(Generalized Anxiety) It is a subjective feeling of fear or apprehension usually accompanied by autonomic system hyperactivity & physical discomfort. NB: Anxiety is a normal emotion which in a moderate degree can be a helpful force by increasing effort & alertness. It is also protective function in the face of danger. It becomes pathological when symptoms are out of proportion to external circumstances or if persist long after a threatening situation. Also normal anxiety is less severe & of longer duration than pathological anxiety. Lastly normal anxiety improve performance but pathological anxiety decrease it. Types & Differential diagnosis: - Normal Anxiety it is a universal feeling, see above. - Anxiety neurosis. - Anxiety symptoms secondary to other psychiatric diseases e.g. depression, hysteria, schizophrenia, mania. - Anxiety secondary to medical diseases: e.g. thyrotoxicosis, pheochromcytoma, cerebral atherosclerosis, mitral valve prolapse, hypoglycemia, angina, bronchial asthma, alcohol & drug withdrawal. Etiology: 1- Heredity: increase rate among twins. 2- Learnt response: child learn to be anxious in situations which they experience as threatening. 3- Physiological basis: increase level of catecholamines 4- Psychological basis: A continuous conflict which pushes the individual beyond the last limit of adaptation. 5- Personality: obsessive personality are more liable. Clinical picture of anxiety disorders: A- Psychological symptoms: - Unexplained fears apprehension, irritability. - Insomnia, night mares. B- Somatic manifestations: CVS: Tachycardia. Lt mammary pain, systolic hypertension. GIT: Nausea, Vomiting, indigestion, diarrhea, anorexia. Chest: Sighing, tightness, hyperventilation resulting sometimes in tetany & numbness (Hyperventilation syndrome) Urogenital: Frequency, dysmenorrhea, impotence, premature ejaculation. Nervous System: Headache, tremors, hyperreflexia. Muscles: Pains due to muscular spasm. Skin: Rashes, urticaria, & neurodermatitis C- Cognitive manifestations: - Lack of concentration - Lack of remembering & recall - Decreased ability to learn D- Psychosomatic illness: - Bronchial asthma, CHD, ulcerative colitis, peptic ulcer. - Psychosomatic illness usually occur with chronic generalized anxiety. Classification of Anxiety Disorders: 1. Generalized Anxiety: (chronic persistent anxiety). 2. Panic Disorders (acute anxiety): - Recurrent attacks of severe anxiety which are sudden & unpredictable - They are not related to a particular situations - They may lead to secondary agoraphobia i.e. fear of being in open spaces, outside the home a loner in a crowd. Diagnostic C/P for panic disorder (At Least 4 of the following features must be present during the attack) - Shortness of breath - Tachycardia - Shaking - Abdominal distress - Paresthesias - chest pain - Fear of dying 3. Terror status: (acute anxiety): Immobility characterizes this anxiety condition. Also there are tachycardia, sweating, palpation & trembling. Investigations of anxiety disorders: 1- No specific test for anxiety. 2- Non-specific EEG changes. 3- Echocardiogram show mitral valve prolapse in good percent of patients. 4- T3, T4, VMA, blood sugar, ECG: to exclude medical condition. Treatment of anxiety: 1. Psychotherapy: This to vntilate all his conflicts & through suggestion, reassurance & guidance getting him to overcome his anxiety, group psychotherapy may be used. 2. Environmental & social manipulations: to remove the patient from the disturbing factors. 3. Slow breathing to reduce physical symptoms of anxiety: - Breath in for 4 seconds & out for 4 sec. & pause for 4 sec before breathing in again. - Practice 20 min morning or night (5-10 min is better than nothing) - Use before & during situations that make you anxious. - Regularly check & slow down breathing throughout the day. 4. Drugs: I) Generalized anxiety Benzadiazepines - Diazepam 2-10 mg / 8 hr but should be reduced & tailed off after 3 weeks or dependence may occur. Non benzodiazepines: - Buspisone (Buspar) 5-10 mg bid. - Antidepressants e.g. amitriptyline 10-100 mg at night. - SSRIs - Inderal 10-30 mg / day controls out manifestations. II) Panic disorders Tricyclic anti-depressant e.g. clomipramine (Anafranil 25 mg tab) 100-150 mg/D Selective seratonine reuptake inhibitors (SSRIs) - Prozac 20 mg/D - Cipram 20 mg/D - Lustural 50 mg/D Benzodiazepines - Alprazolam (Xanax®) 0.25-0.5 mg/d Non bezoodiazepines buspar Beta-blockers
