Anxiety disorders part II

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Myron Elliott
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1 Anxiety disorders part II

2 ICD 10- Neurotic, stress-related and somatoform disorders (F40-F48) F42 Obsessive-compulsive disorder F43 Reaction to severe stress, and adjustment disorders F44 Dissociative [conversion] disorders F45 Somatoform disorders F48 Other neurotic disorders

3 F 42. OBSESSIVE COMPULSIVE DISORDER (OCD) This disorder is marked by unwanted, intrusive, persistent thoughts (obsessions) or repetitive behaviors (compulsions) that reflect the patient's anxiety or attempts to control it.

OBSESSIVE COMPULSIVE DISORDER Obsessional thoughts (obsessions) are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form.

4 OBSESSIVE COMPULSIVE DISORDER Obsessional thoughts (obsessions) are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant.

5 OBSESSIVE COMPULSIVE DISORDER Compulsive acts or rituals (compulsions) are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist.

6 Examples contamination an obsession of contamination, followed by washing or accompanied by compulsive avoidance of the presumably contaminated object pathological doubt an obsession of doubt, followed by a compulsion of checking intrusive thoughts intrusive obsessional thoughts without a compulsion (usually repetitious thoughts of a sexual or aggressive act that is reprehensible to the patient) symmetry the obsessive need for symmetry or precision, which can lead to a compulsion of slowness

7 Diagnostic criteria for OCD (ICD-10) 1. Obsessional symptoms or compulsive acts or both must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities 2. Obsessional symptoms should have the following characteristics: they must be recognised as the individual's own thoughts or impulses. there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists. the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense). the thoughts, images, or impulses must be unpleasantly repetitive.

8 Epidemiology The prevalance of OCD in general popuation is estimated at 2 to 3% OCD is the fourth most common psychiatric diagnosis after phobias, substance abuse and major depressive disorder Men and women ale equally likely to be affected The mean age of onset is about 20 years People with obsessive- compulsive disorder are commonly affected by other mental disorders

9 DIFFERENTIAL DIAGNOSIS Anxiety disorder due to a general medicial condition Subsance- induced anxiety disorder Schizophrenia Major depression episode (rumination) Hair pulling in trichotillomania Ticks Obsessive- compulsive personality disorder...

10 TREATMENT Pharmacotherapy Psychotherapy SSRIs in higher dosis TCA- clomipramine Addition of low-dose neuroleptic medications Cognitive- behavioural therapy Insight orientated therapy

11 F43 Reaction to severe stress, and adjustment disorders F43.0 Acute stress reaction F43.1 Post-traumatic stress disorder F43.2 Adjustment disorders F43.8 Other reactions to severe stress F43.9 Reaction to severe stress, unspecified

12 REACTION TO SERVE STRESS AND ADJUSTMENT DISORDERS Exogenous/ reactive/situational Response to traumatic event or prolonged stress Symptoms vary widely and my be simmilar to other anxiety or mood disorders

ACUTE STRESS REACTION A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress The symptoms show a

13 ACUTE STRESS REACTION A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress The symptoms show a typically mixed and changing picture and include an initial state of "daze" with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present.

ACUTE STRESS REACTION The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days

14 ACUTE STRESS REACTION The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.

POSTTRAUMATIC STRESS DISORDER Develops after traumatic, shocking, dangereus even To be diagnosed with PTSD, an adult must have all of the following for at least 1 month: At least one re-experiencing

15 POSTTRAUMATIC STRESS DISORDER Develops after traumatic, shocking, dangereus even To be diagnosed with PTSD, an adult must have all of the following for at least 1 month: At least one re-experiencing symptom: Flashbacks reliving the trauma over and over, including physical symptoms like a racing heart or sweating Bad dreams Frightening thoughts At least one avoidance symptom: Staying away from places, events, or objects that are reminders of the traumatic experience Avoiding thoughts or feelings related to the traumatic event

PTSD At least two arousal and reactivity symptoms Being easily startled Feeling tense or on edge Having difficulty sleeping Having angry outbursts At least two cognition and mood

16 PTSD At least two arousal and reactivity symptoms Being easily startled Feeling tense or on edge Having difficulty sleeping Having angry outbursts At least two cognition and mood symptoms Trouble remembering key features of the traumatic event Negative thoughts about oneself or the world Distorted feelings like guilt or blame Loss of interest in enjoyable activities

17 Course of PTSD Trauma months years acute stress disorder (ASD) acute PTSD chronic PTSD PTSD of late oneset

18 ADJUSTMENT DISORDER States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event. The symptoms vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine.

