ANXIETY DISORDER

1. Jaison Joseph

2. ANXIETY
Anxiety is a diffuse unpleasant,
vague sense of apprehension
often accompanied by
autonomic symptoms

3. Fear is a response to known external,
definite ,nonconflictual threat
Anxiety is a response to unknown
internal, vague, conflictual

4. Symptoms of Anxiety
- 1.Psychological
- Awareness of being nervous or
frightened
- 2.Physiological
- 3.Interfere with learning
- Decreased concentration
- Reduced Recall
- 4.Selective Attention

5. Physiological Symptoms
– Palpitation
– Tachycardia
– Dizziness
– Light – Headedness
– Hypertension
– Diarrhea
– Restlessness – Pacing
– Stomach upset
– Urinary frequency

6.  Abraham Lincoln (president - USA)
 Michael Jackson (singer)
 Sigmund Freud (psychiatrist)
 Sir Isaac Newton (scientist)

7.  “Irritable Heart” – Da Costa
(1871)
 Anxiety neurosis – Sigmund
Freud (1926)
– Mental illnesses in which the
dominant feature is excessive
and prolonged anxiety
Early “Anxiety Disorders”

8. Etiology-
1.Psychological theories
Anxiety is the psychic conflict
between unconscious (sexual
or aggressive) wishes and
corresponding threats from
the super ego or external
reality
1. Psychoanalytic Theory

9. Psychodynamic Themes
 Caregiver seperation
 Controlling/rejecting parenting
 Childhood sexual or physical abuse
 Chronic sense of feeling trapped
 Excessive criticism

10. Etiology
Anxiety is a conditioned response
to specific environmental stimuli.
2. Behavioral Theory

11. 2.Biological Theories
Patient with anxiety disorder
exhibit increased sympathetic
tone and respond excessively to
moderate stimuli
1. Autonomic Nervous System

12. Biological Theories
a. Nor epinephrine
b. Serotonin
c. GABA
2. Neurotransmitters

13. Biological Theories
- Increased size of cerebral
ventricles
- Defect in right temporal lobe
- Abnormal findings in right
hemisphere
3. Brain Imaging Studies

14. Biological Theories
High incidence among relatives
4. Genetic Studies

15. Biological Theories
Locus Ceruleus and raphae
nucleus project primarily to limbic
system and cerebral cortex
5. Neuro Anatomical Consideration

16. Classification of Anxiety Disorders
F.40 Phobic Anxiety Disorders
Agoraphobia
Social Phobia
Specific Phobia
F.41 Other Anxiety Disorders
Panic Disorder
Generalized Anxiety Disorder
Mixed Anxiety and Depressive
Disorder

17. CASE NO 1
 36 yr old woman experienced several
episodes of feeling dizzy and faint over a-3
month period .A full medical check up did
not reveal any physical problem .Her
physician told her ``you do not have any
medical problem .The problem Is all in
your head’’

18.  This reasoning advice did not lessen her concern
that she might experience the symptoms in a
situation where she could not find help.
 Her fears led to a significant constriction of her
previously active life style.
 She would not leave the household without
afriend, walk in a crowd, drive by herself, or wait
in the line at a super market for fear that she
would have an attack.

20. AGORAPHOBIA

21. Agoraphobia
Patient experience severe panic
attack when patient is alone in public
places where a rapid exit would be
difficult in the course of panic attack

22. CASE NO .2.
 A 35 yr old cloth sales man was
showing a suit to a customer and
began to sweat profusely. His heart
started to pound, he felt dizzy ,and
became fearful that he was about to
die .The customer did not notice this
and continued to question about the
suit

23.  In minute detail. The patient feeling faint,
abruptly left the customer and went to lie down in
the back of store. The customer became insulted,
complained to manager and left. When the
manager found the patient he was slumped in a
chair in the back room trembling
 Approximately 10 mnts later the patient`s
symptoms began to subside. He saw his
physician the next day.
 He found no evidence of any medical problems.
Two weeks later he had another similar
unexpected attack. His friends noticed that he is
no longer as spontaneous and out going as he
had been in the past.

25. PANIC DISORDER

26. Panic Attack
Spontaneous, unexpected
occurrence of severe anxiety with
prominent autonomic arousal
symptoms which starts abruptly,
reaches the maximum, and subsides
by it self

27. Panic Disorder
Repeated occurrence of Panic Attack

28. Social Phobia
Strong persistent fear of situations in
which patient is under scrutiny by
other people in comparatively small
groups, leading to avoidance of
social situations
- Speaking in public
- Eating in Public
- Encounter with opposite sex

29. CASE VERBATIM
 “In any social situation, I felt fear.
 “When I would walk into a room full of people, I’d
turn red and it would feel like everybody’s eyes
were on me.
 It was humiliating. I felt so clumsy, I couldn’t wait to
get out.”

