2nd CME Anxiety Disorders

1. 2nd CME Anxiety Disorders Doct. Jean-louis Aillon 28-10-10 “The Scream” Edward Munch

2. Definition Anxiety A diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic sintoms, such as headache, perspiration, palpitation, tighness in the chest, mild stomach discomfort, restless… is an ALERTING SIGNAL! 1)SOMATIC SINTOMS 2) PSYCHOLOGICAL SINTOMS + Sympathetic nervous system EMOTION: Distress, alarm, terror COGNITIVE: evaluation of threat Fight/flight

3. Anxiety as a Normal and an Abnormal Response • Some amount of anxiety is “normal” and is associated with optimal levels of functioning. • Abnormal: + intensity or + duration to given stimuli • Pathological: Interfere with social, occupational or other important areas of functioning like stress..

4. The Fear and Anxiety Response Patterns • Fear: response to a threat: known, external, definite, non conflictual. Every people. • Phobia: not same alarm in majority of people • Anxiety: response to a threat: unknown, internal, vague or conflictual origin

5. DSM-IV Anxiety disorders trauma • Fear: • Phobia: • Anxiety: Acute Stress Disorder Post Traumatic Stress Disorder Interfere with functioning Specific Phobia, Social Fobia, Agorafobia avoidance Acute +++ Panic Attack/ Disorder Chronic - Generalized Anxiety Disorder Abnormal response Obsessive Compulsive Disorder General medical condition or drugs: Hypo/Hyperthyroidism, Hyperparathyroidism, deficit B12, Pheochromocytoma, brain lesion, Hypoglycemia, cardiac arhythmia. Anphetamine, cocaine, Miràa, caffeine.

6. Epidemiology in the world • Worldwide lifetime prevalence of anxiety disorders is 16.6% (18.5% F; 10.4%M) • One year prevalence: 10.6% Somers JM et al., Evid Based Mental Health , 2006

7. Epidemiology in Kenya n. 2770 (10 health facilities) On average, anxiety neurosis and general anxiety were recorded in at least 11% of the patients and the levels ranged from 1.5% to 37.7% across all the centres.

8. Our data Generalized Anxiety Disorder Panic Disorder Post Traumatic Stress Disorder Obsessive Compulsive Disorder Social Phobia Agoraphobia

9. Generalized Anxiety Disorder A) Have you worried excessively or been anxious about several things of day to day life, at work, at home, in your close circle over the past 6 months ? Are these worries present most days ? B) Do you find it difficult to control the worries or do they interfere with your ability to focus on what you are doing ?

10. C) When you were anxious over the past 6 months, did you, almost every day, 3 or more of these sintoms : • Feel restless, keyed up or on edge ?  • Feel tense ? • Feel tired, weak or exhausted easily ?   • Have difficulty concentrating or find your mind going blank ?  •  Feel irritable ?  • Have difficulty sleeping (difficulty falling asleep, waking up in the middle of the night, early morning wakening or sleeping excessively) ?  D) The focus of the anxiety and worry is not confined to features of an Axis I disorder,: social phobia, obsessive-compulsive disorder, separation anxiety disorder, somatization disorder, hypochondriasis, posttraumatic stress disorder. E)The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social or occupational functioning.

11. Panic Disorder A)1. Recurrent unexpected panic attacks 2. At least one of the attacks has been followed by at least 1 month of oneor more of the following: - Persistent concern about having additional panic attacks • Worry about the implications of the attack or its consequences • A significant change in behavior related to the attacks B) Presence or absence of agoraphobia C) 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). D) The panic attacks are not better accounted for by another mental disorder.

12. What is a panic attack? • Have you, on more than one occasion, had spells or attacks when you suddenly felt anxious, frightened, uncomfortable or uneasy, even in situations where most people would not feel that way ? Did the spells peak within 10 minutes ? • Requiring at least four of the following sintoms: • Did you have skipping, racing or pounding of your heart ? • Did you have sweating or clammy hands ? • Were you trembling or shaking ? • Did you have shortness of breath or difficulty breathing ? • Did you have a choking sensation or a lump in your throat ? • Did you have chest pain, pressure or discomfort ? • Did you have nausea, stomach problems or sudden diarrhea ? • Did you feel dizzy, unsteady, lightheaded or faint ? • Did things around you feel strange, unreal, detached or unfamiliar, or did you feel outside of or detached from part or all of your body ? • Did you fear that you were losing control or going crazy ? • Did you fear that you were dying ? • Did you have tingling or numbness in parts of your body ? • Did you have hot flashes or chills ?

