Anxiety, Behavioural and Personality Disorders F40 –.pptx

Anxiety, Behavioural and Personality Disorders F40

1. Anxiety, Behavioural and Personality Disorders F40 – F48 ICD 10 Group of conditions that manifest with psychological and somatic symptoms that are associated neither with psychoses nor organic disorders.

2. AD

3. Presentation AD Problems controlling worries, they interfere with everyday life 1/20 in UK Most common form of mental illness

4. Presentation Symptoms vary on the type of anxiety disorder but include Panic Fear Uneasiness Uncontrollable obsessive thoughts Repeated thoughts or flashbacks of traumatic experiences Night mares

5. Presentation Ritualistic behaviours such as repeated hand washing Problem sleeping Cold and sweaty hands/ feet Shortness of breath Palpitations An inability to stay still and calm Dry mouth Numbness or tingling in hands or feet Nausea Muscle tremors dizziness

6. Presentation Compulsion Action such as to wash hands, orderly, cant see dirt, arranges things Obsession Thoughts i.e. germs on the hands make him wash hands always These activities impact on ones life . Day to day activities. These actions and thoughts take all the time and other activities , affecting them negatively.

7. What causes anxiety Stress Major cause or contributing factor to anxiety disorders Break down Depression Stress impacts directly on the cognitive process and hormonal process Being in grip with stress is the beginning of healing

8. stress

9. stress Chronic Continual exposure Cumulative effects Psychophysiological adaptation Relaxation response failure

10. stress Acute Immediate Physiological response Fight or flight Cortisol and catecholamine Direct experiences- RTA, Violence, sudden bereavement, witnessing, physical trauma, perceived emotional threat, potential redundancy

11. Responses Acute Autonomic nervous system arousal Involuntary regulation

12. Responses Activation of hypothalamic pituitary adrenal axis Release of glucocorticoids- cortisol and catecholamines - adrenaline , epinephrine, noradrenaline – adrenal cortex and medulla Effects- pupils dilate Inhibits salivary flow Increased HR RR Dilates bronchi Inhibits peristalsis Conversion glucagon to glucose Inhibits bladder contraction Cognition increases Pain sensation reduces

13. Responses Antagonist recovery system through V agus nerve Parasympathetic system Increase salivation Slows all other functions- return to normal

14. Response Chronic stress Prolonged exposure ensures loss of regulation, return to base rates repeatedly, fails Injury is sustained Adverse health behaviour sets in / smoking/drinking/ unpredictable emotional outbursts Poor performance Mood swings Cognition decline Inattention Indecision Physical health fails – hypertension, abdominal fat, comfort eating/ internal visceral fat increases Immune suppression

15. Treating stress Self help/religion/social support Therapies Psychodynamic/ psychoanalytic CBT Copping strategies Stressor modification Emotional response to stressor Self awareness Autogenic training Relaxation techniques Psycho pharmacology

16. Treating stress Pharmacotherapy B blockers – single dose propranolol improves cognition dysfunction Combination approach CBT SSRI- sertraline

17. Acute Stress Disorder DSM IV Trauma response within 30 days More than 3 dissociative symptoms must register Numbness Absence of emotional responses Detachment from surrounding Depersonalization Dissociative amnesia Marked avoidance and significant anxiety After 4 weeks Diagnosis changes PTSD

18. Anxiety D isorders Phobic anxiety disorders Agoraphobia/ market Social phobia Specific phobia Panic disorder Generalised Anxiety Disorder

19. Phobic Anxiety disorders Anxiety evoked only in certain well defined situations that are not currently dangerous Situations are avoided or endured with dread Physical symptoms must be paid attention to Palpitations Fainting Sweating vomiting Secondary fear of dying Losing control Going mad Anticipatory anxiety NB phobic anxiety and depression co exist

20. Aetiology Genetics Situational phobias more environmentally determined Behavioural learning theory- Pavlov- little albert and furry things Operant conditioning – Skinner- avoidance re informant behaviour Psychoanalytic theory- Sigmund Freud- emotional conflict concentrated on specific situations by displacement Preparedness theory- Selman- fear may be evolutionary adaptive Childhood parental death Dependant , emotionally immature or introvert premorbid personality Traumatic events Alcohol and drug use Collusion of family members

21. Epidemiology Lifetime prevalence Agoraphobia 15-30% Social phobia 13% Specific phobias 11% More common in females 2.5 :1