30. Specific Phobias
Strong persistent fear of specific
objects or situations
- Animals
- Heights
- Thunder
- Darkness
- Sight of Blood
- Eating Certain Food

31. Phobias
 Acrophobia
 Agoraphobia
 Ailurophobia
 Hydrophobia
 Claustrophobia
 Cynophobia
 Mysophobia
 Pyrophobia
 Xenophobia
 Zoophobia
 fear of heights
 fear of open places
 fear of cats
 fear of water
 fear of closed spaces
 fear of dogs
 Fear of dirt and
germs
 fear of fire
 fear of strangers
 fear of animals

32. Generalized Anxiety Disorder
Person who seem to be anxious
about almost every thing

33. CASE VERBATIM
 “I always thought I was just a worrier. I’d feel
keyed up and unable to relax.
 I’d worry about anything and everything.I just
couldn’t let something go.”
 I’d have terrible sleeping problems. There were
times I’d wake up wired in the middle of the
night.
 I had trouble concentrating, even reading the
newspaper or a novel.
 I was always imagining things were worse than
they really were

34. Anxiety is seen in
 Anxiety Disorder
 Phobic Anxiety Disorder
 Depressive Disorder
 Schizophrenia
 Psychoactive Substance Use Disorder
 Organic Mental Disorder

35. General Medical Causes of Anxiety
CVS - Arrhythmias
- Atrial Tachycardia
- Angina
- Mitral Valve Prolapse
- Myocardial Infarction

36. Endocrine
– Hyper Thyroidism
– Phechromocytoma
– Hypoparathyroidism
– Insulinoma
– Cushing’s Syndrome

37. Respiratory
– C.O.P.D.
– Hypoxia
– Pulmonary Embolism

38. Neurological
– Aura of Migraine
– Early Dementia
– Delirium
– Complex Partial Seizures
– Demyelinating Disease
– Withdrawal from sedatives

39. Treatment
– Pharmacotherapy
– Psychotherapy

40. Pharmacotherapy
1. Benzodiazepines
- Rapid onset
- Effective
- Cause Sedation
- May Impair Performance
- May cause Dependence
- Abuse potential

41. Pharmacotherapy
2. Buspirone
- Delayed onset of effect
- Effective
- No Sedation
- No impairment in performance
- No dependence
- No abuse potential
- Dose : 5mg tid
Increase by 5mg/day
every 3 days
max 60mg/day

42. Pharmacotherapy
3. SSRI
- Delayed onset of effect
- Effective
- May cause Sedation
- May cause insomnia
- No Dependence
- No Abuse potential
- Fluoxetin : 20mg/day
- Sertralin : 50mg/day
- Escitalopram : 5 to 20mg/day

43. Psychotherapy
– Supportive Psychotherapy
– Insight oriented psychotherapy
– Cognitive – Behavior Therapy
– Relaxation

44. Phobic Anxiety Disorder
– Systemic Desensitization
– Exposure to phobic stimulus
• Imaginal flooding
• Implosion

45. Thought challenging in cognitive behavioral therapy
 Identifying your negative thoughts.
 Challenging your negative thoughts.
 Replacing negative thoughts with realistic
thoughts.

46. Systematic desensitization
 Learning relaxation skills
 Creating a step-by-step list.
 Working through the steps

47. Facing a Fear of Flying
 Step 1: photos
 Step 2: video.
 Step 3: real planes take off.
 Step 4: plane ticket.
 Step 5: Pack for your flight.
 Step 6: Drive to the airport.
 Step 7: Check in for your flight.
 Step 8: Wait for boarding.
 Step 9: Get on the plane.
 Step 10: Take the flight.

48. ICD-10
 F40-F48
Neurotic, stress related and somatoform
disorders
F 40- Phobic anxiety disorder
F 41- Other anxiety disorders
F 42- OCD
F 43- Reaction to severe stress &adjustment
disorders
F 44- Dissociative disorders
F 45- Somatoform disorders
F 48- Other neurotic disorders

49. Case-5
 “Getting dressed in the morning was
tough, because I had a routine, and if I
didn’t follow the routine, I’d get anxious
and would have to get dressed again.
 I always worried that if I didn’t do
something, my parents were going to die.
I’d have these terrible thoughts of
harming my parents.
 That was completely irrational, but the
thoughts triggered more anxiety and more
senseless behavior.

50. Obsessive Compulsive Disorder
Obsession is a recurrent intrusive
thought, feeling, idea or sensation.
Compulsion is a conscious
recurrent behavior carried out in an
attempt to reduce anxiety associated
with obsession but it may not reduce
anxiety.

