Anxiety disorder....................pptx

Psychiatric nursing students in Ethiopia

1. Anxiety Disorders 5/23/2024 Takele T. 1 For 3 th year BSc. Midwifery students

2. ANXIETY DISORDERS Definition of Anxiety disorders Etiology of Anxiety disorders Epidemiology of Anxiety disorders Classifications of Anxiety disorders DSM Criteria of Anxiety disorders Management of Anxiety disorders 5/23/2024 Takele T. 2

3. Definition Anxiety disorder is: a vague, subjective, Non-specific feeling of uneasiness, tension, fears & irrational avoidance of objects or situations & anxiety attack. 5/23/2024 Takele T. 3

4. Fear versus Anxiety Fear is a response to a known, external, definite, or non conflict threat. anxiety is a response to a threat that is unknown, internal, vague, or conflict. Anxiety is universal and an integral part of human existence – everyone becomes anxious at sometime in life. 5/23/2024 Takele T. 4

5. Etiology Psychodynamic factors Unconscious conflict resulting from guilt, Shame, repressed wishes, drives, desires Biologic factors Genetic predisposition factors, GABA, Serotonin and other neurotransmitters Occipital lob pathology Basal ganglia problems Limbic system pathology 5/23/2024 Takele T. 5

6. Behavioral factors Anxiety is conditioned responses to Certain internal or environmental stimuli, learned behavior Environment factors Disaster, rape, assault, continual trauma, stressor can produce anxiety. 5/23/2024 Takele T. 6

7. EPIDEMIOLOGY 1% -5% of the total population is affected. Post- traumatic stress disorders may occur in 50%-80% of individuals after the experiences of trauma. 5/23/2024 Takele T. 7

8. CLASSIFICATION OF ANXIETY DISORDERS 1.Generalized Anxiety Disorder (GAD) 2. Panic disorder with or without Agoraphobia 3. Specific phobia 4. Social phobia 5/23/2024 Takele T. 8

9. 5. Obsessive-Compulsive Disorder (OCD) 6. Post Traumatic Stress Disorder (PTSD) & Acute Stress disorder (ASD) 7. Anxiety Disorder due to General Medical Condition (ADGMC) 8. Substance Induced Anxiety Disorder (SIAD) 5/23/2024 Takele T. 9

10. Generalized Anxiety Disorder (GAD) Epidemiological -generalized anxiety disorder occurs at a 2:3 male-to- female ratio.   The prevalence is approximately 5% of the general population, children often have more concrete worries, and they often worry about competences.   Etiology – may be genetic predisposition for an anxiety trait. 5/23/2024 Takele T. 10

11. DSM-V-TR Diagnostic Criteria for Generalized Anxiety Disorder A. Excessive anxiety and worry ,occurring more days for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. 5/23/2024 Takele T. 11

12. C. The anxiety and worry are associated with three (or more) of the following six symptoms Note : Only one item is required in children. 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 5/23/2024 Takele T. 12

13. 3. Difficulty concentrating or mind going blank/empty/ 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) 5/23/2024 Takele T. 13

14. D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder) E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5/23/2024 Takele T. 14

15. F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a General Medical Condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder. 5/23/2024 Takele T. 15

16. TREATMENT FOR GAD Antidepressants e.g. SSRIs Benzodiazepines Some form of behavioral psychotherapy e.g. Relaxation training. CBT 5/23/2024 Takele T. 16

17. Panic Disorder Is characterized by the spontaneous unexpected occurrence of panic attack, the attacks are relatively short lived (usually less than one hour) periods of intense anxiety or fear, which is accompanied by such somatic symptoms palpitation and tachypnea. 5/23/2024 Takele T. 17

18. Epidemiological This disorder occurs at a 1:3 female: male ration. The incident is about 5,6% of the population and there is a life prevalence of 2-6% Etiology Biological factor :- Autonomic nervous systems of some panic disorder patients The major neurotransmitter abnormalities (serotonin, nor epinephrine and  -amino- butyric acid (GABA). 5/23/2024 Takele T. 18

19. DSM-V-TR Criteria for Panic Attack A. A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: 1. Palpitations, pounding heart, or accelerated heart rate 2.Sweating 3. Trembling or shaking 5/23/2024 Takele T. 19

20. 4. Sensations of shortness of breath or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded, or faint 5/23/2024 Takele T. 20

21. 9. Derealization or depersonalization 10. Fear of losing control or going crazy 11. Fear of dying 12. Paresthesias (numbness or tingling sensations) 13. Chills or hot flushes 5/23/2024 Takele T. 21

22. Treatment: Pharmacotherapy: - SSRIs -TCAs -MAOIs -BDZ Psychotherapy: -Relaxation training for panic attack -Systemic desensitization for Agoraphobia 5/23/2024 Takele T. 22

