Leader: Hossam Saleh Alawad

Done by: Alwaleed Alotaibi & Wael AL saleh

Revised by: Hossam Saleh Alawad

Doctor's note Team's note Not important Important Book's note

 Mind Map

Anxiety
Disorders

2- 4- 5- 6-
1- 3-
Agoraphobia Social/ Generalized Obsessive Acute
Panic Anxiety Compulsive Stress
Disorders Specific
phobia Disorder Disorder Disorder
(GAD) (OCD) (ASD) &
Post-
traumatic
Stress
Disorder
(PTSD)
 Anxiety Disorders

Definitions of Relevant Symptoms:

1. Anxiety: subjective feeling of worry, fear, and apprehension accompanied by

autonomic symptoms (such as palpitation, sweating, and muscles), caused by
anticipation of threat/danger. Free-floating anxiety: diffuse, unfocused anxiety,
not attached to a specific danger.
2. Fear: anxiety caused by realistic consciously recognized danger.
3. Panic: acute, self-limiting, episodic intense attack of anxiety associated with
overwhelming dread and autonomic symptoms.
4. Phobia: irrational exaggerated fear and avoidance of a specific object, situation or
activity.

State vs. Trait Anxiety:

• State anxiety (cross–sectional view): anxiety is experienced as a response to
external stimuli.
• Trait anxiety (longitudinal view): part of personality character in which a
person has a habitual tendency to be anxious in a wide range of different
circumstances.

Features of Anxiety:
Psychological Physical

- Excessive worries & fearful anticipation. - Chest: chest discomfort & difficulty in
inhalation.
- Feeling of restlessness/irritability. - Cardiovascular: palpitation & cold
- Hypervigilance. extremities.
- Neurological: tremor, headache,
- Difficulty concentrating. dizziness, tinnitus, numbness &
blurred vision.
- Subjective report of memory deficit. - Gastrointestinal: disturbed appetite,
- Sensitivity to noise. dysphagia, nausea, vomiting, epigastric
discomfort & disturbed bowel habits.
- Sleep: insomnia / bad dreams. - Genitourinary: increased urine
frequency and urgency, low libido,
erectile dysfunction, impotence &
dysmenorrhea.
- Musculoskeletal: muscle tension, joint
pain, easily fatigued.
- Skin: sweating, itching, hot & cold skin.
 Mild degree of anxiety is unavoidable and is not considered abnormal.

Anxiety Disorders are a group of abnormal anxiety states not caused by an organic
brain disease, a medical illness nor a psychiatric disorder.

Roll out “Medication and substance abuse - Medical disorders - other psychiatry
disorders” to diagnose Anxiety

1. Panic Disorder: recurrent sudden attacks of severe fear.

2. Phobias: situational anxiety with avoidance.
3. Generalized Anxiety Disease: prolonged nonspecific anxiety (free-floating).
4. Agoraphobias: anxiety about self-safety in crowded places.
5. Social phobia: anxiety about personal performance.
6. Specific phobia: anxiety about certain objects e.g. Injections.

In DSM-5 Separated in new categories:

1. OCD: excessive worries due to distressing obsessions.

2. Acute & PTSD: severe fear with avoidance following a life-threatening event.
 Panic Disorder

Panic attack Panic Disorder

A symptom not a disorder.

Episodic sudden intense fear (of dying, Diagnostic Criteria:

going mad or loosing self-control).
1. Recurrent sudden unexpected panic
Can be part of many disorders: panic attacks. (+/- situationally bound).
disorder, GAD, phobias, sub. Abuse,
acute & PTSD. 2. At least one of the attacks has been
followed by ≥ 1 month of ≥ one of
There are some somatic and cognitive the following:
symptoms that accompany fear:
A. Persistent concern about having
Derealization (feelings of unreality) or additional attacks “Anticipation”.
depersonalization (being detached from B. Worry about the implications/
one self) consequences of the attacks (e.g.
going mad or death).
Palpitation - Tremor - Sweating - Chills C. A significant change in behavior
or hot flushes related to the attacks.

3. Not due to other disorders.

Panic attacks can be:

1. Unexpected panic attacks: sudden

spontaneous attacks. Essential for
the diagnosis of panic disorder.

2. Situationally bound panic attacks:

occur on exposure to the situational
trigger seen in phobias.

3. Situationally predisposed panic

attacks: more likely to occur on
exposure to (but are not invariably
associated with) the situational
trigger e.g. attacks are more likely to
occur while driving.

Mr. Hadi is a 34-year-old man came to outpatient psychiatry clinic complaining of 3 month history of
recurrent sudden attacks of severe fear of death, palpitation, shortness of breath, excessive sweating,
and impaired concentration. The attack lasts for about 20 minutes then disappears completely.
Between, the attacks, although he is free from physical symptoms, he is anticipating the next attack.
Epidemiology of Panic Disorder:

• Women > men.

• Lifetime prevalence is 1 – 3 % (throughout the world).
• One-year prevalence rates 1 – 2 %.
• Age at onset: bimodal distribution, with one peak in late adolescence and a
second smaller peak in the mid-30s.

