stress and Anxiety Disorder

Stress And Anxiety Stress And Anxiety DisordersDisorders

ByBy Heba EssawyHeba Essawy

Definition Of StressDefinition Of Stress

Set of emotional, physical, and cognitive Set of emotional, physical, and cognitive ((ii..ee.., , thoughtthought) ) reactions to a changereactions to a change..

Stress as a reaction to change suggests that it is Stress as a reaction to change suggests that it is not necessarily bad,not necessarily bad,

Could even be a good thingCould even be a good thing..

Causes OfCauses Of StressStress

When person-environment transactions to: When person-environment transactions to: Perceive a discrepancy.Perceive a discrepancy. Whether real or not. Whether real or not. Between the demands of a situation and the Between the demands of a situation and the

resources of the person's.resources of the person's. Either biological, psychological or social Either biological, psychological or social

systemssystems

StressStress

In medical termsIn medical terms::

Stress is the disruption of homeostasis through Stress is the disruption of homeostasis through physical or psychological stimuli.physical or psychological stimuli.

Stressful stimuli can be mental, physiological, Stressful stimuli can be mental, physiological, anatomical or physical reactionsanatomical or physical reactions

Hans Selye, defined the General Adaptation Hans Selye, defined the General Adaptation Syndrome or GAS paradigm in 1936.Syndrome or GAS paradigm in 1936.

Types of stressTypes of stress

Richard Lazarus(1974) dividing stress into:Richard Lazarus(1974) dividing stress into:

- - EustressEustress and - and - Distress.Distress.

Eustress stressEustress stress : : Enhances function (physical or mental,) such as Enhances function (physical or mental,) such as

through strength training or challenging work. through strength training or challenging work.

Distress stressDistress stress : : Persistent stress that is not resolved through coping Persistent stress that is not resolved through coping

or adaptation may lead to escape anxiety or withdrawal or adaptation may lead to escape anxiety or withdrawal depression behavior.depression behavior.

Types Of StressTypes Of StressEustress, or positive stress, has the following characteristicsEustress, or positive stress, has the following characteristics :: Motivates, focuses energy Motivates, focuses energy Is short-term Is short-term Is perceived as within our coping abilities Is perceived as within our coping abilities Feels exciting Feels exciting Improves performanceImproves performanceIn contrast, Distress, or negative stress, has the following characteristics:In contrast, Distress, or negative stress, has the following characteristics: Causes anxiety or concern Causes anxiety or concern Can be short- or long-term Can be short- or long-term Is perceived as outside of our coping abilities Is perceived as outside of our coping abilities Feels unpleasant Feels unpleasant Decreases performance Decreases performance Can lead to mental and physical problems Can lead to mental and physical problems

General Adaptation SyndromeGeneral Adaptation Syndrome

RResearched mainly by esearched mainly by Hans SelyeHans Selye on rats on rats exposing animals to unpleasant or harmful stimuli exposing animals to unpleasant or harmful stimuli such as injections or extreme cold .such as injections or extreme cold .

He found that all animals showed a series of He found that all animals showed a series of reactions, broken into three stages. He describes reactions, broken into three stages. He describes this universal response to the stressors as the this universal response to the stressors as the General Adaption SyndromeGeneral Adaption Syndrome or or GASGAS in 1956. in 1956.

Stages Of StressStages Of Stress

Stage oneStage one: Alarm: Alarm the body's stress response is a state of alarm.the body's stress response is a state of alarm. During this stage adrenaline will be produced in order to bring about During this stage adrenaline will be produced in order to bring about

the fight-or-flight response.the fight-or-flight response. Activation of the HPA axis producing cortisol.Activation of the HPA axis producing cortisol.

Stage twoStage two: Resistance: Resistance If the stressor persists.If the stressor persists. Necessary to attempt means of coping with stress.Necessary to attempt means of coping with stress. The body begins The body begins toto try to adapt ,to the strains or demands of the try to adapt ,to the strains or demands of the

environment.environment. The body cannot keep this up , so its resources are gradually depleted.The body cannot keep this up , so its resources are gradually depleted.

Stages Of StressStages Of Stress Stage threeStage three: Exhaustion: Exhaustion All the body's resources are depleted.All the body's resources are depleted. The body is unable to maintain normal function. The body is unable to maintain normal function. At this point the initial At this point the initial autonomic nervous system symptomsautonomic nervous system symptoms may may

reappearreappear - sweating,- sweating, - raised heart rate .- raised heart rate .

If stage three is extended:If stage three is extended: long term damage may result as the capacity of the adrenal gland.long term damage may result as the capacity of the adrenal gland. The immune system is impaired and resulting in decompensation. The immune system is impaired and resulting in decompensation. The result can manifest itself in illnesses such asThe result can manifest itself in illnesses such as Ulcers, depression or cardiovascular problems.Ulcers, depression or cardiovascular problems.

Stages of A Stress ReactionStages of A Stress Reaction

Stage 1Stage 1: : RecognitionRecognition of environmental demand of environmental demand Stage 2Stage 2: : AppraisalAppraisal of the demand of the demand

by asking by asking : : 11) ) Does this event present a threat ? Does this event present a threat ?

22) ) Do we have the resources to cope with this Do we have the resources to cope with this event?event?

If we believe that the event is a threat , or if we we lack If we believe that the event is a threat , or if we we lack the means to effectively respond to the event, feeling the means to effectively respond to the event, feeling stressedstressed

Stage 3Stage 3: : Mobilization of the nervous Mobilization of the nervous systemsystem

Sympathetic nervous systemSympathetic nervous system automatically automatically signals our body to prepare for actionsignals our body to prepare for action..

The SyNS prepares for fighting or fleeing The SyNS prepares for fighting or fleeing by by triggering or activating the hypothalamictriggering or activating the hypothalamic--pituitarypituitary--adrenal axis, or HPA axis adrenal axis, or HPA axis (( brain's brain's 'stress circuit' 'stress circuit' ).).

Neurochemistry of General Neurochemistry of General Adaptation Syndrome Adaptation Syndrome

The body reacts to stress first by releasingThe body reacts to stress first by releasing:: Catecholamine hormones.Catecholamine hormones. Epinephrine and NorepinephrineEpinephrine and Norepinephrine Glucocorticoid hormones, cortisol and cortisone.Glucocorticoid hormones, cortisol and cortisone.

The hypothalamic-pituitary-adrenal axis (HPA); The hypothalamic-pituitary-adrenal axis (HPA); Involving the interactions of the hypothalamus, the pituitary gland, and Involving the interactions of the hypothalamus, the pituitary gland, and

the adrenal glands. the adrenal glands.

The HPA axis is believed to play a primary role in the body's reactions The HPA axis is believed to play a primary role in the body's reactions to stress by balancing hormone releases from the adrenaline-producing to stress by balancing hormone releases from the adrenaline-producing adrenal medulla, and from the corticosteroid-producing adrenal cortex.adrenal medulla, and from the corticosteroid-producing adrenal cortex.