22. Agoraphobia Agora- market Fear leaving home Crowded places Entering shops Public places Travelling alone on trains, buses or planes Panic disorder is a frequent feature of both present and past experiences Depression and obsessional symptoms, social phobia commonly present as subsidiary features Avoidance of phobic situations

23. Social phobias Fear of scrutiny by other people Avoidance of social situations Low esteem Blushing, Hand tremors Nausea Urgency micturition May panic

24. Specific Phobia Restricted to highly specific situations Animals Heights Thunder Darkness Flying Closed spaces Urinating or defaecation in public places Eating certain foods

25. Specific phobia Prognosis Animal phobias do well Social phobic improve gradually Agoraphobia do worse/ tendency to chronicity/ especially comorbid or drug and alcohol use

26. Panic Disorder Several severe attacks in 1/12 No objective danger Not confined to predictable situations Epidemiology Prevalence 1-2 % 2 -3 x more common in females Age of onset is bimodal 15- 25 45-54

27. A etiology Genetic preponderance Fhx of agoraphobia , depression, suicide Increased concordance in monozygotic twins 95% of sufferers have genomic duplication on Chr 15 Childhood parental death Premorbid anxiety disorders Benign joint laxity- 15 x higher incidence Caffeine, sympathomimetic – the individuals tend to be sensitive to drugs Increased post synaptic response to serotonin/ adrenergic activity Decreased related GABA inhibitory response

28. prognosis Rx prognosis good 50- 60 % remit with medication 80-100% remit with CBT Less than 50% of all patients remain panic free, others can be managed because of tx at 20yrs follow-up Untreated may develop into other disorders- depression

29. GAD Generalised / persistent Free floating Complaints of persistent nervousness Trembling Muscle tension Sweating Light headedness Palpitations Dizziness Epigastric discomfort

30. Epidemiology Life time prevalence of 21% Female preponderance 2:1 Begins early adult life 15- 20 yrs. Increases with age especially after 35 years

31. Aetiology Genetics Social learning- anxious mums can learning to anxious children Premorbid anxious dependant personalities Early childhood separation Noradrenergic pathway dysfunction Current life stressors such as loss can precipitate symptoms

32. P rognosis Chronicity worse outcome Development of depression Alcohol use Agoraphobia All poor prognostic factors

33. Differential Diagnosis of Anxiety disorders Endocrine Hypothyroidism Hypoparathyroidism Hypoglycaemia Pheochromocytoma Carcinoid syndrome Cushing's syndrome CVS arrhythmias atypical chest pain mitral valve prolapse

34. DD RS COAD/ Haematological Anaemia Substances Stimulants Theophylline Alcohol withdrawal

35. OCD Recurrent obsessional thoughts/ ideation/ images/impulses that enter pts head again and again in a stereotype form Distressing/ pt tries to get rid but unsuccessful Own thoughts even though repugnant and involuntary Compulsions act as rituals/ stereotyped behaviours repeated again and again

36. OCD Not inherently enjoyable nor completion of intended tasks Prevent completion of objective tasks Pt recognizes the act Anxiety is invariably present If compulsive acts are resisted , anxiety gets worse

37. Types Predominantly obsessional thoughts or ramifications Predominantly compulsive acts Mixed Other obsessive / compulsive disorder

38. Clinical features Cleaning Handwashing Cant sit with people, has to do something Takes alcohol to calm down Cant sleep No suicidal tendencies

39. Epidemiology 2-3 % of general population Female preponderance 1.5:1 Males earlier onset 75 % onset in early twenties Can begin in childhood Course tends to be chronic

40. Aetiology Genetic preponderance Brain injury 5HT / dopamine abnormality Autoimmune aetiology( B haemolytic streptococcal infections) in children Premorbid anankastic personality Freudian anal stage fixation Magical thinking

41. PTSD Occurs following exposure to traumatic event Re-experience Reliving Avoidance Numbness Increased arousal Impairment and distress Acute 1-3 months Chronic beyond 3 months Lifetime exposure 10.4% Female. 5.0 % males

42. PTSD Co morbidity More than 50 % cases Major depression Panic disorder Other anxiety disorder Substance misuse Dissociation

43. management Trauma focused CBT (TFCBT) approaches Exposure CBT- deal with cognition, modification of misinterpretation, modification of beliefs, shame and guilt Non TFCBT approach Stress management Relaxation techniques Breathing techniques Positive thinking / self talk Assertive training Stress modulating training

44. management EMDR- eye movement desensitization reprocessing Standard tx Focused Several elements Use of bilateral physical stimuli