Etiology:

• Genetic basis (panic disorder occurs more often among relatives).

• The biochemical hypothesis (panic attacks can be induced by chemical agents like
sodium lactate, and can be reduced by drugs like imipramine).
• Panic disorder develops in a person with poorly regulated autonomic responses
to stressors.
• Pathological hyperactivity in Locus Ceruleus (alarm system in the brain essential
for anxiety expression). Neurotransmitters involved are norepinephrine and
serotonin.
• Mitral Valve Prolapse (MVP) is more common in patients with panic disorder
(40-50 %) than in general population (6 – 20 %). Whether this association has a
causal relationship it is not clear.

Course & Prognosis:

• The usual course is chronic but waxing and waning.

• Some patients recover within weeks others have a prolonged course (those with
symptoms persisting for 6 months or more).
• With therapy prognosis is excellent in most of the cases.

• Note: Panic Disorder can be either; with or without agoraphobia.

Treatment:

• Attention to any precipitating or aggravating personal or social problems.

• Support, explanation (based on the autonomic nervous system functions, alarm
system, & fight/flight response), and reassurance (that no serious physical
disease behind the repeated panic attacks).
• Cognitive Behavior therapy (CBT): detection and correction of wrong thoughts &
thinking process (negative cognition) about the origin, meaning and consequence
of symptoms & relaxation training.

• Medications: Choose one of SSRIs (selective serotonin reuptake inhibitors). All

are effective for panic disorder although the most widely used is paroxetine.
 Imipramine or clomipramine (tricyclic antidepressants) can be a good
alternative. For rapid onset of action add a benzodiazepine (usually alprazolam
or lorazepam) for 2-4 weeks then taper it down slowly. SSRI (or
clomipramine/imipramine) is generally continued for 6-12 months. When
treatment is discontinued relapse rate is high (30-90%) even when the condition
has been successfully treated. This emphasizes the role of combining
psychotherapy with medications.

Phobic Disorders

Irrational excessive fear ± panic attack on exposure + avoidance or endured with +++
(great) discomfort

Agoraphobia Social phobia Specific

Where it is difficult When observed Objects or situations:

or embarrassing to performing badly or
escape or get help. showing anxiety - Blood.
features. - Dental clinic.
1) Away from home. - Hospital.
2) Crowded places. e.g. speaking in - Airplane (height).
3) Confinement (in- public, leading - Animals.
closed spaces e.g. prayer, serving - Insects.
bridges or in-closed guests - Thunder.
vehicles (e.g. bus). - Storms.
- Closed spaces/lifts.
* Anxiety about * Functional impair. - Darkness.
fainting and / or loss - Clowns.
of control

1- Agoraphobia

Mrs. Mona is a 36-year-old woman seen at outpatient clinic because of several

weeks' history of excessive fear of fainting when in crowds or in situations that she
cannot leave easily

Fear and avoidance of market places and open spaces.

Fear in agoraphobic patients is about being alone in crowded places from which escape
seems difficult or help may not be available in case of sudden incapacitation.
Fear is usually revolving around self-safety issues (fainting / losing control of behavior
e.g. screaming, vomiting, or defecating) rather than personal performance in the
presence of others (which is the case in social phobia).

Diagnostic Criteria:

- Anxiety about being in places or situations from which escape might be difficult, or
in which help would not be readily available in the event of a panic attack (shopping
malls, social gathering, tunnels, and public transport).
- The situations are either avoided, endured with severe distress, or faced only with
the presence of a companion.
- Symptoms cannot be better explained by another mental disorder.
- Functional impairment.
youtube.com/watch?v=eCdd2ZAaXUs
Associated conditions:

o Panic disorder (in > 60 % of cases).

o Social phobia (in around 55 % of cases).
o Depressive symptoms (in > 30 % of cases).

• As the condition progresses, patients with agoraphobia may become increasingly

dependent on some of their relatives or spouse for help with activities that
provoke anxiety such as shopping.
• Housebound-housewife syndrome may develop. It is a severe stage of agoraphobia
when the patient cannot leave the house at all.

Etiology:

Predisposing Factors:

- Separation anxiety in childhood.

- Parental overprotection.
- Dependent personality traits.
- Defective normal inhibitory mechanisms.

Precipitating Factors:

- A Panic attack in a public place where escape was difficult.

- Conditioning (public places trigger fear of having subsequent attacks).
- Often precipitated by major life events.

Maintaining Factors:

• Avoidance reduces fear & ensures self-safety.

Epidemiology:

• Women:men = 2:1.
• Onset: most cases begin in the early or middle twenties, though there is a further
period of high onset in the middle thirties. Both of these ages are later than the
average onset of specific phobia (childhood) and social phobias (late teenagers or
early twenties).
• One-year prevalence: men; about 2 %, women: about 4 %.
• Lifetime prevalence: 6 – 10 %.

Treatment:

1- Cognitive-Behavior Therapy (CBT):

A- Cognitive Component:

Detection and correction of wrong thoughts & illogical ways of reasoning (cognitive
distortions) about the origin, meaning, and consequence of symptoms. E.g. of
cognitive distortions: magnification of events out of proportion to their actual
significance.

