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A mental health disorder characterised by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities.
The term "anxiety disorder" refers to specific psychiatric disorders that involve extreme fear or worry, and includes generalized anxiety disorder (GAD), panic disorder and panic attacks, agoraphobia, social anxiety disorder, selective mutism, separation anxiety, and specific phobias.
Anxiety and Related Disorders
-Definition:Vague,subjective, nonspecific feeling of uneasiness,
tension, apprehension,& sometimes dread or impending doom.
-Symptoms:hypertension, tachycardia, muscle hypertonia,
*Predisposing factors: (2)
-Average of anxiety in identical twins: >50%.
-Anxiety increases in Children (Immature nervous system).
-Anxiety increases in Elderly (Atrophic nervous system).
Sx in pediatric: phobia in night, phobia from strangers, animals,
older children, being alone, nightmares, urinal or fecal incontinence,
walking during sleeping.
Sx in adolescent: unsuitability, irritability, social embarrassment esp.
when facing or meeting the other sex, guilty feeling, anxious about
genital area, being very shy, speech stutter.
Sx in in Adulthood: DECREASE.
Sx in in elderly: INCREASE (regarding dz., death)
Types of anxiety (according to level)
1. Mild anxiety:
a. Physiologic: V/S normal, minimal muscle
tension, pupils normal, constricted.
b. Cognitive: perceptual field is broad
-Thought may be random but controlled.
c. Emotional/Behavioral: relative comfort &safety,
relaxed, calm appearance & voice.
**Habitual behaviors occur here.
2. Moderate Anxiety:
a. Physiologic: V/S normal or slightly elevated,
Tension experienced, may be uncomfortable.
b. Cognitive: alert; perception narrowed, focused
(Optimum state for solving & learning), Attentive.
c. Emotional/ Behavioral: Readiness & challenge
(energize), engage in competitive activity & learn
new skills, voice & facial expression concerned.
3. Severe Anxiety: symptoms
a. Physiologic: Fight or flight, autonomic N. system
excessively stimulated (highly increase in v/s,
diaphoresis, urine urgency & frequency, diarrhea, dry
mouth, decrease appetite, dilated pupil), muscles rigid,
tension, decrease heating & pain sensation.
b. Cognitive / perceptual: Perceptual field greatly
narrowed, problem solving: difficult, automatic behavior,
selective attention (focus on one detail).
c. Emotional/Behavioral: Feels threatened, seem or feel
depressed, becomes very disorganized or withdrawn,
may close eyes to shut out environment.
Definition: A discrete period of intense fear or discomfort in
which four or more of the following Sx developed abruptly and
reached a peak within10 minutes.
3-Trembling or shaking
4-Sensations of shortness of breath
5-Feeling of shocking
6-Chest pain or discomfort
7-Nausea or abdominal distress
8-Feeling dizzy, unsteady or Faint
9-Realization of losing control
10-Fear of dying
12-Chills or hot flashes
-Pt. experiences panic attack in response to particular
situations or learns to avoid situations that evoke panic
-Phobia results even pt. knows that it won’t happen & no
danger if exposed to situation.
-Even pt. knows that very well he/she can’t control phobia
and doesn’t confront internal conflict but convert it into
Types of phobias:
1-Agoraphobia: Anxiety about being in places or
situations from which escape may be difficult (or
embarrassing) or in which help might not be readily
available in event of unexpected panic attack.
-This includes: fear of being alone, being in crowded area
or standing in a line, being, on a bridge, traveling in a bus;
becomes in need to have a companion.
2- Social phobia: fear from being under observation from
others, which may lead to avoiding social need.
-Usually accompanied with low self-esteem (evaluation and
fear of criticism).
Course & prognosis:
-Usually starts in late childhood & early adolescence.
-May become chronic & decreases after midlife.
-Rarely that disorder is severe & interfere with vocational
performance because of avoidance.
-Addiction (Alcohol, anti-anxiety).
1-Drugs: anti-anxiety or anti-depression.
Behavioral psychotherapy: with drugs in severe cases by
Gradual Desensitization by exposing him to the fear object
gradually and could be accompanied by some drugs or
relaxation training or Flooding: by exposing pt. suddenly to
fear object in reality or imagination.
Insight psychotherapy: To make pt. understand the cause
phobia & secondary gain symptoms, role of resistance and
this will make him able to find methods more acceptable to
control anxiety with motivating pt. to be exposed to phobia
3- Simple phobia (isolated phobia) (specific
-Includes specifies conditions:
1-Claustrophobia: Fear of closed places.