51. Features of Obsessions and Compulsions
– Patient recognize as absurd or irrational
• Unwanted behaviour
– Strong desire to resist
– Causes distress to patient
– Anxiety is increased when a person resist
carrying out a compulsion

52. Classification
ICD-10
 F42.0 Predominantly obsessional
thoughts
 F42.1 Predominantly compulsive acts
 F42.2 Mixed obsessional thoughts and
acts
 F42.8 Other OCD
 F42.9 OCD, unspecified

53. Symptom Pattern
1. Contamination - Washing
2. Doubt - Checking, Counting
3. Intrusive Thoughts - Sexual or aggressive
4. Symmetry - Compulsive slowness
5. Others - Religious obsessions
- Compulsive Hoarding
- Compulsive hair pulling
- Compulsive nail biting

54. Treatment
1. Pharmacotherapy
- SSRI - High dose
- TCA - Clomipramine

55. Pharmacotherapy
 10-12 wks of SSRI adequate dose
 6 weeks of maximum tolerable dose
Duration of treatment:
 1 – 2 yrs after remission
 25% reduction per month
Usual treatment outcomes:
 Response( >35% )
 Partial response( 25 – 35 %)

56. Treatment- first line
 Medication Average dose Max dose
 Fluoxetine 40 80
 Citalopram 40 80
 Sertraline 150 200
 Fluvoxamine 150 300
 Paroxetine 40 60
 Clomipramine 150 300

57. Treatment
 Psychosurgery – 25-30% (Jenike et al)
– Sub caudate tractotomy
– Anterior cingulotomy
– Limbic leucotomy
– Anterior capsulotomy
 ECT

58. Treatment
2. Behaviour Therapy
- Exposure and response prevention
- Desensitization
- Thought stopping
- Flooding

59. ERP - Steps
 Behavioral assessment
 Education
 Preparation of hierarchy
 Exposure sessions with anxiety grading
 Progress through hierarchy
 Coping with anxiety

60. Treatment
3. Psychotherapy
- Insight Oriented Psychotherapy
- Supportive Psychotherapy
- Family Therapy
- Group Therapy
- Brain lock

61. Treatment resistant OCD
Definition:
1. 2 failed SSRI trial
2. 20 hours of CBT trial failed

62. PROGNOSIS
 Good prognosis  Bad prognosis
– Good social and
occupational
adjustment
– Presence of a
precipitating event
– Episodic nature of
the symptoms.
– Childhood onset
– Bizarre compulsions
– Need for hospitalization
– Coexisting major
depressive disorder
– Delusional beliefs
– Presence of overvalued
ideas
– Presence of a personality
disorder

63. Reaction to Stress
 Acute Stress Reaction
– Exposure to severe stress - death,
accident, rape,loss.
– Onset of symptoms – soon after
exposure to stress
– Initial state of daze
– Rapidly changing -- depression, anxiety
anger, despair and over activity
– Resolves with in few days

64. Treatment
Benzodiazepines
Supportive Psychotherapy

65. Post Traumatic Stress Disorders
Delayed or protracted response to
stressful event or situation of an
exceptionally threatening or
catastrophic nature – man made and
natural calamities

66. Clinical Features
1. Recurrent recollection of stressful
event
1. Flash back – image, thought, perception
2. Dreams
2. Re-experiencing of event
3. Avoidance of events or situations
that arouse recollection of event

67. Treatment
– Prevention
– Disaster Management
– Supportive Psychotherapy
– Drugs

68. Adjustment Disorder
Maladaptive response to stressful life
events

69. Older terminology – hysteria
Epidemiology- Females affected more
Etiology
Conflict Repression Dissociation
A partial or complete loss of the normal
integration between memories of the past,
awareness of identity, immediate sensations, and
control of bodily movements.
Dissociative (Conversion) Disorders

70. Clinical Features
1. Symptoms suggests a medical or neurological
disorder
2. Onset and termination may be sudden
3. Chronic state may also be seen (insoluble
problem or interpersonal difficulties)
4. Usually follows traumatic life events but patient
denies
5. Symptoms are not produced intentionally
6. Detailed physical examination and investigation
does not reveal any abnormalities

71. Classification
- Dissociative Amnesia – Partial or
complete for events that are stressful
- Dissociative Fugue – Amnesia +
Purposeful travel beyond the usual every
day range maintenance of basic self care
and normal social interaction.
- Dissociative Stupor - Diminution /
absence of voluntary movements and
normal response to external stimuli.

