1. Anxiety disorders. .pptx

Mental health

1. Anxiety disorders Kilaye

2. Learning objectives A t the end of this session you should be able to: D efine anxiety disorders Understand the e pidemiology of anxiety disorders Describe etiological factors/pathophysiology Manage a patient with anxiety disorders (specific)

3. I ntroduction What is Anxiety? Anxiety is a normal reaction to stressful situations A universal human experience Anxiety is the subjective emotional response to the stressor Fear is the emotional response to a real or perceived imminent threat Anxiety is the anticipation of future threat

4. Introduction cont… Normal Anxiety Brief and situational Doesn't significantly impact daily life Anxiety Disorder Excessive and persistent Interferes with daily activities

5. I ntroduction cont … Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances Anxiety may be regarded as pathological when it interferes with social and occupational functioning

6. It can be informed by considering the following criteria: Excessiveness Intensity Duration Impairment

7. Anxiety is manifest in physical, affective, cognitive, and behavioral domains. Physical - autonomic arousal- Emotional - feelings of uneasiness and edginess to terror and panic. Cognitive - worry, apprehension, and thoughts regarding emotional, bodily, or social threat. Behaviorally - avoidance, escape, and safety-seeking behaviors

8. Etiological factors for anxiety disorders The complex interaction of factors Genetics Brain chemistry Life experiences/stressful events Environmental exposure Medical conditions Psychological

9. E pidemiology Anxiety disorders are the most common of all psychiatric illnesses and result in considerable functional impairment and distress Most occur more frequently in females than in males (approximately 2:1 ratio) Prevalence rates for anxiety disorders within the general population is 3 to 5 % for GAD and panic disorder, 13% for social anxiety disorder, and 25 % for phobias. Prevalence of anxiety disorders in children ranges from 2 to 43% The symptoms are more prevalent among girls than boys Studies of familial patterns suggest that a familial predisposition to anxiety disorders probably exists

10. Types of anxiety disorders Generalized anxiety disorder (GAD ) Social anxiety disorder (SAD) Panic disorder (PD) Separation anxiety disorder Agoraphobia Selective mutism Specific phobias

11. Separation anxiety disorder Separation anxiety disorder present with fearful or anxious about separation from attachment figures to a degree that is developmentally inappropriate There is persistent fear or anxiety about harm coming to attachment figures and events that could lead to loss of or separation from attachment figures and reluctance to go away from attachment figures, as well as nightmares and physical symptoms of distress Although the symptoms often develop in childhood, they can be expressed throughout adulthood as well .

12. Selective mutism Selective mutism (SM) is a childhood disorder characterized by a consistent failure to speak in specific social situations ( eg , school) despite speaking normally in other settings ( eg , at home) The failure to speak has significant consequences on achievement in academic or occupational settings or otherwise interferes with normal social communication. selective non-speaking behavior is required to be present for at least 1 month Not be attributable to a lack of knowledge of, or discomfort with, the spoken language required in the social situation Interfere significantly with daily functioning in school, work, or social life Disturbance is not better explained by a communication disorder ( eg , childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder

13. Comorbidities : Enuresis Encopresis Obsessive-compulsive disorder Depression Premorbid speech and language abnormalities Developmental delay ASD, dissociative disorders Ddx : adjustment disorder, intellectual disabilities, pervasive developmental disorders, expressive language disorders, mood disorders, and hearing impairment.

14. T reatment Psycho-education Breathing and muscle relaxation Behavioral training – contingency management, hierarchical exposure, Cognitive training – positive self-talk and cognitive restructuring P arent training – enhancing parents’ skills in assisting their child and gradually discontinuing the mutism behaviors SSRIs (fluoxetine) and antianxiety

15. Phobias Phobia is an inappropriate situational anxiety/ fear with avoidance. Or phobia is defined as any persistent and irrational fear of specific object or situation that results in a compelling desire to avoid the feared stimulus. Can be classified as follows: Specific (isolated) phobias or simple phobias Agoraphobia Social phobia or SAD