23. PHOBIAS Definition:-Phobia is an irrational fear of objects or situations Can be divided in to: Specific phobias Social phobias Agoraphobia more common in women than men 5/23/2024 Takele T. 23

24. Specific phobias e.g. of specific phobias Heights Acrophobia Water Hydrophobia Enclosed places Claustrophobia Animals Zoophobia Death Thanatophobia Sex Gynophobia Women Gynophobia Pain Algophobia 5/23/2024 Takele T. 24

25. Specific phobia types in DSM-V-TR Specific phobia Epidemiology A specific phobia is an excessive or irrational fear of an objector situation and is usually associated with avoidance of the feared object. Spiders, bugs, mice, snakes, and heights are the most prevalent feared objects or situations 5/23/2024 Takele T. 25

26. Treatment: Behavioral therapy E.g. Systemic Desensitization Flooding-massive exposure to the feared object or situation 5/23/2024 Takele T. 26

27. Social Anxiety Disorder Epidemiology It is more common in women than in men (ratio about 3 to 2) . SAD has an early onset, peaking between ages 0 and 5 years, and again between ages 11 and 15 years; onset after age 25 years is rare. Behavioural inhibition, a personality style beginning in early childhood that involves a tendency to exhibit withdrawal and excessive autonomic arousal when presented with the unfamiliar,may be a precursor of SAD for some individuals. SAD is generally chronic, with a mean duration of 20 years or longer. 5/23/2024 Takele T. 27

28. Social Phobia DSM-V-TR Diagnostic Criteria for Social Phobia A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. 5/23/2024 Takele T. 28

29. B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. C. The person recognizes that the fear is excessive or unreasonable. D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress. 5/23/2024 Takele T. 29

30. E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, F. The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition 5/23/2024 Takele T. 30

31. Treatment Cognitive Behavioral Therapy (CBT) Β-blockers e.g. Propranolol SSRIs e.g. Sertraline, Fluoxetine BDZs 5/23/2024 Takele T. 31

32. Agoraphobia Agoraphobia consists of multiple and varied fears and avoidance behavior that center around three main themes: Fear of leaving home Fear of being alone and Fear of being away from home in situations where one can feel trapped or helplessness.   5/23/2024 Takele T. 32

33. According to DSM-V, the fear is one of developing; distressing symptoms in such situation where escape is difficult or help is unavailable. Typical agoraphobia fears are of using public transportation (buses, trains, subways (metro), planes, being in crowds, theaters , elevators, hotels, Supermarket , department of stores, waiting in line or traveling, a duration from home. 5/23/2024 Takele T. 33

34. The criteria have never been met for panic disorder The disturbance is not due to the direct physiological effects of substance (e.g. a drug abuse, medication) or general medication. If a general medical condition is present, the fear described in criteria “A” all is clearly in excess of the usually associated with the condition.   5/23/2024 Takele T. 34

35. Treatment: Behavioral therapy Systemic Desensitization Flooding-massive exposure to the feared object or situation 5/23/2024 Takele T. 35

36. Case study A 17-year-old girl blushes, stammers, and feels completely foolish when one of her classmates or a teacher asks her a question. She sits at the back of the class hoping not to be noticed because she is convinced that the other students think she is unattractive and stupid . 5/23/2024 Takele T. 36

37. 5/23/2024 Takele T. 37 Obsessive Compulsive Disorder (OCD)

38. Obsessive Compulsive Disorder (OCD) Obsessive compulsive disorder is recurrent thoughts & behaviors that are extremely distressing to individuals or that interfere with a normal life pattern. Obsession is persistent, intrusive thought, ideas, feelings, sensations or impulses that the person knows are irrational or senseless & that cause excessive anxiety. 5/23/2024 Takele T. 38

39. Example : contamination, doubt (worry about having something wrong). Compulsion is a conscious, standardized, repetitive, intentional behavior performed in stereotypical, routine way. Example : counting, checking, shouting or closing or avoiding ,washing Epidemiology - This disorder occurs at a 1:1male-female ratio. The prevalence is 2% of the general population 5/23/2024 Takele T. 39

40. 5/23/2024 Takele T. 40 Some example of OCD

41. DSM-V-TR Diagnostic Criteria for Obsessive-Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3) and (4): 1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 5/23/2024 Takele T. 41

42. 2. The thoughts, impulses, or images are not simply excessive worries about real-life problems 3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action 4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) 5/23/2024 Takele T. 42

43. Compulsions as defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly 5/23/2024 Takele T. 43

44. 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive 5/23/2024 Takele T. 44

45. Differential Diagnosis Psychotic symptoms …The keys to distinguishing OCD from psychosis are (1) patients with OCD can almost always acknowledge the unreasonable nature of their symptoms, and (2) psychotic illnesses are typically associated with a host of other features that are not characteristic of OCD. …Obsessive symptoms associated with depression are only found in the presence of a depressive episode, whereas true OCD persists despite remission of depression. 5/23/2024 Takele T. 45

