CHAPTER 5 Anxiety and Related Disorders

1. CHAPTER 5Anxiety and Related Disorders -Definition: Vague, subjective, nonspecific feeling of uneasiness, tension, apprehension, & sometimes dread or impending doom. -Symptoms:hypertension, tachycardia, muscle hypertonia, hyperactivity, irritability.

2. -Common disorders that have anxiety symptoms: 1- Neurotic Disorders: Hysterical Disorder, Depression, PTSD. 2- Psychotic Disorders: Major depressive disorder, Schizophrenia. 3- Organic Disorders: Hyperthyrodism, Athersoclerosis, Hypoglycemia, Post-concussion, Menopause, Pre-menstruation.

3. *Predisposing factors: (2) 1-Hereditary factors: -Average of anxiety in identical twins: >50%. 2- Age: -Anxiety increases in Children (Immature nervous system). -Anxiety increases in Elderly (Atrophic nervous system). Sx in pediatric: phobia in night, phobia from strangers, animals, older children, being alone, nightmares, urinal or fecal incontinence, walking during sleeping. Sxin adolescent: unsuitability, irritability, social embarrassment esp. when facing or meeting the other sex, guilty feeling, anxious about genital area, being very shy, speech stutter. Sxin in Adulthood:DECREASE. Sxin in elderly:INCREASE(regarding dz., death)

4. Types of anxiety (according to level) • Mild anxiety: a. Physiologic:V/S normal, minimal muscle tension, pupils normal, constricted. b. Cognitive:perceptual field is broad -Thought may be random but controlled. c. Emotional/Behavioral:relative comfort &safety, relaxed, calm appearance &voice. **Habitual behaviors occur here.

5. 2. Moderate Anxiety: a. Physiologic:V/S normal or slightly elevated, Tension experienced, may be uncomfortable. b. Cognitive:alert; perception narrowed, focused (Optimum state for solving & learning), Attentive. c. Emotional/ Behavioral:Readiness & challenge (energize), engage in competitive activity & learn new skills, voice & facial expression concerned.

6. 3. Severe Anxiety: symptoms a. Physiologic: Fight or flight, autonomic N. system excessively stimulated (highly increase in v/s, diaphoresis, urine urgency & frequency, diarrhea, dry mouth, decrease appetite, dilated pupil), muscles rigid, tension, decrease heating & pain sensation. b. Cognitive / perceptual:Perceptual field greatly narrowed, problem solving: difficult, automatic behavior, selective attention (focus on one detail). c. Emotional/Behavioral: Feels threatened, seem or feel depressed, becomes very disorganized or withdrawn, may close eyes to shut out environment.

7. Panic Attack: Definition: A discrete period of intense fear or discomfort in which four or more of the following Sxdeveloped abruptly and reached a peak within10 minutes. 1-Palpitations 2-Sweating 3-Trembling or shaking 4-Sensations of shortness of breath 5-Feeling of shocking 6-Chest pain or discomfort 7-Nausea or abdominal distress 8-Feeling dizzy, unsteady or Faint 9-Realization of losing control 10-Fear of dying 11-Parenthesis 12-Chills or hot flashes

8. 1. Phobias -Pt. experiences panic attack in response to particular situations or learns to avoid situations that evoke panic attack. -Phobia results even pt. knows that it won’t happen & no danger if exposed to situation. -Even pt. knows that very well he/she can’t control phobia and doesn’t confront internal conflict but convert it into external Sx.

9. Types of phobias: 1-Agoraphobia: Anxiety about being in places or situations from which escape may be difficult (or embarrassing) or in which help might not be readily available in event of unexpected panic attack. -This includes: fear of being alone, being in crowded area or standing in a line, being, on a bridge, traveling in a bus; becomes in need to have a companion.

10. 2- Social phobia: fear from being under observation from others, which may lead to avoiding social need. -Usually accompanied with low self-esteem (evaluation and fear of criticism). Course & prognosis: -Usually starts in late childhood & early adolescence. -May become chronic & decreases after midlife. -Rarely that disorder is severe &interfere with vocational performance because of avoidance. -Complications: -Addiction (Alcohol, anti-anxiety). -Depression.

11. Rx: 1-Drugs: anti-anxiety or anti-depression. 2-Psychotherapy: Behavioral psychotherapy: with drugs in severe cases by Gradual Desensitizationby exposing him to the fear object gradually and could be accompanied by some drugs or relaxation training or Flooding: by exposing pt. suddenly to fear object in reality or imagination. Insight psychotherapy: To make pt. understand the cause phobia & secondary gain symptoms, role of resistance and this will make him able to find methods more acceptable to control anxiety with motivating pt. to be exposed to phobia situation.