Stress can significantly affect many of the body's immune systems, as Stress can significantly affect many of the body's immune systems, as can an individual's perceptions of, and reactions to, stress. can an individual's perceptions of, and reactions to, stress.

Biological Systems For Stress ReactionsBiological Systems For Stress Reactions

The hypothalamus is like a thermostat that The hypothalamus is like a thermostat that receives inputs about the body's internal receives inputs about the body's internal environmentenvironment..

If body functions are out of balance, the If body functions are out of balance, the hypothalamus sends messages to the ANS and hypothalamus sends messages to the ANS and to the pituitary gland to speed up or slow down to the pituitary gland to speed up or slow down relevant glands and organs to bring the body relevant glands and organs to bring the body back into balance at the setback into balance at the set--point appropriate to point appropriate to each system each system


The main job of the hypothalamus is to maintain the The main job of the hypothalamus is to maintain the homeostasis ashomeostasis as

Blood pressure, Blood pressure, Body temperature,Body temperature, Fluid balance,Fluid balance, Body weight,Body weight, Sexual activity, Sexual activity, SleepSleep//wakefulnesswakefulness EmotionsEmotions. .


Some of the hormones secreted by the hypothalamus Some of the hormones secreted by the hypothalamus and pituitary gland stimulate the limbic system,and pituitary gland stimulate the limbic system,

The limbic system is heavily interconnected with the The limbic system is heavily interconnected with the brain's frontal cortex,brain's frontal cortex,

The limbic system and the frontal lobes work together The limbic system and the frontal lobes work together to make possible the appraisals or judgments regarding to make possible the appraisals or judgments regarding whether or not a stressor is dangerous or exceeds our whether or not a stressor is dangerous or exceeds our coping abilitycoping ability

. . The combined limbicThe combined limbic//frontal system also influences frontal system also influences whether we fight, flee, or freeze in the presence of a whether we fight, flee, or freeze in the presence of a stressorstressor..

Factors Influencing the Stress ResponseFactors Influencing the Stress Response

Arousal Vs AnxietyArousal Vs Anxiety Physiological arousal is necessary to prime our bodies Physiological arousal is necessary to prime our bodies

for taking actionfor taking action.. If aroused increased in response to stressors, alertness If aroused increased in response to stressors, alertness

increases and attention sharpensincreases and attention sharpens.. Increasingly focused on the stressor itself, while other Increasingly focused on the stressor itself, while other

aspects of the environment fade into the backgroundaspects of the environment fade into the background.. A narrowed focus of attention towards a threat is A narrowed focus of attention towards a threat is

typically adaptive, as it allows to eliminate some of the typically adaptive, as it allows to eliminate some of the available responses available responses ..

Factors affecting ArousalFactors affecting Arousal

Amount of mental energy .Amount of mental energy . Baseline level of anxiety Baseline level of anxiety (( level of 'trait' level of 'trait'

anxietyanxiety)),, level of anticipatory anxiety level of anticipatory anxiety ((how worried we how worried we

are in advance of an upcoming eventare in advance of an upcoming event).).

""YerkesYerkes--Dodson CurveDodson Curve".".

A diagram suggests, increasing levels of arousal A diagram suggests, increasing levels of arousal initially improve performance, but there quickly initially improve performance, but there quickly comes a point of diminishing returnscomes a point of diminishing returns..

At high levels of stress, performance ability At high levels of stress, performance ability declines dramaticallydeclines dramatically..

Primary and Secondary AppraisalPrimary and Secondary Appraisal

Primary Appraisal : A stressor that is perceived Primary Appraisal : A stressor that is perceived as important will cause a stress reaction as important will cause a stress reaction ))""Does Does this matter for me?this matter for me?").").

Primary and Secondary AppraisalPrimary and Secondary Appraisal

In secondary appraisal: evaluate coping In secondary appraisal: evaluate coping resources resources ((ee..gg.., how healthy we are, how much , how healthy we are, how much energy we have, whether family and friends can energy we have, whether family and friends can help, our ability to rise to the challenge, and how help, our ability to rise to the challenge, and how much money or equipment we havemuch money or equipment we have)), our , our available options, and the possibilities we have available options, and the possibilities we have for controlling our situationfor controlling our situation.. If we believe that If we believe that we lack the coping resources necessary to deal we lack the coping resources necessary to deal with the situation, we will perceive it as negative with the situation, we will perceive it as negative stressstress

Appraisals Influence How You FeelAppraisals Influence How You Feel: : The Cognitive ModelThe Cognitive Model

Beliefs Beliefs ((driven by appraisal processdriven by appraisal process) ) strongly strongly

influence subsequent mood stateinfluence subsequent mood state.. Having the ability and resources to handle the Having the ability and resources to handle the

stressors , mood will be generally positive stressors , mood will be generally positive

Cognitive Model Cognitive Model

the letter the letter ""AA" " stands for an stands for an ""Activating EventActivating Event."." Activating Events are the stressors that create demands Activating Events are the stressors that create demands and cause potential stressand cause potential stress..

letter letter ""BB" " in the equation stands for in the equation stands for ""BeliefsBeliefs."." We We come into the world with no preconceivedcome into the world with no preconceived..

letter letter ""CC" " in the Ain the A++BB==C equation stands for C equation stands for ""ConsequencesConsequences."." Consequences refer to the feelings Consequences refer to the feelings that occur as a result of beliefs and selfthat occur as a result of beliefs and self--talk in response talk in response to the activating eventto the activating event..

Oxidative stressOxidative stress

CausesCauses:: An imbalance between the production of reactive oxygen An imbalance between the production of reactive oxygen

and a biological system's ability to detoxify the reactive and a biological system's ability to detoxify the reactive intermediates.intermediates.

Slow repair the resulting damage.Slow repair the resulting damage.

Oxidative stress is involved inOxidative stress is involved in:: Atherosclerosis.Atherosclerosis. Parkinson's disease.Parkinson's disease. Alzheimer's disease.Alzheimer's disease. Prevention of ageing by induction of a process named Prevention of ageing by induction of a process named

mitohormesis.mitohormesis.

Oxidative stressOxidative stress

PathophysiologyPathophysiology : : All forms of life maintain a reducing environment All forms of life maintain a reducing environment

within the cells.within the cells. Reducing environment is preserved by enzymes Reducing environment is preserved by enzymes

that maintain the reduced state through a constant that maintain the reduced state through a constant input of metabolic energy. input of metabolic energy.

Disturbances in this normal redox state can cause Disturbances in this normal redox state can cause toxic effects through the production of toxic effects through the production of peroxidesperoxides and and free radicalsfree radicals that damage all components of that damage all components of the cell, including proteins, lipids, and DNA.the cell, including proteins, lipids, and DNA.

Stress ScaleStress Scale

To measure stress according to the Holmes and Rahe To measure stress according to the Holmes and Rahe Stress ScaleStress Scale

Number of Number of ""Life Change UnitsLife Change Units" " that apply to events that apply to events in the past year of an individual's life are added in the past year of an individual's life are added

and final score will give a rough estimate of how stress and final score will give a rough estimate of how stress affects healthaffects health..