16. Specific phobia Specific phobias are characterized by an unreasonable or excessive, persistent inappropriate fear of a circumscribed external object or situation, which leads to avoidance For example fear of heights, dark and spider. The fear, anxiety, or avoidance is almost always immediately induced by the phobic situation, to a degree that is persistent and out of proportion to the actual risk posed Such specific phobias start and are normal in children, they often clear in early adulthood but are still common in a mild form in adults The diagnosis of specific phobia requires the presence of reduced functioning and interference with social activities and relationships because of the avoidant behavior , anticipatory anxiety, and distress caused by the exposure to the feared stimulus

17. Cont... Common specific phobia includes:- Zoophobia - fear of animals Haematophobia – fear of blood Nectrophobia – fear of corpses Pathophobia – fear of disease Gymophobia – fear of naked body Gynophobia – fear of women Androphobia – fear of men Geno phobia – fear of sex Thanatophobia – fear of death Hydrophobia – fear of water Mysophobia – fear of dirty Antrophobia – fear of people.

18. Agoraphobia An anxiety disorder is characterized by a specific fear of particular places and situations that the person feels anxious or panics, such as open spaces, crowded places, and places from which escape seems difficult Phobias involving fears of leaving home. entering shops. crowds and public places. or traveling alone in trains. buses or planes The individual fears these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms These situations almost always induce fear or anxiety and are often avoided and require the presence of a companion

19. E tiology Childhood experiences/Traumatic childhoods Personality characteristics Psychosocial risk factors P resence of childhood fears or night terrors Experience of grief or bereavement early in life Genetic predisposition Comorbid personality types include dependent, obsessive-compulsive, or otherwise “highly-neurotic Environmental (negative or traumatic events in childhood, and reduced warmth or overprotectiveness in childhood)

20. Social anxiety disorder Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others Such situations may include eating in a restaurant or public speaking, meeting unfamiliar people Fear of scrutiny by other people leading to avoidance of social situations More pervasive social phobias are usually associated with low self-esteem and fear of criticism Can be precipitated by stressful or humiliating experiences, death of a parent, separation or chronic exposure to stress, it may have insidious onset The cognitive ideation is of being negatively evaluated by others, by being embarrassed, humiliated, or rejected, or offending others Fear of scrutiny by other people leading to avoidance of social situations More pervasive social phobias usually associated with low self-esteem / fear of criticism. They may present as a complaint of blushing. hand tremor. nausea. or urgency of micturition

21. Social anxiety disorder Epidemiology Lifetime prevalence rates 7% and 13%. More common in women than in men, with a ratio of about 3:2 Early age of onset, surfacing in either childhood or adolescence.

22. Social anxiety disorder Pathophysiology Interaction between an innately anxious and early negative social environments. Heritable, biological processes confer increased risk. Family, twin, and high-risk studies Sexual abuse before age 18 Emotional abuse and neglect in the childhood Adverse peer social experiences in school situations

23. Social anxiety disorder Neurobiology Disrupted modulation within central norepinephrine , serotonin, and dopamine systems.

24. Management of Patient with Phobias Education about the nature of anxiety, management of the fight and flight response, and common fears help by people who panic Graded exposure to feared situations or immediately confronting the most anxiety-provoking situation (flooding). Behavioral therapy is the treatment of choice for phobias. The treatment of choice for specific phobias is exposure, in vivo or using techniques of guided imagery, pairing relaxation exercises with exposure to the feared stimulus .

25. Cont... Systemic desensitization – The stimulus is presented in a progressively more anxiety – provoking form in graded hierarchy. Flooding (implosion) – Is a behavioral technique where the individual is maximally exposed to the fear stimulus, under supervision, until anxiety reduction and /or exhaustion occurs. Modelling - individual observers the therapist engaging in non – avoidant behaviour in relation to the phobic stimulus.

