ANXIETY DISORDERs

Department of Psychiatry Medical Faculty Padjadjaran University Hasan Sadikin Hospital

Epidemiology
The most prevalent mental disorder s in the general population Nearly 30 million person are affected in the US Women nearly twice as frequently as men

 Anxiety disorder are frequently co morbid with many other condition (beside MDD and other anxiety disorder) substance abuse, ADHD, bipolar, pain disorder, sleep disorder

 Anxiety normal or disorder Anxiety is a normal emotion under circumstances of threat and is thought to be part of the evolutionary fight or flight reaction of survival. Every experiences anxiety a diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms.

Fear vs Anxiety
Anxiety is an alerting signal It warns of impending danger and enables a person to take measures to deal with a threat Is unknown, internal, vague, or conflictual Fear Is similar alerting signal A known, definite, or non conflictual threat

General sign and symptoms of anxiety

Core symptom of anxiety excessive fear and worry , feeling dizzy, unsteady, faint, light-headed Autonomic symptoms : headache, perspiration, sweating, trembling, shaking, dry mouth, palpitation, pounding heart, tightness in the chest, chest pain or discomfort, mild stomach discomfort, nausea, restlessness (inability to sit or stand still for long, etc), difficulty of breathing , feeling choking,

Pathophysiology of Anxiety
I. Psychological factors Psychoanalytic theories (Freud theory) anxiety as a signal of the presence of danger in the unconscious psychic conflict unconscious sexual or aggressive wishes and superego or external reality Behavioral theories a conditioned response to a specific environmental stimulus. Existential theories persons experience feeling of living in a purposeless universe.

2. Biological Factors Autonomic Nervous system Neurotransmitter (serotonin, norepinephrine) Hypothalamic-Pituary-Adrenal (HPA) axis Corticotrophin-releasing hormone (CRH) GABA

 Anxiety and fear symptoms are regulated by an amygdala-centered circuit. Worry by a cortico-striatal-thalamo-cortical (CSTC) loop AMYGDALA plays a central role in the experience of anxiety and fear, has reciprocal connections with a wide range of other brain region Amygdala anterior cingulated cortex, hypothalamus, thalamus, hippocampus, orbital prefrontal cortex, brainstem sites (e.g., PAG, raphe

 Affect of fear over activation of circuit of amygdale with anterior cingulate cortex (ACC) and Amygdala with orbitofrontal cortex Avoidance amygdale and periaqueductal gray (PAG). Avoidance is a motor response ~ freezing under threat, fight or flight Endocrine output of fear amygdale activation of HPA axis increases in cortisol.

 A quick boost of cortisol may enhance survival when a person is encountering a real but short term threat. Prolonged HPA activation and cortisol release significant health implication CAD, Type 2 DM, and stroke. Respiration inappropriate or excessive activation of the parabrachial nucleus (PBN) via the amygdale increase in the rate of respiration, shortness of breath, exacerbation of asthma, or a sense of being smothered/chocking especially in panic attacks

 Traumatic memories stored in the hippocampus activate the amygdale activate other brain regions and generate a fear response

Classification
Panic disorder with or without agoraphobia Agoraphobia with or without Panic disorder Specific Phobia Social Phobia PTSD (Post Traumatic Stress Disorder) Acute Stress disorder Generalized Anxiety Disorder Obsessive Compulsive Disorder

AGORAPHOBIA
Fear or avoidance of at least two : Crowds places Public places Travelling alone Travelling away from home

Social Phobia
Marked fear of being the focus of attention, or behaving in a way that will be embarrassing or humiliating avoidance social situations eating or speaking in public, parties, meeting, classroom)

Specific Phobia
Marked fear of a specific object or situation not included in agoraphobia or social phobia Marked avoidance of an object or situation specific (animal, birds, insects, heights thunder, flying, injection, blood, etc)

Obsessive Compulsive Disorder (OCD)

Either obsession or compulsion (or both) are present on most days for a period of at least 2 weeks Obsessions (thoughts, ideas, or images) and compulsions (acts). Repetitive, unpleasant, acknowledged as excessive or unreasonable Patient tries to resist them, but unsuccessfully Cause distress

Panic attack/disorder
Recurrent unexpected panic attack , characterized by 4 or more: - palpitation - sweating - trembling or shaking - shortness of breath - feeling of chocking - chest pain or discomfort - nausea or abdominal distress - feeling dizzy, lightheaded or faint - derealization or depersonalization - fear of losing control or going crazy - fear of dying - Numbness or tingling - chills or hot flushes Significant change in behavior related to the attack

Acute stress disorder

Has been exposed to the traumatic events (experienced, witnessed, or was confronted) The persons response involved intense fear, helplessness, or horror 3 or more of symptoms: - a subjective sense of numbing, detachment, or absence of emotional - a reduction in awareness of his or his surroundings - derealization - depersonalization - dissociative insomnia Persistently re experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or sense of reliving the experience Marked avoidance of the stimuli that arouse recollections of the trauma (e.g,: thought, feelings, conversation, activities, places, people) Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper vigilance, exaggerated startle response, motor restlessness. Clinically distress or impairment in social , occupational , or other important areas of functioning

Generalized Anxiety Disorder

Excessive anxiety or worry about a number of events or activities (future oriented), occurring more days than not for at least 6 months Worry is difficult to control Worry is associated with at least three of the following symptoms: - restlessness or feeling keyed up on edge - easily fatigued - difficulty concentrating - irritability - muscle tension - sleep disturbance Anxiety and worry cause significant distress and impairment in social, occupational, or other daily functioning

Therapy
Pharmacotherapy (benzodiazepines, Antidepressant SSRI) Psychotherapy (CBT, Insight oriented) Behavior therapy (flooding, desensitization)