19 F43 Reaction to severe stress, and adjustment disorders Psychopharmacology 1. Benzodiazepines - short acting (lorazepam - long acting (clonazepam, bromazepam, cloranxen) 2. TCI (clomipramine ) 3. SSRI, SNRI, (fluoxetyna, fluwoksamina), (wenlafaksyna) 4. Inhibitors MAO A (moklobemid) 5. Buspiron 6. Neuroleptics

20 F43 Reaction to severe stress, and adjustment disorders Psychotherapy cognitive behavioral therapy exposure therapy eye movement desensitization and reprocessing (EMDR) virtual reality

21 F 44. DISSOCIATIVE (CONVERTION) DISORDERS Partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. All types of dissociative disorders tend to remit after a few weeks or months, particularly if their onset is associated with a traumatic life event. (ICD-10)

22 DISSOCIATIVE (CONVERTION) DISORDERS (as defined in DSM-IV) a disorder characterized by the presence of one or more neurological symptoms (paralysis, blindness, mutism) that cannot be explained by a known neurological or medical disorder psychological factors must be associated with the initiation or the exacerbation of the symptoms the symptom of deficit is not intentionally produced or feigned

23 DISSOCIATIVE (CONVERTION) DISORDERS EPIDEMIOLOGY Conversion disorder can have its onset at any time (most common in adolescents and young adults) The prevalence of some symptoms of conversion disorder may occure in one third general population 75% may not expirience another episode The ratio of women to men is at least 2 to 1 (to 5 to 1) the lifetime prevalence of some symptoms of conversion disorder may occur in one third of the general population Diferential diagnoses major depressive disorder, anxiety disorders, and schizophrenia

24 DISSOCIATIVE AMNESIA Loss of memory, usually of important recent events, that is not due to organic mental disorder, and is too great to be explained by ordinary forgetfulness or fatigue. The amnesia is usually centered on traumatic events, such as accidents or unexpected bereavements, and is usually partial and selective.

25 DISSOCIATIVE FUGE Dissociative fugue has all the features of dissociative amnesia, plus purposeful travel beyond the usual everyday range. Although there is amnesia for the period of the fugue, the patient's behaviour during this time may appear completely normal to independent observers.

26 Trance and possession disorders Disorders in which there is a temporary loss of the sense of personal identity and full awareness of the surroundings. Include here only trance states that are involuntary or unwanted, occurring outside religious or culturally accepted situations.

27 DISSOCIATIVE MOTOR DISORDERS In the commonest varieties there is loss of ability to move the whole or a part of a limb or limbs. There may be close resemblance to almost any variety of: ataxia apraxia akinesia aphonia dysarthria dyskinesia seizures paralysis

28 DISSOCIATIVE CONVULSIONS Dissociative convulsions may mimic epileptic seizures very closely in terms of movements, but tongue-biting, bruising due to falling, and incontinence of urine are rare, and consciousness is maintained or replaced by a state of stupor or trance.

29 DISSOCIATIVE ANAESTHESIA AND SENSORY LOSS Anaesthetic areas of skin often have boundaries that make it clear that they are associated with the patient's ideas about bodily functions, rather than medical knowledge. There may be differential loss between the sensory modalities which cannot be due to a neurological lesion. Sensory loss may be accompanied by complaints of paraesthesia. Loss of vision and hearing are rarely total in dissociative disorders.