26. Cont... Cognitive behavioral therapy is the treatment of choice in treatment of agoraphobia disorder accompanied by panic disorder, social phobia. involves explanation, structures exercises for recognizing maladaptive thinking, exposure to simulated provoking anxiety situations, etc. Group therapy Relaxation training. Drug treatment – antidepressants (if indicated), and minor tranquilizers such as benzodiazepines, propranolol are effective in case of somatic symptoms.

27. Panic disorder Panic is a sudden overwhelming feeling of terror or impending doom This most severe form of emotional anxiety is usually accompanied by behavioral , cognitive, and physiological signs and symptoms considered to be outside the expected range of normalcy Panic disorder is characterized by recurrent panic attacks, the onset of which is unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort Is characterized by acute and unprovoked discrete periods of intense fear

28. The symptoms come on unexpectedly; that is, they do not occur immediately before or on exposure to a situation that usually causes anxiety (as in specific phobia) They are not triggered by situations in which the person is the focus of others’ attention (as in social anxiety disorder). The role of organic factors in the etiology has been ruled out. The patient is diagnosed with panic disorder when there are recurrent, unexpected episodes of panic attacks and there is at least 1 month of persistent concern, worry, or behavioral change associated with the attacks. Panic attacks may be expected or unexpected

29. Panic disorder (PD) Diagnosis Presence of recurrent panic attacks (at least some of which have been unexpected), At least 1 month of persistent worry about the possibility of future attacks. Development of situational avoidance ( physician visits due to fears of an undiagnosed medical condition)

30. D sm-5 criteria At least four of the following symptoms must be present to identify the presence of a panic attack. Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feelings of choking Chest pain or discomfort

31. Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Chills or heat sensations Paresthesias (numbness or tingling sensations) Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself) Fear of losing control or going crazy Fear of dying

32. Panic disorder (PD) Epidemiology Prevalence ranging from 3% to 8% Twice as many females as males Onset in late adolescence or early adulthood. Preexisting history of anxiety-related symptoms in childhood. Declining prevalence and severity in older adults The course of the disorder is chronic and unremitting

33. Panic disorder (PD) Impairment and Quality of Life Disruptions in work, social, and family function. Greater health-related problems (both physical and emotional). Excessive health care utilization, often for treatment of nonpsychiatric complaints .

34. Panic disorder (PD) Co-morbidity Social anxiety disorders General anxiety disorders Posttraumatic stress disorders Major depressive disorders Bipolar disorders.

35. Panic disorder (PD) Pathophysiology Complex interaction of biological, psychological, and environmental factors. Twin studies. First degree relatives. Stressful life events. Childhood physical and sexual abuse Negative life events Teenagers who smoke have increased risk.

36. Panic disorder (PD) Neurobiology Central neurotransmitter systems ( norepinephrine , serotonin, and γ- aminobutyric acid [GABA]) Role of noradrenergic mechanisms(locus coeruleus,LC ) (benzodiazepines and antidepressants) have been found to block LC firing .

37. M anagement Pharmacological treatment such as antidepressants and benzodiazepines The combination of an SSRI (paroxetine) and a benzodiazepine (alprazolam) Cognitive – behavioral therapy (involves initial education in the nature of panic attacks and fear). Cognitive restructuring to enable the individual to identify particular catastrophic interpretation and to take more adaptive cognitions in their place. For example looking to a mirror for a period to produce depersonalization Situational exposure and anxiety management techniques and skills such as muscle relaxation techniques (Relaxation therapy )

38. Interoceptive exposure involves strategically inducing the somatic symptoms associated with the threat appraisal and anxiety, and then encouraging the patient to maintain contact with the feared sensation without distraction.

39. G eneralized anxiety disorder Generalized anxiety disorder is characterized by chronic, unrealistic, and excessive anxiety and worry which is generalized and persistent and not restricted to a particular environmental circumstances This worry could be multifocal such as finance, family, health, and the future It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms Excessive worry is the central feature of generalized anxiety disorder

40. Generalized anxiety disorder T he individual experiences physical symptoms, including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance

41. Generalized anxiety disorder Clinical Characteristics and Diagnosis Anxious worry, tension and fears about everyday events and problems Persistent, excessive, and difficult to control worry and tension about a variety of events and activities in one’s daily life. - Financial matters. - Work/school. - Relationships. - Minor matters (e.g., punctuality or small household repairs), - One’s own health or the health/safety of loved ones, Community or world affairs.

