ANXIETY DISORDERS

Anxiety is a state of tension & apprehension with hyperactivity of the autonomic nervous system as a natural response to perceived threat. Anxiety disorders have three components. Cognitive component. Physiological responses. Behavioral Response.

BEHAVIORAL RESPONSES
Avoidance of certain situation. Impaired task performance COGNITIVE COMPONENT Subjective feelings of apprehension. A sense of impending danger. A feeling of inability to cope.

PHYSIOLOGICAL RESPONSES
Increased heart rate. Raised blood pressure. Muscle tension. Rapid breathing. Nausea. Dry month. Diarrhoea. Frequent urination.

Anxiety disorders may be classified as follows Generalized anxiety disorder (GAD). Panic disorder. Phobic disorders agoraphobia, specific phobias and social phobias. Obsessive compulsive disorder (O.C.D) Post traumatic stress disorder (PTSD) Secondary disorders due to general medical condition and substances.

GENERALISED ANXIETY DISORDER

Persistent generalized & excessive feelings of anxiety not attached to any particular specific situations but rather caused by a general tendency to worry excessively. It may last for months. There is a sense of impending disorder, through not specific

Typical worries include excessive worries about work or social performance, exaggerated concern about finances & the possibility of becoming ill or having an accident.

Common symptoms of GAD

Nervousness, restlessness, trembling. shortness of breath Sweating Muscle tension Feeling jittery, tense and constantly on edge Trouble falling or staying asleep

Poor concentration Irritable mood, depressed mood Palpitations frequent urination Easily fatigued , light headedness Difficulty making decisions

PANIC DISORDER
PANIC ATTACK

A panic attack is a discrete period of intense fear or discomfort, in which four or more of the following symptoms develop abruptly & reached a peak within ten minutes. Palpitations Sweating Trembling and shaking

Symptoms of panic attacks can be terrifying & distressing. They may last a few minutes or longer. In MOST cases, panic attacks occur in the absence of any identifiable stimulus. Attacks may be followed by persistent concerns a bout having another panic attack. They are mysterious and terrifying due to their unpredictable quality.

Many people with panic attacks develop agoraphobia (a fear of public places) for fear of having an attack in public. Panic disorder can be classified as being with or without agoraphobia; panic disorders tend to appear in late adolescence or early adulthood (mid 20s). They are more frequent in females.

The situations include

Being outside the home alone Being in a crowd or standing on a line Being on a bridge, elevators. Travelling in a bus ,train or car They feel relieved when accompanied by someone else. It usually develops after the individual has experienced of panic like symptoms.

PHOBIC DISORDERS
Phobias are strong and irrational fears of certain object or situations. The word is derived from phobos, a Greek god of fear. People with phobias relies that their fears are out of proportion to the danger involved. However, they feel helpless to deal with fears. Instead, they make strenuous effort to avoid the phobic situation or object.

AGORAPHOBIA. Its anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic like symptoms.

SOCIAL PHOBIA.
Social phobia is common as panic and agoraphobia disorders. It is experienced by both men and women. It is chronic disorder that fluctuates over time and may cause marked impairment in social and occupational functioning if untreated. The key feature of social phobia is excessive fear of situations in which the person might be scrutinized, evaluated and judged negatively.

 Individuals doing something embarrassing or acting in a way that may be humiliating. Fear of specific social situation results in avoidance. A more generalized social phobia may lead to almost complete social isolation. Social phobia is often under-recognized by medical workers, because they either confuse it with shyness or judge the secondary depression or substance dependence to be the primary disorder. If a person says, people make me anxious or nervous, consider social phobia.

 Common situations feared include speaking in public, writing in the presence of others eating or drinking in public or using public toilets. Common (embarrassing) symptoms include blushing, nausea, shaking and the urge to go the toilet.

SPECIFIC PHOBIA
Specific phobias may include fear of dogs, spiders, snakes, elevators, heights and enclosed spaces, airplanes, still water, injections, illness, or death. Common symptoms consists of trembling, accelerated heart rate, difficulty breathing, lightheadedness and sweating. Phobias can develop at any point in life. Many of them develop during childhood, adolescence and early adulthood.