45. Pharmacotherapy SSRI antidepressants Paroxetine Sertraline Atypical antipsychotics Drug rating Paroxetine Mirtazapine Amitriptyline Phenylzine Olanzapine Risperidone Fluoxetine Venlafaxine Quetiapine Anti adrenergic- prazosin

46. DD Acute polymorphic psychotic disorder Hallucinations and delusions are present

47. DD Dissociative disorder Depersonalization Derealisation Syndrome also share some clinical features of an acute stress disorder Associated increased depression Anxiety Alcohol use 80% of PTSD have other psychiatry diagnoses

48. DD Dissociative Disorder 10% people have experienced significant stressor and go into PTSD Risk factors Female 2x Rape Fhx psychiatry disorders Hx traumatic experience in childhood .sexual/ physical/ separation of parents Low intelligence- personality traits / neuroticism

49. DD Dissociation Aetiology Fhx HPA axis dysfunction Brain structure/ reduced hippocampus Prolonged exposure to stressors Early childhood trauma EMDR is also considered during mgt CBT Social support Reduction of further trauma SSRIs SNRIs /venlafaxine

50. Principles of Management of Anxiety Disorders Acceptance and agreed explanation for the patient symptoms provide essential starting point on which to build further management plans Patient must understand pharmacological psychological and behavioural therapies Multifaceted approach The biological therapies would include Drug therapy/ pharmacological therapy Neurosurgery and transcranial magnetic stimulation

51. principles Psychological and behavioural therapies Behavioural therapies Cognitive behavioural therapies Psychoanalytical therapies Other psychotherapies

52. principles Social therapies Lifestyle , environmental, relationships, occupation etc.

53. Drug Therapies Benzodiazepines, Buspirone TCA SSRI SNRI Other anti depressants are the main stay of management NB atypical antipsychotic drugs have a positive role

54. Benzodiazepines Act immediately / rapidly Effective fro short term relief of AD symptoms, somatic symptoms However on higher doses sedation is the problem OCD is not affected by benzodiazepines They do not have anti depressant effects addiction Palpitations Tingling Sweating Difficult concentration irritability

55. Benzodiazepines Tremors Tinnitus Blurred vision formication Muscle twitching Epilepsy Paranoia Psychosis Anterograde amnesia Need restriction to maximum of 4 weeks to avoid dependence.

56. Classes of drugs Sedative hypnotics Benzodiazepines Barbiturates Propanediols/di ethyl ether Miscellaneous MOA – facilitation of GABA transaminase

57. Antiepileptics Progabalin Antagonist at α 2- delta calcium channel blockers

58. Azospirodecanediones Buspirone Partial agonist of 5HT1A receptors

59. B blockers Propranolol Atenolol Peripheral B blockade

60. Antihistamines Promethazine Chlorpheniramine Histamine receptor blockade

61. TCA Amitriptyline Clomipramine Lofepramine dothiepine

62. MAO Phenelzine moclobamide

63. SSRIs- selective serotonin reuptake inhibitors Citalopram Escitalopram Fluoxetine Paroxetine Sertraline MOA- down regulation in Noradrenaline and 5 HT receptor Short term relief sedatives

64. SNSRI Venlafaxine duloxetine

65. Buspirone Partial agonist at 5HT1A receptors and reduces 5HT2A neurotransmission Azospirodecanendione No dependence Indication is short to medium term mgt Useful in AD Adverse Dysphoria Makes people feel bad Dizziness Hyperprolactinaemia B blocking Antihistamine Used for blocking for blocking autonomic and somatic arousal HR increase awareness Flushing Tremors No sedation

66. A ntipsychotics chlorpromazine but useful 1950 discovery Second generation Risperidone quetiapine olanzapine especially non response to or partial to SSRIs Adverse tardive dyskinesia induction of DM cardiac effects

67. psychotherapy Behavioural Persuasion to change Overcome tendency to avoid Exposure Expose self to feared stimuli gradually, Deconditioning of that maladaptive behaviour pattern( desensitization) Cognitive Replacement of bad thoughts, to be thinking about situations/ awareness/ replacement of thoughts with realistic ones Anxiety mgt and relaxation Relaxation training ,controlled breathing , muscle relaxation, positive imagery Hypnotherapy Talking to patients in a commanding voice/ inducing sleep in some cases/ distribution of energy (mesmerisation) Combined pharmacological and psychotherapy CBT/ Drugs combined