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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)

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.

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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.

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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.

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•Panic Attack: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.

1-Palpitations2-Sweating3-Trembling or shaking 4-Sensations of shortness of breath5-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

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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.

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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.

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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.

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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.

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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.

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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.

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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 experience.

-Pt. response: intense fear, helplessness or horror.

-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.

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-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).

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.

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*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.

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

4-Social support & involving family & friends in caring & understanding pt.'s condition.

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3-Acute Stress Disorder

• The same condition of PTSD, but the period to have the Sx is 2 days-1 month.

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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:1- Restlessness2- Easily to be fatigued 3- Irritability 4- Difficulties in concentration 5- Muscle tension 6- Sleep disturbances

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Prognosis:-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.

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.

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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.

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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.

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

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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.

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Rx: 1-Drugs:-Anfranil (Clomipramin): Drug 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.

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6-Somatororm Disorders

-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 occupational functioning.-Preoccupation is not better accounted for by another mental disorder.

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.

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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.

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).

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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.

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).

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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. -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.

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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 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.

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.

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.

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

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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.

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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).

Course & prognosis:-Mostly starts in 20’s.-1/3 of pts. don’t improve & social/vocation disturbed.-Males & female: equal.

Rx:-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.

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Comparison b/w Somatization & Hypochondriasis

Somatization Hypochondriasis7 yrs needed for dx 6 months for dxLook about sx & Rx Look about disorder

behind sxC/O 13 or >sx C/O 1 or 2 sxDoesn’t like Dr. visit Multiple Dr. visit

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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.

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-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.

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.

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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.

-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.

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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.

-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.

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.