B- Behavioral Component:

- Detailed inquiry about the situations that provoke anxiety, associated thoughts, and
how much these situations are avoided.
- Hierarchy is drawn up (from the least – to the most anxiety provoking).
- The patient is then taught to relax (relaxation training).
- Exposure: the patient is persuaded to enter the feared situation (to confront
situations that he generally avoids).
- The patient should cope with anxiety experienced during exposure and try to stay in
the situation until anxiety has declined.
- When one stage is accomplished the patient moves to the next stage.
- The patient is trained to overcome avoidance (as escape during exposure will
reinforce the phobic behavior).

2- Medications: as for panic disorder (SSRIs +/- anxiolytics as per need).

Prognosis:

A- Good prognostic factors:

1- Younger age. 2- Presence of panic attacks. 3- Early treatment.

 B- Bad prognostic factors:

1- Age > 30 years. 2- Absence of panic attacks. 3- Late treatment.

It can be chronic disabling disorder complicated by depressive symptoms.

2- Social Phobia “Social anxiety disorder”

Mr. Jamal is a 28-year-old man presented with 3-year history of disabling distress
when talking to important people. He would feel anxious, and his voice would
become so disturbed that he had difficulty speaking.

Marked irrational performance anxiety when a person is exposed to a possible scrutiny

by others particularly unfamiliar people or authority figures leading to a desire for
escape or avoidance associated with a negative belief of being socially inadequate.

The problem leads to significant interference with functioning (social, occupational,

academic...). The person has anticipatory anxiety.

The response may take a form of panic attack (situationally - bound or situationally -
predisposed).

Common complaints: palpitation, trembling, sweating, and blushing.

Examples: speaking in public (meetings, parties, lectures) - serving coffee or tea to

guests - leading prayers.

Social phobia can be either:

A. Specific to certain situations (e.g. speaking to authority).

B. Generalized social anxiety.

Associated Features:

Hypersensitivity to criticism and negative evaluation or rejection (avoidant personality

traits). Other phobias.

Complications:

1- Secondary depression.
2- Alcohol or stimulant abuse to relieve anxiety and enhance performance.
3- Deterioration in functioning (underachievement in school, at work, and in social
life e.g. delayed marriage).
Differential Diagnosis:

• Other phobias. However, multiple phobias can occur together.

• Generalized anxiety disorder.
• Panic disorder.
• Depressive disorder primary or secondary to social phobia.
• Patients with persecutory delusions avoid certain social situations.
• Avoidant personality disorder may coexist with social phobia.

Etiology:

• Genetic factors: some twins' studies found genetic basis for social phobia.
• Social factors: excessive demands for social conformity and concerns about
impression a person is making on others, (high cultural superego increases
shame feeling), some Arab cultures are judgmental and impressionistic.
• Behavioral factors: sudden episode of anxiety in a social situation followed by
avoidance, reinforces phobic behavior.
• Cognitive factors: exaggerated fear of negative evaluation based on thinking
that other people will be critical, and one should be ideal person.

Epidemiology:

• Age: late teenage or early twenties. It may occur in children.

• Lifetime prevalence: 3–13 %.
• In the general population, most individuals fear public speaking and less than half
fear speaking to strangers or meeting new people.
• Only 8–10 % is seen by psychiatrists.
• Local studies in Saudi Arabia suggested that social phobia is a notably common
disorder among Saudis, (composes 80% of phobic disorders). Social and cultural
differences have some effect on social phobia in terms of age at treatment,
duration of illness and some social situations.

Treatment:

A. Psychological:
1. Cognitive-Behavior Therapy (CBT) (the treatment of choice for social phobia).
Exposure to feared situations is combined with anxiety management
(relaxation training with cognitive techniques designed to reduce the effects of
anxiety-provoking thoughts).
2. Social Skill Training: e.g. how to initiate, maintain and end conversation.
3. Assertiveness Training: how to express feelings and thoughts directly and
appropriately.
 B. Medications:

1. Antidepressants (one of the following): SSRIs (e.g. fluoxetine 20mg) or SNRIs

(e.g. Venlafaxine 150mg).
2. Beta-blockers (e.g. propranolol 20- 40 mg), as they are non-sedative, they are
useful in specific social phobia e.g. test anxiety to reduce palpitation and tremor.
Be aware of bronchial asthma.
3. Benzodiazepines (e.g. alprazolam 1mg): small divided doses for short time (to
avoid the risk of dependence).

Prognosis:

If not treated, social phobia often lasts for several years and the episodes gradually
become more severe with increasing avoidance. When treated properly the prognosis
is usually good. Presence of avoidant personality disorder may delay the improvement.

3- Specific Phobia “Simple phobia”

Feature:

Persistent irrational fear of a specific object or situation (other than those of

agoraphobia and social phobia) accompanied by strong desire to avoid the object or the
situation, with absence of other psychiatric problems.