46. Course and Prognosis More than half of patients with OCD have a sudden onset of symptoms. The onset of symptoms for about 50 to 70 percent of patients occurs after a stressful event, such as a pregnancy, a sexual problem, or the death of a relative. About one third of patients with OCD have major depressive disorder, and suicide is a risk for all patients with OCD. 5/23/2024 Takele T. 46

47. Course and Prognosis… About 20 to 30 percent of patients have significant improvement in their symptoms, and 40 to 50 percent have moderate improvement. The remaining 20 to 40 percent of patients either remain ill or their symptoms worsen . 5/23/2024 Takele T. 47

48. Psychotherapy Behavioral e.g. - relaxation training, -guided imaginary & exposure - Desensitization -thought stopping techniques Pharmacological: SSRIs e.g. fluoxetine TCA- Chlomipramine 5/23/2024 Takele T. 48

49. Post Traumatic Stress Disorder (PTSD) 5/23/2024 Takele T. 49

50. Post Traumatic Stress Disorder (PTSD) The defining feature of posttraumatic stress disorder is development of anxiety symptoms after an excessively distress life event that is experienced with terror, Fear, and helplessness. The event is serious. Example - Seeing a child killed (Involvement in a major:- earthquake, fire,Plane crash,war and rape) 5/23/2024 Takele T. 50

51. Epidemiology The lifetime incidence of PTSD is estimated to be 9 to 15 percent and the lifetime prevalence of PTSD is estimated to be about 8 percent of the general population The prevalence is much higher in areas where conflict has occurred, where it ranges from 16% to 37%(lifetime) Onset is generally in the mid to late 20s,and prevalence is higher among women than men. 5/23/2024 Takele T. 51

52. The World Health Organization’s Global Burden of Disease study predicted that exposure to traumatic events, such as motor vehicle accidents,war, and violence,will be the third, eighth, and twelfth leading causes of disability worldwide by the year 2020 The disorder is most likely to occur in those who are single, divorced, widowed, socially withdrawn, or of low socioeconomic level. 5/23/2024 Takele T. 52

53. Comorbidity Comorbidity rates are high among patients with PTSD, with about two thirds having at least two other disorders. Common comorbid conditions include depressive disorders, substance-related disorders, other anxiety disorders, and bipolar disorders. Comorbid disorders make persons more vulnerable to developing PTSD. 5/23/2024 Takele T. 53

54. Etiology 1.Stressor 2.Risk Factors Predisposing Vulnerability Factors in PTSD Presence of childhood trauma Inadequate family or peer support system Being female Genetic vulnerability to psychiatric illness Recent stressful life changes Recent excessive alcohol intake 5/23/2024 Takele T. 54

55. DSM-V-TR Diagnostic Criteria for Posttraumatic Stress Disorder A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others 2. The person's response involved intense fear, helplessness or horror. 5/23/2024 Takele T. 55

56. B. The traumatic event is persistently re-experienced in one (or more) of the following ways: 1. Recurrent distressing recollections of the event including images, thoughts or perceptions . 2. Recurrent distressing dreams of the event. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). 5/23/2024 Takele T. 56

57. 4. Markedly diminished interest or participation in significant activities 5. Feeling of detachment from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) 5/23/2024 Takele T. 57

58. C. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hyper vigilance 5. Exaggerated startle response 5/23/2024 Takele T. 58

59. D. Duration of the disturbance is more than 1 month. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5/23/2024 Takele T. 59

60. Treatment Psychotherapy :- Group psychotherapy with other survivors Pharmacotherapy :-SSRIs, BZDs 5/23/2024 Takele T. 60

61. Thank you! 5/23/2024 Takele T. 61

62. Quiz two 1. Two years after she was saved from her burning house, a 32-year old woman continues to be distressed by recurrent dreams and intrusive thoughts about the event. what the most likely diagnosis is? What the possible choice treatment? 5/23/2024 Takele T. 62

63. A woman washes her hands hundreds of times a day for fear of contamination. She cannot stop herself although her hands are raw and chafed. What the possible choice treatment? 5/23/2024 Takele T. 63

64. 3. A 23-year-old woman arrives at the emergency room complaining that, “out of the blue,” she had been seized by an overwhelming fear, associated with shortness of breath and a pounding heart. These symptoms lasted for approximately 20 minutes and, while she was experiencing them, she feared that she was dying or going crazy. The patient has had four similar episodes during the past month and she has been worrying that they will continue recurring. The most likely diagnosis is 5/23/2024 Takele T. 64

65. 4. For several months, a 32-year-old house wife has been unable to leave her house unaccompanied. When she tries to go out alone, she is overwhelmed by anxiety and fears that something terrible will happen to her and nobody will be there to help. The most likely diagnosis is 5/23/2024 Takele T. 65