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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 ... – PowerPoint PPT presentation

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Title: Anxiety disorder

Anxiety disorder
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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

Anxiety disorders
  • Sigmund Freud---anxiety neurosis
  • Normal anxietyfear 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)

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 pts1
    affected relatives higher frequency of lst.
    Degree relative
  • Neuroanatomical locus ceruleus raphe nuclei
    project to limbic system cerebral cortex

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

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  • Life time prevalence rate of panic
    disorder1.5-5 (Taiwan 0.2/0.3), panic
    attack3-5.6, agoraphobia 0.6-6 (Taiwan
  • WomenMen2-3/1
  • Mean age of onset 25 y/o
  • Etiologies Panic-inducing substances
    adrenergic antagonist,serotonin releasing agents,
    GABA receptor antagonist Brain imaging
    studiespathology in temporal, lobes,
    hippocampus mitral valve prolapse?
    Genetic4 to 8x increase in lst. Degree
    rela, higher concordant in monozygotic twin

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

Course prognosis of agoraphobia
  • Panic disorder with agoraphobiasx (-) while
    panic disorder (-)
  • Agoraphobia without panic---incapacitating,
  • Depression alcohol dependence often complicated

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

Specific phobia social phobia
  • Phobiairrational 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 roomshy
  • Specific phobia animal, storm,height, illness,
    injury, death, narrow closed space
    (claustrophobia), blood (erythrophobia)

  • Specific phobia 6 month prevalence5-10
    (Taiwan 3.6-4.8) Femalemale2/1 pe
    ak age of onset for natural environment type
    blood5-9 y/o,for situational type-mid 20s
  • Social phobia 6 month prevalence---2-3
    (Taiwan 0.6/0.5) Femalegtmale peak
    age of onset---teens

Etiologies of specific phobia
  • Behavioral factorsconditional 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 pts with l lst. Degree

Etiologies of social phobia
  • Genetic factors---specific phobia run in
    families, 2/3 to 3/4 of pts with l lst. Degree
  • Social phobia---trait of behavioral inhibition,
    parents of persons with social phobialess
    caring, more rejecting, more overprotective
  • Neurochemical factorsadrenergic, dopaminergic
  • Genetic factors3x affected in lst. Degree
    relative higher concordance in monozygotic twin

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

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

  • 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

Generalized anxiety disorder (GAD)
  • Excessive pervasive worry, with a variety of
    somatic sxsig. Impairment in social or
    occupational function, marked distress in pt
  • 1 year prevalence---3-8 (Taiwan 3.7-10.5)
  • 50-90 of GAD pts-comorbid with another mental
  • Women/men2/1

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 pt-GAD higher(50)
    concordance rate of monozygotic twin
  • Psychosocial factors cognitive-behavioral
    theory, psychoanalytic theory

Clinical features of GAD
  • Primary txanxiety,motor tension,ANS
    hyperactivity,cognitive vigilance
  • Excessive anxiety, interfere life
  • Motor tensionshakiness,restless,headache
  • ANS hyperactivity-SOB,sweating,palpitation, G-I
  • Cognitive vigilanceirritability, ease to be

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

Treatment of GAD
  • Psychotxcognitive-behavior (relaxation
    biofeedback), supportive, insight-oriented
  • PharmacotxBZD, buspirone, B-antagonist, TCA

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

  • 2-3 in general population (Taiwan 0.9/0.5)
  • 10 of psychiatric outpatients
  • Malefemale in adults,boysgtgirls
  • Mean age of onset---20 y/o
  • Comorbid with major depression (67), social
    phobia (25), alcohol use disorder, specific
    phobia, panic disorders, eating disorders

Etiologies of OCD
  • Biologicaldysregulation 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 ptsobsessional
  • Psychodynamic---defense mechanism---isolation,
    undoing, reaction formation

Clinical features of OCD
  • 75 with both obsession compulsion
  • Feelings of anxiouscountermeasures 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

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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,40-50mod.improve, 20-40
    remain same or worse
  • 1/3 with major depression
  • Poor pxyielding to compulsion,childhood
    onset,bizarre compulsion,need hosp.,with MD,
    delusional, schizotypal PD
  • Good pxgood social occupational adjustment,
    ppt(), episodic nature

Treatment of OCD
  • Pharmacotx---SSRI or anafranil
  • Behavior tx---exposure response
    stopping,flooding, aversive conditioning
  • Psychotxinsight-oriented psychotx,supportive
  • Family tx, group tx, ECT, psychosurgery

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 traumadreams, 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)

  • Lifetime prevalence of PTSDF---1-3 of general
    population, 5-15 of subclinical forms
  • High risk group experience traumatic
    eventslifetime prevalence 5-75
  • 30 Vietnam veteransPTSD, 25 subclinical
  • Single, divorced, widowed, economically
    handicapped, or socially withdrawnlikely to occur

Etiologies of PTSD
  • Stressor
  • Predisposing vulnerability factors childhood
    trauma borderline,paranoid,dependent,antisoci
    al PD inadequate support system genetic-const
    itutional vulnerability to psychiatric
    illness recent stressful life
    changes perception of external locus of
    control recent excessive alcohol intake

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

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

Course and prognosis
  • Onset some time after trauma,sometimes delay as
    30 yrs
  • 30 complete recovery,40 mild sx,20,10
    unchanged or worse
  • Good-pxrapid onset,short duration of sx
    (lt6m),good premorbid function,strong social
    support,absence of psychiatric, medical,
    substance disorder
  • Very young very old more difficulty,
    preexisting psychiatric disability, PD more

  • Support,encourage to discuss,education coping
    mechanisms, behavioral tx, cognitive tx,
    hypnosis, family tx,group tx
  • PharmacotxTCA, SSRI, anticonvulsant, inderal,
    propranolol, clonidine