Score of 300+Score of 300+: At risk of illness.: At risk of illness. Score of 150-299+Score of 150-299+: Risk of illness is moderate (reduced : Risk of illness is moderate (reduced

by 30% from the above risk).by 30% from the above risk). Score 150-Score 150-: Only have a slight risk of illness.: Only have a slight risk of illness.

Life event Life event Life change units Life change units Death of a spouse100/Divorce73/Marital separation65Death of a spouse100/Divorce73/Marital separation65 Imprisonment63/Death of a close family member63/Personal injury or Imprisonment63/Death of a close family member63/Personal injury or

illness53/Marriage50/Dismissal from work47/illness53/Marriage50/Dismissal from work47/ Marital reconciliation45/Retirement45/Change in health of family Marital reconciliation45/Retirement45/Change in health of family

member44/Pregnancy40/Sexual difficulties39/member44/Pregnancy40/Sexual difficulties39/ Gain a new family member39Business readjustment39Change in financial Gain a new family member39Business readjustment39Change in financial

state38Change in frequency of arguments35state38Change in frequency of arguments35 Major mortgage32Foreclosure of mortgage or loan30Change in responsibilities at Major mortgage32Foreclosure of mortgage or loan30Change in responsibilities at

work29Child leaving home29work29Child leaving home29 Trouble with in-laws29Outstanding personal achievement28Spouse starts or stops Trouble with in-laws29Outstanding personal achievement28Spouse starts or stops

work26Begin or end school26Change in living conditions25Revision of personal work26Begin or end school26Change in living conditions25Revision of personal habits24Trouble with boss23Change in working hours or conditions20Change in habits24Trouble with boss23Change in working hours or conditions20Change in residence20Change in schools20Change in recreation19Change in church residence20Change in schools20Change in recreation19Change in church activities19Change in social activities18Minor mortgage or loan17Change in sleeping activities19Change in social activities18Minor mortgage or loan17Change in sleeping habits16Change in number of family reunions15Change in eating habits16Change in number of family reunions15Change in eating habits15Vacation13Christmas12Minor violation of law11habits15Vacation13Christmas12Minor violation of law11

http://en.wikipedia.org/wiki/Holmes_and_Rahe_stress_scale

http://en.wikipedia.org/wiki/Holmes_and_Rahe_stress_scale

Epidemiology Of Anxiety DisordersEpidemiology Of Anxiety Disorders

The most common mental illness .The most common mental illness . One of 4 person met the diagnosis for one One of 4 person met the diagnosis for one

the anxiety disorders.the anxiety disorders. In 12- month prevalence rate of 17.1%.In 12- month prevalence rate of 17.1%. Women have 30.5 % lifetime prevalence Women have 30.5 % lifetime prevalence

more affected than men ( 19.2%).more affected than men ( 19.2%).

Epidemiology Of Anxiety DisorderEpidemiology Of Anxiety Disorder

SEX: SEX: The female-to-male ratio for any lifetime anxiety disorder is 3:2.The female-to-male ratio for any lifetime anxiety disorder is 3:2.

AgeAge Most anxiety disorders begin in childhood, adolescence, and early adulthood.Most anxiety disorders begin in childhood, adolescence, and early adulthood. Separation anxiety is an anxiety disorder of childhood .Separation anxiety is an anxiety disorder of childhood . Panic disorder in the age groups of 15-24 years and 45-54 years.Panic disorder in the age groups of 15-24 years and 45-54 years. social phobia was 16 years.social phobia was 16 years. The age of onset for OCD appears to be in the mid 20s to early 30s. The age of onset for OCD appears to be in the mid 20s to early 30s.

New-onset anxiety symptoms in older adultsNew-onset anxiety symptoms in older adults : : unrecognized general medical condition.unrecognized general medical condition. substance abuse disorder.substance abuse disorder. Major depression with secondary anxiety symptoms.Major depression with secondary anxiety symptoms.

Classification of Anxiety DisordersClassification of Anxiety Disorders

Anxiety due to a general medical condition Anxiety due to a general medical condition Substance-induced anxiety disorder Substance-induced anxiety disorder Generalized anxiety Generalized anxiety Panic disorder Panic disorder Acute stress disorder Acute stress disorder Posttraumatic stress disorder (PTSD) Posttraumatic stress disorder (PTSD) Adjustment disorder with anxious features Adjustment disorder with anxious features Social phobia Social phobia Obsessive-compulsive disorder (OCD) Obsessive-compulsive disorder (OCD) Specific phobiasSpecific phobias

PathophysiologyPathophysiology

Anxiety disorders appear to be caused by an Anxiety disorders appear to be caused by an interaction of biopsychosocial factors.interaction of biopsychosocial factors.

Genetic vulnerability.Genetic vulnerability. Interaction with situations, stress, or trauma Interaction with situations, stress, or trauma

to produce clinically significant syndromes.to produce clinically significant syndromes.

Biological FactorsBiological Factors

Central nervous systemCentral nervous system: The major mediators of the : The major mediators of the symptoms of anxiety disorders:symptoms of anxiety disorders:

Norepinephrine .Norepinephrine . Serotonin.Serotonin. Peptides, such as corticotrophin-releasing factor.Peptides, such as corticotrophin-releasing factor.

PeripherallyPeripherally:: the autonomic nervous system, especially the the autonomic nervous system, especially the

sympathetic nervous system, mediates many of the sympathetic nervous system, mediates many of the symptoms.symptoms.

Causes of Anxiety DisordersCauses of Anxiety Disorders

Personal environment:Personal environment: - Poverty.- Poverty. - Early separation from the mother.- Early separation from the mother. - Family conflict.- Family conflict. - Critical and strict parents.- Critical and strict parents. Personality.Personality. Family dynamics.Family dynamics. Brain chemistry.Brain chemistry. Genetic vulnerability .Genetic vulnerability .

Risk Factor For AnxietyRisk Factor For Anxiety

Brain chemistryBrain chemistry:: Imbalance of neurotransmitters such as Imbalance of neurotransmitters such as

serotonin, GABA, and epinephrine may serotonin, GABA, and epinephrine may contribute to anxiety disorders. contribute to anxiety disorders.

Abnormalities in the stress hormone cortisol .Abnormalities in the stress hormone cortisol .


Personality traitsPersonality traits People with anxiety disorders often view People with anxiety disorders often view

themselves as powerless and the world as a themselves as powerless and the world as a threatening place.threatening place.

Pessimistic perspective can lead to low self-Pessimistic perspective can lead to low self-confidence and poor coping skills.confidence and poor coping skills.


Heredity Factor:Heredity Factor: Anxiety run in families.Anxiety run in families. People have a family history of anxiety People have a family history of anxiety

disorders, mood disorders, or substance .disorders, mood disorders, or substance . One risk factor may be a biological vulnerability One risk factor may be a biological vulnerability

to stress. to stress.

