MODULE TOPIC

OUTLINE: I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV.

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

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February 3, 2010 Dr. Luz Katigbak

Anxiety Epidemiology of Anxiety in the Philippines Anxiety from the Failure to Cope Medical Illnesses mimicking Anxiety Disorders Anxiety Mimicking Medical Illnesses Drugs that Cause Anxiety ANXIETY DISORDERS Panic Disorder Specific Phobia and Social Phobia Obsessive-Compulsive Disorder Post Traumatic Stress Disorder Acute Stress Disorder Generalized Anxiety Disorder Etiology and Treatment a. Biological b. Psychosocial Take it Easy

Ex. The pre-schooler has been going to the class for the past 6 months, but he still has not yet adjusted

Fear vs Anxiety Fear also an alerting signal; a response to a stimulus that is known, external, or a definite threat Anxiety - a response to a threat that is unknown, threat, internal Diagnostic approach to anxiety symptoms Medical assessment o Anxiety disorder due to ________ (hypertension/PTB/drug induced) Psychosocial assessment o Why do you think you are so anxious? If you ask them when it started o You would find out that there were external stressors present Self-regulation o Relaxation exercises, breathing exercises, meditation Medication o Therapy treats problems; medication treats symptoms

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II. Epidemiology of Anxiety in the Philippines I. Anxiety Anxiety A diffuse, unpleasant, vague sense of apprehension, often accompanied by symptoms, i.e., headache, perspiration, tightness in the chest, mild stomach An alerting signal It warns us of impending danger and enables us to take measures to deal with a threat Adaptive, lifesaving quality Normal anxiety a univeral experience It is adaptive and is a lifesaving quality An accompaniment of growth, of change Examples o For a child, separation from parents o First day of school; first date o News of chronic or terminal illness o If theres a new or novel situation we are facing, we have a sense of feeling anxious Prevalence of Psychiatric Disorders in the Philippines Condition Prevalence Anxiety 14.3 Panic 5.6 Depression Among chronically-ill medical patients Mood 32 Anxiety 16 Somatoform disorder 11 Probable alcohol abuse 8 Overall 48 Most prevalent is mood disorders o Depressive The idea of being sick, activities will be limited, medical imbalance Prevalence in the Primary Care setting 60% of patients with psychiatric conditions Anxiety: 5th most common diagnosis Panic disorder: o 6-12% in PCP practice (primary care practice) o 10-14% in Cardiology Anxiety in the Medical Setting The hospitalized patient encounters internal and external dangers: Assaults in the body o Youll have injections, blood extractions Atmosphere of illness, pain and death o Synonymous to not knowing what is going to happen Separation from loved ones and familiar surroundings Uncertainty about his illness The implications of the illness in his capacity to work and maintain social and family relationship

Pathological anxiety Indications when you should seek professional help: Evident to patients families, friends, clinician Based on patients internal states, behavior and level of functioning the person himself who is anxious is uncomfortable. He does not feel well. An inappropriate response to a given stimulus by virtue of intensity or duration A persons reaction is not proportionate to a situation
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MODULE TOPIC

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

February 3, 2010 Dr. Luz Katigbak

III. Anxiety from the Failure to Cope gives a sense of fear and vulnerability

Absence of significant life events exacerbating anxiety Lack of avoidance behavior Poor response to standard anti-anxiety

Factors: Personality features with brittleness or tendency to regress in the face of threat o This kind of personality, these are the ones who are not very flexible, they are very rigid Suddenness of the onset of threat Unavailability of familial or other social support Feelings of aloneness or abandonment Meaning of the illness or injury o Could not be comprehended The patient becomes frightened, trembles, cannot sleep, repeatedly seeks attention and reassurance, complains of excessive pain, becomes disruptive

V. Anxiety Mimicking Medical Illness Most patients usually end up with systemic specialists Three most common symptoms o Cardiac palpitations, chest pain o GI diarrhea, nausea, dyspepsia o Neurologic dizziness, headache Predominance of physical symptoms o You cannot correlate the symptoms Absence of affective, cognitive and behavioral components Physical symptoms of Anxiety Respiratory o Chest pressure o Choking o Sighing o Dyspnea Autonomic o Dry mout o Sweating o Headaches o Hot flashes Cardiovascular o Tachycardia o Palpitations o Chest pain o Faintness Musculoskeletal o Aches and pains o Twitching o Stiffness GU o Frequency o Urgency o Sexual dysfunction o Menstrual problems GI o Swallowing o Abdominal pain o Nausea o Irritable bowel Neurologic o Dizziness o Tremor o Tingling sensation

IV. Medical Illness Mimicking Anxiety Disorder 5-42% of anxiety symptoms have underlying medical illness Primarily, there is medical illness but presents as anxiety disorders Medical o o o o o o Causes of Anxiety Neurological problems Endocrine problems Cardiologic problems Rheumatoid collagen problems Chronic infection problems Intoxication or withdrawal from alcohol or drug use most common What are the symptoms: cold sweats, tremors, nausea, irritability, palpitations

