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