ANXIETY DISORDERS

1. ANXIETY DISORDERS Yard. Doç. Dr. Berfu Akbaş

2. A diffuse, unpleasant, vague sensation of apprehension, often accompanied by autonomic symptoms; palpitations, perspiration, headache, tightness in the chest, mild stomach discomfort, restlessness, dizziness, diarrhea, tremors, urinary frequency, hesitancy. • Normal Anxiety : advantageous response to a threatening situation • Pathological Anxiety: inappropriate response to a given stimulus. • Fear: A response to a known, external, definite threat

3. Epidemiology: • women life-time prevalence: % 30.5 • Men : % 17.7 • Autonomic Nervous System • Neurotransmitters: • Norepinephrine, serotonin, GABA • Neuroanatomy:Locus cereleus, raphe nuclei, limbic system, temporal lobes • Genetics:

4. Anxiety Disorders • PanicDisorder • SpecificPhobia • SocialPhobia • PosttraumaticStressDisorder ( PTSD ) • AcuteStressDisorder • GeneralizedAnxietyDisorder

6. PANIC DISORDER • Epidemiology: PD:1.5-5%,PA: 3-5.6% A: 0.6-6% • DSM 5 CRITERIA FOR PANIC DISORDER • 1- Recurrentunexpectedpanicattacks • 2- Persistentconcernabouthavingadditionalattacks • 3- Worryaboutitsconsequences ( goingcrazy..) • 4- Significantchange in behaviour • 5- Panicattacksare not dueto a substanceor a medicalconditionoranothermentaldisorder

7. PANIC ATTACK • 4 or more of the following symtoms: • * palpitations • * sweating • * trembling or shaking • * shortness of breath • * feeling of choking • * chest pain • * nausea or abdominal discomfort • * feeling dizzy, lightheaded, faint • * derealization- depersonalization • * fear of losing control or going crazy • * fear of dying • * numbness or tingling sensations • * chills or hot flushes

8. MEDİCAL CONDITIONS THAT CAN MIMIC A PANIC ATTACK • Angina pectoris • Arrithmias • COPD • Temporal lobe epilepsy • Pulmonary Embolism • Asthma • Hyperthyroidism • Hypoglycemia • Pheochromacytoma

9. COURSE AND PROGNOSIS • Onset: early adulthood • %30-40→long term symptom free • %50→mild symptoms • %10-20→significant symptoms • %40-80→depression develops • %20-40→alcohol adn substance dependance TREATMENT: • Benzodiazepines ( alprazolam, lorazepam ) • SSRI’s ( paroxetine, sertraline, citalopram ) • Cognitive behaviour therapy

10. SPECIFIC PHOBIAS

11. SPECIFIC PHOBIA • A phobia is defined as an irrationalfearthatproducesconsciousavoidance of thefearredsubject, activityorsituation. • 5-10% ( mostcommonanxietydisorder ) • Earlybeginning • Animals ( ailurophobia-cats, cynophobia-dogs) • Natural enviroment( storms,acrophobia-height) • Blood-injection-injury • Situational ( elevators, airoplane ) • Other ( mysophobia-germs,nasophobia-illness, death) • Treatment: • Exposuretherapy • benzodiazepines

12. SOCIAL PHOBIA • 3-13%, teens • hyperactivation of the amygdala and insula in fMRI • A marked fear of social or performance situations in which the person is exposed to unfamiliar people. The individual fears that he will act in a way that will be humiliating or embarrassing. • Exposure to the feared social situation provokes anxiety which may take the form of panic attack • The person recognizes that the fear is excessive or unreasonable. • The feared social or performance situations are avoided • Treatment: • SSRI’s, benzodiazepines • Behavioral and cognitive therapy

13. GENERALIZED ANXIETY DISORDER • Prevalance: ~ % 5 • More likely to occur in people with «behavioral inhibition» • Excessive anxiety and worry about a number of events or activities. • Anxiety and worry is associated with at least 3 of the followings: restlessness, being easily fatiqued, difficulty in concentrating, irritability, muscle tenion, sleep disturbance. • Treatment: • Cognitive and behavioral therapy • SSRI’s, benzodiazepines