Epidemiology:

• Prevalence in the general population: 4-8% (less than 20 % of patients are seen
by psychiatrists).
• Animal phobia: common in children and women.
• Most specific phobias occur equally in both sexes.
• Most specific phobias of adult life are a continuation of childhood phobias. A
minority begins in adult life, usually in relation to a highly stressful experience.

o Hospital/needle/dental/blood phobias may lead to bad consequences. If started

in adult life after stressful events the prognosis is usually good.
o If started in childhood, it usually disappears in adolescence but may continue for
many years.

Treatment:

• Behavior therapy: exposure techniques either desensitization or flooding.

• Medications (e.g. benzodiazepines, beta-adrenergic antagonists) before exposure
sessions.
 Generalized Anxiety Disorder (GAD)

Mr. Emad is a 38-year-old married man seen at outpatient clinic for a 7-month history
of persistent disabling anxiety, irritability, muscle tension, and disturbed sleep.

Diagnostic Criteria:

A- ≥ 6 months history of excessive anxiety occurring more days than not, about a
number of events or activities (such as work or school performance).
B- The person finds it difficult to control the worry.
C- The anxiety and worry are associated with ≥ 3of 6:

1- Restlessness or feeling keyed up or one edge.

2- Difficulty concentration or blank mind.
3- Being easily fatigued.
4- Irritability.
5- Muscle tension.
6- Sleep disturbance.

D- It causes significant distress or functional impairment in social / occupational / or

other areas.
E- The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism)
and does not occur exclusively during a mood disorder, a psychotic disorder, or a
pervasive developmental disorder.

Comorbidity:

More than 50% of patients with GAD have a coexisting mental disorder, especially
anxiety disorders (social or specific phobia, or panic disorder) and major depression.

Epidemiology:

• One year prevalence rate: 3 %.

• Life time prevalence rate: 5 %. Women > men (2:1).
• Often begins in early adult life, but may occur for the first time in middle age.
• There is a considerable cultural variation in the expression of anxiety.
• Frequent in primary care and other medical specialties.
• Patients usually come to a clinician's attention in their 20s.
• Only one third of patients seek psychiatric treatment. Many go to general
practitioners, or specialized clinics seeking treatment for the somatic component
of the disorder.
Etiology:

Combination of genetic and environmental influences in childhood. Maladaptive

patterns of thinking may act as maintaining factors. Anxiety as a trait has a familial
association.

Course and Prognosis:

Chronic, fluctuating and worsens during times of stress. Symptoms may diminish, as
patient gets older. Over time, patient may develop secondary depression (common if
left untreated). When patient complains mainly of physical symptoms of anxiety and
attributes these symptoms to physical causes, he generally seems more difficult to help.
Poor prognosis is associated with severe symptoms and with derealization, syncopal
episodes, agitation and hysterical features.

Differential Diagnosis:

1. Anxiety disorder due to medical conditions / medications: e.g.

anemia/hyperthyroidism.
2. Other anxiety disorders.
3. Mood disorders (depression/mania).
4. Adjustment disorders (with anxious mood).
5. Substance abuse.

Management

A- Rule out medical causes.

B- Cognitive–behavior therapy (CBT): Anxiety management training: relaxation with
cognitive therapy to control worrying thoughts, through identifying and changing
the automatic faulty thoughts.
C- Medications:
1. Antidepressants (one of the following): SSRIs (e.g. paroxetine 20mg) or SNRIs
(e.g. Venlafaxine 150mg).
2. Buspirone: it is more effective in reducing the cognitive symptoms of GAD than
in reducing the somatic symptoms. Its effect takes about 3 weeks to become
evident.
3. Benzodiazepines: for a limited period (to avoid the risk of dependence), during
which psychosocial therapeutic approaches are implemented.
 Obsessive Compulsive Disorder (OCD)

Ms. Maha is a 20-year-old college student seen at outpatient clinic complaining of

recurrent intrusive thoughts about incomplete ablution, bathing, and prayers. She
spends 3- 4 hours/day repeating prayers to feel fully satisfied and relaxed. She
realizes that her thoughts are silly but she cannot resist them.

Diagnostic Criteria:

• Recurrent obsessions or compulsions that are severe enough to be time

consuming (> 1 hour a day) or causes marked distress or significant impairment.
• The person recognizes that the obsessions or compulsions are excessive and
unreasonable.
• The disturbance is not due to the direct effect of a medical condition, substance
or another mental disorder.

Main themes in OCD:

1. Contamination  washing.
2. Religious, e.g. repeating Ablution, prayers, divorce, Blasphemous.
3. Sexual.
4. Aggression.
5. Symmetry  slowness. Trichotillomania: recurrent pulling out of
6. Hoarding. one's hair, resulting in a noticeable hair loss,
it is associated with OCD

Associated features/complications:
1. Anxiety is an important component of OCD. Compulsions are done to reduce
anxiety. Thus, reinforces obsessive-compulsive behavior.
2. Severe guilt due to a pathological sense of self-blaming and total
responsibility to such absurd thoughts especially in blasphemous,
aggressive and sexual obsessions.
3. Avoidance of situations that involve the content of the obsessions, such as
dirt or contamination.
4. Depressive features either as precipitating factor (i.e. primary), secondary
to, or simultaneously arising with OCD.
Differential diagnosis:
• OCD should be differentiated from other mental disorders in which some
obsessional symptoms may occur, like:
a) Depressive disorders. Anxiety, panic and phobia disorders.
b) Hypochondriasis.
c) Schizophrenia: some schizophrenic patients have obsessional thoughts, these are
usually odd with peculiar content (e.g. sexual or blasphemous). The degree of
resistance is doubtful.
d) Organic disorders: some organic mental disorders are associated with obsessions
e.g. encephalitis, head injury, epilepsy, dementia.
e) Obsessive Compulsive Personality Disorder (OCPD).