Other Medical Causes of Anxiety Respiratory: o COPD o Pulmonary embolism o Asthma o Hypoxia o Pulmonary edema Cardiovascular o Angina pectoris o Arrythmia Endocrine o Hyperthyroidism o Hypoglycemia o Pheochromocytoma Metabolic o Hypercalcemia o Hyperkalemia o Hyponatremia Suspect a Medical cause if: Onset of anxiety symptoms occur after 35 years old o Anxiety disorder usually occur before 35 yo Lack of personal or family history of anxiety disorder o Strong genetic link for anxiety disorder

VI. Drugs that Cause Anxiety Just to caution you that the medicines that we give to our patients could harm them. We should weigh the risk vs benefits. You might cause them more harm that cure Stimulants Sympathomimetics Drug withdrawal Anticholinergics
Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

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MODULE TOPIC

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

February 3, 2010 Dr. Luz Katigbak

Dopaminergics Miscellaneous o Baclofen o Cycloserine o Hallucinogens o Indomethacin

The panic disorder can be with or without agoraphobia This is not a diagnosis. Just a specifier Agora means market an anxiety about being in places or situations from which escape might be difficult or embarrassing; or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms Examples: Being alone outside the home Being in a crowd On a bridge Traveling Epidemiology Lifetime prevalence 1-4% Women 2-3x more affected than men Recent history of divorce or separation Age: 25 years Co-morbidity Depressive disorder Suicidality Agoraphobia, other phobias, OCD

ANXIETY DISORDERS

VII. Panic Disorder Same as the symptoms in anxiety disorder Panic attack discrete period of intense fear of discomfort, characterized by the following symptoms developing abruptly and reaching a peak in 10 minutes Significant change in behavior o Because of so much worry of going in to attack, they refrain from going out, they withdraw from people, cant go to work Symptoms: o Palpitations, pounding, or accelerated heart rate o Sweating o Trembling or shaking o Sensations of shortness of breath or smothering o Feeling of choking o Chest pain or discomfort o Nausea or abdominal distress o Feeling dizzy, unsteady, lightheaded, or faint o Derealization ( feeling of unreality) or depersonalization (feelings of being detached from oneself) o Fear of losing control or going crazy o Fear of dying o Paresthesias (Numbness or tingling sensations) o Chills or hot flushes

VIII. Specific Phobia and Social Phobia Phobia an excessive fear of a specific object, circumstance or situation Fear in phobia is characterized as marked and persistent, excessive and unreasonable, and provokes an immediate anxiety response The person recognizes that the fear is excessive or unreasonable = He has Insight about his condition Epidemiology 5-10% of the population Most common mental disorder among women 2nd most common among men 6 months prevalence: 5-10% Peak age of onset: o Natural environment and blood-injection injury type: 5-9 years o Situational type: mid-20s Descending frequency: animals, storms, heights, illness, injury, death Substance abuse most common in men Acrophobia heights. Claustrophobia closed spaces Exposure to the phobic situation almost always invariably provokes an immediate anxiety response which usually take the form of a panic attack The phobic situation is either avoided or endured with intense anxiety or distress Social phobia fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny Fear embarrassing and humiliating

DSM IV-TR Criteria for Panic Disorder Recurrent unexpected panic attacks At least one of the attacks has been followed by at least 1 month of one or more of the following: I. Persistent concern about having additional panic attacks II. Worry about the implications of the attack or its consequences III. A significant change in behavior related to the attacks Presence or absence of agoraphobia The panic attacks are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). The panic attacks are not better accounted for by another mental disorder.

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Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

MODULE TOPIC

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

February 3, 2010 Dr. Luz Katigbak

IX. Obsessive-Compulsive Disorder Essential features: presence of obsessions or compulsions Obsessions repetitive thoughts. Compulsions repetitive actions Severe enough to cause marked distress; time consuming; interfere significantly with the persons normal routine An individual with OCD may have either an obsession or a compulsion, or both OCD different from OC personality disorder and people with OC traits Obsession A recurrent and persistent thought, impulse, or image; experienced as intrusive or inappropriate and which cause marked anxiety or distress These are not simply excessive worries about real-life problems The individual attempts to suppress or neutralize them with some other thought or action The individual recognizes them as a product of ones mind Compulsion Repetitive behavior or mental act that the person is driven to perform in response to an obsession The behavior is aimed at preventing or reducing distress or preventing dreaded event or situation However the behavior is not realistically connected with what they are designed to neutralize or prevent, and are clearly excessive Epidemiology: Lifetime prevalence: 2-3% 4th most common psychiatric diagnosis Among adults, men = women; among adolescents, boys > girls Mean age of onset: 20 years Co-morbidity Major depression: 67% (the issue is control, so if we cant control everything, then it causes depression) Social phobia: 25% Alcohol use disorders, generalized anxiety disorder, specific phobia, panic disorder, eating disorders, personality disorders Tourettes disorder; 5-7% Symptom patterns Contamination fear of dirt, dust, microbes Pathological doubt you left the gas/window open Intrusive thoughts Symmetry roommates who would get furious if you touch their books Other symptom patterns: religious obsessions, compulsive hoarding The traumatic event is frequently re-experienced in various ways o Nightmares, flashbacks, avoidance of stimuli Persistent avoidance of stimuli associated with the trauma as well as numbing of general responsiveness o Psychotic components, hypervigilance Persistent symptoms of increased arousal The duration of the disturbance is more than 1 month Examples: o Ondoy, 911, etc Epidemiology Lifetime incidence: 9-15% Lietime prevalence: 8% 10-12% among women; 5-6% among men Most prevalent in young adults Single, divorced, widowed, socially withdrawn, low socioeconomic level Severity, duration, proximity to exposure most common risk factor