12. 3- Simple phobia (isolated phobia) (specific phobia) : -Includes specifies conditions: 1-Claustrophobia: Fear of closed places. 2-Mysophobia: fear of dirt, germs and contamination. 3-Acrophobia: fear of heights. 4-Zoophobia: fear of animals. 5-Aqua phobia (or hydrophobia): fear of water. 6-Nectrophobia: fear of darkness. 7-Pyrophobia: fear of fire. 8-Hematophobia: fear of blood. 9-Necrophobia: fear of dead bodies. 10-Xenophobia: fear of strangers. 11-Astrophobia: fear of lightening.

13. Course & prognosis: -Beginning of simple phobias is varied. -Zoophobia starts in childhood. -Hematophobia often starts in adolescence or early adulthood. -Acrophobia often starts in the fourth decade. -Most of other phobias that start in childhood disappear without treatment. -Disability results from simple phobias is slight if avoidance was easy as zoophobia, but disability is increasing if stimulus is common, spread & not avoidable as fear of riding cars for student.

14. 2-Post Traumatic Stress Disorder (PTSD) -Pt. must have experienced traumatic event prior to onset of Sx. -Pt. may have experienced event, witnessed it, or have been confronted with event that involved actual or threatened death or serious injury. -Event should be outside range of usual human experience. -Pt. response: intense fear, helplessness or horror.

15. -Pt. will have Sx from 1-3 months (Acute) or 3-6 months(Chronic) - Event cause this disorder could be: 1-Natural: Earthquakes, volcans. 2-Man-made: Rape, Torture. -PTSD could happen in one individual or more among group.

16. -Pt. will have the following Sx: 1-Re-experiencing the event: a. Recurrent dreams of the event. b. Sudden acting or feeling as if traumatic event was recurring (including sense of re-living the experience, illusions, hallucinations). 2-Persistent avoidance of stimuli associated with trauma. 3-Persistent Sxof increased arousal (difficulty to sleep, irritability, concentration).

17. Course & prognosis: -May occur in any age after event (1wk-30 yrs). -Sx: fluctuating & become severe during stressful events. -Acute PTSD lasts for <3 months but it could become chronic (>3 months). -30% of pts. with PTSD recovers, 40%slight symptoms, 20%moderate symptoms,10% become worse. -Prognosis is conditioned by: rapid onset, good pre-morbid functioning & good social support. -Complications:social phobia disturbance in relations with others guilty feeling that may lead to suicide.

18. *Rx: 1-Drugs: Tofranil( Imipramine), Inderal ( Propanolol). Catapress(Clonidine). 2-Psychotherapy: -Cognitive-behavioral approach: 1-Building good relationship with pt. 2-Cognitive appraisal of event & explaining to pt. effect of stress on human being & that symptoms are a normal outcome to an abnormal situation.

19. 3-Relation training & desensitization by building a hierarchy of stressful moments & relaxation. 4-Social support & involving family & friends in caring & understanding pt.'s condition.

20. 3-Acute Stress Disorder • The same condition of PTSD, but the period to have the Sx is 2 days-1 month.

21. 4-Generalized Anxiety Disorder -Excessive worry & anxiety about 2 or >of life conditions: Worry of a child of being dying or exposing to any harm (in fact no danger at all). -3 or more of the following sxwill appear: 1- Restlessness 2- Easily to be fatigued 3- Irritability 4- Difficulties in concentration 5- Muscle tension 6- Sleep disturbances .

22. Prognosis: -May start in any age but is >in 20s& 30s. -Mainly chronic & may continue for life. -Complication: is panic attack. -other complication: addiction because of self-treatment. Rx: 1-Drugs: should decrease prescribed anti-anxiety as possible (because disorder is chronic). 2-Psychotherapy:Rx of choice. a-Psychoanalytic psychotherapy: through long-term insight. b-Behavioral psychotherapy: focuses on desensitization with entrance to cognitive therapy aims to stop conditioning in addition to relaxation & modifying behavior.

23. 5- Obsessive Compulsive Disorder 1-Obsession:undesirable but persistent thought or idea forced into consciousness & can’t be erased or dismissed, thought may be trivial or morbid. Always distressing or anxiety provoking. 2-Compulsion: unwanted urge to perform act or ritual contrary to pt.'s ordinary conscious wishes or standards. -Uncontrolled & done to relieve extreme tension. -Obsession produces anxiety managed by compulsive act. 3-Obsession compulsion:repetitive acts or rituals to release tension or relieve anxiety. -Pt. carries out these acts even if he recognizes that they are inappropriate or foolish.