42. Generalized anxiety disorder It must be associated with at least three of the following six psychological and somatic symptoms: Feeling keyed up, restless, or on edge. Fatigability. Irritability. Muscle tension. Impaired concentration Disrupted sleep

43. Clinical Features Feeling of threat Difficulty in concentrating or mind “going blank” Restlessness (Tense and unable to relax) Being easily fatigued Irritability Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) this includes Early insomnia and night mares Distractible

44. Cont... Noise intolerance Lability of mood Depersonalization Hallucinations Perceptual disturbances. Not triggered by situation Intense fear or discomfort.

45. Etiology The aetiology may include: Life events associated with fear of loss A physical condition such as diabetes or other comorbidities such as depression Genetic, first-degree relatives with generalized anxiety disorder (25%) Environmental factors, such as child abuse, early childhood separation Substance use disorder Biochemical changes: The serotonin system and the noradrenergic systems are common pathways Dysregulated neurochemical systems (GABA, norepinephrine, serotonin, and CRF).

46. Diagnostic criteria DSM-5 Excessive anxiety and worry for at least six months Difficulty controlling the worrying The anxiety is associated with three or more of the below symptoms for at least 6 months: Restlessness, feeling keyed up or on edge Being easily fatigued Difficulty in concentrating or mind going blank, irritability Muscle tension Sleep disturbance Irritability

47. The anxiety results in significant distress or impairment in social and occupational areas The anxiety is not attributable to any physical cause

48. M anagement Psychotherapeutic Pharmacotherapeutic Supportive approaches

49. Psychotherapy CBT Supportive Insight oriented

50. Management Cognitive therapy to enable patient to recognize and re examine his anxious thoughts Counseling and reassurance following investigations. Relaxation therapy Supportive psychotherapy Family and marital therapy to resolve interpersonal conflicts Drug treatment of diazepam for up to four weeks, in the longer term use antidepressant

51. Pharmacotherapy Benzodiazepines SSRIs e.g Setraline SNRIs duloxetine, venlafaxine, escitalopram, pregabalin (GAD), and quetiapine, venlafaxine, escitalopram, or sertraline Buspirone (GAD)

52. Treatment Others Imipramine Antihistamines. β-adrenergic antagonists (e.g., propranolol )

53. Evaluation A client who is experiencing a panic attack has just arrived at the emergency department. Which is the priority nursing intervention for this client? a. Stay with the client and reassure of safety. b. Administer a dose of diazepam c. Leave the client alone in a quiet room so that she can calm down d. Encourage the client to talk about what triggered the attack. Which of the following is the most appropriate therapy for a client with agoraphobia? a. 10 mg Valium qid b. Group therapy with other agoraphobics c. Facing her fear in gradual step progression d. Hypnosis

54. With implosion therapy, a client with phobic anxiety would be a. taught relaxation exercises. b. subjected to graded intensities of the fear. c. instructed to stop the therapeutic session as soon as anxiety is experienced. d. presented with massive exposure to a variety of stimuli associated with the phobic object/situation

55. R eferences Ströhle , A., Gensichen , J. and Domschke , K., 2018. The diagnosis and treatment of anxiety disorders.  Deutsches Ärzteblatt International ,  115 (37), p.611. Munir, S. and Takov , V., 2017. Generalized anxiety disorder. Townsend, M.C., 2013.  Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice . FA Davis. American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders . fifth ed. Burlington, VA: American Psychiatric Association; 2013. Muris , P. and Ollendick , T.H., 2015. Children who are anxious in silence: a review on selective mutism, the new anxiety disorder in DSM-5.  Clinical child and family psychology review ,  18 , pp.151-169.