30 F44 Dissociative disorders EPIDEMIOLOGY the lifetime prevalence of some symptoms of conversion disorder may occur in one third of the general population 75 % of patients may not experience another episode the ratio of women to men is at least 2 to 1 (to 5 to 1) conversion disorder can have its onset at any time (most common in adolescents and young adults) comorbid diagnoses major depressive disorder, anxiety disorders, and schizophrenia

31 DISSOCIATIVE ANAESTHESIA AND SENSORY LOSS DIFFERENTIAL DIAGNOSIS TREATMENT the initial conversive symptoms of % patients resolve spontaneously in a few days or less than a month insight-oriented, supportive or behavior therapy, brief and direct forms of short-term psychotherapy may be effective

32 F45. SOMATOFORM DISORDERS physical symptoms suggesting a medical condition, severe enough to cause significant distress or impaired functioning, not intentionally produced, but not explained by any medical condition

33 F45 Somatoform disorders F45.0 Somatization disorder F45.1 Undifferentiated somatoform disorder F45.2 Hypochondriacal disorder F45.3 Somatoform autonomic dysfunction F45.4 Persistent somatoform pain disorder F45.8 Other somatoform disorders F45.9 Somatoform disorder, unspecified

34 SOMATIZACION DISORDER The main features are multiple, recurrent and frequently changing physical symptoms of at least two years duration. Symptoms may be referred to any part or system of the body. The course of the disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal, and family behaviour.

HYPOCHONDRIACAL DISORDER Characterized less by a focus on symptoms than by patients beliefs that they have a specific disease Prevalence of 4-6% in general medical clinic population Men and women are

35 HYPOCHONDRIACAL DISORDER Characterized less by a focus on symptoms than by patients beliefs that they have a specific disease Prevalence of 4-6% in general medical clinic population Men and women are equally affected by hypochondriasis Symptoms can occur at any age, bu the most common onset appeart in 20s to 30s Hypochondriasis is often accompanied by symptoms of depression and anxiety and commonly coexists with a depressive or anxiety disorder

PAIN DISORDER persistent, severe, and distressing pain perception, which cannot be explained fully by a physiological process or a physical disorder, and

36 PAIN DISORDER persistent, severe, and distressing pain perception, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences

37 BODY DYSMORPHIC DISORDER Characterized by a fals belief or exaggerated perception that a body part is defective

38 F48 Other neurotic disorders F48.0 Neurasthenia F48.1 Depersonalization-derealization syndrome F48.8 Other specified neurotic disorders F48.9 Neurotic disorder, unspecified

39 Neurasthenia a condition characterized by chronic fatigue and disability neurasthenia is characterized by a wide variety of signs and symptoms the most common are chronic weakness and fatigue, aches and pains, general anxiety or nervousness feelings of bodily or physical weakness and exhaustion (after only minimal effort, accompanied by muscular aches and pains and inability to relax)

40 DEPERSONALIZATION AND DEREALIZATION SYNDROME Depersonalization the person fells unreal: detached, numb, or emotionally distant Derealization: the world feels unreal like a film set

41 PSYCHOSOMATIC DISORDERS A somatic disorder resulting from, or being intensified by psychical factors For example: Angina pectoris, arythmias, bronchial asthma, systemic diseases (RA), headaches, hypertension, metabolic and hormonal disturbances, and other...

42 PSYCHOSOMATIC DISORDERS Onset, or exacerbation of a somatic disorder must be time- related to a psychical trauma In general medical examination there must be present some organic changes or specific physiopathological disturbances

43 PSYCHOSOMATIC DISORDERS ETIOLOGY- theories Flanders Dunbar s- specific personality features typical for psychosomatic disorders Franz Alexander s- unconsious conflicts as anxiety sources, cousing specific diseases, through autonomic nervous system activation locus minoris resistentiae - each long- term acting stressor may couse psychosomatic disorder, afection the most stress- sensitive organ

44 PSYCHOSOMATIC DISORDERS TREATMENT Cooperation among specialist treating psychosomatic patients Pharmacotherapy (symptomatic only) Psychotherapy

Anxiety disorders part II

Anxiety disorders part II OBSESSIVE-COMPULSIVE DISORDER obsession a recurrent and intrusive thought, feeling, idea, or sensation compulsion a conscious, standarized, recurring pattern of behavior, such