhedonia and decreased affection highways, towards his girlfriend. His girlfriend also notes that he has been very irritable and startles easily since the accident. Slide 55: Post traumatic Stress Disorder- PTSD ????Exposure to a traumatic event ????Response involving intense fear, Helplessness and horror ????Re-experiencing of the traumatic event Avoidance of stimuli/psychological numbing ????Increased arousal ????Symptoms greater than 1 month Slide 57: Separation Anxiety Disorder - SAD Slide 59: Medical conditions causing anxiety ????Endocrine conditions ????Cardiovascular conditions ????Respiratory conditions ????Metabolic conditions ????Neurological conditions Slide 60: Substances causing anxiety ????Alcohol Alcohol ????Amphetamines ????Caffeine ????Cannabis ????Cocaine ????Hallucinogens ????Inhalants ????Phencyclidine Substances that cause anxiety (withdrawal) ????Alcohol ????Cocaine ????Sedatives ????Hypnotics ????Anxiolytics Slide 61: Medications causing anxiety Anesthetics Analgesics Sympathomimetics Bronchodilators Anti-cholinergics ??Insulin Thyroid hormones Oral contraceptives Antihistamines Anti-parkinsonians ??Corticosteroids Antihypertensives Cardiovascular drugs Anticonvulsants Anxiety Disorders : Anxiety Disorders Current Management Strategies Slide 64: Management of Anxiety Disorders ?? Pharmacotherapy (Medications) Psycho-analytic therapy – PT Behavior Therapy - BT Cognitive Behavior Therapy – CBT Computer therapy - CT ?? Virtual Realty – VR Mood GYM Slide 65: Drug Rx. of Anxiety Disorders Clonazepam Slide 66: How do anxiolytics act ? GABA and Glycine are inhibitory neurotransmitter Serotonin and Noradrenaline are excitatory Anxiety is increased excitatory transmitters BZNs increase GABA and increase inhibition SSRI decrease the serotonin levels and ?excitation TCAs act by ?both serotonin and noradrenaline Slide 67: Drug Rx. of Anxiety Disorders Slide 68: Comparison of Benzodiazepines Slide 69: Different strategies of therapy Behavior therapy Desensitization Behavior modification Behavioral activation Cognitive therapy Rational-emotive therapy Beck’s cognitive therapy Newer approaches Mindfulness meditation Acceptance and commitment therapy Dialectical Behavior Therapy (BPD) Slide 71: Cognitive Behaviour Therapy - CBT CBT is a method used to treat anxiety Recognition of “distorted thinking,” “Cognitive restructuring.” It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder. Slide 72: CBT – Obstacles - Restructuring Hopelessness Self-criticism Fear of getting worse Shame and embarrassment Partial exposure Blaming other people Low motivation Looking for complex solution Depressing ruminations There must be an easier way Slide 73: Computer Therapy Pts are ashamed to seek help, and may fear the consequences at work and home. Therapy is expensive and beyond the reach of many patients. Computer therapy is very cheap and available by comparison. Slide 74: Computer Therapy – Softwares Fearfighter - for phobia/panic Cope - for depression/anxiety Balance - for GAD BTSteps - for OCD These are PC based in a CD-Rom or phone based or Web-based Slide 75: MENTAL OUTSIDE Slide 76: Virtual Reality - VR VR therapy via SD (Systematic Desensitization) is becoming very popular. SD is a process of gradually introducing a disturbing stimulus (e.g. view from a high place) in otherwise pleasant surroundings. This process gradually suppresses the anxiety response. Slide 77: Virtual Reality – VR - Advantages Patients often have difficulty imagining the stimulus themselves. They are often afraid of experiencing it directly – which may also be expensive and time-consuming. VR affords patient privacy and confidentiality during treatment. Very good for phobias Slide 78: Virtual Reality – VR - Imagination “Projection in time” – rationally reconstructing the future “De-catastrophizing an image” – modifying a disturbing image “Image modeling and substitution” –interrupting a negative train of images “Covert conditioning” – subtle conditioning using imagined rather than real stimuli Slide 79: Virtual Reality – VR - Hutchworld Hutchworld is a virtual community attached to the Hutchison Cancer Research Center. Designed to provide social support for cancer patients and their families. Based on Microsoft’s Vworld’s system. Slide 80: Mood GYM on the Internet Few GPs are trained in CBT Clinical psychologists are expensive Young people are not easily reached They may not want them – embarrassment The web is accessible, convenient and popular with young people. Deliver CBT via internet – 5 modules Slide 81: Mood GYM Modules 5 Modules - analysis and results Essentials of CBT with examples and interactive exercises Warpy Thoughts Questionnaire, Identifying dysfunctional thoughts. Methods to contest such thoughts Other methods for overcoming warpy thoughts Life Event Stress, Relaxation, meditation, music Pleasant Events Schedule, parental style Simple problem solving, responses to relationship break-up Web stats summary : Web stats summary Sessions Slide 88: Take home points ????Anxiety disorders are very common ????Just as fevers these are of different types ????Accurate Dx. and Rx. by GP is essential ????Depression and substance abuse potential Minimum of six weeks to see Rx effect Prolonged Rx. is necessary 6 m or more Drug Rx is only a small part of management SSRI, TCAs, BZNs, MAOIs, ß-blockers etc. CBT, Computer treatment, VRs, Mood GYM Thank You All Visit us at : : Thank You All Visit us at : This is sponsored by Torrent – Makers of Clonotril (Clonazepam)

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