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SALCEDO, Alesa Maureen M.

Med 3B
ANXIETY
Emotional state in which person feels uneasy,
apprehensive, or fearful. Usually experiences
of anxiety occurs in events they cannot control
or predict, or about events that seem
threatening or dangerous.

There is a feeling of vulnerability and severe


anxiety can persist and become disabling
Epidemiology
Anxiety disorders are
highly prevalent; rates
of illness are common
women are more like
to have anxiety
disorder like social
phobia than men,
however men are
twice likely to seek
treatment
NEUROBIOLOGY
Conditioned fear in animals depends on normal
function of central nucleus of the amygdala (CNA)
studies show that sodium lactate infusion can induce
panic attacks in patients with panic disorder
Substances with panicogenic properties
Noradrenergic stimuli yohimbine
Carbon dioxide
Cholecystokinin

Conditions appear to be caused by both genetic


predisposition and traumatic separation distress
Psychodynamic Aspects
Gabbard shows development of Freuds
theory, pointed out that panic attacks are not
entirely out of the blue phenomena but are
likely to be related to meaningful stressors in
the patients life

childhood precursor to panic disorder, and


showed that early separation distress in
infants produces an anxiety prone adult
ANXIETY DISORDERS
EPIDEMIOLOGY
DSM-III and DSM-III-R of Donald Kleins
conceptualization of panic disorder as a separate
entity, have anxiety states begun to be subdivided
into distinct entities such as panic disorder with or
without agoraphobia, social phobia, post
traumatic disorder, obsessive-compulsive disorder
and generalized anxiety disorder.

found out that anxiety states were fairly common


and more prevalent in women, particularly
between 16 to 40 years old
PANIC DISORDER
In DSM-IV criteria require recurrent unexpected
panic attacks and persistent concern about
having further attacks, worry about the
implication of attacks, or a significant change in
behavior because of the attacks.
AGORAPHOBIA
a fear and avoidance of being in places or
situations from which escape might be
difficult or in which help might not be available
in the event of sudden incapacitation

result of such fears, the person avoids travel


outside the home and require company when
away from home.
AGORAPHOBIA
DSM-III-R redefined it as condition
accompanying panic disorder or panic like
symptoms

DSM-IV further emphasizes that agoraphobia


occurs specifically in response to the fear of
developing panic like symptoms.
AGORAPHOBIA
Moderate cases
may cause some
lifestyle
constriction
Severe cases may
result in person
being completely
housebound or
unable to leave
home without
company
SOCIAL PHOBIA
DSM-III social phobia is a persistent, irrational fear
accompanied by a compelling desire to avoid
situations in which a person might act in a humiliating
or embarrassing way while under the scrutiny of
others
DSM-III-R allowed the phobic situations to be avoided
or endured with intense anxiety and required that the
avoidant behavior interfered with occupational or
social functioning or that there was marked distress
about having the fear
DSM-IV adds that the person recognizes the fear as
excessive or unreasonable.
SOCIAL PHOBIA
Common social phobias involve fear in
speaking or eating in public, urinating
in public toilets, writing in front of
others or saying foolish things in social
situations.
Risk Factors: occur more commonly in
women who are young (18-29 years
old), less educated, single, living with
their parents, students and of lower
socioeconomic class
OBSESSIVE-COMPULSIVE
DISORDER
Obsessions are defined as recurrent, persistent
thoughts, images or impulses that are
experienced as intrusive and inappropriate

Compulsions are repetitive behavior (eg.


Checking locked doors or gas jets, hand
washing) or mental acts (eg. Counting,
repeating words) s0 that the person feels
driven to perform in response to an obsession or
according to rigid rules
OBSESSIVE-COMPULSIVE
DISORDER
DSM-III defines it as presence of obsessions or
compulsions that are sources of significant
distress or impairment and are not due to
another mental disorder
DSM-III-R required that obsessions or
compulsions caused marked distress,
consume more than 1 hour a day or
significantly interfere with the persons
normal routine or occupational or social
functioning
OBSESSIVE-COMPULSIVE
DISORDER
DSM-IV added a
requirement that
the person
recognizes that the
obsessions or
compulsions are
excessive or
unreasonable.
POST TRAUMATIC STRESS
DISORDER
DSM-III defines it as constellation of symptoms in response
to a stressor, including reexperiencing a traumatic event,
numbed responsiveness and symptoms of an increased level
of arousal
DSM-III-R defined it as symptoms must persist for at least 1
month and the criteria are broadened by adding intense
psychological distress in response to events that symbolize
or resemble an aspect of the trauma and avoidance of
stimuli associated with the event
DSM-IV adds the requirement for functional impairment or
clinically significant distress
Risk Factors & Comorbidity
Men and women differ in types of trauma to
which they are likely to be exposed and in their
liability to develop post traumatic stress
disorder once exposed.

significantly higher in women than in men


since women are more likely to be exposed to
high impact traumas, or traumas that are
associated with developing post traumatic
stress
GENERALIZED ANXIETY
DISORDER
DSM-III criteria require the
presence of unrealistic or
excessive anxiety or worry
accompanied by symptoms
from three of four categories:

1. motor tension,
2. autonomic hyperactivity,
3. vigilance and scanning and
4. apprehensive expectation

The anxious mood must


continue for at least a month
GENERALIZED ANXIETY
DISORDER
DSM-III-R requiring a minimum of six
symptoms and duration of 6 months