XI. Acute Stress Disorder Just like in PTSD, the person has been exposed to a traumatic event, the conditions of which are similar Experiencing of the same signs and sypmtoms The duration lasts for a min. of 2 days and max. of 4 weeks, and occurs within 4 weeks of traumatic event

XII. Generalized Anxiety Disorder Excessive anxiety and worry more days than not for at least 6 months Difficult to control the worry 3 or more of the following: o Restlessness o Easily fatigued o Difficulty concentrating o Irritability o Muscle tension o Sleep disturbance Epidemiology Anxious for as long as they can remember First seek consult in their 20s Only 1/3 seek psychiatric treatment Goals of Anxiolytic Treatment: Assuage anxiety and tension Lessen physical symptoms Induce a state of well-being

X. Post Traumatic Stress Disorder A syndrome which develop after the person has been exposed to a traumatic event in which the following were present: o The person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury Even if he did not witnessed or experienced the traumatic experience but was presented with it (e.g. in the news) he could still develop PTSD o The persons response involved intense fear helplessness, or horror

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Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

MODULE TOPIC

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

February 3, 2010 Dr. Luz Katigbak

XIII. Etiiology and Treatment A. Biological Autonomic nervous system B-adrenergic receptor (propranolol for social phobia o Sweating, palpitation

Neurotransmitters:

Beta adrenergic receptor antagonist (propranolol), alpha-2 receptor agonist (clonidine) Norepinephrine o Chronic symptoms characteristic of inc. noradrenergic function o Poorly regulated noradrenergic system o Stimulation of locus ceruleus CRH o Hypothalamic levels of CRH inc by stress, activation of HPA axis, increase release of cortisol; excessive and sustained cortisol secretion causes hypertension, osteoporosis, immunosupression, insulin resistance, dyslipidemia, cardiovascular disease Serotonin GABA Cerebral asymmetry Abnormality in the frontal cortex, occipital, temporal areas in anxiety DO; parahippocampal gyrus in panic DO Caudte nucleus in OCD Inc. activity in the amygdala in PTSD

Advantages: o Effective o Benign side-effect o Safety o No dependence issues o Once a day dosing Disadvantages o Delayed onset of action (2-4 weeks, sometimes even 4-6 weeks) o Early anxiogenic effect o Sexual side effects o Usually requires dose titration iii. Benzodiazepines Alprazolam, bromazepam, clonazepam, diazepam, clorazepate

Brain imaging studies:

Advantages: o Rapid onset o Effective o Well-tolerated o General anti-anxiety effects o Safe in overdose Disadvantages o Withdrawal reaction o Sedation o Multiple daily dosing o Abuse potential with history of abusing o Poor antidepressant effect B. Psychosocial Psychoanalytical o Anxiety as result of psychic conflict between unconscious sexual or aggressive wishes and corresponding threats from the superego or external reality Psychodynamic therapy o Goal: increase anxiety tolerance Behavioral theories o Anxiety is a conditioned response to a specific environmental stimulus o Social learning: anxious parents, anxious child o Biofeedback o Behavior therapy Systematic desensitization Relaxation training Hierarch construction Desensitization of the stimulus Therapeutic graded exposure Flooding Participant modeling anxious parent breeds an anxious child Exposure to stimuli presented in virtual reality

Genetic studies Neuroanatomical considerations

o Limbic system: Increased activity in the septohippocampal pathway and anxiety Cingulate gyrus and OCD Cerebral cortex Frontal and temporal cortex i. Tricyclic antidepressants (TCAs) Clomipramine, imipramine, nortriptyline

Advantages: o Single daily dose o Antidepressant effect o No abuse potential o Well studied o Effective o Generics available Disadvantages o Delayed onset o Anticholinergic side-effects o Postural hypotension o Weight gain o Sexual side-effects o Initial stimulation o Dangerous in overdose ii. Selective Serotonin Reuptake Inhibitors Fluoxetine (Prozac), fluvoxamine, paroxetine, sertraline, venlafaxine, citalopram, escitalopram

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Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

MODULE TOPIC

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

February 3, 2010 Dr. Luz Katigbak

XIV. Take It Easy POST-TRAUMATIC STRESS DISORDER

GENERALIZED ANXIETY DISORDER

OBSESSIVE-COMPULSIVE DISORDER

PANIC DISORDER

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MODULE TOPIC

Psychiatry Anxiety Disorders

Pioneer Batch Class of 2012 DATE LECTURER

February 3, 2010 Dr. Luz Katigbak

G7: G7ood Luck! G7od bLess!

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