Risk factors for Anxiety Risk factors for Anxiety

Major life stressorsMajor life stressors Financial difficulties.Financial difficulties. Marital problems.Marital problems. Bereavement Bereavement It is important to realize that no single factor It is important to realize that no single factor

causes an anxiety disorder.causes an anxiety disorder. The various anxiety risk factors are interrelated The various anxiety risk factors are interrelated

and can interact with and impact one anotherand can interact with and impact one another..

Generalized Anxiety DisorderGeneralized Anxiety Disorder

Definition Definition :: GAD is defined as excessive anxiety and GAD is defined as excessive anxiety and

worry about several events or activities for worry about several events or activities for most days during at least 6- month period.most days during at least 6- month period.

Worry is difficult to control and is associated Worry is difficult to control and is associated with somatic symptoms, such as muscle with somatic symptoms, such as muscle tension, irritability, difficulty in sleeping and tension, irritability, difficulty in sleeping and restlessnes.restlessnes.


EpidemiologyEpidemiology One year prevalence range from 3 to 8%.One year prevalence range from 3 to 8%. Male : Female is 2 : 1.Male : Female is 2 : 1. Life Time prevalence is 5-8%.Life Time prevalence is 5-8%. 25% of all patients with anxiety is suffering GAD.25% of all patients with anxiety is suffering GAD. Onset : Late adolescence or early adulthoodOnset : Late adolescence or early adulthood GAD patients are seen @ primary care settings.GAD patients are seen @ primary care settings. Separation anxiety in childhood that includes anxiety Separation anxiety in childhood that includes anxiety

related to going to school, is one of the precursor for adult related to going to school, is one of the precursor for adult anxiety disordersanxiety disorders


Characterized by excessive anxiety and worry. Characterized by excessive anxiety and worry. Worrying is difficult to control.Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the Anxiety and worry are associated with at least 3 of the

following symptoms: following symptoms: Restlessness or feeling keyed-up or on edge Restlessness or feeling keyed-up or on edge Being easily fatigued Being easily fatigued Difficulty concentrating or mind going blank Difficulty concentrating or mind going blank Irritability Irritability Muscle tension Muscle tension Sleep disturbance Sleep disturbance Although not a diagnostic feature, suicidal ideation and completed Although not a diagnostic feature, suicidal ideation and completed

suicide have been associated with generalized anxiety disorder.suicide have been associated with generalized anxiety disorder.

PhysiologicalPhysiological Symptoms of GADSymptoms of GAD

Muscle tension. Muscle tension. -- Cognitive Vigilance Cognitive Vigilance Fatigue. Fatigue. -- Autonomic hyperactivity Autonomic hyperactivity Restlessness. Restlessness. -- Difficulty sleeping. Difficulty sleeping. Irritability. Irritability. --Edginess.Edginess. Gastrointestinal discomfortGastrointestinal discomfort or diarrheaor diarrhea..

Lab StudiesLab Studies in GAD in GAD

CBC count .CBC count . Chemistry profile .Chemistry profile . Thyroid function tests. Thyroid function tests. Urinalysis .Urinalysis . Urine drug screen.Urine drug screen.

Treatment Of GADTreatment Of GAD

The most effective treatment is the combination of The most effective treatment is the combination of psychotherapy , pharmacotherapy and supportive psychotherapy , pharmacotherapy and supportive approachesapproaches..

Behavior TherapyBehavior Therapy ** To modify and gain control over unwanted behavior. To modify and gain control over unwanted behavior. **The individual learns to cope with difficult situations, The individual learns to cope with difficult situations,

often through controlled exposure to them.often through controlled exposure to them. ** Gives the individual a sense of having control over their Gives the individual a sense of having control over their

life.life.

Treatment Of GADTreatment Of GAD

Cognitive TherapyCognitive TherapyThe goal of Cognitive Therapy:The goal of Cognitive Therapy:

To change unproductive or harmful thought To change unproductive or harmful thought patterns. patterns.

The individual examines his feelings and learns The individual examines his feelings and learns to separate realistic from unrealistic thoughts.to separate realistic from unrealistic thoughts.

As with Behavior Therapy, the individual is As with Behavior Therapy, the individual is actively involved in his own recovery and has a actively involved in his own recovery and has a sense of control. sense of control.

Cognitive Behavioral TherapyCognitive Behavioral Therapy

CBT examines distortions in our ways of looking CBT examines distortions in our ways of looking at the world and ourselvesat the world and ourselves

Negative thoughts lead to negative emotions, so Negative thoughts lead to negative emotions, so CBT aims to change those negative thoughts CBT aims to change those negative thoughts before they trigger psychological difficulties.before they trigger psychological difficulties.

CBT for generalized anxiety disorder involves CBT for generalized anxiety disorder involves retraining the way you think.retraining the way you think.

Therapist identify automatic negative thoughts Therapist identify automatic negative thoughts that contribute to your anxiety. that contribute to your anxiety.


EducationEducation:: CBT teaches you about the cognitive, physical, and CBT teaches you about the cognitive, physical, and

behavioral .behavioral . Teaches you how to distinguish between helpful and Teaches you how to distinguish between helpful and

unhelpful worry. unhelpful worry. An increased understanding of anxiety encourages a more An increased understanding of anxiety encourages a more

accepting and proactive response to it.accepting and proactive response to it.MonitoringMonitoring Learn to monitor anxiety, including what triggers it.Learn to monitor anxiety, including what triggers it. Specific things you worry about, and the severity and Specific things you worry about, and the severity and

length of a particular episode.length of a particular episode. This get perspective, as well as track your progress. This get perspective, as well as track your progress.


Physical control strategiesPhysical control strategies:: Deep breathing and progressive muscle relaxation help decrease Deep breathing and progressive muscle relaxation help decrease

the physical over-arousal of the “fight or flight” response that the physical over-arousal of the “fight or flight” response that maintains the state of fear and anxiety.maintains the state of fear and anxiety.

Cognitive control strategiesCognitive control strategies:: Realistically evaluate and alter the thinking patterns that Realistically evaluate and alter the thinking patterns that

contribute to anxietycontribute to anxiety Challenge these negative thoughts, fears will begin to subside. Challenge these negative thoughts, fears will begin to subside.

CBT also teaches you to test the beliefs you have about worry CBT also teaches you to test the beliefs you have about worry itself, such as “Worry is uncontrollable” or “If I worry, bad itself, such as “Worry is uncontrollable” or “If I worry, bad things are less likely to happen.” things are less likely to happen.”


Behavioral strategiesBehavioral strategies:: Instead of avoiding situations you fear.Instead of avoiding situations you fear. CBT teaches to tackle them .CBT teaches to tackle them . Start by imagining the thing you’re most afraid of. Start by imagining the thing you’re most afraid of. By focusing on your fears without trying to avoid By focusing on your fears without trying to avoid

or escape them.or escape them.

---------→---------→ Feeling more in control and less Feeling more in control and less anxiousanxious. .