13. Post Traumatic Stress Disorder A) The person has been exposed to a traumatic event in which both of the following were present: • The person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity of others. • The person's response involved intense fear, helplessness, or horror. EXEMPLE: SERIOUS ACCIDENT, SEXUAL OR PHYSICAL ASSAULT, A TERRORIST ATTACK, BEING HELD HOSTAGE, KIDNAPPING, HOLD-UP, FIRE, DISCOVERNG A BODY, UNEXPECTED DEATH, WAR, NATURAL DISASTER...

14. B) The traumatic event is persistently re-experiencedin at least one of the following ways: • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions • Recurrent distressing dreams of the event. • Acting or feeling as if the traumatic event were recurring, including a sense of reliving the experience, illusions, hallucinations, and flashback episodes. • Intense psychological distress at exposure to cues that symbolize an aspect of the traumatic event. • Physiologic reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event. C) The person persistently avoids stimuli associated with the trauma and has numbing of general responsiveness including at least three of the following: -Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect

15. D) Persistent symptoms of increased arousal are indicated by at least two of the following: -Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response E) Duration of the disturbance is more than 1 month. F) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Less: Acute Stress disorder

16. Post Traumatic Stress Disorder • Extreme traumatic event • Re-experience • Avoidance • Increased Arousal • More than 1 month • Significant Distress

17. Obsessive Compulsive Disorder Obsession Anxiety Compulsion Thoughts, impulses, or images: Recurrent Persistent Intrusive Innapropriate Distressing + + + Repetitive behaviors or mental acts to reduce anxiety related to obsessions • Fearing act on some impulse • Fear of harming someone even though you didn’t want to • Sexual thoughts, images or impulses • Fear or superstitions that you would be responsible for things going wrong • Religious obsessions • hoarding, collecting • To be dirty, contaminated or had germs • Fear of contaminating others, • Superstitious rituals • Counting or checking • - Repeating • Collecting Arranging things • Washing or cleaning excessively

18. A) Either obsession or compusion Obsession • Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate, causing anxiety or distress. • The thoughts, impulses, or images are not simply excessive worries about real-life problems. • The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action. • The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind. Compulsions • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. • These behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or they are clearly excessive.

19. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. • The obsessions or compulsions cause marked distress, take up more than 1 hour a day, or significantly interfere with the person's normal routine, occupation, or usual social activities

20. Agoraphobia Fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event of having unexpected panic-like symptoms. The situations are typically avoided or require the presence of a companion. Often associated with Panic Disorder

21. Social Phobia • A fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others and feels he or she will act in an embarrassing manner. • Exposure to the feared social situation provokes anxiety, which can take the form of a panic attack. The person recognizes that the fear is excessive or unreasonable. • The feared social or performance situations are avoided or are endured with distress.The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person's normal routine, occupational functioning, or social activities or relationships

22. etiology • Psychological Theories: • Psychoanalitic: conflict • Behavioural: faulty, distorted thinking pattern • Existential: awareness ot nothingness of life. • Biological Theories: • autonomic system • neurotrasmitters • Genetic ( + panic) External: world pressure vs Ego Internal: impulses vs conscience

23. Theraphy • The fundamental problem in dealing with the pharmacological treatment of anxiety doesn’t seem to be which medicine to use, but whether to use it or not- • Altesman, Cole, 1983 • Psychotherapy: + cognitive-behavioural • Relaxation techniques • Farmacotheraphy: Benzodiazepine: Diazepam,alprazolam Amitriptyline Fluoxetine (SSRIs) For anxiety that is severe, disabling and causing extreme distress or associated with somatic sintoms