Epidemiology:

• M=F.
• Mean age at onset = 20 – 25 years.
• Mean age of seeking psychiatric help = 27 years.
• Lifetime prevalence in the general population is 2-3 % across cultural boundaries.
• About 10 % of outpatients in psychiatric clinics.

Etiology:

1. Genetic Factors.

2. Neurobiological hypothesis: serotonin dysregulation.

3. Psychodynamic Theories: unconscious urges of aggressive or sexual nature reduced

by the action of the defense mechanisms of repression, isolation, undoing, and reaction
formation.

4. Behavioral Theory: Excessive obsessions when followed by compulsions or

avoidance are reinforced, maintained and perpetuated.

Management:

• Search for a depressive disorder and treat it, as effective treatment of a

depressive disorder often leads to improvement in the obsessional symptoms.
• Reduce the guilt through explaining the nature of the illness and the exaggerated
sense of responsibility.
 • Medications:

1. Antidepressants with an antiobsessional effect; enhancing 5HT activity:

a) Clomipramine: required doses may reach 200 mg / day.
b) SSRIs (e.g. paroxetine 40-60mg). Treatment of OCD often requires high doses of
SSRIs.

2. Anxiolytics (e.g. lorazepam 1mg) to relief anxiety.

• Behavior therapy:
- For prominent compulsions but less effective for obsessional thoughts. Exposure
and response prevention.
- Thought distraction / thought stopping. Behavior therapy may be done at outpatient
clinics, day centers or as in – patient.
- It is important to interview relatives and encourage them to adopt an empathetic
and firm attitude to the patient. A family co-therapist plays an important role.

• In-patient behavior therapy:

Can appreciably be helpful for resistant cases and can reduce patient’s disability, family
burden and major demands on health care resources that are incurred by severe
chronic OCD patients.

Course and Prognosis:

• In most cases onset is gradual but acute cases have been noted.
• The majority has a chronic waxing and waning course with exacerbations related to
stressful events.
• Severe cases may become persistent and drug resistant. Depression is a recognized
complication.
• Prognosis of OCD is worse when the patient has OCPD.
• Good prognosis: presence of mood component (depression/anxiety), compliance
with treatment, and family support.

Acute Stress Disorder (ASD) & Post-traumatic Stress Disorder (PTSD)

Mr. Fahad is a 25-year-old man was injured in a serious road traffic accident 3
months ago in which he witnessed his friend dying. Two weeks later, he developed
recurrent distressing feelings of horror, bad dreams, and irritability.
Life-threatening traumas:

Major road accidents, fire, physical attack, sexual assault, mugging, robbery, war,
flooding, earthquake.

• Detachment happens usually in soldiers after war.

• PTSD patients usually have interrupted sleep due
to frequent nightmares.

Diagnostic Criteria:

A. Exposure to a traumatic threatening event (experienced, or witnessed) &

response with horror or intense fear.
B. Persistent re-experience of the event (e.g. flashback, recollections, or distressing
dreams).
C. Persistent avoidance of reminder (activities, places, or people).
D. Increased arousal (e.g. hypervigilance, irritability).
E. ≥ 1 month duration of the disturbance.

• In PTSD, They can have transit hallucinations.

• The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
Epidemiology:

• The lifetime incidence is 10-15% & the lifetime prevalence is about 8 % of the
general population.
• PTSD can appear at any age but young > old & females > males.

Comorbidity:

1. Depressive disorders.

2. Substance-related disorders (Alcohol).

3. Other anxiety disorders.

4. Bipolar disorders.

Differential diagnosis:

1. Acute stress disorder:

A. Similar features to PTSD but a-onset is within 1 month after exposure to a
stressor (If symptoms appeared after one month consider post-traumatic stress
disorder (PTSD).
B. Duration: a minimum of 2 days and a maximum of 4 weeks (If symptoms
continued more than one month consider PTSD).

• Treatment: same as for PTSD.

2. Other anxiety disorders (GAD, Panic d., & phobias).

3. Adjustment disorders:
(Stressor is not life-threatening, no dissociative features, mental flash backs or horror).

4. Head injury sequence:

(If the traumatic event has included injury to the head, e.g. road accident). Neurological
examination should be carried out to exclude a subdural hematoma or other forms of
cerebral injury.

5. Substance abuse: (intoxication or withdrawal).

Etiology:

• Recent research work places great emphasis on a person’s subjective response to

trauma than the severity of the stressor itself, which was considered the prime
causative factor.
• The traumatic event provokes a massive amount of information and emotions,
which is not processed easily by the brain (There are alternating periods of
acknowledging the event and blocking it, creating distress).