Relaxation TechniquesRelaxation Techniques

Help to develop the ability to more effectively Help to develop the ability to more effectively cope with the stresses that contribute to anxiety.cope with the stresses that contribute to anxiety.

as well as with some of the physical symptoms as well as with some of the physical symptoms of anxiety. of anxiety.

The techniques taught include breathing re-The techniques taught include breathing re-training and exercise.training and exercise.

BiofeedbackBiofeedback

What Exactly is Biofeedback?What Exactly is Biofeedback? Biofeedback is a self-training, mind-over-Biofeedback is a self-training, mind-over-

body technique developed in the 1940s.body technique developed in the 1940s.

It's a method in which we consciously It's a method in which we consciously control a body function that normally is control a body function that normally is regulated automatically by the body like regulated automatically by the body like skin temperature, heart rate, or blood skin temperature, heart rate, or blood pressure.pressure.

PharmacotherapyPharmacotherapy

Selective Serotonin Reuptake InhibitorsSelective Serotonin Reuptake Inhibitors : : CitalopramCitalopramEscitalopramEscitalopramFluvoxamineFluvoxamineParoxetineParoxetineFluoxetineFluoxetineSertraline . Sertraline .

Affects the concentration serotonin linked Affects the concentration serotonin linked to anxiety disorders to anxiety disorders


Tricyclic Antidepressants (TCAsTricyclic Antidepressants (TCAs

Affects the concentration and activity of the Affects the concentration and activity of the neurotransmitters serotonin and norepinephrine, neurotransmitters serotonin and norepinephrine, chemicals in the brain thought to be linked to chemicals in the brain thought to be linked to anxiety disorders .anxiety disorders .


Monoamine Oxidase Inhibitors (MAOIsMonoamine Oxidase Inhibitors (MAOIs Blocks the effect of an important brain enzyme, preventing Blocks the effect of an important brain enzyme, preventing

the breakdown of serotonin and Norepinephrine)the breakdown of serotonin and Norepinephrine) Other AntidepressantsOther Antidepressants CymbaltaCymbalta

Desyrel *Desyrel *Effexor †Effexor †Remeron Remeron

Affects the concentration of the neurotransmitters serotonin Affects the concentration of the neurotransmitters serotonin and/or norepinephrine, chemicals in the brain thought to and/or norepinephrine, chemicals in the brain thought to be linked to anxiety disorders be linked to anxiety disorders


AzapironesAzapirones (BuSpar) :Enhances the activity of (BuSpar) :Enhances the activity of serotonin . serotonin .

** BenzodiazepinesBenzodiazepines:: Exact mechanism unknown. Exact mechanism unknown.

Some research shown to enhance the function Some research shown to enhance the function of gamma aminobutyric acid (GABA).of gamma aminobutyric acid (GABA).

AntihistaminesAntihistamines :Sedative effects through :Sedative effects through blockade of histamine receptors in the brain .blockade of histamine receptors in the brain .


Beta BlockersBeta Blockers: Blocks receptors associated with : Blocks receptors associated with physiologic symptoms of anxiety. physiologic symptoms of anxiety.

Atypical AntipsychoticsAtypical Antipsychotics : : Augmentation therapy.Augmentation therapy. These medications may be added when These medications may be added when

symptoms only partially respond to another symptoms only partially respond to another medication to increase the overall response to medication to increase the overall response to treatmenttreatment

THANK YOUTHANK YOU

Anxiety DisordersAnxiety Disorders:: unpleasant emotional state,unpleasant emotional state, sources of which are less readily identified.sources of which are less readily identified. It is frequently accompanied by physiological It is frequently accompanied by physiological

symptomssymptoms lead to lead to fatiguefatigue or even or even exhaustionexhaustion. .

http://en.wikipedia.org/wiki/Fatigue_%28physical%29

http://en.wikipedia.org/wiki/Exhaustion

Panic DisorderPanic Disorder

ByBy Heba EssawyHeba Essawy

Panic disorderPanic disorder

Background Background Panic attacks:Panic attacks: A period of intense fear in which 4 of 13 defined symptoms.A period of intense fear in which 4 of 13 defined symptoms. Develop abruptly and peak rapidly less than 10 minutes . Develop abruptly and peak rapidly less than 10 minutes . Cannot result from substance use, medical conditions, or Cannot result from substance use, medical conditions, or

another psychiatric disorderanother psychiatric disorder . . The frequency can vary from several attacks a day to only a The frequency can vary from several attacks a day to only a

few attacks a year.few attacks a year. Is qualified with the presence or absence of agoraphobiaIs qualified with the presence or absence of agoraphobia . .

Panic Disorder With Agoraphobia Panic Disorder With Agoraphobia

Agoraphobia isAgoraphobia is:: Anxiety toward places or situations in Anxiety toward places or situations in

which escape may be difficult or which escape may be difficult or embarrassing.embarrassing.

These anxiety-provoking situations are These anxiety-provoking situations are avoided or are endured with anxiety. avoided or are endured with anxiety.

Agoraphobia is not a stand-alone disorder; Agoraphobia is not a stand-alone disorder; it is a descriptive term .it is a descriptive term .

DSM-IV-TRDSM-IV-TR Criteria For panic Criteria For panic Attack Attack

Uncoded , 4 or more symptomsUncoded , 4 or more symptoms Palpitations, pounding heart, or accelerated heart rate Palpitations, pounding heart, or accelerated heart rate Sweating Sweating Trembling or shaking Trembling or shaking Sense of shortness of breath or smothering Sense of shortness of breath or smothering Feeling of choking Feeling of choking Chest pain or discomfort Chest pain or discomfort Nausea or abdominal distress Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Feeling dizzy, unsteady, lightheaded, or faint Derealization or depersonalization (feeling detached from oneself) Derealization or depersonalization (feeling detached from oneself) Fear of losing control or going crazy Fear of losing control or going crazy Fear of dying Fear of dying Numbness or tingling sensations. Numbness or tingling sensations. Chills or hot flashes.Chills or hot flashes.

Diagnosis Of Panic DisorderDiagnosis Of Panic Disorder

Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text RevisionDisorders, Fourth Edition, Text Revision::

Recurrent unexpected panic attacks Recurrent unexpected panic attacks One of attacks has been followed for more than 1 One of attacks has been followed for more than 1

month :month : ** subsequent persistent worry about having subsequent persistent worry about having

another attack.another attack. ** Consequences of the attack. Consequences of the attack. ** Significant behavioral changes related to the Significant behavioral changes related to the

attack.(Loosing control, having heart attack.) attack.(Loosing control, having heart attack.)

Pathophysiology Of Panic : Pathophysiology Of Panic : BiologicalBiological

Serotonergic modelSerotonergic model: : 5HT system or one of its subsystems may 5HT system or one of its subsystems may

play a role in the pathophysiology of panic play a role in the pathophysiology of panic disorder, disorder,

Exaggerated postsynaptic receptor Exaggerated postsynaptic receptor response to synaptic serotonin. response to synaptic serotonin.