24. 1° approach “Empathic listening, reassurance and guidance should always be offered. Additionally, specific psychotherapeutic techniques, such as cognitive-behavioural therapy, are effective measures to reduce anxiety. Relaxation techniques may additionally be offered. WHO

25. Cognitive-Behavioural Psychotherapy GAD: relaxation tecnique, biofeedback/ distorted thinking Panic Disorder: instruction about false beliefs: tendency to misinterpret mild bodly sensation as indicative of impending panic attack. Panic attack are time limited and not life-thretening. PTSD: reconstruction/review of traumatic event. Abreact emotional feeling associated with trauma. DOC: exposure and response prevention, desensibilization

26. Relaxation technique 1) Breathing And Relaxation exercise for Insomnia • Take a deep breath. Breathe in through your nose and visualize the air moving down to your stomach. Breathe out slowly through your mouth. As you breathe in again, silently count to four. Purse your lips as you exhale slowly. This time count silently to eight.Repeat this process six to ten times. • 2)Lay on your back on the floor with your feet slightly apart, your hands by your sides, and your palms turned upward. Close your eyes and concentrate on every part of your body.Begin at the top of your head and work your way down to your toes.Start by feeling your forehead tense, then your eyes, face, and jaw. Tense and release each muscle group, such as your shoulders and neck.Pay attention to each area of your body from the top of your head, down through the trunk of your body, along your legs, and ending at the tips of your toes.Stay in this relaxed condition for a few minutes. Concentrate on your breathing and let all worry and stress dissipate from your mind and body. Make sure that your breathing comes from deep in your stomach and flows slowly and evenly.Stretch slowly before standing up.

27. Farmacotheraphy 1) Benzodiazepine for short term • Diazepam: 2 mg PO OD/TID, up to oral doses of 5-10 mg BD. • Alprazolam: 1 mg OD/TID, up to 2 mg TID Lowest effective dose for as short a period as possible (maximum 4 weeks) Lower doses are generally advised in children and adolescents. “The main objective may be to reduce symptoms enough to allow the patient to engage in treatments based on cognitive-behavioural techniques.” WHO Start: 2,5 mg bid Start: 0,25 mg bid

29. Antidepressants for long term treatment • Amitriptiline 25 mg NOCTE: gold standard 2) Fluoxetine 20 mg OD For Disorders that are severe, disabling and causing extreme distress, or somatic sintoms No responding o no possibility of Psychotherapy Contraindications Not tollerate side effects

30. Amitriptyline • + dosage in DOC Start with: 25 mg NOCTE 1/12 * 2 weeks If problem to review soon Monitoring acute treatment Psychological counseling 4-6 weeks Evaluation of response to treatment Remarkable emprouvement Light emprouvement NO emprouvement Long term therapy at least 6-8 months + 25 mg every week (max: 200 mg) Change antidepressant Refer Psychiatrist

31. Amitriptiline Contraindication: : Pregnancy and breast feeding, Glaucome, hyperthyroidism, prostatic hypertrophy, Stenosis pillorica, heart failure, serious rhythm disturbances, Hypotension, treatment with thyroid ormons, liver diseases, Dementia. Inform patients about side effects - Dosage in elders

32. Fluoxetine *Better 10 mg 1° week 20 mg 2° week Administer in morning or after lunch + dosage in DOC Start with: 20 mg OD 1/12 * 2 weeks Monitoring acute treatment Psychological counseling 4-6 weeks Evaluation of response to treatment Remarkable emprouvement Light emprouvement NO emprouvement Long term therapy at least 6-8 months + 10 mg every week (max: 40-60 mg) Change antidepressant Refer Psychiatrist

33. Fluoxetine Contraindication: Pregnancy and breast feeding, Hypersensibility

34. Asante sana for your attention http://www.who.int/mental_health/management/psychotropic/en/index.html Utopia lies at the horizon. When I draw nearer by two steps, it retreats two steps. If I proceed ten steps forward, it swiftly slips ten steps ahead. No matter how far I go, I can never reach it. What, then, is the purpose of utopia? It is to cause us to advance.” Eduardo Hughes Galeano For any suggestion: jean.84@libero.it 0735525429