2. CASE VIGNETTE: Layla is 31 year old female. She came to your clinic complaining of fearfulness, palpitations, shortness of breath and impaired concentration. She is afraid that she will die. These symptoms come suddenly in episodes for the last two months. Layla started to be fearful whenever she leaves her home and ask for company all the time. She anticipated these episodes. She also has irrational fear from injections and she has the same episodes when she is exposed to them. DIAGNOSES: - Agoraphobia with panic attacks. - Specific phobic disorders

3. CASE DEVELOPMENT 1: 10 years ago, when she was in the university, she developed same episodes only in social situations like parties and presentations. DIAGNOSIS: - Social Anxiety Disorder (social phobia) CASE DEVELOPMENT 2: Layla describes herself as shy person, not assertive and cannot express herself well. She is very sensitive for criticism. PREMORBID PERSONALITY: - Avoidant Personality Disorder.

4. CASE DEVELOPMENT 3: Family History: One of Layla’s sisters has recurrent intrusive silly doubts regarding ablutions and praying that she cannot resist. This makes her repeat ablution and praying frequently. Also her brother Saad, has the same symptoms of Layla whenever he is exposed to cues that remind him with the car accident that he had 2 years ago. Saad had serious injuries in that accident and he was in coma for 3 weeks. His friend died in the same accident. He also has flashbacks related to that accident. Also, he refuses to talk about the accident and avoids drive in the street where the accident happened. Her aunt is anxious for the last 8 years. She has excessive worries about daily events mainly toward safety of her kids. SISTER: - Obsessive Compulsive Disorder. BROTHER: - Post-traumatic Stress Disorder. AUNT: - Generalized Anxiety Disorder (GAD).

5. ANXIETY DISORDERS: FEAR FREE FLOATING OBJECT & SITUATION EPISODIC GAD PHOBIA STRESS RELATED PANIC DISORDER RECURRENT SILLEY IRRESISTABLE OBJECTS SOCIAL LIFE-THREATENING NON-LIFE SITUATIONS THREATENING OCDSPECIFIC PHOBIA PTSD & ACUTE ADJUSTMENT DUE TO:DISORDER DISORDER - GENERAL MEDICAL CONDITIONS SOCIAL ANXIETY - MEDICINES DISORDER - SUBSTANCE ABUSE (SOCIAL PHOBIA) - ORGANIC ANXIETY DISORDERS OTHER SITUATIONS AGORAPHOBIA DISORDER EXAM PHOBIA DISORDER HEIGHT PHOBIC DISORDER ETC..

6. OUTLINES OF MANAGEMENT (IN ORDER):  Biopsychosocial  Rule out physical causes.  Social: a. EXPLANATION: nature, cycle and symptoms production. b. REASSURANCE & SUPPORT: For patient and family.  PSYCHOLOGICAL: 1. Counseling. 2. CBT. 3.Behavior therapy e.g. Anxiety Management Training, Relaxation Exercise and Specific Behavioral techniques. 4. Meditation 5. Psychodynamic Psychotherapy. PHARMACOLOGICAL: 1. SSRI. 2. SNRI. 3. Buspirone. 4. Beta Blockers. 5. Other Antidepressants TCA. 6. Benzodiazepines in severe cases for short use 2-4 weeks e.g. lorazepam, alprazolam.

7. PSYCHOPHARMACOLOGY: 1. SSRI, SNRI and TCA. Covered in mood disorder theme. 2. Buspirone 3. Benzodiazepines BUSPIRONE: 1. PHARMACOLOGY:  Well absorbed from the G.I. tract.  Metabolized by the liver.  Peaks in plasma in 1-1.5 hours.  Well tolerated & safe.  Takes more than two weeks to work.  Does not cause dependence. 2. MECHANISM OF ACTION:  Unlike benzodiazepines, it has no effect on GABA neurotransitter.  It is an agonist of 5HT-1-A, reduces serotogenic neurons.

8. PSYCHOPHARMACOLOGY (cont): BUSPIRONE: 3. SIDE EFFECTS:  Dizziness and headache.  Nervousness or excitement.  Dry mouth and diarrhea. 4. CONTRAINDICATIONS:  Caution in pregnancy.  Renal and hepatic disease.  MAOIs interaction.