Recent studies report subsensitivity of Recent studies report subsensitivity of 5HT1A receptors. 5HT1A receptors.

Pathophysiology Of Panic : Bio.Pathophysiology Of Panic : Bio.

Catecholamine modelCatecholamine model : : ** Increased sensitivity to adrenergic CNS Increased sensitivity to adrenergic CNS

discharges, with hypersensitivity of presynaptic discharges, with hypersensitivity of presynaptic alpha-2 receptors. alpha-2 receptors.

Locus ceruleus modelLocus ceruleus model:: ** Increased local discharge resulting in adrenergic Increased local discharge resulting in adrenergic

neuron stimulation. neuron stimulation. ** Affects hypothalamic-pituitary-adrenal axis, Affects hypothalamic-pituitary-adrenal axis,

which can respond abnormally to clonidine in which can respond abnormally to clonidine in patients with panic disorder. patients with panic disorder.


Panic inducing substances → Respiratory stimulation →shift Panic inducing substances → Respiratory stimulation →shift acid- base balanceacid- base balance

SodiumSodium Lactates Lactates : focuses on symptom production by : focuses on symptom production by postulated aberrant metabolic activity induced by lactate. postulated aberrant metabolic activity induced by lactate.

Carbon dioxide (False suffocation hypothesis)Carbon dioxide (False suffocation hypothesis): explains : explains panic phenomena by hypersensitive alarm system by↑ co2 panic phenomena by hypersensitive alarm system by↑ co2 and Lactate activate asphyxia monitor @ brain stem and Lactate activate asphyxia monitor @ brain stem receptors. receptors.

Bicarbonate.Bicarbonate.Act through neurotransmitters include yohimbine , Act through neurotransmitters include yohimbine , αα2- 2-

adrenergic , mCPP, cholecystokinine adrenergic , mCPP, cholecystokinine


GABA modelGABA model:: postulates decreased inhibitory postulates decreased inhibitory receptor sensitivity, with a resultant excitatory receptor sensitivity, with a resultant excitatory effect. effect.

The neuroanatomic modelThe neuroanatomic model: : * Mediated by a "fear network" in the brain that * Mediated by a "fear network" in the brain that

involves the amygdala, the hypothalamus, and the involves the amygdala, the hypothalamus, and the brainstem centers. brainstem centers.

*Cortical atrophy @ rt. Temporal lobe *Cortical atrophy @ rt. Temporal lobe The genetic hypothesisThe genetic hypothesis :MZ>DZ. :MZ>DZ. Definable genetic loci ??Definable genetic loci ??


Mitral valve prolapse:Mitral valve prolapse:

Heterogeneous disorder.Heterogeneous disorder.

Prolapsed one leaflets.Prolapsed one leaflets.

Mid-Systolic click.Mid-Systolic click.

Psychological FactorsPsychological Factors Cognitive- Behavioral TheoriesCognitive- Behavioral Theories:: - Learned from parental behavior - Learned from parental behavior - through classic conditioning- through classic conditioning Psychoanalytic TheoriesPsychoanalytic Theories:: - Unsuccessful defense against anxiety.- Unsuccessful defense against anxiety. - Agoraphobia due to- Agoraphobia due to ** loss of a parent in childhood and history of loss of a parent in childhood and history of

separation anxiety.separation anxiety. ** Parental separation in childhood. Parental separation in childhood. **Death of the parent before 10ys. Death of the parent before 10ys.

Demographic DataDemographic Data

PrevalencePrevalence : 1.5-5% for panic disorder . : 1.5-5% for panic disorder . 3-5.6% for panic attacks3-5.6% for panic attacks.. Race:Race: * * African Americans presenting with somatic African Americans presenting with somatic

symptoms .symptoms . ** seeking help in medical settings. seeking help in medical settings. SexSex: One-month prevalence women:men, 0.7%: 0.3% : One-month prevalence women:men, 0.7%: 0.3%

(1: 2-3 folds) . (1: 2-3 folds) . AgeAge : : ** Bimodal distribution. Bimodal distribution. ** Highest incidence in late adolescence . Highest incidence in late adolescence . ** Second peak in the mid 30s. Second peak in the mid 30s.

Patterns of Panic AttacksPatterns of Panic Attacks

Unexpected panic attacks have no known precipitating cue Unexpected panic attacks have no known precipitating cue → → panic disorder without agoraphobiapanic disorder without agoraphobia..

Situationally bound (cued) panic attacks recur predictably Situationally bound (cued) panic attacks recur predictably in temporal relationship to the trigger →in temporal relationship to the trigger →specific phobia-specific phobia-type diagnosis.type diagnosis.

Situationally predisposed panic attacks are more likely to Situationally predisposed panic attacks are more likely to occur in relation to a given trigger, with inability to escape occur in relation to a given trigger, with inability to escape → → panic disorder with agoraphobiapanic disorder with agoraphobia..

Use of caffeine, alcohol, nicotine, or other substances can Use of caffeine, alcohol, nicotine, or other substances can trigger or potentiate panic attacks.trigger or potentiate panic attacks.

Comorbidities Of PanicComorbidities Of Panic

Panic disorder often coexists with mood disorders.Panic disorder often coexists with mood disorders. Alcohol and other substance use disorders are a sequelae Alcohol and other substance use disorders are a sequelae

of panic disorderof panic disorder MMedical conditions :edical conditions : Mitral valve prolapse.Mitral valve prolapse. Hypertension.Hypertension. Cardiomyopathy . Cardiomyopathy . Chronic obstructive pulmonary disorder,Chronic obstructive pulmonary disorder, Irritable bowel syndrome.Irritable bowel syndrome. Migraine headache.Migraine headache.

PharmacothearapyPharmacothearapy

Selective serotonin reuptake inhibitors (SSRIs) are Selective serotonin reuptake inhibitors (SSRIs) are generally used as first-line agents.generally used as first-line agents.

followed by tricyclics.followed by tricyclics. **Benzodiazepines can achieve long-term control but Benzodiazepines can achieve long-term control but

should be reserved for patients with refractory panic should be reserved for patients with refractory panic disorder.disorder.

Fluoxetine (Prozac) can be used at very low starting Fluoxetine (Prozac) can be used at very low starting doses. doses.

**Paroxetine (Paxil) has a more sedating effect, potentially Paroxetine (Paxil) has a more sedating effect, potentially making its potential aggravation of anxiety better tolerated making its potential aggravation of anxiety better tolerated initially. Drug alter metabolism of cytochrome P-450 -2D. initially. Drug alter metabolism of cytochrome P-450 -2D.

Cognitive and behavioral Cognitive and behavioral psychotherapypsychotherapy

Cognitive therapy :Cognitive therapy : Understand false beliefs/distortions .Understand false beliefs/distortions . Provides information about panic attacks.Provides information about panic attacks. Behavioral therapyBehavioral therapy ; ; Involves sequentially greater exposure of the patient to Involves sequentially greater exposure of the patient to

anxiety-provoking stimuli; over time, the patient becomes anxiety-provoking stimuli; over time, the patient becomes desensitized to the experience.desensitized to the experience.