Treatment:

1- Psychological (the major approach):

a) Support – reassurance – explanation – education.

b) Encourage discussing stressful events and overcome patient’s denial.

c) In vivo (imaginary) exposure with relaxation and cognitive techniques.

d) Eye movement desensitization and reprocessing (EMDR):

While maintaining a mental image of the trauma the patient focuses on, and
follow the rapid lateral movement of the therapist's finger so that the traumatic
mental experience is distorted and the associated intense emotions are
eliminated.

e) Group therapy (for group of people who were involved in a disaster e.g. flooding,
fire).

2- Pharmacological:

• Symptomatic treatment: anxiolytics (e.g. alprazolam) and serotonin-selective

reuptake inhibitors (e.g. sertraline) or tricyclics (e.g. imipramine).

Prognosis:

It is good (40-50%) if:

1- The person is cooperative with treatment and has healthy premorbid function.
2- The trauma was not severe or prolonged.
3- Early intervention and social support exist.
 Adjustment Disorders

Mrs. Nora is a 35-year-old mother of 4 children delivered a baby defected with

cleft palate , 3 weeks later she developed excessive crying, hopelessness, agitation,
social withdrawal, & insomnia, . Her husband reported that she has low frustration
tolerance when she faces moderate stresses.

• The adjustment disorders are abnormal emotional response to a stressful event.

• The stressor involves financial issues, a medical illness, or a relationship problem.

• The symptoms must begin within 3 months of the stressor and must remit within
6 months of removal of the stressor.

Maladaptive psychological responses to usual life stressors resulting in

impaired functioning (social, occupational or academic).

Presentation and Features:

• Symptoms develop within 3 months of the onset of the stressor (if more than 3
months it is less likely that the reaction is a response to that stressor).
• There should be a marked distress that exceeds what would be expected from
exposure to the stressor.
• There should be a significant functional impairment.
• Symptoms vary considerably; there are several types of adjustment disorders:

1. With depressed mood.

2. With anxiety.
3. With mixed anxiety and depressed mood.
4. With disturbance of conduct (violation of rules and disregard of others rights).
5. With mixed disturbed emotions and conduct.
6. Unspecified e.g. inappropriate response to the diagnosis of illness, such as social
withdrawal without significant depressed or anxious mood, severe
noncompliance with treatment and massive denial.

# In adults: depressive, anxious and mixed features are the most common.
# In children and the elderly: physical symptoms are most common.
• Disturbance of conduct occurs mainly in adolescents.
 • Once the stressor (or its consequences) has terminated, the symptoms do not
persist for more than an additional 6 months.
• Adjustment disorder can be Acute: if the disturbance lasts less than 6 months.
Or Chronic: if the disturbance lasts for 6 months or longer (when the stressors
or consequences continue).

Etiology:

• Common in those who have preexisting vulnerability: Abnormal personality

traits / Less mature defense mechanisms / Low frustration tolerance / High
anxiety temperament / Overprotection by family / Lost a parent in infancy /
Loss of social support.
• The severity of the stressor does not predict the severity of the adjustment
disorders, because there are other factors involved (personality, nature of the
stressor & It’s subconscious meaning).

Differential diagnosis:

1. Normal psychological reaction: e.g. bereavement.

2. PTSD/ASD: (life threatening stressor followed by extreme fear, horror, avoidance and
flashbacks).
3. Anxiety disorders: (GAD or panic disorders).
4. Major depressive disorder.
5. Personality disorders: these are common co-existing problems e.g. histrionic,
obsessive compulsive, avoidant, paranoid or borderline personality disorders.
6. Dissociative Disorders: (dissociative symptoms).
7. Brief reactive psychosis: (hallucinations/delusions).

Epidemiology:

A. Female:Males → 2:1.
B. It may occur at any age but most frequent in adolescents.
C. Common among hospitalized patients for medical and surgical problems.
D. The prevalence of the disorder is estimated to be from 2 - 8 % of the general
population.
Management:

A. Psychological (treatment of choice):

 Empathy, understanding, support & ventilation.

 Psychosocial Education: explanation & exploration (explore the meaning of the

stressor to the patient).

 Crisis Intervention: (Several sessions over 4 – 8 weeks):

1. The patient, during crisis, is passing through emotional turmoil that impairs
problem-solving abilities.
2. Build good relationship with the patient.
3. Review the steps that have led to the crisis (stresses, defense mechanisms).
4. Identify and understand the maladaptive reactions.
5. Manipulate the environment to reduce distress (e.g. hospitalization).
6. Give small doses of drugs (e.g. anxiolytics) to reduce symptoms.
7. Encourage and support the patient until he goes through the problem.
8. Transform that into learning a more adaptive ways of coping strategies (for the
future, to prevent such maladjustment reactions).
9. After successful therapy the patient usually emerges stronger.

B. Medication:
• Short course of benzodiazepines in case of adjustment disorder with anxious
mood.
• Small doses of antidepressants might be beneficial for adjustment disorder with
depressed mood.

Course and Prognosis:

• Generally, it is favorable, particularly with early intervention.

