ANXIETY DISORDERS

ANXIETY DISORDERS

• Anxiety is a diffuse, unpleasant sense of apprehension (nervousness).

• It presents with physiological symptoms:
• Sweating
• Tachycardia, tremors
• Restlessness
• Chest pain
• Cold clampy skin
• Headache

• Certain physiological symptoms: L, B, O, P, O, L.

Epidemiology

• Most common psychiatric disorder in the world:
• Anxiety disorders.

• Most common individual disorder:
• Specific phobias.

• All anxiety disorders are more common in females than males.
• An exception is social anxiety disorder that is equally presented in males and females.

Anxiety disorders

1. Panic disorders

2. Phobias (Situational anxiety)
• Agoraphobia
• Specific phobias
• Social phobias

3. Generalized anxiety disorder

• 1. Panic Disorder:
• Sudden intense anxiety.
• Feeling of impending doom/fear of dying.

• Phobias situational Anxiety:
• 2. Agoraphobia
• 3. Specific phobia
• 4. Social phobia

• 5. Generalized Anxiety Disorder (GAD):
• Generalized, not restricted to situation (free-floating).
• Apprehension (worries).

Panic Attack

• Acute sudden attack of intense anxiety.

• Presented with:
• palpitations
• sweating
• tremors
• shortness of breath
• chest pain

• Fear of impending doom or fear of dying or losing control or going crazy.

• Panic attacks are unexpected.

• Not restricted to any particular situation.

• Usually lasting for 20-30 minutes.
• Rarely last > 1 hour.

1. Panic disorder

• Recurrent panic attacks of 1 month duration
• Recurrent Panic Attacks
• 1 Month
• Office
• Home
• Car

• In between the attacks the patient is normal.

Differential diagnosis

• Physical disorders include:
• Cardiovascular:
• Myocardial infarction
• Angina
• Mitral valve prolapse
• Anemia
• Respiratory causes
• Asthma
• Pulmonary embolism
• Seizure disorder
• Migraine
• Endocrine
• Hypothyroidism
• Pheochromocytoma
• Hypoglycemia

Treatment

Pharmacotherapy

• SSRIs are the drug of choice.

• Short term use of benzodiazepine is the DOC for acute attack.

• SSRIs + BZD (short term).

• Venlafaxine

Psychotherapy

• Cognitive behavioral therapy (CBT).

Treatment of choice

• Combination of pharmacotherapy and psychotherapy.
• SSRIs + CBT.

2. Agoraphobia

• Fear or anxiety in 2 or more of the following situations:
1. Public transportation.
2. Open spaces.
3. Closed spaces.
• Like lift
4. In crowded places/standing in line.
5. Alone out of home.

• Patients have anxiety in places from where escape might be difficult.

• Most common comorbid psychiatric disorder with agoraphobia:
• Panic disorder.

3. Specific phobia

• Strong, persistent, irrational fear of an object or situation.

• Some common phobias.

Phobia	Fear of	Mnemonic
Batophobia	Slanting or tilted spaces	Im Batman
Acrophobia	Heights	Acromion nte mukalinnn chadunnath
Ailurophobia	Cats	Cat comes to our Ail
Cynophobia	Dogs	Cyanosis vanna dog
Claustrophobia	Closed spaces	ㅤ
Mysophobia	Dirt and germs	Myself → full of germs and dirt
Hydrophobia	Water	ㅤ
Thanatophobia	Death	ㅤ
Nyctophobia	Dark	ㅤ
Xenophobia	Strangers	ㅤ
Pyrophobia	Fire	ㅤ
Acarophobia	Mites or small insects.	car odunnapole insects
Algophobia	Pain	ㅤ

Treatment

Psychotherapy

• Behaviour therapy
• Behaviour therapy is preferred than CBT.

• Systematic desensitization
• Therapy of choice.
• Coined by Joseph Wolfe
• Individuals are taught relaxation techniques.
• Hierarchy (least anxiety to maximum anxiety provoking situations) is made.
• Patient moves up to the next step once he masters relaxation in previous situation.

• Therapeutic graded exposure/In-vivo exposure.
• Also known as Exposure and response prevention.
• Similar to systematic desensitization except no relaxation techniques are used.
• Patient learns to get habituated to anxiety.

• Flooding/Implosion.
• Patient is exposed to supra-maximal stimulus.
• Patient experiences intense anxiety which gradually decreases

Pharmacotherapy

• SSRIs + BZDs.