Relaxation techniquesRelaxation techniques : : Control patients' levels of anxiety. Control patients' levels of anxiety. Respiratory trainingRespiratory training Control hyperventilation during panic attacks. Control hyperventilation during panic attacks.

Specific PhobiaSpecific Phobia

An excessive fear of a specific object, An excessive fear of a specific object, circumstance , or situation.circumstance , or situation.

Specific phobia is a strong , persistent fear of Specific phobia is a strong , persistent fear of an object or situation.an object or situation.

Person with specific phobia may anticipate Person with specific phobia may anticipate harm ( bitten by dog, fainting).harm ( bitten by dog, fainting).

Social phobiaSocial phobia

Intense, irrational and persistent fear of being Intense, irrational and persistent fear of being

criticized or negatively evaluated by others.criticized or negatively evaluated by others. Feared social or performance situations typically Feared social or performance situations typically

provoke an immediate anxious reaction ranging provoke an immediate anxious reaction ranging from diffuse apprehension to situational panic.from diffuse apprehension to situational panic.

To meet the diagnostic criteria for this disorder, To meet the diagnostic criteria for this disorder, the symptoms must be severe enough to cause the symptoms must be severe enough to cause significant distress or disability . significant distress or disability .

Diagnostic Criteria for Social Phobia Diagnostic Criteria for Social Phobia

A. A marked and persistent fear of one or more social or performance A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. possible scrutiny by others.

The individual fears will be humiliating or embarrassing. The individual fears will be humiliating or embarrassing. note: In children, there must be evidence of the capacity for age-note: In children, there must be evidence of the capacity for age-

appropriate social relationships with familiar people and the anxiety appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.must occur in peer settings, not just in interactions with adults.

B. Exposure to the feared social situation almost invariably provokes B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or anxiety, which may take the form of a situationally bound or situationally predisposed panic attack.situationally predisposed panic attack.

note: In children, the anxiety may be expressed by crying, tantrums, note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people freezing, or shrinking from social situations with unfamiliar people

Diagnostic Criteria for Social PhobiaDiagnostic Criteria for Social Phobia

C. The person recognizes that the fear is excessive or unreasonable.C. The person recognizes that the fear is excessive or unreasonable. NOTE: In children, this feature may be absent.NOTE: In children, this feature may be absent.

D. The feared social or performance situations are avoided or else are D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.endured with intense anxiety or distress.

E. The avoidance, anxious anticipation interferes significantly with the E. The avoidance, anxious anticipation interferes significantly with the person's normal routine, occupational (academic) functioning .person's normal routine, occupational (academic) functioning .

F. In individuals under 18 years of age, the duration is at least six F. In individuals under 18 years of age, the duration is at least six months.months.

G. The fear or avoidance is not due to the direct physiologic effects of a G. The fear or avoidance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder .condition and is not better accounted for by another mental disorder .

Diagnostic Criteria for Social PhobiaDiagnostic Criteria for Social Phobia

H. If a general medical condition or another H. If a general medical condition or another mental disorder is present, the fear in Criterion A is mental disorder is present, the fear in Criterion A is unrelated to it; (e.g., the fear is not of stuttering, unrelated to it; (e.g., the fear is not of stuttering, trembling in Parkinson's disease or exhibiting trembling in Parkinson's disease or exhibiting abnormal eating behavior in anorexia nervosa or abnormal eating behavior in anorexia nervosa or bulimia nervosa.)bulimia nervosa.)

Specify if:Specify if:Generalized: if the fears include most social Generalized: if the fears include most social situations (also consider the additional diagnosis situations (also consider the additional diagnosis of avoidant personality disorder).of avoidant personality disorder).

Common Fears in Social Phobia Common Fears in Social Phobia

Public speaking or performing.Public speaking or performing. Making "small talk.Making "small talk.

**Small group discussion.Small group discussion. **Asking questions in groups.Asking questions in groups. * *Being introduce.Being introduce. **Meeting or talking with strangers.Meeting or talking with strangers. * *Being assertivenessBeing assertiveness. .

Common Fears in Social PhobiaCommon Fears in Social Phobia

Being watched doing something (e.g., Being watched doing something (e.g., eating, writing).eating, writing).**Attending social gatheringsAttending social gatherings **Using the telephoneUsing the telephone **Using public restroomsUsing public restrooms **Interacting with "important" peopleInteracting with "important" people **Indirect evaluation (e.g., test taking) Indirect evaluation (e.g., test taking)

Epidemiology Epidemiology

lifetime prevalence rate of 13.3 percent .lifetime prevalence rate of 13.3 percent . One-year prevalence rate of 7.9 percent. One-year prevalence rate of 7.9 percent. It s the third most prevalent psychiatric It s the third most prevalent psychiatric

disorder, following substance abuse and disorder, following substance abuse and depression.depression.

Fears of public speaking or performing are Fears of public speaking or performing are most prevalentmost prevalent. .

Onset of social phobiaOnset of social phobia

Occurs between 11 and 19 years of age.Occurs between 11 and 19 years of age. Onset after age 25 is rare, until some new social or Onset after age 25 is rare, until some new social or

occupational demand forces these persons into occupational demand forces these persons into social encounters that trigger the syndrome. social encounters that trigger the syndrome.

(e.g., meeting new people, public speaking, (e.g., meeting new people, public speaking, promotion).promotion).

Slightly more females than males have social Slightly more females than males have social phobia.phobia.

Comorbidity OfComorbidity Of social phobia social phobia

* * One half of patients with have comorbid mental, One half of patients with have comorbid mental, drug or alcohol problems.drug or alcohol problems.

70% had comorbid major depression.70% had comorbid major depression. Up to 16 % of patients who present with social Up to 16 % of patients who present with social

phobia have alcohol abuse problems.phobia have alcohol abuse problems. Patients presenting for treatment of substance Patients presenting for treatment of substance

abuse meet the criteria for social phobia.abuse meet the criteria for social phobia. longitudinal data show that social phobia longitudinal data show that social phobia

precedes approximately 70 percent of these precedes approximately 70 percent of these comorbid condition.comorbid condition.