9. PSYCHOPHARMACOLOGY (cont): BENZODIAZEPINES a. CLASSIFICATION:  Short acting: e.g. Lorazepam (Ativan), Alprazolam (Xanax).  Long acting: e.g. Diazepam (Valium), Chlordiazepoxide (Librium), Clonazepam (Rivotril). b. PHARMACOLOGY:  Completely absorbed from the G.I. tract.  Rapid action due to high lipid solubility.  Peaks in plasma in 1-3 hours.  Metabolized in the liver. c. MECHANISM OF ACTION:  Through its own receptors.  Through increased affinity for GABA receptors which inhibits neurons.

10. PSYCHOPHARMACOLOGY (cont): BENZODIAZEPINES d. SIDE-EFFECTS:  Sedation and lethargy.  Dizziness, ataxia and confusion.  Respiratory depression especially intravenously.  CNS depression when used with sedative substances or alcohol.  Aggression release.  Withdrawal symptoms especially convulsions.  Dependence.

11. PSYCHOPHARMACOLOGY (cont): BENZODIAZEPINES e. INDICATIONS:  Insomia.  Anxiety Disorders.  Sedation.  Muscle Spasm.  Akathesia: side effect of antipsychotics.  Alcohol Withdrawal.  Antiepileptics.

12. PSYCHOPHARMACOLOGY (cont): BENZODIAZEPINES f. CONTRA-INDICATIONS:  Potential abuse  Compromised cardiovascular system functions.  Caution in elderly.  Driving & operating heavy machines.

13. TREATMENTS FOR SPECIFIC ANXIETY DISORDERS: GAD: a.) DRUGS: 1. SSRI, SNRI, for 1 year 2.Buspirone. 3. B-blockers. 4. TCA. 5. Benzodiazepines adjunctive in severe cases. b.) PSYCHOLOGICAL: 1. Relaxation exercise. 2. Anxiety Management Training. 3. CBT.

14. TREATMENTS FOR SPECIFIC ANXIETY DISORDERS (cont.): PANIC DISORDER: a.) DRUGS: 1. Benzodiazepines (3-6 weeks). 2. SSRI,SNRI for 1 year. b.) PSYCHOLOGICAL: 1. Relaxation exercise. 2. CBT.

15. TREATMENTS FOR SPECIFIC ANXIETY DISORDERS (cont.): SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER), AGORAPHOBIA AND OTHER NON-SPECIFIC PHOBIAS: a.) PSYCHOLOGICAL: 1. Behavior Therapy: - Graded exposure. - Relaxation Exercise. 2. CBT. b.) DRUGS: 1. SSRI & SNRI, for 6-12 months. 2. TCA. 3. B-blockers adjunctive with 1&2. 4. Benzodiazepine for short time with 1&2. c.) High efficacy to combine both drugs and psychological treatments.

16. TREATMENTS FOR SPECIFIC ANXIETY DISORDERS (cont.): SPECIFIC PHOBIAS: a.) PSYCHOLOGICAL: 1. Behavior Therapy: - Graded exposure. - Sudden exposure. - Relaxation exercise. - Modelling. 2. CBT. b.) DRUGS: 1. B-blockers. 2. Benzodiazepine (2-6 weeks).

17. TREATMENTS FOR SPECIFIC ANXIETY DISORDERS (cont.): OCD: a.) DRUGS: 1. SSRI: high dose and longer time to act. For 1-2 years. 2. TCA: Clomipramine. b.) PSYCHOLOGICAL: 1. Behavior Therapy: - Response prevention. - Modelling. 2. CBT. 3. Dynamic Psychotherapy. c.) Combination of a & b is highly effective.

18. TREATMENTS FOR SPECIFIC ANXIETY DISORDERS (cont.): STRESS – RELATED DISORDERS: a.) DRUGS: 1. SSRI & SNRI with short term Benzodiazepines or Buspirone. 2. TCA. b.) PSYCHOLOGICAL: 1. Relaxation exercise. 2. CBT. 3. Dynamic Psychotherapy.