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Anxiety disorder

Anxiety disorder. DSMIV-TR-2000 classification of anxiety disorders. Panic disorder without agoraphobia Panic disorder with agoraphobia Agoraphobia without panic disorder Specific phobia Social phobia Obsessive compulsive disorder Posttraumatic stress disorder Acute stress disorder

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Anxiety disorder

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  1. Anxiety disorder

  2. DSMIV-TR-2000 classification of anxiety disorders • Panic disorder without agoraphobia • Panic disorder with agoraphobia • Agoraphobia without panic disorder • Specific phobia • Social phobia • Obsessive compulsive disorder • Posttraumatic stress disorder • Acute stress disorder • Generalized anxiety disorder • Anxiety disorder due to medical condition • Anxiety disorder NOS

  3. Anxiety disorders • *Sigmund Freud---anxiety neurosis • Normal anxiety:*fear vs. anxiety, psychological and cognitive sx • Pathological anxiety: *Psychological theory: Id,superego anxiety, separation anxiety, castration anxiety *Behavioral theory: conditioned response *Biological theory: NE(panic disorder), serotonin (OCD), GABA(general anxiety disorder)

  4. Anxiety disorders • Brain imaging studies *increase size of ventricles *abnormal in right hemisphere *functional abnormality in frontal cortex, occipital & temporal areas • Genetic studies *1/2 of panic p’ts—1 affected relatives *higher frequency of lst. Degree relative • Neuroanatomical: locus ceruleus & raphe nuclei project to limbic system & cerebral cortex

  5. Panic disorder & agoraphobia • Clinical sx of panic attacks: spontaneous first attack rapidly increasing sx in 10 minutes fear and sense of impending death or fainting last 20 to 30 minutes rarely more than l hr intense anxiety or fear with somatic sx of palpitation or tachycardia with anticipatory anxiety • Clinical sx of agoraphobia: avoid situations in which it would be difficult to obtain help, depression,marital discord,loss work,financial problem

  6. Life time prevalence rate of panic disorder—1.5-5% (Taiwan 0.2/0.3%), panic attack—3-5.6%, agoraphobia 0.6-6% (Taiwan 1.1/1.5%) • Women:Men=2-3/1 • Mean age of onset 25 y/o • Etiologies: *Panic-inducing substances: adrenergic antagonist,serotonin releasing agents, GABA receptor antagonist *Brain imaging studies—pathology in temporal, lobes, hippocampus *mitral valve prolapse? *Genetic—4 to 8x increase in lst. Degree rela, higher concordant in monozygotic twin

  7. Course & prognosis of panic disorder • Onset during late adolescence or early adult • Chronic, 30-40% symptom free, 50% sx mild, 10-20% significant sx • 40-80% with depression, 20-40% substance abuse • Good prognosis: good premorbid function, brief duration

  8. Course & prognosis of agoraphobia • Panic disorder with agoraphobia—sx (-) while panic disorder (-) • Agoraphobia without panic---incapacitating, chronic • Depression & alcohol dependence often complicated

  9. Treatment of panic disorder, agoraphobia • Drugs: TCA, MAOI, SSRI, BZD, B-blocker • Cognitive & behavior tx • Family tx • Insight-oriented psychotx

  10. Specific phobia & social phobia • Phobia—irrational fear---conscious avoidance of feared objects, activity,situation • Social phobia---excessive fear of humiliation or embarrassment in various social settings (public speaking,urinating in public rest room—shy bladder--) • Specific phobia: animal, storm,height, illness, injury, death, narrow closed space (claustrophobia), blood (erythrophobia)

  11. Specific phobia *6 month prevalence—5-10% (Taiwan 3.6-4.8%) *Female:male=2/1 *peak age of onset for natural environment type & blood—5-9 y/o,for situational type-mid 20s • Social phobia *6 month prevalence---2-3% (Taiwan 0.6/0.5%) *Female>male *peak age of onset---teens

  12. Etiologies of specific phobia • Behavioral factors—*conditional emotional reactions (John B. Watson, 1920), stimulus-response model of conditioned reflex (Pavlov), *learning theory • Psychoanalytic factors--*forbidden unconscious drive, *unressolved childhood oedipal,*castration anxiety, *interaction between genetic factors & environment (temperament of behavior inhibition to the unfamiliar) • Genetic factors---specific phobia run in families, 2/3 to 3/4 of p’ts with l lst. Degree

  13. Etiologies of social phobia • Genetic factors---specific phobia run in families, 2/3 to 3/4 of p’ts with l lst. Degree • Social phobia---trait of behavioral inhibition, parents of persons with social phobia—less caring, more rejecting, more overprotective • Neurochemical factors—adrenergic, dopaminergic dysfunction • Genetic factors—3x affected in lst. Degree relative higher concordance in monozygotic twin

  14. Clinical features • Arousal of severe anxiety • Panic attacks • Anticipatory anxiety • Avoidance behavior • Substance related disorders • 1/3 of social phobia with major depression

  15. Course & prognosis • Financial dependence • Impairment of social life, occupational performance, school performance • Substance related disorders---adversely affect the course & prognosis

  16. Treatment • Insight-oriented psychotx • Hypnosis • Supportive tx • Family tx • Exposure tx (Joseph Wolpe) for specific phobia • Behavioral & cognitive tx for social phobia • Pharmacotx---B antagonist, MOAI,xanax,SSRI

  17. Generalized anxiety disorder (GAD) • Excessive & pervasive worry, with a variety of somatic sx—sig. Impairment in social or occupational function, marked distress in p’t • 1 year prevalence---3-8% (Taiwan 3.7-10.5%) • 50-90% of GAD p’ts-comorbid with another mental disorder • Women/men=2/1