Drugs Used in Treating Social Drugs Used in Treating Social Phobia Phobia

MAOIsMAOIs Phenelzine (Nardil) 45 to 90 mg / dayPhenelzine (Nardil) 45 to 90 mg / day

Tranylcypromine (Parnate) 40 to 60 mg / dayTranylcypromine (Parnate) 40 to 60 mg / day SSRIsSSRIs Fluoxetine (Prozac) 10 to 100 mg / day..Fluoxetine (Prozac) 10 to 100 mg / day.. Paroxetine (Paxil) 20 to 60 mg / day Paroxetine (Paxil) 20 to 60 mg / day Sertraline (Zoloft) 50 to 200 mg / day Sertraline (Zoloft) 50 to 200 mg / day Fluvoxamine (Luvox) 50 to 150 mg /dayFluvoxamine (Luvox) 50 to 150 mg /day Citalopram (Celexa) 40 mg / dayCitalopram (Celexa) 40 mg / day

Drugs Used in Treating Social Drugs Used in Treating Social PhobiaPhobia

BenzodiazepinesBenzodiazepines Alprazolam (Xanax) 2 to 10 mg / day Alprazolam (Xanax) 2 to 10 mg / day Lorazepam (Ativan) 2 to 6 mg /day Lorazepam (Ativan) 2 to 6 mg /day Clonazepam (Klonopin) 1 to 3 mg / day Clonazepam (Klonopin) 1 to 3 mg / day

Nonbenzodiazepine, azaspironeNonbenzodiazepine, azaspirone Buspirone (Buspar) 35 to 60 mg / dayBuspirone (Buspar) 35 to 60 mg / day

Beta blockersBeta blockers Propranolol (Inderal) 40 mg as neededPropranolol (Inderal) 40 mg as needed

Components of Cognitive Behavior Components of Cognitive Behavior Therapy for Social Phobia Therapy for Social Phobia

Anxiety management skillsAnxiety management skillsMay involve controlled breathing, relaxation exerciseMay involve controlled breathing, relaxation exercise

Social skills trainingSocial skills training verbal and nonverbal skills that facilitate social effectiveness, verbal and nonverbal skills that facilitate social effectiveness, such as initiating and maintaining conversation, making such as initiating and maintaining conversation, making appropriate eye contact .appropriate eye contact .

Cognitive restructuringCognitive restructuringInvolves learning to identify, challenge and change fearful Involves learning to identify, challenge and change fearful thinking that overestimates social threat, underestimates one's thinking that overestimates social threat, underestimates one's ability to manage social demands and catastrophizes the ability to manage social demands and catastrophizes the consequences of social miscuesconsequences of social miscues

Gradual exposure to feared situationsGradual exposure to feared situationsInvolves gradual reentry into feared social situations to reduce Involves gradual reentry into feared social situations to reduce the anxiety that they engender the anxiety that they engender

THANK YOUTHANK YOU

THANK YOUTHANK YOU

Lab Studies in GADLab Studies in GAD

Initial lab studies might be limited to the following: Initial lab studies might be limited to the following: CBC count .CBC count . Chemistry profile. Chemistry profile. Thyroid function tests. Thyroid function tests. Urinalysis .Urinalysis . Urine drug screen.Urine drug screen.


SertralineSertraline -- First drug approved by FDA for PTSD. May be -- First drug approved by FDA for PTSD. May be effective in reducing some symptoms in at least some patients. effective in reducing some symptoms in at least some patients.

Adult Dose : Adult Dose : 50-200 mg PO qd .50-200 mg PO qd . Pediatric Dose: Pediatric Dose: Not establishedNot established Contraindications: Contraindications: Documented hypersensitivity.Documented hypersensitivity. Interactions; Interactions; Increases toxicity of MAOIs, diazepam and Increases toxicity of MAOIs, diazepam and

warfarin, due to inhibition of cytochrome P-450 enzymes .warfarin, due to inhibition of cytochrome P-450 enzymes . Pregnancy : Pregnancy : not established.not established. Precautions Precautions Caution in preexisting seizure disorders, recent Caution in preexisting seizure disorders, recent

myocardial infarction, unstable heart disease, and hepatic or renal myocardial infarction, unstable heart disease, and hepatic or renal impairmentimpairment

ParoxetineParoxetine – – For PTSD, causing reduction in reexperiencing, For PTSD, causing reduction in reexperiencing,

numbing/avoidance, and hyperarousal.numbing/avoidance, and hyperarousal. Adult DoseAdult Dose starting dose: 20 mg/d PO; if indicated, starting dose: 20 mg/d PO; if indicated,

may be increased in 10-mg increments at intervals may be increased in 10-mg increments at intervals >>1 1 wk; doses from 20-50 mg are effective .wk; doses from 20-50 mg are effective .

Pediatric Dose: Pediatric Dose: Not established.Not established. Contraindications: Contraindications: MAOIs or thioridazine. MAOIs or thioridazine. Precautions: Precautions: Caution in history of seizures, mania, Caution in history of seizures, mania,

renal disease, and cardiac disease; the CR product renal disease, and cardiac disease; the CR product should not exceed 50 mg/d for elderly, debilitated, or should not exceed 50 mg/d for elderly, debilitated, or severely renally or hepatically impaired personsseverely renally or hepatically impaired persons

ParoxetineParoxetine InteractionsInteractions : Avoid alcohol, tryptophan, and : Avoid alcohol, tryptophan, and

thioridazine; avoid within 14 d of MAOIs; may thioridazine; avoid within 14 d of MAOIs; may inhibit metabolism of TCAs; inhibit metabolism of TCAs;

- May change concentrations with plasma-bound - May change concentrations with plasma-bound drugs; hyperreflexia, weakness, and incoordination drugs; hyperreflexia, weakness, and incoordination have been reported ;have been reported ;

- Monitor theophylline; caution with lithium, - Monitor theophylline; caution with lithium, digoxin, diuretics, cimetidine, phenobarbital, digoxin, diuretics, cimetidine, phenobarbital, warfarin, phenytoin, quinidine, and drugs warfarin, phenytoin, quinidine, and drugs metabolized by CYP-450 2D6 (eg, type 1C metabolized by CYP-450 2D6 (eg, type 1C antiarrhythmics, phenothiazines, antidepressants)antiarrhythmics, phenothiazines, antidepressants)

PregnancyPregnancy : - not established. : - not established.

Phenelzine Phenelzine for symptoms of panic disorders. for symptoms of panic disorders. Adult Dose Adult Dose starting dose: 1 tab (15 mg) PO tid; lower starting doses are starting dose: 1 tab (15 mg) PO tid; lower starting doses are

advised in patients sensitive to medications (ie, the 7% of the population who advised in patients sensitive to medications (ie, the 7% of the population who are slow metabolizers) are slow metabolizers)

Pediatric Dose: Pediatric Dose: Not established Not established Contraindications : Contraindications : Documented hypersensitivity; alcoholism, Documented hypersensitivity; alcoholism,

congestive heart failure, and pheochromocytoma.congestive heart failure, and pheochromocytoma. Interactions :Interactions :Co administration with foods containing tyramine can increase Co administration with foods containing tyramine can increase

blood pressure; concurrent use with tryptophan should be approached with blood pressure; concurrent use with tryptophan should be approached with caution because serotonin syndrome may result; may enhance therapeutic and caution because serotonin syndrome may result; may enhance therapeutic and toxic response of meperidine, and concomitant administration of these drugs toxic response of meperidine, and concomitant administration of these drugs should be avoided.should be avoided.

Pregnancy Pregnancy - not established. - not established. Precautions: Precautions: monitor for postural hypotension; convulsion . monitor for postural hypotension; convulsion .

stress and Anxiety Disorder

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