6 anxiety disorders updated 90

Anxiety Disorders became three separate categories in DSM5.  These three categories are: Anxiety Disorders (Generalized anxiety disorder, Separation anxiety disorder, Selective mutism, Specific phobia, Social phobia, Agoraphobia and Panic disorder.) 2. ObsessiveCompulsive Disorders (Obsessivecompulsive disorder, Body dysmorphic disorder, Hoarding disorder, Trichotillomania, and Excoriation disorder.) 3. Trauma and StressorRelated Disorders (Reactive attachment disorder, Disinhibited social engagement disorder, PTSD, Acute stress disorder and Adjustment disorder.)

DR.M.ASHFAQ BURNEY

MBBS, Dip Diab, MRCGP

Anxiety Disorders became three separate categories in DSM-5.  These three categories are:

1.Anxiety Disorders  (Generalized anxiety disorder,

Separation anxiety disorder, Selective mutism, Specific

phobia, Social phobia, Agoraphobia and Panic disorder.)

2 Obsessive-Compulsive Disorders

 (Obsessive-compulsive disorder, Body dysmorphic disorder, Hoarding disorder, Trichotillomania, and Excoriation disorder.)

3 Trauma and Stressor-Related Disorders  (Reactive attachment disorder, Disinhibited social engagement

INTRODUCTION - DSM-5

At the end of this core session, we will be able to:

– Describe how do the patients with anxiety disorders often

ANXIETY DISORDERS

Anxiety disorders are abnormal states in which

the most striking features are mental and physical symptoms of anxiety, occurring in the absence of organic brain disease or any other

psychiatric disorder

• What is anxiety?

–a state of apprehension, uncertainty, and fear from the anticipation of a realistic or imagined

threatening event, impairing functioning.

• When is anxiety a disorder?

–no real threat

–out of proportion to the threat present.

• So when was pathological anxiety first

recognized as a mental disorder?

–Freud coined the term "anxiety neurosis"

• General irritability

• Chronic apprehension

• Anxiety attacks

• Secondary phobic avoidance.

•Overall prevalence: 9.1% to 16.9% interquartile

range (IQR)

•In Pakistan, the mean overall prevalence of Anxiety and Depression based on community samples is

33.62%,

•In India, Anxiety Disorders 20.7%

•In USA, Anxiety Disorders 18.1%

The statistics illustrates the number of lifetime prevalent cases

of anxiety disorders among adults in the selected countries

worldwide in 2018, by gender.

Pounding

TYPES OF ANXIETY DISORDERS

A Generalized Anxiety Disorder

B Phobic Anxiety Disorder (Specific Phobia, Social Phobia, Agoraphobia)

C Panic Disorder

D Separation Anxiety disorder

E Selective Mutism

Obsessive Compulsive Disorder (OCD)

(is a separate entity in DSM-5)

and Post Traumatic Stress Disorder (PTSD)

(is included in a separate category of "Trauma

and stressor-related disorders”)

Generalized Anxiety Disorder (GAD)

(Ghabrahat, Beycheny, Ikhtilaj, Tashweesh ki Bimari)

(A disease of Un-easiness, Restlessness, Palpitation and

worries)

1.“Excessive worry for most of the days for more

than or up to 6 months…”

(possibility of “Acute Stress Reaction” and other anxiety

disorders should be ruled out)

2 Any four of the following:

- Apprehension or fear for no apparent reason

- “Ghabrahat” or “Gas” or “Gola” (“Un-easiness”, “Wind” or

“Wind trapping”

- Restlessness

- Irritability

- Muscle Tension / aches & pains

- Vague physical symptoms (such as tremors, palpitation, chest Generalized Anxiety Disorder (Cont.)

DSM-5 Criteria for Diagnosing GAD

When assessing for GAD, clinical professionals are looking for the

following:

A.The presence of excessive anxiety and worry about a variety of topics, events,

or activities Worry occurs more often than not for at least six months and is clearly excessive.

B The worry is experienced as very challenging to control The worry in both

adults and children may easily shift from one topic to another

C The anxiety and worry are accompanied by at least three of the following

physical or cognitive symptoms (In children, only one of these symptoms is

necessary for a diagnosis of GAD):

1 Edginess or restlessness

2 Tiring easily; more fatigued than usual

3 Impaired concentration or feeling as though the mind goes blank

4 Irritability (which may or may not be observable to others)

5 Increased muscle aches or soreness

6 Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness

at night, or unsatisfying sleep)

D The anxiety, worry, or physical symptoms cause clinically

significant distress or impairment in social, occupational, or other

important areas of functioning

E The disturbance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical

condition (e.g., hyperthyroidism)

F The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having panic attacks in panic disorder,

negative evaluation in social anxiety disorder [social phobia],

contamination or other obsessions in obsessive-compulsive disorder,

separation from attachment figures in separation anxiety disorder,

reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom

• What will you further inquire this patient?

