BS 13

1. BS 13 Anxiety, somatoform & factitious disorders and malingering

2. Fear • Anxiety • Physiological manifestations: palpitaion, shaking of hands, sweating, dizziness (syncope), mydriasis, GIT & Urinary frequency

3. Classification of anxiety disorders(DSM IV classiciation) • Panic disorder: sudden onset of symptoms lasting for 10 – 30 mts - episodic twice a week – cardiac & respiratory symptoms – attack can be induced by sodium lactate / CO2 – genetic component – agrophobia (fear to go in public / open places) • Phobias (specific / social) – irrational fear for some objects like escalator (specific) – exaggerated fear for public speaking, eating etc – phobias are most common mental health problem

4. 3. Obsessive - compulsive disorder (OCD) – recurring intrusive feelings, thoughts / images which may cause anxiety & performing repetetive actions (compulsions) – increased in 1st degree relatives of tourette’s syndrome pts • Generalized anxiety disorder: persistant anxiety symptoms for > 6 months – symptoms are not due to specific person / situation – common in 3rd decade of life

5. Post traumatic stress disorder (PTSD) & acute stress disorder (ASD): symptoms occuring after a catastrophic event, serious accident / watching a violent crime / rape etc) – symptoms include anxiety, recurrent nightmares, intrusive memories of event – PTSD symp lasts for > 1 month and can last for years – in ASD symptoms lasts for 2 – 4 days • Adjustment disorder: anxiety, depression & emotional symptoms occuring within 3 months and lasting < 6 months – e.g. divorce , bankruptsy etc

6. Organic basis of anxiety • GABA & Serotonin show decreased activity - Nor epinephrine show increased activity • Locus ceruleus, raphae nucleus, caudate nu,temporal & frontal lobe are involved in the anxiety • Excessive caffein, substance abuse, hyperthyroidism, vit B12 deficiency phaechromacytoma etc

7. Treatment of anxiety disorders 1. Anti anxiety agents – benzodiazepines (valium alprzolam etc) act quickly – used in panic attacks – habit forming Busprione (Buspar) has low abuse potential – ideal for long term maintenance (GAD) – takes 2 weeks to work Beta blockers (propranalol) – for autonomic symptoms like tachycardia

8. 2. Antidepressants: MAOIs & SSRIs are effective longterm therapy for panic disorder & OCD 3. Psychological therapy: systemic desensitization, reciprocal inhibition – for phobias behavioral therapy like flooding / implosion support groups – victim survivor group – in ASD / PTSD

9. Somatoform disorders • Physical symptoms without any organic cause – unconscious expression of unacceptable feelings – more common in women • D. D: unidentified organic disorder / malingering • Treatment: individual & / group therapy / anti anxiety agents / hypnosis / behavioral relaxation therapy

10. DSM classification of somatoform disorders • Somatization disorder: many physical complaints over many years GIT symp (nausea), pain symptom, mentstrual symp’ etc – onset before 30 years • Hypochondriasis: exaggerated concern of health & illness for > 6months – common in middle & old age • Conversion disorder: goes to many different doctors – doctor shopping – blindness / paralysis associated with stressful event – common in quiet individual

11. Body dysmorphic disorder: excessive concern over minor /imagined physical defect – common in teens • Pain disorder: intense prolonged pain not explained by physical illness – common in 30 – 40 years of age

12. Factious disorder(malingering) • Factious disorder – conscious simulation of physical / psychiatric disorder to gain attention of medical personnel – undergone unnecessary investigation • Factious disorder by proxy –conscious simulation of illness in children (form of child abuse) – must be reported • Malingering: for financial gain (insurance settlement, avoiding incarceration)