2-Mysophobia: fear of dirt, germs and contamination.
3-Acrophobia: fear of heights.
4-Zoophobia: fear of animals.
5-Aqua phobia (or hydrophobia): fear of water.
6-Nectrophobia: fear of darkness.
7-Pyrophobia: fear of fire.
8-Hematophobia: fear of blood.
9-Necrophobia: fear of dead bodies.
10-Xenophobia: fear of strangers.
11-Astrophobia: fear of lightening.
Course & prognosis:
-Beginning of simple phobias is varied.
-Zoophobia starts in childhood.
-Hematophobia often starts in adolescence or
-Acrophobia often starts in the fourth decade.
-Most of other phobias that start in childhood
disappear without treatment.
-Disability results from simple phobias is slight if
avoidance was easy as zoophobia, but disability is
increasing if stimulus is common, spread & not
avoidable as fear of riding cars for student.
2-Post Traumatic Stress Disorder (PTSD)
-Pt. must have experienced traumatic event prior
to onset of Sx.
-Pt. may have experienced event, witnessed it, or
have been confronted with event that involved
actual or threatened death or serious injury.
-Event should be outside range of usual human
-Pt. response: intense fear, helplessness or horror.
-Pt. will have Sx from 1-3 months (Acute) or 3-6
- Event cause this disorder could be:
1-Natural: Earthquakes, volcans.
2-Man-made: Rape, Torture.
-PTSD could happen in one individual or more among
-Pt. will have the following Sx:
1-Re-experiencing the event:
a. Recurrent dreams of the event.
b. Sudden acting or feeling as if traumatic event was
recurring (including sense of re-living the experience,
2-Persistent avoidance of stimuli associated with
3-Persistent Sx of increased arousal (difficulty to
sleep, irritability, concentration).
Course & prognosis:
-May occur in any age after event (1wk-30 yrs).
-Sx: fluctuating & become severe during stressful events.
-Acute PTSD lasts for <3 months but it could become
chronic (>3 months).
-30% of pts. with PTSD recovers, 40%slight symptoms,
20%moderate symptoms,10% become worse.
-Prognosis is conditioned by: rapid onset, good pre-morbid
functioning & good social support.
-Complications: social phobia disturbance in relations with
others guilty feeling that may lead to suicide.
Tofranil ( Imipramine), Inderal ( Propanolol).
1-Building good relationship with pt.
2-Cognitive appraisal of event & explaining to pt.
effect of stress on human being & that symptoms
are a normal outcome to an abnormal situation.
3-Relation training & desensitization by building a
hierarchy of stressful moments & relaxation.
4-Social support & involving family & friends in caring
& understanding pt.'s condition.
3-Acute Stress Disorder
The same condition of PTSD, but the
period to have the Sx is 2 days-1
4-Generalized Anxiety Disorder
-Excessive worry & anxiety about 2 or > of life conditions:
Worry of a child of being dying or exposing to any harm (in
fact no danger at all).
-3 or more of the following sx will appear:
2- Easily to be fatigued
4- Difficulties in concentration
5- Muscle tension
6- Sleep disturbances
-May start in any age but is > in 20s & 30s.
-Mainly chronic & may continue for life.
-Complication: is panic attack.
-other complication: addiction because of self-treatment.
1-Drugs: should decrease prescribed anti-anxiety as possible
(because disorder is chronic).
2-Psychotherapy: Rx of choice.
a-Psychoanalytic psychotherapy: through long-term insight.
b-Behavioral psychotherapy: focuses on desensitization with
entrance to cognitive therapy aims to stop conditioning in
addition to relaxation & modifying behavior.
5- Obsessive Compulsive Disorder
1-Obsession: undesirable but persistent thought or idea
forced into consciousness & can’t be erased or dismissed,
thought may be trivial or morbid. Always distressing or
2-Compulsion: unwanted urge to perform act or ritual
contrary to pt.'s ordinary conscious wishes or standards.
-Uncontrolled & done to relieve extreme tension.
-Obsession produces anxiety managed by compulsive act.
3-Obsession compulsion: repetitive acts or rituals to release
tension or relieve anxiety.
-Pt. carries out these acts even if he recognizes that they are
inappropriate or foolish.
a. Endless hand washing.
b. Checking re-checking doors if they're locked.
c. Elaborate dressing rituals.
-Pt. is trying to resist this, but because of long period of
disorder, resistance may decrease.
-As a result, pt. will have much difficulties in social r/s.
-Pt. is neurotic (because pt. believes that these ideas are
not true & silly).
