PSYCHIATRY

(
II
1ST SEMESTER)|Management of Anxiety and Other Non-Psychotic Disorders|Dra. Hannah Trinidad

OUTLINE II. ANXIETY DISORDERS

I. MANAGEMENT OF ANXIETY DISORDERS 1. Panic Disorder
A. Etiology 2. Agoraphobia
II. ANXIETY DISORDERS 3. Specific Phobia
III. PANIC DISORDER 4. Social Anxiety Disorder (Social Phobia)
IV. AGORAPHOBIA
5. Generalized Anxiety Disorder
V. SPECIFIC PHOBIA
VI. SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
All of these disorders may manifest Panic attack
VII. GENERALIZED ANXIETY DISORDER
VIII. MANAGEMENT OF OTHER NON-PSYCHOTIC DISORDERS
Panic Attack – not a disorder but a specifier
IX. OCD
X. PTSD/ACUTE STRESS DISORDER III. PANIC DISORDER
XI. ADJUSTMENT DISORDER • Recurrent unexpected panic attack
XII. SOMATIC SYMPTOM DISORDER • Persistent worry about additional panic attacks
XIII. ILLNESS ANXIETY DISORDER • Significant maladaptive change in behavior

I.MANAGEMENT OF ANXIETY DISORDERS PHARMACOTHERAPY________________________________

ANXIETY • SSRIs: Paroxetine, Escitalopram & Sertraline
o Paroxetine: Sedating, can cause weight gain
• Excessive anxiety and worry
and short-acting medication
• Increased muscle aches or soreness
• Benzodiazepine
• Fatigue
o Benzodiazepines have the most rapid onset
• Impaired concentration
of action against panic
• Irritability
o Alprazolam - most widely used
• Restlessness benzodiazepine for panic disorder
• Difficulty sleeping • Others: TCAs, MAOIs
• 8 to 12 months
A. ETIOLOGY
1. PSYCHOANALYTIC
PSYCHOTHERAPY___________________________________
o Freud: Anxiety as a signal of the presence of
• Cognitive therapy: Instruction about false beliefs and
danger in the unconscious
information about panic attacks
• Behavior therapy
2. BEHAVIORAL THEORIES
o Anxiety is a conditioned response to a • Data indicate that panic disorder is a chronic, perhaps
specific environmental stimulus (e.g. lifelong, condition that recurs when treatment is
classical conditioning, social learning model) discontinued.

3. EXISTENTIAL THEORIES IV. AGORAPHOBIA

o Models for generalized anxiety (no Fear of:
specifically identifiable stimulus exists for a • Public Transportation
chronically anxious feeling) • Open Spaces
o Feelings of living in a purposeless universe • Enclosed Spaces
o Anxiety as a response to perceived void in • Lines or Crowd
existence and meaning • Outside home alone

NEUROTRANSMITTERS INVOLVED: 1. Avoids situations

• Serotonin 2. Require companion
• Norepinephrine 3. Out of proportion
• GABA 4. 6 months or more

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PHARMACOTHERAPY________________________________ o As they identify with the avatars in repeated

• Benzodiazepine computer sessions, they are able to master
o Alprazolam their anxiety through deconditioning.
o Immediate effect with short duration of
action thus, not suitable for maintenance V. SPECIFIC PHOBIA
meds • Fear Specific objects or situations
• SSRIs • Actively Avoided
PSYCHOTHERAPY___________________________________ • Out of proportion
• Supportive Psychotherapy • 6 months or more
o Use of psychodynamic concepts and a
therapeutic alliance to promote adaptive PSYCHOTHERAPY___________________________________
coping. • Behavior Therapy
o Adaptive defenses are encouraged and o The key aspects of successful treatment are
strengthened, and maladaptive ones are 1. The patient's commitment to treatment
discouraged. 2. Clearly identified problems and
o The therapist assists in reality testing and objectives; and
may offer advice regarding behavior. 3. Available alternative strategies for
• Insight oriented psychotherapy coping with the feelings.
o Goal is to increase the patient's o Systematic desensitization – most common
development of insight into psychological • Insight Oriented Therapy
conflicts that, if unresolved, can manifest as o Help the patient understand the origin of
symptomatic behavior phobia
• Behavior Therapy • Virtual Therapy
o Basic assumption is that change can occur • Others: Hypnosis, Supportive therapy, Family
without the development of psychological Therapy
insight into underlying causes.
o Techniques include positive and negative VI. SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
reinforcement, systematic desensitization,
• Fear Social situations; negatively evaluated
flooding, implosion, graded exposure,
• Actively Avoided
response prevention, stop thought,
• Out of proportion
relaxation techniques, panic control therapy,
• 6 months or more
self-monitoring, and hypnosis.
• Cognitive Therapy
PHARMACOTHERAPY________________________________
o Based on the premise that maladaptive
• SSRIs
behavior is secondary to distortions in how
people perceive themselves and in how • Benzodiazepine
others perceive them. • Venlafaxine
o Treatment is short term and interactive, with • B blocker
assigned homework and tasks to be
performed between sessions that focus on PSYCHOTHERAPY___________________________________
correcting distorted assumptions and • Cognitive Behavior Therapy
cognitions. o Cognitive retraining
o The emphasis is on confronting and o Desensitization
examining situations that elicit interpersonal o Rehearsal during sessions
anxiety and associated mild depression. o Homework
• Virtual Therapy
o Computer programs have been developed VII. GENERALIZED ANXIETY DISORDER
that allow patients to see themselves as A. Fear number of events or situations
avatars who are then placed in open or B. Restlessness
crowded spaces (e.g., a supermarket). Fatigue