15. POSTRAUMATIC STRESS DISORDER • Develops after a person sees, is involved in or hears of an extreme traumatic stressor. The persons response involves intense fear, helplessness or horror. • The event is persistantly reexperienced as images, flashbacks, thoughts, dreams. • Intense psychological distress at exposure to cues that symbolize or resemble the event • Persistance avoidance of the stimuli and numbing of general responsiveness • Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response • 1 week-30 years

16. ACUTE STRESS DISORDER • Develops after a person sees, is involved in or hears of an extreme traumatic stressor. The persons response involves intense fear, helplessness or horror • A subjective sense of numbing, detachment, absence of emotions • Derealization, depersonalization, • Dissociative amnesia • The event is persistantly reexperienced as images, flashbacks, thoughts, dreams • Sleep disturbances, irritability, hypervigilance, difficulty concentrating, exaggerated startle response

17. Pharmacotherapy • Benzodiazepines: GABA A agonist • SSRI’s • TCI’s • MAO inhibitors • B- adrenergic receptor antagonists ( propranolol • Antihistaminics • Buspirone ( HT1a agonist) • Ca channel blockers

18. ANXIETY DISORDER DUE TO A GENERAL MEDICAL CONDITION • Thyroid disorders ( hyper-hypothyroidism ) • Hypoglycemia • Neurological Disorders ( MS, epilepsy, CVD, Parkinson) • Anemia • Cardiomyopathies, hypoxia, cardiac arrytmias • SLE, RA, PAN • ALCOHOL – DRUG WITHDRAWAL • caffeine

19. Obsessive Compulsive Disorder

20. Facts and Figures • Prevalence • Originally believed to be rare • >0.1% • Recent evidence suggests 1-3% Onset / Characteristics: • Males:, high prevalence of checking • Females:, high prevalence of washing

21. OCD Diagnosis (1): DSM IV • Obsessions defined by all of the following: • Recurrent and persistent thoughts, impulses or images experience at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. • The thoughts/impulses/images are not simply excessive worries about real life problems. • The person attempts to ignore or suppress such thoughts/impulses/images, or neutralize them with some other thought or action. • The person recognizes that the obsessional thoughts/impulses/images are a product of their own mind (not imposed from without).

22. OCD Diagnosis (2): DSM IV • Compulsions defined by: • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules which must be applied rigidly • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive • Not better accounted for by other diagnosis

23. What is an Obsession? • Involuntary intrusive cognition • Types • Doubts (74%) • Thinking (34%) • Fears (26%) • Impulses (17%) • Images (7%) • Other (2%)

24. Themes in Obsessions • Obsessions often have common themes • Contamination, dirt, disease, illness (46%) • Violence and aggression (29%) • Moral and religious topics (11%) • Symmetry and sequence (27%) • Sex (10%) • Other (22%) • The themes often reflect contemporary concerns (the devil, germs, AIDS)

25. Causes of OCD • Elevated activity in the Frontal Lobe and Basal Ganglia • Activity is not typical in people without mental illness • PET (Positron emission Tomography) scan used in brain imaging

26. Pharmacotherapy • SSRI’s • First line, no major difference in class • Higher doses than for MDD (ex. 80 mg fluoxetine) • 10-12 weeks before switching • Clomipramine • first FDA approved, most serotonin specific of TCA’s, side effects • Augmentation, no to Li, atypical antipsychotics, e.g. risperidone (5HT2A blockade suggests there’s more to it than just “low serotonin”)

27. Treatment Refractory • Psychosurgery • For patient’s who have failed meds and therapy • Response rate approx. 50% • Four surgical prodecures • Cingulotomy, subcaudate tractotomy, limbic leukotomy, capsulotomy • Interrupt signals from OFC to basal ganglia • Gamma Knife • Anterior limb of internal capsule