 Once phobias develop, they seldom go away on their own. Phobias may broaden and intensify over time and are twice as common among women than men. Phobias that begin during childhood usually disappear without treatment. However, phobias disappear without treatment. However, phobias that develop later in life are usually more chronic.

OBSESSIVE COMPULSIVE DISORDER (OCD)

Men =women Usually the OCD has two components: Cognitive (thoughts of being infected by germs) and behavioral (washing and cleaning rituals). Either occur alone. Obsessions are persistent, repetitive, intrusive and unwelcome thoughts, images and impulses that invade the individuals consciousness. They are often abhorrent to the person, but very difficult to dismiss or control. Thoughts are recognized as being generated within individual s own mind versus thought insertion found in schizophrenia. Obsessional thoughts focus on contamination, disasters, violence, harm to self or others, blasphemy, sex or other distressing things.

 Compulsions are persistent, repetitive and uncontrollable behavioral urges to perform certain behaviours, such as washing or cleaning rituals, resisted only with two great difficulty. Responses to obsessive thoughts and function to reduce anxiety associated with thoughts. Compulsive rituals result in temporary relief. Behavioural compulsions are extremely difficult to control. Rituals include washing, checking things repeatedly, cleaning, counting, or doing tasks in a specific and rigid order.

 Failure to perform leads to anxiety (perhaps even a panic attack). Like phobic avoidance responses, compulsions appear to reduce anxiety.

OCD may lead to avoidance of certain objects or situations (e.g. dirt, and not leaving the house to avoid locking doors); life disruption; frustration; irritation to individual, family, friends and workmates; depression and anxiety.

POST TRAUMATIC STRESS DISORDER (PTSD)

Is a syndrome that develops after a person sees, is involved ion, or hears of an extreme traumatic stressor. stressor can be war, torture, natural disasters, assault, rape, serious accidents MVA) Reacts with fear and helplessness, reliving the event and trying to avoid being reminded of the event. The symptoms must last for more than a month after the event.

Epidemiology
Lifetime prevalence 8% in gen pop 10-12 % for women and 5-65 FOR MEN 5-15% will experience subclinical PTSD Those who have experienced traumatic events lifetime prevalence is 5-75% Age: any but mainly young adults coz predisposed to precipitating situations Marital status: single, divorced, widowed, socially withdrawn SES: Low SES

Risk factors
Severity of trauma Duration of trauma Proximity of a persons exposure to the actual trauma Hx of depression in 1st degree relatives Presence of childhood trauma Inadequate family or peer support system Being female Genetic vulnerability to psychiatric illness Recent excessive alcohol intake Personality disorder- borderline, dependent, antisocial

Aetiology
STRESSOR: Subjective meaning to a person Preexisting biological factors-neurotransmitter theories- noradrenergic system, endogenous opiate system Increased activity and responsiveness of the autonomic nervous system Psychosocial factors Previous and after traumatic events genetic vulnerability

Clinical features
Painful re-experiencing of the event Pattern of avoidance and emotional numbing Constant hyperarousal MSE reveals: feelings of guilt, rejection, and humiliation Dissociative states, panic attacks, hallucinations, aggression. Violence, poor impulse control, depression, substance related disorders Cognition- impaired memory, and attention

MANAGEMENT PRINCIPLES OF ANXIETY DISORDERS

Rule out organic or physiological pathology. Rule out mood and substance abuse problems. Educate the patient on disorder. Provide training in strategies to control anxiety symptoms. Appropriate referrals. Avoid unnecessary medication especially sedatives

BIOLOGICAL MANAGEMENT
Benzodiazepines may be used for symptoms relief. Antidepressants SSRIs + TCAs ( comorbid features of mood disorder are not uncommon) Beta blockers Antihistamines hydroxyzine in GAD

PSYCHOLOGICAL MANAGEMENT Cognitive behavioral therapy is the most effective approach. SOCIAL MANAGEMENT It includes education & support involving family & relevant support structures