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Difficulty Concentrating IX. OBSESSIVE-COMPULSIVE DISORDER

Irritability A. TREATMENT
Muscle Tension
Sleep Disturbance Treatment = Pharmacotherapy + Behavior Therapy
C. Difficult to control worry
D. 6 months or more PHARMACOTHERAPY ________________________________
• Effects are generally seen after 4 to 6 weeks of
PHARMACOTHERAPY________________________________ treatment
• Benzodiazepine • 8 to 16 weeks needed to obtain maximal therapeutic
• SSRIs: Sertraline or Paroxetine benefit
o Disadvantages of SSRis, especially • SSRIs: Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
fluoxetine, is that they can transiently o Combined with behavioral therapy: best
increase anxiety and cause agitated states. clinical outcome
• Venlafaxine • Clomipramine : Titrated over 2 to 3 weeks to avoid GI
• 6 to 12 months or lifelong effects and orthostatic hypotension
o Combined with behavioral therapy: Best
PSYCHOTHERAPY___________________________________ clinical outcome
• Cognitive Behavior Therapy
o Teaches patients to substitute positive BEHAVIOR THERAPY_________________________________
thoughts for anxiety-provoking ones • Longer lasting beneficial effects
• Supportive psychotherapy • Treatment of choice
o Therapeutic alliance on how you can • Approaches: Exposure and response prevention
encourage the patient • Others: Desensitization, thought stopping, flooding,
• Insight Oriented therapy implosion therapy, and aversive conditioning

VIII. MANAGEMENT OF OTHER NON-PSYCHOTIC DISORDERS X. PTSD/ ACUTE STRESS DISORDER

A. TREATMENT
OBSESSIVE- TRAUMA DISSOCIATIVE PSCYHOSOMATIC Acute Stress Disorder – 3 days to 1 month duration
COMPULSIVE AND DISORDERS MEDICINE
AND RELATED STRESSOR-
DISORDERS RELATED Treatment = Pharmacotherapy + Psychotherapy + Education
DISORDERS
PHARMACOTHERAPY ________________________________
OCD PTSD Dissociative Somatic • SSRIs: Paroxetine, Sertraline
Amnesia Symptom o First line treatment
Disorder
• At least 1 year
Body Acute Stress Depersonalization Illness Anxiety
Dysmorphic Disorder / Disorder • More effective in depression, anxiety, and
Disorder Derealization hyperarousal
Disorder
Hoarding Adjustment Dissociative Functional PSYCHOTHERAPY___________________________________
Disorder Disorder Fugue Neurologic
• Must be individualized
Symptom
Disorder • Behavior therapy, Cognitive therapy
(Conversion • Hypnosis
Trichotillomania Dissociative Psychological • Time limited: Cognitive approach; provides support
Identity Disorder Factors and security
Affecting Other
• Short term: Minimizes the risk of dependence and
Medical
Conditions chronicity
Excoriation Dissociative Factitious • Goal:
Disorder Trance Disorder Disorder o Overcome patients' denial of traumatic
Pain Disorder event

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o Encourage to relax
o Remove them from the source of the stress
• Support provided
• Review and abreact emotional feelings
• Plan for future recovery
• Amobarbital interview – facilitate abreaction
• Crisis intervention:
o Support
o Education
o Development of coping mechanisms and
acceptance
• Exposure therapy
• Stress management to cope with stress
XI. ADJUSTMENT DISORDER
• Characterized by an emotional response to a stressful
event.
• An external stressful event is linked to the
development of symptoms.
o Stressor involves financial issues, a medical
illness, or relationship problem.
o Symptom complex that develops may
involve anxious or depressive affect or may
present with a disturbance of conduct.
o Symptoms must begin within 3 months of
the stressor.
• Last no longer than 6 months
PSYCHOTHERAPY ___________________________________
• Treatment of choice
• Group therapy: with similar stresses
• Individual psychotherapy: Explore the meaning of the
stressor
XII. SOMATIC SYMPTOM DISORDER
• 1 or more somatic symptoms (bodily sensation) that
are distressing and can result in significant disruption
of life
• Focused on the symptom; Pain – most common
• Excessive thoughts, feelings, and behavior related to
the somatic symptoms or associated health concerns.
• They usually resist psychiatric treatment, some prefer
to be treated in a medical setting.
PSYCHOTHERAPY ___________________________________
• Stress reduction and education in coping with chronic
illness
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• Group therapy: Social support and interaction
• Others: insight-oriented psychotherapy, behavior
therapy, cognitive therapy, hypnosis
• Frequent, regularly scheduled physical examinations
PHARMACOTHERAPY ________________________________
• Alleviates somatic symptom if with underlying drug
responsive condition
o Anxiety disorder
o Depressive disorder
• Treat primary mental disorder
XIII. ILLNESS ANXIETY DISORDER
• Preoccupied with being sick or with developing a
disease of some kind.
• It is a variant of somatic symptom disorder
• There are few or no somatic symptoms and persons
are "primarily concerned with the idea they are ill.”
• They usually resist psychiatric treatment; some prefer
to be treated in a medical setting
PSYCHOTHERAPY ___________________________________
• Stress reduction and education in coping with chronic
illness
• Group therapy
• Others: Insight-oriented Psychotherapy, Behavior
therapy, Cognitive therapy, Hypnosis
• Frequent, regularly scheduled physical examinations
controversial
o Some are reassured
o Others are resistant
PHARMACOTHERAPY ________________________________
• Alleviate anxiety
• Does not provide lasting relief
• Psychotherapy is more effective than
pharmacotherapy
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