DSM-IV requires only 3 symptoms from a list of


6 but adds the requirement that the anxiety
causes clinically significant distress or
functional impairment.
SOMATIC TREATMENT
Recently, most anti anxiety medications were
developed empirically

Benzodiazipines remain one of the most often


prescribed drugs for anxiety
TREATMENT
Drugs with primary effects on serotonin
neurotransmission first line
recommendations for panic disorder, social
phobia, obsessive compulsive disorder and
post traumatic stress disorder
Treatment Challenges
Known sensitivity to even relatively minor side effects;
anxious patients have fear of physical sensations,
adverse effects are viewed catastrophically
Start at lowest dose with a slow titration to a fully
therapeutic dose
COGNITIVE BEHAVIORAL
APPROACH
Type of therapy is effective for panic disorders
and response rate is comparable to that
achieved with benzodiazipines
Anxiety Disorders:
Biochemical Aspects
PALMARIO, KATRINA MARIJYKE
PATRICIA B.
Amygdala
Major mediator of stress response, fear, and
possibly anxiety
Lesions to the amygdala attenuated fear
and emotional responsiveness
Direct stimulation fear-like behavior and
autonomic arousal
Electrical stimulation symptoms of anxiety
(fear, anxiety, depersonalization)
Corticotropin Releasing Factor
Produces physiological changes similar to
changes seen upon stimulation of the
amygdala
Also produces range of behaviors analogous to
components of human anxiety and affective
disorders (anorexia, insomnia, decreased
libido)
Serotonin Pathway
Involves post synaptic serotonin receptor
activation anticipatory anxiety
Facilitating active escape or avoidance
behaviors in response to distal threat
PANIC DISORDER
Hallmark: Panic attacks unexpected rapidly
progressive bursts of anxiety accompanied by
an array of cognitive and autonomic
symptoms (fear, palpitations, hyperventilation,
lightheadedness, sweating)
Intensity of symptoms peak in 10mins
Time course of 5-30 mins
PANIC DISORDER: PANICOGENIC AND
ANXIOGENIC CHALLENGE STUDIES
SODIUM LACTATE provokes acute panic
attacks in two thirds of panic disorder patients
Lactate infusion and CO2 inhalation
precipitate panic attacks by increasing the
partial pressure of CO2 in the CNS
D-lactate panicogenic in panic disorder
patients by causing alkalosis which activates
the panic pathway
Hypothalamic Pituitary
Respiratory Panicogens Adrenal Activating Anxiogens
Sodium lactate Yohimbine
CO2 M-chlorophenylpiperazine
Sodium bicarbonate Fenfluramine
Isoproterenol B-carboline
Doxapram
PANIC DISORDER
Noradrenergic System Serotonergic System
Clonidine administration Serotonin agonists increase
blunted GH response, less rates of anxiety in panic
sedation, greater disorder patients
hypotension, decreased May be due to postsynaptic
MHPG serotonin hypersensitivity in
Yohimbine elicits high panic disorder
rates of panic like anxiety
with increasing MHPG
concentration
GABAergic System
BZDs effective in blocking panic attacks
Attenuation of local inhibitory GABAergic
transmission in the basolateral amygdala,
midbrain central gray or dorsomedial
hypothalamus can elicit anxiety-like
physiological and behavioral responses
CRF and HPA Axis
Clonidine greater decrease in cortisol in
panic disorder px than in controls
GENERALIZED ANXIETY DISORDER
Characterized by excessive and uncontrollable
anxiety or worry persisting for at least 6 months
combined with 3 of 6 additional symptoms:
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating of mind going blank
Irritability
Muscle tension
Sleep disturbance
GAD: PANICOGENIC AND ANXIOGENIC
STUDIES
Sodium lactate and CO2 panic in a much
lower rate in response to challenge in GAD
patients than in Panic Disorder patients but
have higher rates of panic, subjective anxiety,
or somatic symptoms than normal controls
CCK analogue Pentagrastrin higher rate of
panic attacks in GAD patients than in controls
Autonomic, Noradrenergic,
Neuroendocrine Systems
GAD patients do not differ from controls with any
consistency in baseline blood pressure, heart rate,
respiration, or skin conductance
Evidence of hyporeactivity to stress challenge
Clonidine blunted GH response but without
difference in blood pressure, heart rate or MHPG
concentrations
Dexamethasone nonsuppression in GAD patients
Serotonergic system
mCPP greater rates of anxiety and anger in GAD
patients than in controls
SOCIAL PHOBIA
Characterized by fear of social or performance
situations involving exposure to unfamiliar
people or possible scrutiny by others
combined with fear of acting in a way that
will be humiliating or embarrassing
CHALLENGE STUDIES
Greater increase in heart rate in patients with
public speaking phobia than in patients with
generalized social phobia
increased BP response to Valsalvas manuever
and exaggerated vagal withdrawal in response
to isometric exercise
Greater pressor effect of TRH
Pentagastrin induces panic attacks in social
phobia at a high rate
Serotonergic System
Fenfluramine challenge no difference in
prolactin response
Significantly greater rise in cortisol
concentration
SPECIFIC PHOBIA
Characterized by a marked and persistent
fear that is excessive or unreasonable and is
brought on by the presence or anticipation of
a specific object or situation
Prominent vasovagal response can be
observed
POST TRAUMATIC STRESS DISORDER
Defined as a disorder in which a person has
been exposed to a traumatic event/s that
included actual or threatened death or
serious injury, or threat to the physical
integrity of self or others and the persons
response involved intense fear, helplessness
or horror
POST TRAUMATIC STRESS DISORDER
Sequelae:
More than 1 month of persistent reexperienceing
in thoughts, images, and dreams
Behaving or feeling the event is recurring
Intense psychological or physiological reactivity to
cues that are reminders of the event
Avoidance of stimuli associated with the trauma
Numbing of general responsivity
Symptoms of increased arousal
PANICOGENIC CHALLENGE
Sodium lactate-induced flashbacks with panic
attacks in combat veterans
Lower cortisol and higher epinephrine
concentrations at end of infusion than those
in panic disorder patients and control
Noradrenergic System
Soldiers with PTSD-like sypmtoms diagnosed with
shell-shock or irritable heart
Epinephrine challenge done in soldiers with
irritable heart manifested nervousness with
signs of autonomic arousal
Yohimbine administration elicited panic
attacks, flashbacks
PET after yohimbine admin dec activity in
prefrontal, orbitofrontal, temporal and parietal
regions
Serotonergic System
Panic rate with mCPP < panic rate with
yohimbine admin
Flashbacks demonstrated with mCPP
Panic attack seen in yohimbine or mCPP
admin but NOT BOTH
Opioid System
Reduced plasma b-endorphin
Chronic PTSD reduced pain threshold

Dopaminergic System
Increased concentrations of dopamine plasma
and urine
CRF and PTA Axis
Low plasma and urinary free cortisol
concentrations in PTSD patients
Exogenous CRF blunted ACTH response but
normal cortisol response vs those of controls
Cortisol suppression with low dose
dexamethasone enhanced in PTSD
CRF concentrations in CSF higher in PTSD
patients
Hypothalamic Pituitary Thyroid
Axis
Higher T3 levels
High rate of blunted TSH response to TRH
stimulation
OBSESSIVE COMPULSIVE DISORDER
Characterized by repetitive thoughts,
impulses, or images that are intrusive and
inappropriate and cause anxiety or distress, or
repetitive behaviors that the person feels
driven to perform in response to an obsession
or rigid rules that must be applied
Noradrenergic System
Clonidine admin decreased severity of OCD
symptoms
Neuroendocrine System
Increased CSF oxytocin correlated with
severity of OCD
Higher somatostatin levels in CSF of OCD
patients
Cytokine IL-6 correlates with severity of
compulsive symptoms
Neuroimmunology
Possible link between strep infection and OCD
Anxiety Disorders:
Genetics
Twin, adoption and DNA marker studies can
provide definite evidence of genetic
contribution
Heritability proportion of the liability for a
disorder that is estimated to be due to genetic
factors
PANIC DISORDER AND AGORAPHOBIA
Best studied anxiety disorder with respect to
intergenerational transmission
Heritability estimates 0.3-0.6 percent; mode
of transmission unknown
Twin + Family Studies
Four twin studies 3 have greater concordance for MZ twin
pairs than DZ twin pairs

Direct interview family studies of panic disorder indicate


that panic disorder is highly familial
Study using family history method panic disorder px with
at least one reported relative with panic disorder had an
earlier onset than patients without affected relatives
Carbon dioxide sensitivity may be a familially transmitted
marker of inherited susceptibility to panic disorder
Panic disorder with agoraphobia may be a more severe
form of panic disorder
DNA Marker Studies
No data indicating association between
chromosomal location, mode of transmission
and the disorder
Twin and family data panic disorder DOES
NOT follow a Mendelian mode of transmission
GENERALIZED ANXIETY DISORDER:
Twin + Family Studies
Six twin studies suggest moderate genetic
contribution to this disorder
GAD was found to be moderately heritable
(0.4-0.5)

No evidence of shared familial diathesis


between GAD and either panic disorder or
major depressive disorder
SOCIAL PHOBIA: Twin and Family
Studies
Rates of social phobia but not of anxiety
disorders were disorders significantly elevated
in the relatives of social phobia compared to
relatives of other groups
Relatives of social phobia almost 3-fold
increased risk for social phobia compared to
relatives of controls
Childhood Temperamants Related to
Social Behavior
Moderate genetic contribution to irrational
social fears and shyness

Twin Studies of Irrational Social Fears


Behavioral inhibition and shyness
Higher rates of social phobia were found in
the parents of behaviorally inhibited versus
behaviorally uninhibited children versus
controls
SPECIFIC PHOBIAS: FAMILY STUDIES
Greater risk for phobic disorders among
relatives of phobia patients as compared to
the relatives of controls
Animal Models
Conditioning: process by which the animal
acquires fear of a previously neutral stimulus
through its repeated association with a
noxious stimulus
It is possible to breed strains of animals who are
more or less fearful of specific stimuli
There is genetic variability between strains in the
strength and persistence of conditioned fear
OBSESSIVE-COMPULSIVE DISORDER
Inconclusive data on heritability
Some cases of OCD may be associated with
specific autoimmune, receptor, or
neuroanatomical abnormalities
Some cases of OCD have heritable
contribution whereas others do not
OCD and TOURETTES DISORDER
There is a familial and genetic relationship
between the two
Most family studies of patients with OCD have
found elevated rates of Tourettes disorder
and chronic motor tics only among the
relatives of probands with OCD who also have
some form of tic disorder
POST TRAUMATIC STRESS DISORDER
Independent genetic factors influence
exposure to combat and development of PTSD
symptoms in twin and family studies of
subjects from Vietnam era veterans registry
SUMMARY
Genetic factors play an impt role in the devt of
anxiety disorders
Moderate heritability thus nongenetic
factors are equally crucial
Patterns of intergenerational transmission do
not follow Mendelian rules
MILLARE, GENINA ANDREA Y.
Placed anxiety at the core
of neurosis
Original theory (1895):
Biological cause
Accumulation of
undischarged libido
anxiety
Actual neurosis
Abandoned original theory
(1926):
Biological cause
Emphasis on how to
understand the role of
anxiety in the individuals
mental life
Traumatic situations central to the devt of
anxiety
Prototype: experience of birth
Stimuli arising from the id
Danger situations
Learn to anticipate a traumatic situation before it
happens and to react to it with anxiety (signal anxiety)
Pleasure principle was intimately related to the function
of the anxiety
Signal anxiety is a way of attenuating a more profound
and terrifying anxiety
Signal of danger produced by the ego offers
opposition to the emergence of repressed id
impulses into conscious awareness
Defense mechanisms are marshaled
Repression: keeps undesirable id impulses
whether desires, whish-fulfilling fantasies,
memories or affect from entering the
consciousness
Reaction formation: overemphasis on one side of
an ambivalent attitude
Melanie Klein expanded
on Freuds view
Developed a theory of
internal object relations
linked to drives
Fear of annihilation
most fundamental
anxiety and related it to
Freuds death instinct
All the derivatives of the death instinct were
evacuated from the infant and projected into the
mother
Persecutory anxiety: linked to the paranoid-schizoid
position, involved a fear that the bad other created
by the infants projections would invade the infant and
destroy all the good aspects of the infant
Paranoid-schizoid position depressive position
Integrative effort that was designed to link good and bad
aspects
Child is now able to see that mother has both good
and bad qualities
Becomes concerned that it may have harmed
or destroyed its mother through its hostile
and sadistic fantasies directed toward he
depressive anxiety
Worries that the good object may be lost through
the childs own aggression and sadism
Depressive anxiety can be summarized as a
concern about the loss of the love object
through ones own destructiveness
Heinz Kohut, 1960s
Deemphasized drives
and conflicts
Emphasis is on infantile
needs rather than
repressed wishes or
drives
Child has powerful needs
To idealize a parent
To receive affirmation
validation and empathy
form that parent
To maintain a sense of
wholeness of the self
Disintegration anxiety most fundamental
concerning of the individual
If empathy affirmation and validation are not
forthcoming form significant individuals, the
child may then resort to pathological
behavior to restore harmony to the self
In adult life these behaviors manifest itself in
acting-out behaviors such as gambling,
substance abuse, etc.
Highest level of developmental danger is that of guilt
Presence of superego anxiety reflects that moral
standards of conduct have been internalized in the form of
parental introjects
Potential damage to or loss of the genitals
Fear is often expressed metaphorically as a loss of a
different body part or any other form of physical injury
Loss of parental love
Even though the parent is present physically, the child
may still fear the loss of that objects love
Behave in a manner that ensures a significant objects
ongoing love and attention to fend off the anxiety that the
object may become disappointed with the patient
Next three points in the hierarchy are often
found as the predominant anxiety in more
severely disturbed patients
Separation anxiety fear of abandonment by the
love object is typical of patients with borderline
personality disorder
Persecutory anxiety use projection as a defense
Disintegration anxiety fear of fragmentation or
through merger or fusion with an object
Most primitive levels of anxiety persist in
everyone
Three separate categories have replaced the neuroses:
Dissociative disorders
Somatoform disorders
Anxiety disorders
Panic disorder
Phobias
Obsessive-compulsive disorder
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Growing empirical evidence linking biological mechanisms
to the generation of anxiety
Encourage clinicians to think about anxiety as only an
illness rather than an overdetermined symptom of
unconscious conflict
Generally experience a
good deal of distress
during the few minutes
that the typical panic
attack lasts
Gasping for breath
Shaking uncontrollably
Feeling lightheaded
Sweating profusely
Feeling certain that
death is imminent
Intensely afraid of being stuck in a situation from
which they cannot escape
Develop anticipatory anxiety secondarily because
they are worried most of the time about when and
where the next panic attack will strike them
Experience the attacks as if they came out of
the blue
Stressors were connected with an alteration of
or decrease in the level of expectations place on
the patient
Often related to job situations in which patients had
to take on increased responsibilities
Analysis of interviews suggested a pattern of
childhood difficulties
Most of the patients described feelings of self-
reproach and inadequacy
Report higher rates of dysfunctional parenting and
more intense separating anxiety in childhood
Strongly and significantly associated with both parental
separation and death
Early maternal separation
Predisposing neuropsychological vulnerability that
may interact with certain kinds of environmental
stressors panic attack
Tendency to be easily
frightened by anything
unfamiliar in the
environment
Rely on their parents to
protect them afraid that
their parents will not be there
to protect and comfort them
Vicious cycle results where
the childs anger threatens
the connection with the
parent and thus increases
the childs hostile and
fearful dependence.
Some form of attachment difficulty appears to be
involved in the pathogenesis of panic disorder
Fearful individuals tend to view separation and
attachment as mutually exclusive
Difficulty developing the normal oscillation between
separating and attachment because they have a
heightened sensitivity to both loss of safety or protection
and loss of freedom
Signal anxiety function is insufficient to deal with anxiety
overwhelming and uncontrollable level of panic
Another etiological factor in women patients appears
to be childhood physical and sexual abuse
Higher in persons with anxiety disorder when compared to
a control group
Examination of characteristic defense
mechanisms
Typically use any combination of the following
defenses:
Reaction formation
Undoing
Somatization
Externalization
Help the patient view the panic as an internally
generated phenomenon rather than to blame
others for it
Most common of all anxiety
disorders
Subdivided into three
categories:
Agoraphobia without history of
panic disorder
Specific phobia
Social phobia (most common
type)
Nongeneralized type
Generalized type
Unacceptable aggressive or
sexual thought fantasy of
punishment begin to emerge
from the unconscious
Signal anxiety is produced specific ego
defense mechanisms
Displacement: involves the redirection of anxiety
associated with an unconscious source to a conscious
substitute that is often intrinsically harmless
Projection: used to get the source outside of
themselves and into the external world
Avoidance: not coming into contact with the displaced
and projected item that the anxiety is associated with
Result combined
defenses may eliminate
the anxiety because the
unacceptable or
forbidden though is re-
repressed
Anxiety generated by
the thought is controlled
at the cost of creating a
phobic neurosis with all
its associated
inconvenience.
Embarrassment and shame are central affects
As the patient begins to feel embarrassed, the therapist
encourages exploration of the patients fantasies of how others
will react to him or her
Find a characteristic pattern of internal object relationships within the
patient that is then externalized in any social situation
Family members may encourage phobic behavior and serve as
obstacles to any treatment plan
Self-exposure to the feared situation is a basic principle of all
treatment
Distinctly different from obsessive-compulsive personality
disorder
View their symptoms ego-dystonically experience distress
connected with their symptoms and are notoriously refractory
to psychodynamic treatment
Anxiety produced by fear of retaliation associated with the
oedipal situation regress to a more primitive
psychosexual developmental stage (anal phase)
Certain characteristic defense mechanisms were
associated with the anal phase:
Reaction formation
Doing and undoing
Isolation of affect
Regression was more likely
because of the long
standing presence of anal
fixations related to
disturbances during toilet
training
Behavior therapy
successful in reducing the
symptoms of OCD
Treatment of choice:
combination of a selective
serotonin reuptake
inhibitor (SSRI) and
behavior therapy
Not usually indicated as the exclusive treatment for
OCD, but in patients who tenaciously hang on to their
symptoms because of their special meaning or
because of the interpersonal control they exercise
over others, a psychodynamic approach may be
extremely useful
Mean reduction of symptoms of OCD when treated
with pharmacotherapy is in the range of 38-40%
Variety of problems persist despite the partial efficacy of
medications area of personal relationships
A high risk of separation or divorce has been linked to OCD
88.2% of parents or spouses report accommodating the
patient through active participation in rituals or
significant modifications of their daily routines
Describe feeling bullied by the patient into doing things to
accommodate the patients obsessions or compulsions.

Helpful in understanding
the meaning of
psychosocial triggers that
exacerbate these
symptoms, which almost
always have interpersonal
meanings that must be
addressed
Freud postulated response to
overwhelming assault on the
individuals stimulus barrier
regression
Suggested that external trauma
reawakened infantile trauma
Abraham Kardiner and Herbert
Spiegel
Suggested that the external
factors related to the trauma were
most decisive
Preexisting conflict might be
symbolically reawakened by the
traumatic event
As the intensity of a violent
event increase, so does the
number of individuals
traumatized by that event
Certain types of events appear to be more likely to create
traumatic reactions in victims than others
More likely to develop the disorder have
History of early separation from parents
Family history of anxiety and neuroticism
Preexisting depression or anxiety
Personal predisposition is necessary to develop PTSD in
the face of trauma
Result from psychic trauma revolve around three different
symptom clusters:
Intrusive and repetitive re-experiencing of the trauma
Avoidance of this re-experiencing
Overactivation of the autonomic nervous system: sleep
difficulties, hypervigilance, startle reactions, and difficult
concentrating
Other patients adapt to psychic trauma
shutting down any affective development
cannot use affects as signals
Powerful feelings are viewed as a threat use
somatization as a defense but do so at a cost
They cannot soothe themselves or relax
Often deficient in self-care
Trauma shatters the individuals view of the
world as a place that is safe, predictable, and
controllable
Forces a confrontation with ones own vulnerability
Many defenses are marshaled by the ego
(primitive or immature) regression to a
developmentally earlier modes of dealing with
helplessness, vulnerability, fear, and anger
Use denial to avoid facing the severity of the
trauma or the extent of distress
Sense of rage at being victimized may be
disavowed and projected into others
Become hypervigilant in an effort to protect
themselves from the aggression they perceive in
others
Guilt (ex: rape victims)
feel responsible for
what happened to
them
Beneath this guilt and
responsibility feel
completely helpless in
a malevolent universe
where violence is
random
Treatment goals of dynamic psychotherapy
Reducing anxiety
Integrating and accepting the trauma as apart of the self
Regaining a sense of mastery
Re-establishing a sense of personal integrity
Moving away from a sense of being haunted by the past
toward feeling fully engaged in the present
Involves striking a balance between
Forcing the patient to reconstruct a complete picture of
the trauma
Assuming an observing, detached posture that allows
much information to be left out
Relatively new diagnostic entity
Shares many of the symptoms of PTSD but occurs
within 4 weeks of the traumatic event
PTSD has its onset at least one month after the trauma
Many of the same principles involved in the
psychodynamic treatment of PTSD apply to acute
stress disorder as well
Individual who has experienced the trauma must be
helped to integrate and process it so that some
mastery is gained over the experience
Specific work on grief and loss may be extremely
beneficial to patients who have experience an
overwhelming trauma.
Recognized as a disorder in
1987
Associated with the highest
rate of comorbidity of any of
the other anxiety disorders
Additions of specific somatic
symptoms fairly high
degree of construct validity
Chronic worriers
Lifetime prevalence of
generalized anxiety disorder
is thought to range from 4.1-
6.6%
Tends to be chronic
significant amount of
disability and impairment in
the quality of life
Begun to identify specific interpersonal issues
and traumatic events connected to the
diagnosis of generalized anxiety disorder
Affected patients also tend to avoid thinking
about the past events they consider
traumatic
Worrying appears to distract these patients
with superficial matters prevent them
from worrying about more disturbing
underlying concerns
Characteristic defensive pattern of avoidance
Linked to an insecure on conflicted attachment
in childhood
Focus a great deal on symptoms, especially
those related to the body
Therapist should encourage the patient to think
in broader terms and to include broader patterns
of adaptation to work and to love relationships
When attention is drawn away from the somatic
focus of worrying, patient often feel that they
have renewed energy to devote to the true
underlying conflicts
Anxiety Disorders
Clinical Features
Outline
I. Panic Disorder and Agoraphobia
II. Specific and Social Phobias
III. Obsessive-Compulsive Disorder
IV. Posttraumatic Stress and Acute Stress
Disorders
V. Generalized Anxiety Disorder
VI. Substance-Induced Anxiety and Anxiety Due to
a General Medical Condition
VII. Anxiety Disorder not otherwise Specified
Panic Disorder and Agoraphobia
DSM IV
Panic attack
Episode of abrupt
intense fear that is
accompanied by
atleast 4 autonomic
or cognitive
symptoms
Panic Disorder and Agoraphobia
ICD 10
Panic Disorder and Agoraphobia
3 types:
i. Spontaneous panic attack occurs without cue
or warning
ii. Situationally bound panic attacks upon
exposure to
iii. In anticipation of
Panic Disorder and Agoraphobia
Ms. S. was a 25-year-old student who was referred for a psychiatric
evaluation from the medical emergency room at a larger university-based
medical center. Ms. S. had been evaluated three times over the preceding 3
weeks in this emergency room. Her first visit was prompted by a paroxysm
of extreme dyspnea and terror that occurred while she was working on a
term paper. The dyspnea was accompanied by palpitations, choking
sensations, sweating, shakiness, and a strong urge to flee. Ms. S. thought
that she was having a heart attack, and she immediately went to the
emergency room. She received a full medical evaluation, including an
electrocardiogram (ECG) and routine blood work, which revealed no sign of
cardiovascular, pulmonary, or other illness. Although Ms. S. was given the
number of a local psychiatrist, she did not make a follow-up appointment,
since she did not think that her episode would recur. She developed two
other similar episodes, one while she was on her way to visit a friend and a
second that woke her up from sleep. She immediately went to the
emergency room after experiencing both paroxysms, receiving full medical
workups that showed no sign of illness.
Panic Disorder and Agoraphobia
DSM IV

Agoraphobia
Developing fear or
anxiety of places
where escape might
be difficult
Panic Disorder and Agoraphobia
ICD 10
Specific and Social Phobias
Phobia
Intense anxiety
Fear interferes with functioning or causes marked
distress
Feared object is either avoided or endured with a
great difficulty
Specific and Social Phobias
Specific Phobia
Fear is
circumscribed to
a specific object.
4 subtypes
Animal type
Natural
environment
Blood Injection
Situational type
Specific and Social Phobias
Mr. A. was a successful businessman who presented for treatment
following a change in his business schedule. While he had formerly
worked largely from an office near his home, a promotion led to a
schedule of frequent out-of-town meetings, requiring weekly flights. Mr.
A. reported being deathly afraid of flying. Even the thought of getting on
an airplane led to thoughts of impending doom as he envisioned his
airplane crashing to the ground. These thoughts were associated with
intense fear, palpitations, sweating, clammy feelings, and stomach upset.
While the thought of flying was terrifying enough, Mr. A. became nearly
incapacitated when he went to the airport. Immediately before boarding,
Mr. A. often had to turn back from the plane and run to the bathroom to
vomit.
Specific and Social Phobias
Social Phobia
Fear of a social
situation
E.g. Gathering, oral
presentation,
meeting new people
Fear of
embarrassing
themselves in a
social situations.
Specific and Social Phobias

Social Phobia Agoraphobia

Afraid of encountering
people Afraid of situations from
which escape would be
Flees other people
difficult
Reassured in the presence
of other people
Specific and Social Phobias
Ms. M. was a successful secretary working in a law firm. While she
reported a long history of feeling uncomfortable in social situations, Ms.
M. came for treatment when she began to feel that her uneasiness was
interfering with her social life and job performance. Ms. M. reported that
she noticed herself feeling increasingly nervous whenever she met a new
person. For example, upon meeting a new member of the law firm, she
described feeling suddenly tense and sweaty, noticing that her heart was
beating very fast. She had the sudden thought that she would say
something foolish in these situations or commit a terrible social gaffe
that would make people laugh at her. At social gatherings she described
similar feelings that led her to either leave the gathering early or decline
invitations to attend.
Obsessive-Compulsive Disorder
Obsessions Compulsion
Persistent ideas, thoughts, Repetitive acts, behavior
images that are that are designed to
experienced as intrusive counteract the anxiety
and inappropriate. associated with obsessions.