4. Social Anxiety Disorder/Social Phobia

• Fear of social situations, including situations that involve contact with strangers.

• Fear of embarrassing oneself in front of others.

Treatment

Pharmacotherapy

• SSRIs + BZDs (short term).

• SNRIs: Venlafaxine.

• β-blockers e.g. propranolol used for performance anxiety.

Psychotherapy

• Cognitive behaviour therapy.

5. Generalized anxiety disorders (GAD)

• Excessive anxiety and excessive worries.

• Generalized and persistent anxiety not restricted to any particular situation
• free floating anxiety

• It occurs continuously.

• Excessive Worries may involve simple daily activities, timelines and health.
• (e.g., worried about husband being late, children being late, managing a party

Treatment

Pharmacotherapy

• SSRIs + BZD (short term).

• SNRIs: Venlafaxine.

Psychotherapy

• Cognitive behavioural therapy.

OBSESSIVE COMPULSIVE RELATED DISORDERS

1. Obsessive compulsive disorder (OCD)

• Patient has recurrent obsessions and compulsions.

• Obsession is an abnormality of possession of thought.

• A/w Depression and Anorexia

Obsessions:

• Mnemonic - 'ROSI':
• R - Recurrent:
• Recurrent and intrusive thoughts / images / impulses.
• Not pleasurable.
• O - Own:
• Patient acknowledges that thoughts are his own, not imposed by others.
• S - Senseless:
• Patient also acknowledges them to be senseless.
• Helps to differentiate from delusion.
• I - Irresistible:
• Wants to rid of these thoughts, but these are irresistible.

Compulsions:

• Repetitive behaviors (e.g., washing, checking).

• Mental acts (e.g., counting).

• Performs in response to obsessions or in a rigid rule-bound manner.

• They are often time consuming (e.g.: >1 hour/day).

• Cause clinically significant distress/impairment in functioning.

Obsessions and Compulsions:

• Egodystonic (ego alien).
• Unacceptable to mind.

Patient can have:

• Only obsessions.

• Only compulsions.

• Both obsessions and compulsions (most common).

Epidemiology

• Lifetime prevalence: 2 to 3%

• Most common comorbidity associated with OCD:
• Depression

Etiology

• Serotonin hypothesis of OCD:
• Serotonin dysregulation.

Neuroanatomical model of OCD

• Striatum (Caudate)

• Prefrontal cortex (Orbitofrontal cortex)

• Thalamus

• Mnemonic: Thalade frontil caudati → paranjondirikkum

• Dysfunction in CSTC Circuit
• Cortico — Striatal — Thalamic — Cortical

• Bilaterally smaller caudates.

Major symptoms and patterns

Most common Obsessions:

• Contamination: Most common.

• Pathological doubt: 2nd most common.

• Aggressive

• Sexual

• Multiple

Most common Compulsions:

• Checking: Most common.

• Washing: 2nd most common.

• Counting

• Symmetry & precision

Most common pattern of OCD:

• Contamination and washing.

Treatment

Treatment of choice

• Combination of pharmacotherapy and psychotherapy.

Pharmacotherapy

• 1st line: SSRIs (DOC).
• Sertraline, Fluoxetine, Fluvoxamine.
• Clomipramine (most common serotonin selective tricyclic antidepressants).

• Antipsychotics:
• Risperidone, Aripiprazole, Haloperidol, Olanzapine.

Psychotherapy

• Exposure and response prevention (ERP).
• Cognitive behaviour therapy (CBT).
• Primarily using exposure and response prevention (ERP).
• In vivo or imaginal exposure of feared situations is given.
• Patient is asked not to engage in compulsive response.

Other somatic therapies

• For extreme and treatment-resistant cases:
• Electroconvulsive therapy (ECT).
• Psychosurgery can be considered:
• Subcaudate tractotomy
• Anterior cingulotomy
• Anterior capsulotomy/gamma knife capsulotomy

2. Body Dysmorphic Disorder

• Preoccupation with perceived defects or flaws in physical appearance.

• Most common concerns involve the face and head (e.g., hair, nose, skin).

• Differential diagnosis:
• Delusional dysmorphophobia
• patient is totally convinced that their body part is flawed.

• Rx: CBT

3. Hoarding Disorders

• Acquiring and not discarding things of little or no value.