24. Examples: a. Endless hand washing. b. Checking re-checking doors if they're locked. c. Elaborate dressing rituals. -Pt. is trying to resist this, but because of long period of disorder, resistance may decrease. -As a result, pt. will have much difficulties in social r/s. -Pt. is neurotic (because pt. believes that these ideas are not true & silly).

25. Course & prognosis: -Usually starts in adolescence. -Chronic disorder & pt. may not present to psychiatrist for 5-10 years. -About 30% of pts.: good improvement, 30-40%: mild improvement, & the rest: chronic or worse. -Some pts. may have depression, suicide or addiction.

26. Rx: 1-Drugs: -Anfranil(Clomipramin): Drug of choice (6-12months). 2-Behavioral therapy: -Effective in 60-70% of pts.(may be Rx of choice). -Techniques used:Desensitization, thought stopping, flooding & implosion therapy. Aversive conditioning:means giving a painful shock or loud noise when thought occurs. -Some use response preventing as: forcibly stopping pt. from responding to obsession. 3-Psychodynamicpsychoanalytic therapy: -Aims to help pt. get insight into his aggressive impulses & strengthens ego to deal with aggression in mature ways.

27. 6-Somatororm Disorders -Focusing is physical sxin absence of clinically significant organic disease. A-Body Dysmorphic Disorder -Preoccupation with imagined defect in appearance. -Slight anomaly: concern is excessive. -Significant distress or impairment in social or occupational functioning. -Preoccupation is not better accounted for by another mental disorder.

28. Course & prognosis: -Starts in adolescence, 20’s or 30’s, stays constantly & may have result of social & vocational disability. -Complication: Plastic surgeries without any need. Rx: -Pts. refuse psychotherapy despite their severe suffering & insist on having plastic surgeries so it is important for plastic surgeon to refer them to psychiatrist or psychologist. -Meds. may relief Sx(anti-anxiety, anti-depression). -Long-term psychotherapy is recommended.

29. B- Pain disorder -Clinical presentation of pain in 1 or > anatomical sites. -Pain is severe to warrant clinical attention &causes major impairment in 1 or > areas of functioning. -Psychological factors play important role in onset, severity exacerbation, or maintenance of pain. -Acute: less than 6 months (duration). -Chronic: more than 6 months (duration). Course & prognosis: -In female double than males. -Increase at 4th& 5th decade & b/w poor persons.

30. Rx: Drugs: Giving analgesics or narcotics is not useful (?addiction). -Anti-depressant can be given: (Elatrol) or (Prozac). -Anxiolotics or analgesics usually not effective. Psychotherapy:Important that therapist helps pt. recognize psychogenic origin of pain. -Explain to pt. how person state of mind affects how much pain he can feel. -Relaxation technique, sports exercice. -Biofeedback. -Sometimes, admission to hospital is needed to control feeling of pain (behavioral, cognitive & group psychotherapy may be used).

31. C- Somatization Disorder -Frequently seeking & obtaining medical Rx for multiple clinically significant somatic complaints. -Complaints must begin before 30 & cannot be explained by any medical disorder or direct effects of substance. -Multiple sclerosis pt. would not be dxed by somatization. -Differentiated from medical conditions if: -Involvement of multiple organ systems (GI, neurological..). -Sxexhibit early onset & chronic course, without development of physical signs or structural abnormalities. -Absence of clinical (laboratory) abnormalities.

32. Course & prognosis: -Females > males. -Less occurrence if high social class, more among poor & illiterate persons. -Starts before 30. -Increase among first-degree relatives. -Chronic & pt. is rarely free of sx or for medical seeking.

33. Rx: -Long & empathic r/s with one therapist. -Using meds. is not recommended but anti-depressant or anxiolytics can be used symptomatically if anxiety or depression is present (?addiction).

34. D-Conversion Disorder(Hysterical neurosis, Conversion Type): -Loss or change in beady functioning that can’t be explained by any medical disorder, & occurs in response to psychological stress. -In females > males. -Usually starts in adolescence or young adulthood. -Medical exams do not reveal physical abnormality. -Pt. is not conscious of producing sx. -Histrionic personality pt: more exposed than others. -Could happen if exposed to great stress. -Loss or change can give sensory/motor sxor both.

35. Motor sx:Abnormal tremors, jerky movements. * Note: hysterical conversion tremors: it is irregular & disappears if attention moved to another subject, etc… -It differs from tremor in anxiety. -Hysterical aphonia: Pt. can’t speak, but can understand what is said. * Note: to differentiate, ask pt. to cough, if he does so, means vocal cords ok & is hysterical.

36. Comparison b/w organic & hysterical paralysis: Tics: involuntary movement increases in embarrassing situations. Hysterical comas:like normal sleep, doesn’t respond to stimuli, needs care for urination & defecation, usually needs hospitalization, used to escape from reality. Hysterical fits: differ from organic epilepsy as following: Sensory symptoms: Anesthesia or loss of sensation in a part of body or one half of body. Hysterical deafness. Loss of olfactory or taste senses. Hysterical blindness.