72. Classification
- Trance or possession disorder –
- Temporary loss of personal identity and full
awareness of surroundings
- Patient may act as if taken over by another
personality, spirit, deity or force
- Dissociative motor disorders
- Bizarre gait, inability to stand – aphonia
- Dissociative convulsions
- Pseudo seizures
- Dissociative anesthesia
- Mixed

73. Treatment
1. Psychotherapy – Abreaction –
Bringing thoughts, affect and
memories to conscious
awareness
- Hypnosis
- Free Association
- IV Thiopentone

74. Treatment
2. Behaviour Therapy
 Suggestion
 Hypnosis
3. Supportive Psychotherapy
4. Drugs – Limited use
5. Follow up

75. I DON’T KNOW …..??????
Head, Joint,
Chest pain
Deafness
Numbness
weakness

76. Neurotic, stress-related and
Somatoform Disorders (F40- F48)
• Phobic anxiety disorders
• Other anxiety disorders e.g. GAD
• OCD
• Reaction to severe stress and adjustment
disorders
• Dissociative ( conversion) disorders
• Somatoform Disorders
• Other neurotic disorders e.g. Neurasthenia

77. History of Somatoform Disorders
• from the Greek word soma
• recognized since the time of ancient Egypt
• Earlier name hysteria
• 17th Century Thomas Sydenham found that
antecedent sorrows were involved in the pathogenesis
of the symptoms
• 1859 Paul Briquet- Briquet’s Syndrome commented
on multiplicity of symptoms found and chronic
course

78. History of Somatoform Disorders
CONTD…..

79. DEFINITION
Somatoform disorders can be
characterized as the presence of
physical symptoms that suggest a
medical condition without a
demonstrable organic basis to account
fully for them.

80.  Primary gain
Appearance of the pain enables
the client to avoid some unpleasant
activity
 Secondary gain
The pain promotes emotional
support or attention that the client
might not otherwise receive

81. TYPES OF SOMATOFORM
DISORDERS

82. Somatization Disorder
• Multiple somatic complaints over long periods (2 years)
• Before the age of 30 years
• Inadequately explained by independent findings of
physical injury or illness
• Significant impairment
• Distress

83. • 4 symptoms each must be present in some intensity:
(a) 4 pain symptoms (at least at four sites)
(b) 2 gastrointestinal symptoms
(nausea, vomiting, diarrhea)
(c) 1 sexual symptom
( irregular menses, erectile or ejaculatory dysfunction)
(d) 1 pseudo-neurological symptom condition
( paralysis, blindness, deafness)
• Anxiety and depression
• Suicidal threats.

84. Contd..
 A fluctuating course with periods of
remissions and exacerbation
 Clients often receive medical care from several
physicians
 A tendency to seek relief through self
medication
 Drug abuse and dependence are common
complications
Somatization Disorder
SYMPTOMS

85. Undifferentiated Somatoform Disorder
• Residual category
• Contains unexplained
physical symptoms
• Symptoms below a
threshold for the diagnosis
of Somatization disorder
• Last 6 months

86. HYPOCHONDRIASIS
Characterized by the fear of contracting a
serious illness
It is defined as an unrealistic or inaccurate
interpretation of physical symptoms or
sensations, leading to preoccupation and fear
of having a serious disease

87. Hypochondriasis
why not
Hyperchondriasis
Term Hypochondriasis = Hypochondrium (below the
ribs) reflecting common abdominal complaints

88. HYPOCHONDRIASIS
SIGNS AND SYMPTOMS
 Preoccupation with;
- a specific organ or disease
- bodily functions ( peristalsis, heart
beat or minor physical alterations)
 A history of “doctor shopping”
 Anxiety and depression
 Obsessive compulsive traits
 Preoccupation interferes with social or
occupational functioning

89. Somatization disorder
Vs
Hypochondriasis
Somatization disorder Hypochondriasis
Emphasis is on symptoms On presence of underlying
progressive and serious
disease process
Ask for treatment Ask for investigations
Excessive drug use, together
with noncompliance
Fear drugs and their side
effects, reassurance by
frequent visits to diff. Phy.

90. PAIN DISORDER
Severe and prolonged pain that causes
clinically significant distress or impairment
in social, occupational or other important
areas of functioning
Diagnosis is made when psychological
factors is judged to have a major role in
the onset, severity or exacerbation of pain.

91. Pain Disorder
• Presence of pain which is predominant focus of
clinical attention
• Pain in one or more sites
• Not accounted by any biological cause
• Onset 40-50 years
• More frequent in females

92. Pain Disorder
FEATURES
 Frequent visits to physicians to
obtain relief.
 Excessive use of analgesics
 Request for surgery
 Symptoms of depression are
common

93. TREATMENT MODALITIES
SOMATOFORM DISORDERS

94. SOMATOFORM DISORDERS
TREATMENT
 Difficult to treat
-Recurrent, multiple and vague
symptoms and ‘doctor shopping’
 Ignore referrals to psychiatrist
 No follow up

96. ???
???
???

97. “God give me
the serenity to accept the things I cannot
change,
the courage to change the things I can, and
the wisdom to know the difference….
(Dr. Reinhold Niebuhr)