• Leads to cluttering,

• causing clinically
• significant distress
• impairment of functioning
• (eating, sleeping, safety issues).

• Driven by:
• Fear of losing something important.
• Distorted emotional attachment to the item.

Treatment

• Difficult to treat.

• Psychotherapy: Cognitive behavior therapy (CBT).

4. Trichotillomania (Hair-Pulling Disorder)

• Recurrent pulling of one's hair, resulting in hair loss.

• Accompanied by unsuccessful attempts to decrease or stop the behavior.

• Hair plucking may be followed by trichophagy (mouthing of hair).

• Complications:
• trichobezoar
• malnutrition
• intestinal obstruction

5. Excoriation (Skin Picking Disorder)

• Recurrent picking of one's own skin, resulting in the skin lesion.

• Accompanied by unsuccessful attempts to decrease or stop the behaviour.

• Most common areas involved:
• Face, hands, fingers, arms, and legs.

Obsessive compulsive and related Disorders DSM-5

1. OCD

2. Body dysmorphic disorder

3. Hoarding disorder

4. Trichotillomania (hair pulling disorder)

5. Excoriation (skin picking) Disorder

Obsessive compulsive or related Disorders ICD-11

1. OCD

2. Body dysmorphic disorder

3. Hoarding disorder

4. Body focused repetitive behaviour disorder
• Trichotillomania
• Excoriation disorder

5. Olfactory Reference syndrome
• preoccupation that one is
1. emitting foul smell
2. unnoticeable/slightly noticeable to others

6. Hypochondriasis

Separation Anxiety Disorder

• Adults: > 6 months of symptoms

• Children: > 1 month of symptoms

Features

• Failure to develop object constancy at 2–3 years

• Childhood:
• Anxiety of separation from primary caregiver → insecurity, hesitates to attend school

• Adulthood: Clingy, insecure, suffocating relationships

Treatment

• SSRIs

• Psychotherapy (CBT) – to help develop healthy relationships

Selective Mutism

• Childhood anxiety disorder

• Inability to speak in specific situations or to specific people,
• persisting > 1 month

• Age of onset: 3–5 years

• Cause: Social anxiety

Treatment

• Play therapy

• Psychotherapy

TRAUMA OR STRESSOR RELATED DISORDERS

• These disorders require exposure to stressors or trauma.

• Trauma or stressor ——> Major Life-Threatening Event

• For e.g.:
• Serious accidents
• Exposure to war
• Physical assault, kidnapping
• Sexual violence (rape)
• Natural disasters (earthquakes, tsunamis etc.)
• Serious illness

• Two important disorders
1. Posttraumatic stress disorder (lasts ≥ 1 month)
2. Acute stress disorder (lasts < 1 month)
3. Acute stress reaction (< 2 days)

Acute Stress Disorders

Notes

• Most common disorder in cancer patients → Adjustment disorder

• Most common disorder in HIV patients → Depression

Post-Traumatic Stress Disorder

• Exposure to actual or threatened death, serious injury or Sexual violence.

• The duration of symptoms is > 1 month.

Symptoms of PTSD

• M - Mood and Cognitive symptoms:
• Develops negative emotional state like fear, anger and guilt.
• May develop negative beliefs.

• A - Avoidance
• avoid feelings, memories, or thoughts related to the trauma.
• avoid people associated with the trauma.
• avoid the place where the accident occurred.
• avoid objects related to the trauma (e.g., selling the car after repair)

• H - Hyperarousal:
• Irritability
• Hypervigilant
• Insomnia
• Decreased concentration

• I - Intrusion symptoms:
• Distressing dreams, memories
• Re-experiencing symptoms.
• Flashbacks of the event.

Treatment

Psychotherapy

• Treatment of choice.

• Types
• TOC: CBT (Cognitive Behaviour Therapy).
• EMDR (Eye Movement Desensitization and Reprocessing)
• EMDR involves giving a stimulus for eye movement
• (e.g., following a pen)
• while asking the patient to remember the event,
• helps desensitize and reprocess the trauma.

Impulse Control Disorders

• Impulse is a feeling of increasing tension and arousal.

• That leads to performance of a certain act.

1. Pyromania

• Recurrent purposeful setting of fires.

• In absence of a clear motive (E.g.: Monetary gain, revenge).

2. Kleptomania

• Recurrent stealing of objects
• that are not needed for personal use for their monetary value.