Course & prognosis:
-Usually starts in adolescence.
-Chronic disorder & pt. may not present to psychiatrist
for 5-10 years.
-About 30% of pts.: good improvement, 30-40%: mild
improvement, & the rest: chronic or worse.
-Some pts. may have depression, suicide or addiction.
-Anfranil (Clomipramin): Drug of choice (6-12months).
-Effective in 60-70% of pts. (may be Rx of choice).
-Techniques used: Desensitization, thought stopping, flooding
& implosion therapy.
Aversive conditioning: means giving a painful shock or loud
noise when thought occurs.
-Some use response preventing as: forcibly stopping pt. from
responding to obsession.
3-Psychodynamic psychoanalytic therapy:
-Aims to help pt. get insight into his aggressive impulses &
strengthens ego to deal with aggression in mature ways.
-Focusing is physical sx in absence of clinically
significant organic disease.
A-Body Dysmorphic Disorder
-Preoccupation with imagined defect in appearance.
-Slight anomaly: concern is excessive.
-Significant distress or impairment in social or
-Preoccupation is not better accounted for by another
Course & prognosis:
-Starts in adolescence, 20’s or 30’s, stays constantly &
may have result of social & vocational disability.
-Complication: Plastic surgeries without any need.
-Pts. refuse psychotherapy despite their severe suffering
& insist on having plastic surgeries so it is important for
plastic surgeon to refer them to psychiatrist or
-Meds. may relief Sx (anti-anxiety, anti-depression).
-Long-term psychotherapy is recommended.
B- Pain disorder
-Clinical presentation of pain in 1 or > anatomical sites.
-Pain is severe to warrant clinical attention & causes
major impairment in 1 or > areas of functioning.
-Psychological factors play important role in onset,
severity exacerbation, or maintenance of pain.
-Acute: less than 6 months (duration).
-Chronic: more than 6 months (duration).
Course & prognosis:
-In female double than males.
-Increase at 4th & 5th decade & b/w poor persons.
Drugs: Giving analgesics or narcotics is not useful
-Anti-depressant can be given: (Elatrol) or (Prozac).
-Anxiolotics or analgesics usually not effective.
Psychotherapy: Important that therapist helps pt.
recognize psychogenic origin of pain.
-Explain to pt. how person state of mind affects how
much pain he can feel.
-Relaxation technique, sports exercice.
-Sometimes, admission to hospital is needed to control
feeling of pain (behavioral, cognitive & group
psychotherapy may be used).
C- Somatization Disorder
-Frequently seeking & obtaining medical Rx for multiple
clinically significant somatic complaints.
-Complaints must begin before 30 & cannot be explained by
any medical disorder or direct effects of substance.
-Multiple sclerosis pt. would not be dxed by somatization.
-Differentiated from medical conditions if:
-Involvement of multiple organ systems (GI, neurological..).
-Sx exhibit early onset & chronic course, without
development of physical signs or structural abnormalities.
-Absence of clinical (laboratory) abnormalities.
Course & prognosis:
-Females > males.
-Less occurrence if high social class, more among poor
& illiterate persons.
-Starts before 30.
-Increase among first-degree relatives.
-Chronic & pt. is rarely free of sx or for medical seeking.
-Long & empathic r/s with one therapist.
-Using meds. is not recommended but anti-depressant
or anxiolytics can be used symptomatically if anxiety or
depression is present (?addiction).
D-Conversion Disorder (Hysterical neurosis,
-Loss or change in beady functioning that can’t be
explained by any medical disorder, & occurs in response
to psychological stress.
-In females > males.
-Usually starts in adolescence or young adulthood.
-Medical exams do not reveal physical abnormality.
-Pt. is not conscious of producing sx.
-Histrionic personality pt: more exposed than others.
-Could happen if exposed to great stress.
-Loss or change can give sensory/motor sx or both.
Motor sx:Abnormal tremors, jerky movements.
* Note: hysterical conversion tremors: it is irregular &
disappears if attention moved to another subject, etc…
-It differs from tremor in anxiety.
-Hysterical aphonia: Pt. can’t speak, but can understand
what is said.
* Note: to differentiate, ask pt. to cough, if he does so,
means vocal cords ok & is hysterical.
Comparison b/w organic & hysterical paralysis:
Tics: involuntary movement increases in embarrassing
Hysterical comas: like normal sleep, doesn’t respond to
stimuli, needs care for urination & defecation, usually needs
hospitalization, used to escape from reality.
