Anxiety Disorders
By Salina Chan, R32013
Anxiety & Related Disorders
Generalized anxiety disorderSocial Anxiety disorderPanic attacksPanic disorderAgoraphobiaSpecific PhobiasAcute stress reactionPTSDOCD
Anxiety Disorders
Some terms and general applications…“Marked” = intense or severeAvoid triggers or endure them with intense fear
or anxietyAnxiety in children = crying, tantrums, freezing,
clinging or shrinkingRemember, it’s only a disorder when causes sig
adverse impact on important areas of functioningr/o secondary to substances or medical condition
Generalized Anxiety Disorder
WATCHERSWorry, and Anxiety excessive about a number of activities
6 months 3/6 symptoms below (1 only for children)
TensionConcentrationHyperarousalEnergy (fatigue)RestlessnessSleep problems
Generalized Anxiety Disorder
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for > 6 months, about a number of events or activities (e.g. work, school performance)
Difficult to control, i.e. can’t put off and focus on task at hand
3 of the 6 possible associated symptoms Restlessness/keyed up/on edge Easily fatigued Difficulty concentration/mind going blank Irritability Muscle tension Sleep disturbance
Generalized Anxiety Disorder
More worries = more likely GADWorries about everyday, routine life
circumstances, e.g. job responsibilities health finances health of family members misfortune to their children minor matters, e.g. chores
Generalized Anxiety Disorder
Generalized Anxiety Disorder
MSE: Appearance variable Speech can be rapid Thought form can be trailing, blocking, tangential,
overinclusive “What if” phrases
d/t inability to tolerate uncertainty of future events
Social Anxiety Disorder (Social Phobia)
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others Having a conversation Meeting unfamiliar people Being observed Performing in front of others
Social Anxiety Disorder (Social Phobia)
Fears will act in a way or show anxiety that will be negatively evaluated, e.g.: Humiliating Embarrassing Lead to rejection Offend others
Judged as: Anxious Weak Crazy Stupid Boring Intimidating Dirty unlikable
Social Anxiety Disorder (Social Phobia)
MSEAppearance may show
poor eye contact, rigid body posture, agitation (e.g. rubbing hands, tense), blushing Blushing = hallmark
physical response of SAD
Affect may be shy & withdrawn
Speech may be overly soft voice
Thought content Concerns about being
judged: How they look What they say being embarrassed embarrassing others
Public speaking Grocery lines Talking on phone Poverty/blocking: b/c
stress of interview causes thought blocking
Social Anxiety Video
http://www.youtube.com/watch?v=gmEJEfy5f50 (37:08 – 39:39)
Panic Attack
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time > 4 of the following symptoms occur…
Panic Attack
STUDENTS FEAR Cs Sweating Trembling or shaking Unsteadiness/dizziness/faint/lightheaded Depersonalization/derealization Excessive heart rate, palpitations, or pounding heart Nausea/Abdominal distress Tingling/Numbness Shortness of breath or smothering FEAR of dying, losing control, going crazy Chest Pain, Chills, Choking
Panic Attack
4 Head Dizzy/unsteady/
lightheaded/faint Derealization/
depersonalization Fear losing
control/crazy Fear dying
4 Chest SOB Heart Chest pain
4 Hands Trembling/shaking Chills/heat sweating Paresthesias
1 GI Nausea/abdominal
distress
Panic Attack Differential
Generalized anxiety d/o
Social anxiety d/oPanic disorderSpecific phobiaOCD
Depressive d/oBipolar d/oPersonality d/oPsychotic d/oMedical causes
Hyperthyroidism, cardiac, resp, gastro
Substance-induced
Panic Disorder
Recurrent, unexpected panic attacks
> 1 month of: Persistent
concern/worry about more attacks or their consequences
OR Change in behaviour
related to the attacks
Panic Disorder Video
http://www.youtube.com/watch?v=Ii2FHbtVJzc
Agoraphobia
Marked fear or anxiety about > 2 of following situations Using public transportation Being in open spaces Being in enclosed spaces Standing in line or being in a crowd Being outside of the home alone
Fears or avoids these b/c of thoughts that escape might be difficult or help might not be available in event of developing panic-like symptoms or other incapacitating or embarrassing symptoms