Dissociative Disorders, Conversion Disorders,
Somatic Symptoms & Related Disorders

• Previously classified as Hysteria.

• Presentation of these disorders:
• Symptoms
• without any bodily cause
• but physical symptoms are present.
• Examination and investigation seems normal.
• Associated stressor is generally present.

Dissociative Disorders

• Disturbance in ≥ 1 mental functions:
• Action/motor behaviour
• Thoughts/consciousness
• memory
• identity
• perception/sensation

1. Dissociative Amnesia

• Inability to recall important personal information
• Usually of a traumatic event.

• It is inconsistent with ordinary forgetting.

• Example:
• A person is rescued two days after his kidnapping.
• He is unable to recall any information about those two days when asked.
• However, he remembers everything before and after those two days.
• Investigations and examinations are normal.
• No physical or anatomical conditions justify the amnesia.
• After therapy, if the stress is resolved, the person will be able to remember things.

2. Depersonalisation-derealisation disorder

• Recurrent experiences of depersonalization or derealization or both.

• More common after life threatening trauma

• Depersonalization:
• Feeling of detachment from the self.
• Person may feel like he is watching himself in the movie.

• Derealization:
• Feeling of detachment from the world.
• Person feels as if the world is unreal, dreamlike or foggy

• Reality testing is intact in these disorders.

3. Dissociative Identity Disorder (Multiple Personality Disorder)

• Two or more distinct personalities exist in one individual.

• Only one of them is evident at a time.

• The personalities are also known as alters.
• They have their own pattern of thinking and behaving.

• The alters are usually unaware of each other's existence.

• Example:
• A timid person D works in an office.
• When another car scratched his car, he came out with a baseball bat and beat the person.
• Two different personalities of Mr. D are seen.
• These identities may not be aware of one another.

4. Dissociative Fugue

• Dissociative amnesia present

• Primary identity forgotten

• May adopt an alter-ego

• Purposeful wandering occurs

• Regression seen with ↓ stress level

NOTE:

• “Aimless Wandering” seen in Psychotic illness

5. Conversion Disorder

• ICD-11:
• Classified under dissociative disorders.
• Known as Dissociative Neurological Symptom Disorder (DNSD).

• In DSM-5:
• Classified under Somatic Symptom Disorder.
• Known as Functional Neurological Symptom Disorder.

Symptoms:

• E.g.:
• A seven-year-old girl overhears her parents deciding to separate.
• After a few minutes, she reported being unable to see anything.
• Examination and investigation were normal.
• After therapy and stress resolution, the child could see again.
• Due to high stress, the mind converted stress into neurological symptoms (blindness).

La Belle Indifference

• Associated with conversion disorder.

• It is the patient's inappropriately careless attitude towards serious symptoms.

• For instance, the girl who is not able to see; may be sitting very calmly.

Somatic Symptoms and Related Disorders

• Previously known as somatoform disorders.

Somatic Symptom Disorder

• Previously known as somatization disorder or Briquet's syndrome.

• ICD-11 uses the term “bodily distress disorder”.

• Preoccupied with somatic symptoms.
• Patient complains for months or years of symptoms like pain, tingling, nausea, vomiting.

• The patient has many symptoms but investigations are normal.

• The symptoms are caused by the mind and not by the body.

• Mnemonic: Somatic → So many symptoms but no illness of body

Illness Anxiety Disorder (DSM-5) or Hypochondriasis (ICD-11)

• Preoccupied with having or acquiring a serious illness.

• Symptoms may or may not be present.

• Example: A patient may correlate a headache with a brain tumor.
• Persists despite normal investigations and reassurances

Deliberate falsification of symptoms

• Depending upon the aim, it can be divided into different types.

Factitious Disorder

• Also known as Munchausen syndrome.

• Aim is to Receive medical attention
• fake physical or psychological symptoms to assume a sick role with the aim of receiving medical attention.

Factitious Disorder Imposed on Another

• Munchausen syndrome by proxy.

• Example:
• A mother deliberately inducing symptoms on her child
• so mother can receive medical attention.

• Mnemonic: Fact → Medical → Munch

Malingering:

• The aim is to receive any external benefits/gains
• (e.g., money from insurance, avoiding transfer).

• The person is faking symptoms to achieve an external goal.

• Malingering is not a psychiatric diagnosis