Hysterical fits: differ from organic epilepsy as following:
Anesthesia or loss of sensation in a part of body or one half of
Loss of olfactory or taste senses.
-Duration is brief.
-Starts & stops abruptly.
-Tends to recur.
-Prognosis is poor if secondary gain is high.
*Primary gain: Gain achieved by converting anxiety to
somatic sx (symbolic of unconscious conflict).
*Secondary gain: Gain achieved by sx, pt. pain relieved
from work or gets attention & sympathy from family by
taking sick role.
-Exclude organic disease by physical exam.
-Telling pt. that he has no physical problems & sx are
psychological stress & will disappear if pt. expresses his
-Amytal: may be used to produce a state of relaxation &
re-experience trauma which enable pt. to talk freely
about her troubles.
-6 major criteria associated with disorder:
1-Pt is preoccupied with fears of having-or idea of having
serious medical disorder based on his/her interpretation.
2-Misinterpretation of bodily sx persists despite
appropriate medical evaluation & reassurance.
3-Pt’s preoccupation with Sx is not as intense or
distorted as in body dysmorphic disorder.
4-Preoccupation causes clinically significant distress or
impairment in social, occupational, or major areas of
5-Duration of disturbance at least 6 months.
6-Condition is not better accounted for by another
anxiety disorder, somatization disorder, or major
depressive episode (Pt. may show sx of anxiety or
Course & prognosis:
-Mostly starts in 20’s.
-1/3 of pts. don’t improve & social/vocation disturbed.
-Males & female: equal.
-Exclude any organic factor.
-Invasive procedure should be avoided.
-Psychotherapy: preferred treatment even pt. resists this
therapy (may accept it by a physician).
-Group psychotherapy: Rx of choice (pt.’s social support
& interaction can improve their condition).
-Drugs not used unless depression/anxiety present.
Comparison b/w Somatization &
7 yrs needed for dx 6 months for dx
Look about sx & Rx Look about disorder behind
C/O 13 or >sx C/O 1 or 2 sx
Doesn’t like Dr. visit Multiple Dr. visit
-Disruption in usually integrated functions of consciousness,
memory, identity & perception of environment.
A. Dissociative Amnesia
-1or > episodes of inability to recall important personal
information (traumatic or stressful nature); too extensive to be
explained by ordinary forgetting.
-Disturbance doesn’t occur during Dissociative Identity
-Not due to substance effects or general medical condition.
-Most common in females.
-Usually pt. is aware of memory loss.
-Pt. is usually alert & not confused (Some pts. describe a
state of clouded consciousness).
-Onset is sudden & recovery is sudden & complete.
-Recurrence is rare.
-It is important to differentiate psychogenic amnesia from
organic amnesia ( CVA,P.C, etc..).
-Amytal interview: Pt. is given short or medium acting
barbiturates as Amytal IV & in a state of alleged
consciousness pt. is helped to remember.
-Hypnosis: Under hypnosis, pt. is relaxed & in a
somnolent state in which inhabitations are weekend, &
repressed memories can be reached.
-Psychotherapy: After repressed memory is reached
psychotherapy helps pt. resolve conflicts.
B. Dissociative Fugue
-Sudden, unexpected travel away from one’s home or place of
work, with inability to recall one’s past.
-Confusion about personal identity or assumes new identity,
which may be partial (filling in the blanks).
-Disturbance doesn’t occur in context of a dissociative identity
disorder, & is not due to effects of a substance or to a general
-When fugue is over, pt. remembers all he had forgotten but
forgets what happened during fugue.
-Course is usually short.
-Pt. recovers suddenly & completely to find himself in a
-Recurrence is rare.
-No Rx is required if duration is short.
-Hyposis & Amytal interview maybe used to help pt.
remember his identity.
C. Multiple Personality Disorder (Dissociative
-2 or > personalities (each complete & integrated).
-At any time, pt. is dominated by one personality &
unaware of presence of other personalities.
-Mostly occur in adolescence or early adulthood.
-Predisposing factor: severe physical/sexual abuse in
-Epilepsy is found in 25% of pts.
-EEG shows difference in activity in different
personalities in the same pt.
-Each personality is integrated & differ in mood, attitude,
-Usually each personality doesn’t recognize presence of
other personalities (Sometimes one of them knows about
-Pt. may find himself in strange place or hearing voices
inside him or another person taking control over him.
-Poor if onset is early & if >2 personalities.
Psychotherapy: Helps pt. resolve conflict & childhood
-Helps in communication b/w different personalities to
-Hypnosis: Helps in confirming Dx by enhancing
memories & resolving deep conflicts.