Specific Phobias
Marked fear or anxiety about a specific object or situation Persistent (> 6
months) Out of proportion to
the actual danger Nearly every time
Types of Phobia: BEAST Blood/Injection/Injury Environment, natural
(heights, storms) Animal/Insect Situational (airplane,
closed spaces) Things, other (loud
noise, clowns, vomiting)
Trauma-Related Disorders
Acute Stress Reaction
Exposure to actual or threatened death, serious injury, or sexual violation in > 1 of the following ways Directly experiencing the traumatic event Witnessing, in person, the event as it occurred to others Learning that the event occurred to close family/friends
(must be violent/accidental) Experienced repeated or extreme exposure to aversive
details of the traumatic event
> 9 symptoms that last 3 days – 1 monthPrecursor to PTSD
Post-Traumatic Stress Disorder (PTSD)
A. Traumatic event 1. Re-experiencing event (1/5)2. Avoidance and emotional numbing (3/7)3. Arousal increased (2/7)
B. Unable to function C. Month or more
Post-Traumatic Stress Disorder (PTSD)
Traumatic event person experienced, witnessed actual or threatened serious injury, death, or threat to
physical integrity of self or other Person experienced intense helplessness, fear, and horror
Re-experiencing event (1/5) intrusive thoughts, nightmares, flashbacks, or recollection
of traumatic memories and images. Avoidance and emotional numbing (3/7)
detachment from others; flattening of affect; loss of interest; lack of motivation; and persistent avoidance of activity, places, persons, or events associated with the traumatic experience
Unable to function Symptoms are distressing and cause significant
impairment in social, occupational, and interpersonal functioning
Arousal increased (2/7) usually manifested by startle reaction, poor concentration,
irritable mood, insomnia, and hypervigilance
Post-Traumatic Stress Disorder (PTSD)
“Doc, I’ve got Anxiety!”
Anxiety d/oBipolar d/oDepressive d/oPsychotic d/oSleep d/oSubstance use d/o
Social Anxiety Disorder Differential
Normative shynessAgoraphobiaPanic disorderGeneralized anxiety
disorderSeparation anxiety
disorderSpecific phobiasSelective mutism
Major depressive disorder
Body dysmorphic disorderDelusional disorderAutism spectrum disorderPersonality disorderOther mental disorders,
e.g. Scz, eating d/oOther medical conditionsOppositional defiant
disorder
Anxiety Disorders – Treatment
Rule out medical conditions (VINDICATE) TSH, pheochromocytoma, hypoglycemia, arrythmia, asthma
Lifestyle eat well, exercise, socialize, relaxation
Psychotherapy CBT, EMDR
Meds Antidepressants, B-Blockers (must cross BBB) Benzodiazepines & Antipsychotics
Medications
Antidepressants: Use higher doses than for depression, e.g. ~50% more SSRI , e.g.
Cipralex 30mg Setraline 150-200mg
SNRI Venlafaxine: 250-300mg Desvenlafaxine: 100mg
Mirtazapine: 30-45mg Buspirone: 30mg Trazadone: 50 to 400 mg
Medications
Beta-blockers Social Performance anxiety
Benzodiazepines Clonazepam, Ativan Short-term or PRN use Good to use when starting SSRIs to minimize
activating effects
Antipsychotics Seroquel: PRN or regular doses
Medications
Psychotherapy
Details after this lecture
Cognitive Behavioural Therapy
Eye movement desensitization and reprocessing
Obsessive-Compulsive Disorder
Q: What is an Obsession?
A: Recurrent and persistent thoughts, impulse or images
Experienced as intrusive and inappropriate Cause marked anxiety and distress Not just worries about real life problems The person tries to ignore or suppress them Recognized as being part of their own mind
Q: What is a Compulsion?
A: Repetitive behaviours or mental acts that a person feels has to be done: In response to an obsession According to rules that have to be applied rigidly
Aimed at preventing or reducing distress or preventing a dreaded event or situation Excessive or not connected in a realistic way in what
is trying to be prevented
Obsessive – Compulsive Disorder
Obsessions AND/OR Compulsions
Pt recognizes are unreasonable
Cause marked distress, are time consuming (>1hr/day) or interfere with functioning
Treatment
Medications SSRI TCA: Clomipramine
Gold standard Antipsychotics: alone or as adjuvant txn
E.g. Seroquel 400-500mg, Risperidone 1-2mg
Psychotherapy CBT