CHAPTER 5 - PowerPoint Presentation

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CHAPTER 5Anxiety and Related Disorders

-Definition: Vague, subjective, nonspecific feeling of uneasiness, tension, apprehension, & sometimes dread or impending doom.-Symptoms: hypertension, tachycardia, muscle hypertonia, hyperactivity, irritability.

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-Common disorders that have anxiety symptoms:1- Neurotic Disorders: Hysterical Disorder, Depression, PTSD.

2- Psychotic Disorders: Major depressive disorder, Schizophrenia.

3- Organic

Disorders: Hyperthyrodism, Athersoclerosis, Hypoglycemia, Post-concussion, Menopause, Pre-menstruation.

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*Predisposing factors: (2)1-Hereditary factors: -

Average of anxiety in identical twins: >50%.

2- Age

: -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)

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Types of anxiety (according to level)

Mild anxiety:a. Physiologic

:

V/S normal, minimal muscle tension, pupils normal, constricted.b. Cognitive: perceptual field is broad

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Thought may be random but controlled.c. Emotional/Behavioral: relative comfort &safety, relaxed, calm appearance & voice.**Habitual behaviors occur here. 4Slide5

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.5Slide6

3. Severe Anxiety: symptomsa. 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.6Slide7

Panic Attack:Definition: A discrete period of intense fear or discomfort in which four or more of the following S

x developed abruptly and reached a peak within10 minutes.

1-Palpitations

2-Sweating3-Trembling or shaking 4-Sensations of shortness of breath

5-Feeling

of shocking6-Chest pain or discomfort7-Nausea or abdominal distress8-Feeling dizzy, unsteady or Faint 9-Realization of losing control 10-Fear of dying 11-Parenthesis12-Chills or hot flashes 7Slide8

1. Phobias-Pt.

experiences panic attack in response to particular situations or learns to avoid situations that evoke panic attack.

-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 external Sx. 8Slide9

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.9Slide10

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.-Complications: -Addiction (Alcohol, anti-anxiety).-Depression.10Slide11

Rx:1-Drugs: anti-anxiety or anti-depression.

2-Psychotherapy:

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 situation.11Slide12

3- Simple phobia (isolated phobia) (specific phobia) : -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.12Slide13

Course & prognosis:-Beginning

of simple phobias is varied.-Zoophobia starts in childhood.-

Hematophobia

often starts in adolescence or early adulthood.-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.13Slide14

2-Post Traumatic Stress Disorder (PTSD)

-Pt. must have experienced traumatic event prior to onset of

S

x.-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 experience. -Pt. response: intense fear, helplessness or horror.14Slide15

-Pt. will have Sx from 1-3 months (Acute) or 3-6 months(Chronic)

- Event cause this disorder could be: 1-Natural:

Earthquakes,

volcans.2-Man-made: Rape, Torture.-PTSD

could happen in one individual or more among group.Slide16

-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, illusions, hallucinations).2-Persistent avoidance of stimuli associated

with trauma

.3-Persistent Sx of increased arousal (difficulty to sleep, irritability, concentration).16Slide17

Course & prognosis:-May

occur in any age after event (1wk-30 yrs).

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Sx: fluctuating & become severe during stressful events.-Acute PTSD lasts for <3 months but it could become chronic (>3 months).

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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.Slide18

*Rx:1-Drugs:

Tofranil ( Imipramine), Inderal

(

Propanolol).Catapress (Clonidine).2-Psychotherapy

:

-Cognitive-behavioral approach: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. 18Slide19

3-Relation training & desensitization by building a hierarchy of stressful moments & relaxation

.4-Social support & involving family & friends in caring

& understanding pt.'s

condition.19Slide20

3-Acute Stress DisorderThe same condition of PTSD, but the period to have the Sx is 2 days-1 month.20Slide21

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).

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or more of the following sx will appear:1- Restlessness2- Easily to be fatigued

3- Irritability

4- Difficulties in concentration 5- Muscle tension 6- Sleep disturbances.21Slide22

Prognosis:-May start in any age but is >

in 20s & 30s.

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Mainly chronic & may continue for life.-Complication: is panic attack.-other complication: addiction

because

of self-treatment. Rx: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. 22Slide23

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 anxiety provoking.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.23Slide24

Examples: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.