• Most symptoms diminish over time without treatment especially after stressor
removal.
• Most patients return to their previous functioning capacity within few months.
• Adults recover earlier than adolescents do.
• Some patients maintain chronic course with risk of anxiety, depression and
substance abuse.
• Recurrence is common following other usual life stresses.
 Grief: Normal & Abnormal Grief

Mrs. Munirah is a 32-year-old woman lost her husband two days ago in a road
traffic accident. She has lack of emotional response, anger and disbelief. She has
no sadness or crying spells.

 Bereavement: being deprived of someone by death.

 Grief: sadness appropriate to a real loss.
 Mourning: the process of resolution from grief.

Normal Bereavement Reactions:

Stage 1: Shock and Denial. - Stage 2: Anger. - Stage 3: Bargaining.

Stage 4: Depression. - Stage 5: Acceptance. (Some people start at the 3rd stage)

Normal Grief: It is a continuous psychological process of three stages:

Pathological Grief: There are four types of abnormal grief:

 HELPING THE BEREAVED:
Normal process of grief should be explained and facilitated:
• Help to overcome denial, encourage talking about the loss, and allow expressing
feelings.
• Consider any practical problems: financial difficulties, caring for dependent
children.

 Medications:
• Anxiolytics for few days are helpful (when anxiety is severe and sleep is
markedly interrupted).
• Antidepressants do not relieve the distress of normal grief and therefore
should be restricted to pathological grief, which meets criteria for depressive
disorder.

Management of Anxiety Disorders

 Anti-anxiety Medications (Anxiolytics):

1-Benzodiazepines

• They act on specific receptor sites (benzodiazepine receptors) linked with gamma
aminobutyric acid (GABA) receptors in the C.N.S. They enhance GABA action, which
has an inhibitory effect.

• They have several actions:

A. Sedative & hypnotic action.
B. Anxiolytic action.
C. Anticonvulsant action.
D. Muscle relaxant action.

• They differ in potency and half-life:

Relatively short acting e.g. alprazolam (xanax), lorazepam (ativan) & Long acting
(more than 24 hours) e.g. diazepam (valium) and clonazepam (rivotril).

# Side effects:
• Dizziness and drowsiness (patient should be warned about these side effects
which may impair functions e.g. operation of dangerous machinery, driving).
• Release of aggression due to reducing inhibition.
 • Dependence and withdrawal:
- If given for several weeks.
- Short acting drugs have more risk of dependence.

Withdrawal Syndrome:
It generally begins 2 – 3 days after cessation of short acting, and 7 days after
cessation of long acting benzodiazepines and then diminishes in another 3 – 10 days.

• Features:
1. Anxiety, irritability, apprehension.
2. Nausea.
3. Tremor and muscle twitching.
4. Heightened sensitivity to stimuli.
5. Headache.
6. Sweating.
7. Palpitation.
8. Muscle pain.

• Withdrawal fit may occur when the dose of benzodiazepine taken has been high.
• Withdrawal is treated with a long acting benzodiazepine (e.g. diazepam) in
equivalent doses before withdrawal then the dose is reduced gradually by about
10 – 20 % every 10 days.

2-Buspirone (Buspar)

• It has anxiolytic activity comparable to that of benzodiazepines.

• However, it is pharmacologically unrelated to benzodiazepines.
• It stimulates 5HT–1A receptors and reduces 5HT (serotonin) transmission.
• It’s onset of action is gradual (several days – weeks) therefore, it is not effective
on PRN basis.
• It does not cause functional impairment, sedation nor interaction with CNS
depressants.
• It does not appear to lead to dependence.

Adverse effects:

1. Headache.
2. Irritability.
3. Nervousness.
4. Light-headedness.
3-Adrenergic Receptor Antagonists

Beta Blockers (e.g. propranolol; inderal): are frequently used to control tremor and
palpitation in performance anxiety (social phobia) 10 to 40 mg of propranolol 30-60
minutes before the anxiety-provoking situation).

• Other uses in psychiatry:

1- Other anxiety disorders (e.g. GAD).
2- Neuroleptic-induced akathisia.
3- Lithium-induced postural tremor.
4- Control of aggressive behavior.

Caution in patients with asthma, insulin-dependent diabetes, & cardiac diseases

(CCF, IHD).

 Psychological Treatments
Definition: a group of non-pharmacological psychotherapeutic techniques employed
by a therapist to ameliorate distress, abnormal patterns of relations or symptoms
(phobias, obsessions, depressive thinking…).

 Cognitive Therapy:
Concept:

• Maladaptive cognitive processes (ways of thinking, expectations, attitudes and

beliefs) are associated with behavioral and emotional problems.
• Correcting maladaptive cognitive processes reduces patient’s problems.

Process:
Maladaptive thinking is identified; the common cognitive errors include:
1. Magnification and minimization of events out of proportion to their actual
significance, e.g. depressed patient magnifies his faults and minimizes his
achievements.
2. Overgeneralization: forming a general rule from few instances and applying this
rule to all situations no matter how inappropriate.
3. Arbitrary inferences: making an inference without backing it up with evidence,
or alternatively ignoring conflicting evidences.
 4. Selective abstraction: taking a fact out of context while ignoring other
significant features and then proceeding to base entire experience on that
isolated fact.
5. Dichotomous thinking: thinking about events or persons in terms of opposite
extremes (all or none).
6. Personalization: relating events and incidents to self where such incidents have
no personal bearing or significance.