37. Prognosis: -Duration is brief. -Starts & stops abruptly. -Tends to recur. -Prognosis is poor if secondary gain is high. *Primary gain: Gain achieved by converting anxiety to somatic sx(symbolic of unconscious conflict). *Secondary gain: Gain achieved by sx, pt. pain relieved from work or gets attention &sympathy from family by taking sick role.

38. Rx: -Exclude organic disease by physical exam. -Psychotherapy: -Telling pt. that he has no physical problems & sxare psychological stress &will disappear if pt. expresses his feelings. -Amytal: may be used to produce a state of relaxation &re-experience trauma which enable pt. to talk freely about her troubles.

39. E-Hypochondriasis -6major criteria associated with disorder: 1-Pt is preoccupied with fears of having-or idea of having serious medical disorder based on his/her interpretation. 2-Misinterpretation of bodily sxpersists despite appropriate medical evaluation & reassurance. 3-Pt’s preoccupation with Sxis not as intense or distorted as in body dysmorphic disorder.

40. 4-Preoccupation causes clinically significant distress or impairment in social, occupational, or major areas of functioning. 5-Duration of disturbance at least 6 months. 6-Condition is not better accounted for by another anxiety disorder, somatization disorder, or major depressive episode (Pt. may show sxof anxiety or depression).

41. Course & prognosis: -Mostly starts in 20’s. -1/3 of pts. don’t improve & social/vocation disturbed. -Males & female: equal. Rx: -Exclude any organic factor. -Invasive procedure should be avoided. -Psychotherapy:preferred treatment even pt. resists this therapy (may accept it by a physician). -Group psychotherapy: Rx of choice (pt.’s social support & interaction can improve their condition). -Drugs not used unless depression/anxiety present.

42. Comparison b/w Somatization & Hypochondriasis

43. 7-Dissociative Disorders -Disruption in usually integrated functions of consciousness, memory, identity & perception of environment. A. Dissociative Amnesia -1or > episodes of inability to recall important personal information(traumatic or stressful nature); too extensive to be explained by ordinary forgetting. -Disturbance doesn’t occur during Dissociative Identity Disorder. -Not due to substance effects or general medical condition. -Most common in females.

44. -Usually pt. is aware of memory loss. -Pt. is usually alert & not confused (Some pts. describe a state of clouded consciousness). -Onset is sudden & recovery is sudden & complete. -Recurrence is rare.

45. Rx: -It is important to differentiate psychogenic amnesia from organic amnesia ( CVA,P.C, etc..). -Amytal interview: Pt. is given short or medium acting barbiturates as Amytal IV & in a state of alleged consciousness pt. is helped to remember. -Hypnosis: Under hypnosis, pt. is relaxed & in a somnolent state in which inhabitations are weekend, & repressed memories can be reached. -Psychotherapy: After repressed memory is reached psychotherapy helps pt. resolve conflicts.

46. B. Dissociative Fugue -Sudden, unexpected travel away from one’s home or place of work, with inability to recall one’s past. -Confusion about personal identity or assumes new identity, which may be partial (filling in the blanks). -Disturbance doesn’t occur in context of a dissociative identity disorder, & is not due to effects of a substance or to a general medical condition.

47. -When fugue is over, pt. remembers all he had forgotten but forgets what happened during fugue. -Course is usually short. -Pt. recovers suddenly & completely to find himself in a strange place. -Recurrence is rare. Rx: -No Rx is required if duration is short. -Hyposis & Amytal interview maybe used to help pt. remember his identity.

48. C. Multiple Personality Disorder (Dissociative Identity Disorder) -2 or > personalities (each complete & integrated). -At any time, pt. is dominated by one personality & unaware of presence of other personalities. ->in females. -Mostly occur in adolescence or early adulthood. -Predisposing factor: severe physical/sexual abuse in childhood. -Epilepsy is found in 25% of pts. -EEG shows difference in activity in different personalities in the same pt.

49. -Each personality is integrated & differ in mood, attitude, name, etc… -Usually each personality doesn’t recognize presence of other personalities (Sometimes one of them knows about the other). -Pt. may find himself in strange place or hearing voices inside him or another person taking control over him. -Chronic disorder. Prognosis: -Poor if onset is early & if >2 personalities.

50. Rx: Psychotherapy: Helps pt. resolve conflict & childhood memories. -Helps in communication b/w different personalities to reintegrate pt. -Hypnosis: Helps in confirming Dx by enhancing memories & resolving deep conflicts.