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Pt. is neurotic (because pt. believes that these ideas are not true & silly). 24Slide25

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.25Slide26

Rx: 1-Drugs:

-Anfranil (Clomipramin

): D

rug of choice (6-12months).2-Behavioral therapy: -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. 26Slide27

6-Somatororm Disorders-F

ocusing is physical sx in

absence

of clinically significant organic disease. A-Body Dysmorphic Disorder-Preoccupation with imagined defect in appearance.

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Slight anomaly: concern is excessive.-Significant distress or impairment in social or occupational functioning.-Preoccupation is not better accounted for by another mental disorder.27Slide28

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.Rx: -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 psychologist.

-Meds. may relief Sx (anti-anxiety, anti-depression).-Long-term psychotherapy is recommended.Slide29

B- Pain disorder-C

linical 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.29Slide30

Rx:Drugs: Giving analgesics or narcotics is not useful

(?addiction).-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.-Biofeedback.-Sometimes, admission to hospital is needed to control feeling of pain (behavioral, cognitive & group psychotherapy may be used).Slide31

C- Somatization Disorder -Frequently seeking & obtaining

medical Rx for multiple clinically significant somatic complaints.

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Complaints must begin before 30 & cannot be explained by any medical disorder or direct effects of substance.

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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.31Slide32

Course & prognosis:-F

emales > males.

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Less occurrence if high social class, more among poor & illiterate persons.-Starts before 30.

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Increase among first-degree relatives.-Chronic & pt. is rarely free of sx or for medical seeking.Slide33

Rx:-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).Slide34

D-Conversion Disorder (Hysterical neurosis, Conversion Type):

-Loss or change in beady functioning that can’t be explained by any medical disorder, & occurs in response to psychological stress.

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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.34Slide35

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.35Slide36

Comparison b/w organic & hysterical paralysis:

Tics: involuntary movement increases in embarrassing situations.

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: Sensory symptoms: Anesthesia or loss of sensation in a part of body or one half of body.Hysterical deafness.Loss of olfactory or taste senses.Hysterical blindness.Slide37

Prognosis:-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.Slide38

Rx:-Exclude organic

disease by physical exam.

-

Psychotherapy:-Telling pt. that he has no physical problems & sx are psychological stress & will disappear if pt. expresses his feelings.

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Amytal: may be used to produce a state of relaxation & re-experience trauma which enable pt. to talk freely about her troubles.Slide39

E-Hypochondriasis-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.39Slide40

4-Preoccupation causes clinically significant distress or impairment in social, occupational, or major areas of functioning.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 depression).40Slide41

Course & prognosis:-Mostly starts in 20’s.

-1/3 of pts. don’t improve & social/vocation

disturbed.

-Males & female: equal.Rx:-

E

xclude 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.Slide42

Comparison b/w Somatization & Hypochondriasis

SomatizationHypochondriasis

7

yrs needed for dx6 months for dxLook about sx & RxLook about disorder behind sx

C/O

13 or >sx C/O 1 or 2 sxDoesn’t like Dr. visitMultiple Dr. visit42Slide43

7-Dissociative Disorders

-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 Disorder. -Not due to substance effects or general medical condition.-Most common in females. 43Slide44

-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.44Slide45

Rx: -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. Slide46

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 medical condition. 46Slide47

-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 strange place. -Recurrence is rare. Rx:

-No

Rx is required if duration is short.-Hyposis & Amytal interview maybe used to help pt. remember his identity.Slide48

C. Multiple Personality Disorder (Dissociative Identity Disorder)-2 or > personalities (each

complete & integrated).-At any time, pt. is dominated by one personality & unaware of presence of other personalities.

-

>in females.-Mostly occur in adolescence or early adulthood.-Predisposing factor: severe physical/sexual abuse in childhood.-Epilepsy is found in 25% of pts.

-EEG shows difference in activity in different personalities in the same pt.

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-Each personality is integrated & differ in mood, attitude, name, etc…

-Usually each personality doesn’t recognize presence of other personalities (Sometimes

one of them knows about the

other).-Pt. may find himself in strange place or hearing voices inside him or another person taking control over him.-Chronic disorder.

Prognosis:

-Poor if onset is early & if >2 personalities. Slide50

Rx:

Psychotherapy: Helps pt. resolve conflict &

childhood memories.

-Helps in communication b/w different personalities to reintegrate pt.

-

Hypnosis: Helps in confirming Dx by enhancing memories & resolving deep conflicts.