The maladaptive thinking is then challenged by correcting misunderstandings with

accurate information and pointing out illogical ways of reasoning. Then alternative
ways of thinking are sought out and tested.

 Behavior Therapy:
Concept:
• The aim for the client (patient) is to increase desirable behaviors and decrease
undesirable ones.
• Behavioral assessment seeks to observe and measure maladaptive behaviors
focusing on how the behavior varies in particular settings and under specific
conditions.
• Problems will be decreased through client’s learning more adaptive behaviors.

Behavioral techniques:
1. Exposure (flooding or gradual exposure & response prevention; for phobias & OCD).
2. Thought stopping (for OCD).
3. Relaxation training (for anxiety & phobias).
4. Assertiveness training (for dependent and avoidant personality disorders).
5. Token economy (for children, chronic schizophrenic, and intellectually disabled
people).

 Cognitive behavioral therapy (CBT):

• Combines cognitive and behavioral techniques.
• It is indicated in: depressive disorders (mild – moderate, but not severe) &
anxiety disorders (GAD, phobias, and panic disorders).

 Psychodynamic Psychotherapy:
• Person’s behavior is determined by unconscious process.
• Current problems arise from unresolved unconscious conflicts originating in
early childhood.
• Problems will be reduced or resolved through the client attaining insight (greater
understanding of aspects of the disorder) as a mean to gaining more control over
abnormal behavior).
• It helps some chronically depressed or anxious patients and those with
personality problems.

 Marital Therapy:

Indications:
Marital discord & when marital problems act as a maintaining factor of a psychiatric
disorder in one or both partners.

• The couple and the therapist identify marital problems, such as:
1. Failure to listen to the other partner.
2. Failure to express wishes, emotions and thought directly.
3. Mind reading.
• The couple then are helped to understand each other.
• The therapist should remain neutral.
• Techniques used include:
1. Behavioral: reinforcement of positive behavior.
2. Dynamic: eliciting and correcting unconscious aspects of interaction.
3. Problem solving.
 Summary
Diagnostic Criteria Management

1- Unexpected recurrent panic

attacks (+/- situationally bound). 1- Explanation and
reassurance and CBT.
2- At least one of the attacks has been
followed by ≥ 1 month of ≥ one of the 2- Choose one of SSRIs, the
following: most widely used is
paroxetine. SSRI is
A- Persistent concern about having
Panic Disorders generally continued for 6-
additional attacks ”Anticipation”.
12 months. When treatment
B- Worry about the implications / is discontinued relapse rate
consequences of the attacks (e.g. is high.
going mad or death).
3- For rapid onset of action
C- A significant change in behavior add a benzodiazepine
related to the attacks. (usually alprazolam or
lorazepam) for 2-4 weeks.
3- Not due to other disorders.
- Where it is difficult or embarrassing 1- Cognitive-Behavior
to escape or get help. Anxiety about Therapy (CBT).
fainting and / or loss of control.
Agoraphobia 2- Medications: as for panic
- Fear in agoraphobic patients is disorder (SSRIs +/-
about being alone in crowded places anxiolytics as per need).
from which escape seems difficult or
help may not be available.
A. Psychological:
Cognitive-Behavior Therapy
(CBT) (the treatment of
choice for social phobia).

- When observed performing badly B. Medications:

or showing anxiety features. e.g. 1. Antidepressants (one of
speaking in public, leading prayer, the following): SSRIs or
Social phobia serving guests. SNRIs.

- It is Lead to Functional impair. 2. Beta-blockers (e.g.

propranolol) Be aware of
bronchial asthma.

3. Benzodiazepines (e.g.
alprazolam 1mg): small
divided doses for short time
(to avoid the risk of
dependence).
 Behavior therapy:
Exposure techniques either
desensitization or flooding.
Specific phobia Persistent irrational fear of a specific
object or situation accompanied by Medications: (e.g.
strong desire to avoid the object. benzodiazepines, beta-
adrenergic antagonists)
before exposure sessions.

A- ≥ 6 months history of excessive

anxiety occurring more days than
not, about a number of events or A- Rule out medical
activities (such as work or school causes.
performance).

B- The person finds it difficult to

B- Cognitive – behavior
control the worry.
therapy (CBT):
C- The anxiety and worry are
Anxiety management
associated with ≥ 3of 6:
training.
1- Restlessness or feeling keyed
Generalized up or one edge.
Anxiety- 2- Difficulty concentration or C- Medications:
Disorder (GAD) blank mind.
3- Being easily fatigued. 1. Antidepressants: SSRIs or
4- Irritability. SNRIs.
5- Muscle tension.
6- Sleep disturbance. 2. Buspirone: it is more
effective in reducing the
F- It causes significant distress or cognitive symptoms of GAD.
functional impairment in social/
3. