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"I’m scared; I think I’m going to die" 2nd Year Postgraduate Master in Medicine (Family Medicine) Department of Family Medicine, UKMMC 12 August 2014.

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Presentation on theme: ""I’m scared; I think I’m going to die" 2nd Year Postgraduate Master in Medicine (Family Medicine) Department of Family Medicine, UKMMC 12 August 2014."— Presentation transcript:

1 "I’m scared; I think I’m going to die" 2nd Year Postgraduate Master in Medicine (Family Medicine) Department of Family Medicine, UKMMC 12 August 2014

2 General Objective: At the end of this session, the postgraduate trainees in Family Medicine should be able to diagnose and manage patients with different type of anxiety disorders i.e Generalized Anxiety Disorder, Panic Disorder etc Specific Objectives: At the end of the session, the postgraduate trainee should be able to: i. Take proper history, perform an appropriate assessment on patients with anxiety and panic symptoms ii.Assess the severity of anxiety and initiate treatment accordingly iii.Appreciate the role of psychotherapy on patients with anxiety disorders

3 “Anxiety”: A feeling of worry, nervousness, or unease about something with an uncertain outcome “Fear”: An unpleasant emotion caused by the threat of danger, pain, or harm a known threat

4 Signs And Symptoms Of Anxiety Disorder Physical Signs Trembling, twitching, feeling shaky Backache, headache Muscle tension Shortness of breath, hyperventilation Fatigability Startle response Autonomic hyperactivity Flushing and pallor Tachycardia, palpitations Sweating Clod hands Diarrhea Dry mouth (xerostomia) Urinary frequency Paresthesia Difficulty swallowing

5 Feeling of dread Difficulty concentrating Hypervigilence Insomnia Decreased libido “Lump in throat” Upset stomach (butterflies) Psychological Symptoms

6 Anxiety Disorder A.Panic disorder with and without agoraphobia B.Agoraphobia without history of panic disorder C.Generalised Anxiety Disorder D.Specific Phobia E.Social Phobia F.Obsessive-Compulsive disorder G.Post-traumatic and acute stress disorder H.Anxiety Disorder due to medical condition I.Substance induced anxiety disorder J.Mixed anxiety-depressive disorder

7 K.Anxiety disorder not otherwise specified 1)Adjustment disorder with anxiety 2)Anxiety secondary to another psychiatric disorder 3)Situational anxiety 4)Existential anxiety 5)Separation anxiety and stranger anxiety 6)Anxiety related to loss of self-control 7)Anxiety related to dependence or intimancy 8)Anxiety related to guilt and punishment

8 Medical and Neurological Causes of Anxiety  Neurological Disorders Cerebral neoplasms Cerebral trauma and postconcussive syndromes Cerebrovascular disease Subarachnoid hemorrhage Migraine Encephalitis Cerebral syphilis Multiple sclerosis Huntington’s disease Epilepsy  Systemic conditions Hypoxia Cardiovascular disease Pulmonary insufficiency Anaemia  Endocrine disturbances Pituitary dysfunction Thyroid dysfunction Parathyroid dysfunction Adrenal dysfunction Phaechromocytoma Female virilization disorder

9  Inflammatory disorders Lupus erythematosus Rheumatoid arthritis Polyarteritis nodosa Temporal arteritis  Deficiency states Vitamin b12 deficiency Pellagra  Miscellaneous conditions Hypoglycaemia Carcinoid syndrome Systemic malignancies Premenstrual syndrome Febrile illness and chronic infections Porphyria Infectious mononucleosis Posthepatitis syndrome Uraemia  Toxic conditions Alcohol and drug withdrawal Vasopressor agents Penicillin Sulfonamides Mercury Arsenic Phosphorus Organophosphates Carbon disulfide Benzene Aspirin intolerance

10 Substances that may cause anxiety Intoxication Amphetamines and other sympathomimethics Amyl nitrate Anticholinergics Caffeine Cannabis Sedative-hypnotics Cocaine Hallucinogens Theophylline Yohimbine Withdrawal Alcohol Antihypertensives Caffeine Opioids

11 Epidemiology

12 Aetiology A.Biological  ↑ release of catecholamines with ↑ production of norepinephrine metabolites  Alterations in serotonergic system increased dopaminergic activity  ↓ level of GABA cause CNS hyperactivity  ↑ activity in temporal cerebral cortex  Hyperactive locus ceruleus (brain centre of noradrenergic neurons) (esp in panic attacks)  Hyperactivity and dysregulation in the amygdala may be a/w social anxiety

13 B.Psychoanalytic  Unconscious impulses threaten to burst into consciousness and produce anxiety  Anxiety related developmentally with childhood fears of disintegration that derived from fear of an actual or imagined loss of a love object or the fear of bodily harm  “signal anxiety” – anxiety not consciously experienced but trigger defense mechanism used by the person to deal with a potentially threatening situation


15 C.Learning theory  Anxiety produced by continued or severe frustration or stress, then becomes a conditioned response to other situations that are less severely frustrating or stressful  “social learning theory” – learned through identification and imitation of anxiety patterns in parents  Associated with a naturally frightening stimulus (eg accident). Subsequent displacement or transference to another stimulus through conditioning produces a phobia to a new and different object or situation

16 D.Genetics  Half of patients with panic disorder have one affected relative  ~5% persons with high levels of anxiety have polymorphic variant of the gene a/w serotonin transporter metabolism

17 Amy, age 38, is a worrier. She is restless, irritable and has difficulty concentrating. She worries that she worries so much and isn't always sure what it is that she is worried about. She can't let her husband or children leave the house without making them call her regularly to reassure her that they are okay. Her husband is growing weary of her fretting. Her children can't understand what all the fuss is about. Their impatience with her only makes her worry more.

18 Generalized Anxiety Disorder GAD is characterized by persistent anxiety, unrelated to a specific event. People suffering from GAD cannot help worrying about anything and everything, even in calm situations. They have difficulty relaxing, falling asleep, and/or concentrating, and tend to be impatient and irritable. Physical symptoms accompanying GAD include sweating; an upset stomach; diarrhea; frequent urination; cold, clammy hands; a lump in the throat; a dry mouth; shortness of breath; headaches; and dizziness. Managing the normal demands of a job, relationships, and everyday life can become more and more difficult for people with this disorder.

19 Annie is a 20-year-old student at a local community college. On several occasions recently, she has experienced sudden, absolute panic. During these episodes, her heart pounds; she trembles; her mouth gets dry and it feels as if the walls are caving in. The feelings only last a few minutes but, when they occur, the only thing that seems to relieve her fear is walking around her apartment and reminding herself that she is in control. She won't ride in cars any more unless she is driving so she is sure that she can stop if necessary. She will only go to class if she can find an aisle seat in the back row so that she can leave quietly should she have another attack. She avoids any situation in which she might feel out of control or embarrassed by her own terror.

20 Panic Disorder Panic attacks are just that is sudden, unexplainable waves of panic that seem to come out of the blue. The body responds with the "fight-or- flight" response, anticipating clear and immediate danger. Often, these attacks subside as mysteriously as they occur. A person who has experienced one or more panic attacks often develops a fear of having one again. Some professionals call this a "fear of fear." The individual may even try to stay away from anything that reminds him or her of the last attack to avoid having another one. People can have panic attacks with or without agoraphobia. These attacks include symptoms such as heart palpitations, shortness of breath, chest pain, feelings of choking or smothering, nausea, dizziness, sweating, and trembling. An afflicted person might also be overwhelmed by a fear of dying, going crazy, or losing control.

21 Hannah, age 55, was in a major car accident 20 years ago during a cross-country trip. Ever since, she has been unable to drive on major highways. Although she does drive, she goes to great lengths to travel only on back roads and scenic routes. She is able to go where she wants to go but it often takes much longer to get there than it should.

22 Phobias Phobias are attempts to compartmentalize fear into a few situations that can be avoided by attaching all the panicky feelings onto a few situations, the person can avoid those situations and go on with life. Unfortunately, phobias can take on a life of their own and take over more and more of a person's life. Some of the more common phobias include claustrophobia (fear of closed spaces), agoraphobia (fear of public places, sometimes related to panic attacks), and acrophobia (fear of heights).

23 Bert is 40 years old and works on an assembly line in a brush factory. He is terribly afraid of being contaminated by germs. He avoids shaking hands with others. He won't eat in the cafeteria. He has trouble leaving the bathroom because he isn't sure he has washed his hands well enough.

24 Obsessive-Compulsive Disorder: OCD is a disorder in which the mind is flooded with involuntary thoughts, or in which an individual feels compelled to repeat certain acts over and over again (for example, hand washing). This disorder can interfere significantly with everyday living, and usually leads to concern and/or resentment among friends, family, and co-workers. A person who suffers from OCD doesn't want the thoughts and doesn't want to do the behaviors. Unfortunately, he or she really can't help it. About half the people with OCD report that it began in childhood; most others start in adolescence or early adulthood.

25 Joanne, age 32, is involved with the first man that really counts in her life. As the couple has become more intimate, Joanne has started to have flashbacks about an uncle who touched her sexually when she was only eight. She is distressed to find that she is shutting down feelings about her boyfriend and distancing herself from him. Although she has been sexual with other men, she says she can't stand to let herself be sexual with someone she loves and trusts. She startles easily and reports a general increase in anxiety. She is very angry that she has to deal with the feelings about the incidents with her uncle that happened so long ago. She says that she thought she had gotten beyond all that.

26 Posttraumatic Stress Disorder: Posttraumatic stress disorder (PTSD) can develop in the wake of a traumatic event that is outside the usual human experience. A person either experiences direct or threatened injury, or witnesses the serious injury or death of another. In some cases, learning of the unexpected death or injury of a loved one can also bring on symptoms of PTSD. For a diagnosis of PTSD to be made, there must be both an identifiable terrifying event and a response of intense fear, helplessness and horror, as well as one or more characteristic symptoms.

27 These include: Re-experiencing of the event through nightmares, daytime flashbacks, and/or physical sensations that recall the feelings present during the event. In children, this can take the form of repetitive play that contains aspects of the traumatic event. Numbing and shutting down feelings and memory. Feeling detached from others. Dissociating from the distressing memories and feelings. Hyperalertness to danger. The individual often has difficulty shutting down the fight-or- flight response that was quite appropriately activated during the event. This causes sleeplessness, irritability, difficulty with concentration, and general restlessness, and sometimes the development of an exaggerated startle. Hypervigilance and avoidance of any situation associated with the event. These symptoms significantly disrupt an afflicted person’s daily life. Depending on the type of traumatic event, the person might react with distrust of others, avoidance of anyone or anything that reminds them of the event, or lack of confidence in their ability to keep themselves safe.

28 Discussion Ben Walters, an unmarried 24 year old post-graduate university student, was referred to your centre by his supervisor. Presenting problem Ben reported that he has been feeling anxious for a long time but that of late his anxiety has been a lot worse. He says his anxiety is more severe than it used to be.

29 History of present illness Ben described himself as having always been a worrier and could not recall a time when he had not experienced some degree of anxiety. He reported that he tends to overplan everything to prevent disaster, which results in tension and frequent headaches. This problem was particularly bad during the last three years of high school. He said he has always had trouble making decisions for fear of making mistakes and upsetting others, and now worries a lot about what his supervisor will think of him. However, he does not get anxious about engaging in social situations. For the past several weeks he has begun to experience bouts of fearfulness upon waking in the morning, and feels nervous, agitated, light-headed, and his heart pounds. He finds it difficult to concentrate on his study with his thoughts going "round and round like a record" - thoughts from which he has difficulty distracting himself. He has become frightened of going to university, worries about what misfortunes might befall him, or becomes anxious if he feels he has nothing planned for the day. His sleep and appetite are normal and he does not appear to avoid any specific situations.

30 Personal and Family History Ben remembers having lots of friends at school. He also has childhood memories of his father being abusive and constantly telling him that he is stupid. He worked extremely hard at school to counter this criticism and was academically above average. He moved out of home when he started a degree in economics and is now in his second year of a Ph.D. He has had a long-term relationship in the past but currently has no girlfriend.

31 Previous Psychiatric and Medical History Ben was prescribed diazepam by his general practitioner four weeks previously but has only taken this medication on three occasions because it makes him too sleepy. He has had no significant medical or psychiatric problems in the past. He does not smoke, drinks only a small amount of alcohol on social occasions, and does not use illicit drugs. He has avoided caffeine for the past month as he has noted that caffeine increases his anxiety symptoms. Premorbid Personality He presented as a cheerful and sensible individual, with a positive outlook on life despite his current difficulties. He does, however, have obsessional personality traits as indicated by his need to do everything perfectly. He also reports that he was quite moody when he was younger and that he has never had a great deal of self confidence

32 Course & prognosis A.GAD 1.Chronic course, symptoms may diminish as pt gets older 2.Secondary depression may develop 3.Good prognosis with treatmeny – over 70% improve with pharmacological therapy B.Panic disorder 1.Chronic with remissions and exacerbations 2.Attacks tend to recue 2-3x per week 3.↑ risk of committing suicide 4.Good prognosis with combined pharmacotherapy & psychotherapy

33 C.OCD 1.Chronic with waxing & waning of symptoms 2.Pharmacotherapy is more effective than psychotherapy, most effective in combination with CBT 3.Fair prognosis, some cases are intractable D.Phobic disorder 1.Chronic 2.Phobias may worsen or spread if untreated 3.Agoraphobia is the most resistant 4.Excellent prognosis with therapy E.PTSD 1.Chronic 2.Trauma is re-experienced periodically for several years

34 Differential diagnosis A.Depressive disorders 50-70% depressed patient exhibits anxiety or obsessive brooding; 20-30% anxious patients also experience depression B.Schizophrenia Schizophrenic patients may be anxious and have severe obsessions in ddition to or preceding the outbreak of hallucinations or delusions C.Bipolar I disorder Massive anxiety may present during a manic episode D.Adjustment disorder with anxiety Pt had h/o psychological stressor within 3 months of onset E.Medical and neurological conditions F.Substance-related disorders

35 Treatment 1.Psychological 2.Pharmacological

36 Psychological 1.Supportive psychotherapy Encourage & strengthen adaptive defenses, maladaptive ones discouraged 2.Insight-oriented psychotherapy 3.Behavior therapy Positive & negative reinforcement, systematic desensitization, flooding, implosion, graded exposure, response prevention, stop thought, relaxation techniques, panic control therapy, self-monitoring, hypnosis 4.Cognitive therapy 5.Group therapy

37 Pharmacological 1.Benzodiazepines Alprazolam (Xanax), clonazepam, diazepam 2.Selective serotonin re-uptake inhibitor (SSRIs) Citalopram, escitalopram (Lexapro), sertraline (Zoloft), paroxetine (paxil) At initiation of treatment, anxiety may ↑ 3.Tricyclics Imipramine (tofranil), nortriptyline (aventyl) 4.Monoamine oxidase inhibitors (MAOIs) 5.Others Beta-blockers, Venlafaxine (Effexor), Buspirone (Buspar)


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