• What do you think this patient is suffering from?

• How will you investigate and manage him?

PHQ-9 scores > 10 had a sensitivity of 88% and

a specificity of 88% for Major Depressive Disorder

Phobic Anxiety Disorder

(Khauf ki Bimari) (A Disease of being scared)

Persistent irrational fear of objects, situations, persons, place or being social,

leading to avoidance behavior and functional impairment

Anxiety Disorders

Generalized Anxiety Disorders Phobic Anxiety Disorders (Specific,

Social, Agoraphobia)

Panic Attacks

Course Continuous with

fluctuating intensity Episodic EpisodicReason With or without any

reason With reason. Without any reason

POINTS TO REMEMBER ANXIETY DISORDERS

Generalized Anxiety Disorders

PHOBIC ANXIETY DISORDERS

Agora phobia

• Co-morbid states mean two morbid states in the same patient

• The illness which comes first is called primary, and the illness which develops later is called secondary

• Co-morbidity can occur with Physical (primary) and Psychiatric disorder (secondary).

• Psychiatric disorders (primary) and Physical disorders (secondary).

• Or a Psychiatric disorder (primary) e.g., having depression primary and anxiety as (secondary)

•

(Persistent Depressive

Disorder, DSM-5)

(Specific phobia)

CO-MORBIDITY (Cont.)

• A sizeable number of out-patients & in-Patients from all disciplines have psychiatric problems (nearly one third)

• A large number of patients attending Physicians &

Surgeons have co-morbid Psychiatric illness, the estimates

vary from 10% to 40%.

Why is Psychiatric co-morbidity missed?

• Negative attitudes to diagnose Psychiatric disorders

• Unsuitable clinical settings for discussion of personal and

emotional matters

• Patients unwillingness to report symptoms of any

Psychiatric disorder.

IMPACTS OF PSYCHIATRIC CO-MORBID STATES

• Person experiences greater distress

• Increased impaired functioning (disability)

• Increased health care costs

• Less ability to follow medical regimens, elevated risk

of mortality

• Hindering the treatment of any other medical

condition

IMPORTANCE OF IDENTFICATION OF A CO-MORBID STATE

In patients where co-morbid states are identified and treated, the over all improvement is experienced in:

– Over all medical condition – Better compliance with general medical care – Reduced patient discomfort and morbidity – Risk and cost associated with suicide – Costs associated with miss diagnosis

• What is CBT?

–Cognitive behavioral therapy (CBT) is a type of

psychotherapeutic treatment that helps patients to

understand the thoughts and feelings that influence

behaviors

• Relaxation therapy

• Autogenic relaxation, Progressive muscle relaxation, Visualization, Deep breathing, Massage, Meditation, Tai chi, Yoga, Biofeedback, Music and art therapy, Aromatherapy, Hydrotherapy

• Why are we worried?

 “The Transactional model of stress” is a framework

which emphasises appraisal to evaluate harm, threat and challenges, which results in the process

of coping with stressful events

• Strategies to reduce worries

– Make a plan

– Rehearse

– Attend to Your Physical Health

– Discover the Real Source

• Benzodiazepine are used to treat anxiety disorders as

measures of short term management.

• As the effects of antidepressants and other adjuvant therapies take it time to act, Benzodiazepines help to reduce the suffering in the initial phase of treatment Benzodiazepines

• Benzodiazepines have a tendency to develop drug dependence

Ultra short acting, short acting and medium acting benzodiazepine are more prone to cause dependence

• So make it a rule to prefer a long acting Benzodiazepine

• Chlordiazepoxide / Diazepam / Clonazepam / Flurazepam /

Quazepam are the currently available long acting

Benzodiazepines in most of the countries

• Binds to Benzodiazepine receptors at the GABA-A ligand-gated chloride channel complex

• Enhances the inhibitory effects of GABA

• Boots chloride conductance through GABA-regulated channels

• Inhibits neuronal activity presumably in amygdala –centered fear circuits to provide therapeutic benefits in anxiety disorders

How does the drug work?

• Some immediate relief with first dosing is common, can take several weeks with daily dosing for maximal therapeutic benefits

HOW LONG UNTIL IT WORKS?