E.g. most common: E.g. hand washing, checking


contamination, doubts
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder
DDx
Basal ganglia dse
Syndehams chorea
Huntingtons dse
Streptococcal infection in children
Perfectionism
Depression
Tourettes disorder
Obsessive-Compulsive Disorder
Ms. B. presented for psychiatric admission after being transferred from a medical
floor where she had been treated for malnutrition. Ms. B. had been found
unconscious in her apartment by a neighbor. When brought to the emergency
room by ambulance, she was found to be hypotensive and hypokalemic. At
psychiatric admission, Ms. B. described a long history of recurrent obsessions
about cleanliness, particularly related to food items. She reported that it was
difficult for her to eat any food unless it had been washed by her three to four
times, since she often thought that a food item was dirty. She reported that
washing her food decreased the anxiety she felt about the dirtiness of food. While
Ms. B. reported that she occasionally tried to eat food that she did not wash (e.g.,
in a restaurant), she became so worried about contracting an illness from eating
such food that she could no longer dine in restaurants. Ms. B. reported that her
obsessions about the cleanliness of food had become so extreme over the past 3
months that she could eat very few foods, even if she washed them excessively.
She recognized the irrational nature of these obsessive concerns, but either could
not bring herself to eat or became extremely nervous and nauseous after eating.
Posttraumatic Stress and Acute
Stress Disorders
Onset of psychiatric symptoms immediately
following exposure to a traumatic event
e.g. threatened death, injury, natural disasters

3 domains
1. Reexperiencing the trauma
2. Avoiding stimuli
3. Experiencing symptoms of increased autonomic
arousal
Posttraumatic Stress and Acute
Stress Disorders
Posttraumatic Stress and Acute
Stress Disorders
Mr. F. sought treatment for symptoms that he developed in the wake of an
automobile accident that had occurred about 6 weeks prior to his psychiatric
evaluation. While driving to work on a mid-January morning, Mr. F. lost
control of his car on an icy road. His car swerved out of control into oncoming
traffic in another lane, collided with another car, and then hit a nearby
pedestrian. Mr. F. was trapped in his car for 3 hours while rescue workers cut
the door of his car. Upon referral, Mr. F. reported frequent intrusive thoughts
about the accident, including nightmares of the event and recurrent intrusive
visions of his car slamming into the pedestrian. He reported that he had
altered his driving route to work to avoid the scene of the accident, and he
found himself switching the television channel whenever a commercial for
snow tires appeared. Mr. F. described frequent difficulty falling asleep, poor
concentration, and an increased focus on his environment, particularly when
he was driving.
Generalized Anxiety Disorder
Pattern of persistent worry and anxiety that is
out of proportion.

Not acknowledge the nature of their worry


but the degree of their worry.
Generalized Anxiety Disorder
Generalized Anxiety Disorder
DDx.
Neurological
Endocrinological
Metabolic
Medication related
Generalized Anxiety Disorder
Ms. X. was a successful, married, 30-year-old attorney who presented for
a psychiatric evaluation to treat growing symptoms of worry and anxiety.
For the preceding 8 months, Ms. X. had noted increased worry about her
job performance. For example, while she had always been a superb
litigator, she increasingly found herself worrying about her ability to win
each new case she was presented. Similarly, while she had always been in
outstanding physical condition, she increasingly worried that her health
had begun to deteriorate. Ms. X. noted frequent somatic symptoms that
accompanied her worries. For example, she often felt restless while she
worked and while she commuted to her office, thinking about the
upcoming challenges of the day. She reported feeling increasingly
fatigued, irritable, and tense. She noted that she had increasing difficulty
falling asleep at night as she worried about her job performance and
impending trials.
Substance-Induced Anxiety and Anxiety Due to
a General Medical Condition
Both prescribed and illicit sympatomimetic
substance can produce a makred degree of
anxiety

For changes in consciousness or neurological


function never occur in anxiety states unless
there is an underlying medical condition.
Anxiety Disorder not otherwise Specified

Exhibit impairment from anxiety who do not


meet the criteria for one of the specific
anxiety disorders.