  18. Etiologies of GAD • Biological factors *GABA or serotonergic or NA dysregulation *lower metabolic rate in basal ganglia & white matter *25% of lst. Degree relative of p’t-GAD *higher(50%) concordance rate of monozygotic twin • Psychosocial factors: cognitive-behavioral theory, psychoanalytic theory

  19. Clinical features of GAD • Primary tx—anxiety,motor tension,ANS hyperactivity,cognitive vigilance • Excessive anxiety, interfere life • Motor tension—shakiness,restless,headache • ANS hyperactivity-SOB,sweating,palpitation, G-I sx • Cognitive vigilance—irritability, ease to be startled

  20. Course & prognosis of GAD • High incidence of comorbid mental disorders: 25% with panic disorder, many with Major depression • Chronic, may be lifelong

  21. Treatment of GAD • Psychotx—cognitive-behavior (relaxation & biofeedback), supportive, insight-oriented psychotx • Pharmacotx—BZD, buspirone, B-antagonist, TCA

  22. Obsessive compulsive disorder(OCD) • Obsession---recurrent & intrusive thought, feeling, idea or sensation • Compulsion---conscious, standardized, recurrent thought or behavior (counting, checking, avoiding) • Obsessive increase anxiety---compulsions • Realize the irrationality—ego-dystonic (sometimes ego-syntonic) • Disabling & time-consuming

  23. 2-3% in general population (Taiwan 0.9/0.5%) • 10% of psychiatric outpatients • Male=female in adults,boys>girls • Mean age of onset---20 y/o • Comorbid with major depression (67%), social phobia (25%), alcohol use disorder, specific phobia, panic disorders, eating disorders

  24. Etiologies of OCD • Biological—dysregulation of serotonin • Brain imaging---increased activity in frontal lobe,basal ganglia (caudate nucleus),cingulum • Genetics---35% of lst. Degree relative, higher concordance for monozygotic twin • Psychosocial---15 to 35% of OCD p’ts—obsessional trait • Psychodynamic---*defense mechanism---isolation, undoing, reaction formation

  25. Clinical features of OCD • 75% with both obsession & compulsion • Feelings of anxious—countermeasures against the idea of impulse • Recognize it irrational, strong desire to resist • Four major sx patterns: *obsession of contamination-wash,avoidance *obsession of doubt-checking *obsession without compulsion-sexual,aggressive *need for symmetry or precision-compulsion slowness

  26. Course and prognosis • 50-70%--onset after a stressful event • Delay 5 to 10 years to psychiatric attention • Chronic,variable, fluctuating,or constant • 20-30% sig. improved,40-50%mod.improve, 20-40% remain same or worse • 1/3 with major depression • Poor px—yielding to compulsion,childhood onset,bizarre compulsion,need hosp.,with MD, delusional, schizotypal PD • Good px—good social & occupational adjustment, ppt(+), episodic nature

  27. Treatment of OCD • Pharmacotx---SSRI or anafranil • Behavior tx---exposure & response prevention,desensitization,thought stopping,flooding, aversive conditioning • Psychotx—insight-oriented psychotx,supportive psychotx • Family tx, group tx, ECT, psychosurgery

  28. Posttraumatic stress disorder (PTSD) & acute stress disorder • Emotional stress with a magnitude that would be traumatic for anyone---combat, natural catastrophes, assault, rape, serious accidents • Reexperiencing of trauma—dreams, thoughts • Persistent avoidance of reminders of trauma, numbing of responsive to such reminders • Persistent hyperarousal • Depression,anxiety & cognitive difficulties • Minimal duration of one month (PTSD) • Sx occur within 4 wks of events, last for 2 days to 4 wks (acute stress disorder)

  29. Lifetime prevalence of PTSDF---1-3% of general population, 5-15% of subclinical forms • High risk group experience traumatic events—lifetime prevalence 5-75% • 30% Vietnam veterans—PTSD, 25% subclinical • Single, divorced, widowed, economically handicapped, or socially withdrawn—likely to occur

  30. Etiologies of PTSD • Stressor • Predisposing vulnerability factors: *childhood trauma *borderline,paranoid,dependent,antisocial PD *inadequate support system *genetic-constitutional vulnerability to psychiatric illness *recent stressful life changes *perception of external locus of control *recent excessive alcohol intake

  31. Etiologies of PTSD • Psychodynamic factors *unresolved psychological conflict • Biological factors *noradrenergic,endogenous opiate system, hypothalamic-pituitory-adrenal-axis hyperactive *increased activity of ANS *similarity with MD & panic disorder

  32. Clinical features • Painful reexperiencing of events • Avoidance & emotional numbing • Constant hyperarousal • Feelings of guilty,rejection,humiliation • Dissociative states,panic attacks,illusion & hallucination • Impairment of memory & attention • Associated sx:aggression,violence,poor impulse control,depression,substance related disorders

  33. Course and prognosis • Onset some time after trauma,sometimes delay as 30 yrs • 30% complete recovery,40% mild sx,20% mod.sx,10% unchanged or worse • Good-px—rapid onset,short duration of sx (<6m),good premorbid function,strong social support,absence of psychiatric, medical, substance disorder • Very young & very old more difficulty, preexisting psychiatric disability, PD more serious

  34. Treatment • Support,encourage to discuss,education coping mechanisms, behavioral tx, cognitive tx, hypnosis, family tx,group tx • Pharmacotx—TCA, SSRI, anticonvulsant, inderal, propranolol, clonidine

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