• For chronic anxiety disorders, the goal of treatment is complete remission of symptoms as well as prevention of

relapse

• Treatment most often reduces or even eliminates

symptoms, but not a cure since symptoms can recur after

medicines are stopped

• For long-term symptoms of anxiety, consider switching to

• If long term maintenance with a Benzodiazepine is necessary, continue treatment for 6 months after symptoms resolve, and then taper the dose slowly

A 23 year old woman arrives at the emergency room

complaining that, out of the blue, she has been seized

by an overwhelming fear, associated with a shortness

of breath and a pounding heart These symptoms last for approximately 20 minutes, and while she was

experiencing them, she feared she was dying or going crazy She has had one similar episode two months back.

• Spot diagnosis?

• What will you do?

Case 3

• A young man presented to a follow up clinic and

presented with features suggestive of Anxiety

Disorder The Anxiety is continuous with varying

intensity The patient some times knows the reason, while at times he doesn't know the reason This has been going on for the last 8 months.

• a) What is the probable diagnosis?

• b) What are the points in support of Diagnosis.

• c) How would you manage this case?

Case 4

• A young girl presented to an emergency department of a tertiary care hospital having difficulty in breathing and feeling

of sinking heart with fear of dying with out any obvious reason

as stated by her and attendants She has history of more than

5 attacks in a week of the same nature with a fear of further attacks However she remains well between the 2 episodes This is affecting her functionality badly She has had three

similar episodes in the past month.

a) What is the differential diagnosis?

b) What is the most likely diagnosis?

Panic Disorder

(Ghabrahat Ya Becheney key Douron ki Bimari) (A Disease of Un-easiness or Restlessness attacks)

• Recurrent and unexpected panic attacks ≥1 attack has been

followed by 1 month or more of 1 or more of the following

• Persistent concern about additional attacks

Worry about the implications of the attack or its consequences

A significant change in behavior related to the attacks

DSM-5

A panic attack is a sudden

episode of intense fear with

symptoms that may include the

• Chills or hot flashes

mean that she/he is having a panic attack

Some of these symptoms can also be indications of serious medical

conditions that would

• In the past six months

1 Did you ever have a spell or attack when all of a sudden you felt frightened, anxious, or very uneasy?

2 Did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath?

High sensitivity, low specificity

• If a patient presents with a panic attack, she or he should: – Already receiving treatment?

– Investigate to exclude acute physical problems

– No admission required

– Refer to primary care for subsequent care

• Psychological treatment

• Drug treatment:

SSRIs (Sertraline, Fluoxetine, Paroxetine, Fluvoxamine,

Citalopram, Escitalopram) SNRI (Venlafaxine) TCA (Anafranil, Clomipramine, Imipramine) MAOI (Phenelzine)

• Self help options

• Referral

A 17 year old girl blushes, stammers and feels completely foolish when one of her classmates or teacher asks her a question She sits at the back of the class hoping not to be noticed

because she is convinced that the other students think she is unattractive and stupid.

• What is the spot diagnosis?

• How will you treat?

Social Phobia/Social Anxiety Disorder - DSM-5 Criteria

Marked fear or anxiety about one or more social situations in which the

individual is exposed to possible scrutiny by others Examples include

social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech)

Note: In children, the anxiety must occur in peer settings and not just

during interactions with adults

The individual fears that he or she will act in a way or show anxiety

symptoms that will be negatively evaluated (i.e., will be humiliating or

embarrassing; will lead to rejection or offend others)

The social situations almost always provoke fear or anxiety

Note: In children, the fear or anxiety may be expressed by crying,

tantrums, freezing, clinging, shrinking, or failing to speak in social

situations

The fear, anxiety, or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

The fear, anxiety, or avoidance is not attributable to the physiological effects

of a substance (e.g., a drug of abuse, a medication) or another medical

condition

The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder,

or autism spectrum disorder

(If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or

avoidance is clearly unrelated or is excessive

If the fear is restricted to speaking or performing in public

Result :

DSM-5 diagnostic criteria not met.)

Social Phobia/Social Anxiety Disorder - DSM-5 Criteria (Cont.)

1 Fear of embarrassment causes me to avoid doing

things or speaking to people

2 I avoid activities in which I am the center of

attention

3 Being embarrassed or looking stupid is among my

the worst fears

Total

Cut off 6

Rate each item according to the following scale:

(IPT) is a form of psychotherapy that focuses

on person and his relationships with other people It's based on the idea that personal relationships are at the center of

psychological problems (Depression isn't always caused by an

event or a relationship)

A 55 years old policeman who has demonstrated great courage on more than one occasion while on duty is terrified of needles.

• What is the diagnosis?

• How would you screen for this disorder?