1. Anxiety is distressing and interere with


function
2. Anxiety not attributable to any specific
condition
Summary
I. Panic Disorder and Agoraphobia
II. Specific and Social Phobias
III. Obsessive-Compulsive Disorder
IV. Posttraumatic Stress and Acute Stress
Disorders
V. Generalized Anxiety Disorder
VI. Substance-Induced Anxiety and Anxiety Due to
a General Medical Condition
VII. Anxiety Disorder not otherwise Specified
Anxiety Disorders: Somatic
Treatments
History
Alcohol - oldest anti anxiety drug
Paraldehyde - an old fashioned treatment for alcohol
withdrawal
1957 - the first benzodiazepine, Chlordiazepoxide
(Librium), was first synthesized and heralded a new era of
safe and effective management of anxiety
Early 1960s - Imipramine which was used to control panic
attacks, was first evidence that anti depressant drugs may
alleviate anxiety and that this effect may be independent of
their antidepressant property
History
1990 - Fluoxetine which is the first drug in a series of
serotonergic agents became the best selling anti depressant.
General Principles
The administration of drugs affecting specific
neurotransmitter system will correct the underlying
neurochemical imbalance is responsible for the disorder .
A non pharmacologic treatment will almost always be
preferable if comparable efficacy can be established
Evaluation
Begins with psychiatric interview (onset, course,
symptomatology and comorbidity )
Initial evaluation
Choosing the Medication
should be based on rigorous, double blind, placebo trials
In the absence of conclusive evidence for differential
efficacy, the choice is usually determined by adverse effect
profiles.
Duration of Treatment
Since most anxiety disorders, are chronic, frequently life
long conditions, treatment should probably continued
indefinitely but perhaps intermittently
Burn out
Treatment Non Response
Most frequent reason for medication non response remains
under medication
Managing Adverse Effects
One of the main reasons for treatment resistance is
compliance
As an introduction, patients should always be told that most
side effects are benign and do not represent clinically
significant limitations
Antipsychotics
In general, it should not be used for the management of
anxiety disorders.
Medication Monitoring
Initial evaluation
Follow up visit
Panic Disorder With or Without
Agoraphobia
Triad: panic attacks, anticipatory anxiety, and phobic
avoidance or agoraphobia
Five drugs have been approved by FDA to treat panic
disorder: SSRI, MAOIs, and RIMAs, Tricyclic
Antidepressants, Benzodiazepines
SSRI: can cause weight gain, hypomania, or sexual
dysfunction
Advantage: no withdrawal reaction
Panic Disorder With or Without
Agoraphobia
MAOI: efficacious but can cause hypertensive reaction,
weight gin, orthostatic hypotension, insomnia and series of
anticholinergic effects, and withdrawal symptoms
RIMAs: less effective than MAOI
Tricyclics and Tetracyclics: taper SSRI to avoid serotonin
syndrome
Imipramine: first drug shown to possess anti-panic efficacy
and it is still considered as a gold standard in panic disorder

cause withdrawal symptoms


Panic Disorder With or Without
Agoraphobia

Benzodiazepine: considered if all the adverse effects of all


the other alternatives are unacceptable to the patient
first line for patients unwilling/unable to wait a 4 to 5
week delay in response
withdrawal symptoms
Generalized Anxiety Disorders
Excessive and uncontrollable anxiety and worry for at least 6
months
somatic symptoms such as restlessness, irritability, insomnia
and muscle tension
Benzodiazepine remains the traditional medication of
choice
15-25 mg of diazepam usually suffices to relieve most
symptoms
Buspirone is a potential alternative
Obsessive Compulsive Disease
Recurrent ruminations, repeated performance of useless
stereotyped rituals, or both
most difficult anxiety disorder to treat and has the highest
rate of non response
Drugs such as clomipramine, fluvoxamine, fluoxetine,
paroxetine, and sertraline have been shown in double-blind
controlled trials to alleviate the symptoms of OCD.
Social Phobia
Exaggerated fear of negative evaluations ranging from
specific to generalized type
Phenelzine (MAOI): most effective medication for the
treatment of generalized social phobia
SSRIs: alternative
Beta Blockers: moderate response to specific social phobias
like fear of public speaking
Ondansetron: if the patient with social phobia has nausea
or fear of vomiting as the most disabling symptom
Specific Phobias

Only require treatment if they interfere significantly with


the functioning
Treatment is usually behavioral exposure
Low dose benzodiazepines and beta adrenergic receptor
antagonists: as needed
Post Traumatic Stress Disorder
Patients who have experienced a life threatening trauma
Treatment is according to the most prominent symptom
clusters
Antidepressants and benzodiazepines: mainstay drugs
Antipsychotics are occasionally used for flash backs and
behavioral discontrol
SSRIs: target the full symptom spectrum of of PTSD
Considered the first line pharmacological treatment
Anxiety Disorders:
Psychological Treatments
I. COGNITIVE BEHAVIORAL THERAPY
II. PSYCHOSOCIAL THERAPY
COGNITIVE BEHAVIORAL
THERAPY: Panic Disorder
Panic Control Therapy: based largely on Peter Langs 3-
system model of cognitive psychophysiology which includes
physiological, cognitive, and behavioral
Techniques:
1. Breathing control techniques - control the physiological
effects of hyperventilation and progressive muscle
relaxation
2. Cognitive restructuring techniques - focused on
catastrophic thinking errors
3. Interoceptive procedure - repeated exposure to the
physical sensations associated with panic until a
habituation of the anxiety response has been achieved
COGNITIVE BEHAVIORAL
THERAPY: Social Phobia

Cognitive-behavioral approaches for social phobia focus on the use of


coping strategies that can be implemented in current fearful situations
Group therapy: Most thoroughly studied form of cognitive-behavioral
therapy for social phobia
For generalized and more severe forms of social phobia, a
combination of psychological and pharmacological therapy may
be in order.
COGNITIVE BEHAVIORAL
THERAPY: PTSD
Components of empirically validated treatments of
posttraumatic stress disorder
1 Cognitive monitoring and restructuring
2 Exposure in imagination to the original traumatic event
3 Exposure in vivo to trauma-related stimuli

Overall goal: To reduce or eliminate the patients anxiety


reaction to trauma-related cognitive and environmental
stimuli
COGNITIVE BEHAVIORAL
THERAPY:GAD
Patients exhibit less emotionally charged conditions on an
ongoing basis.
Treatment Programs:
Cognitive restructuring designed to identify worry-
related thoughts and replace them with more positive
coping responses
Relaxation training designed to reduce excessive
physiological arousal
PSYCHOSOCIAL THERAPY

Patient Support Groups


Group Therapy
Combined Treatments
Psychodynamic Psychotherapy

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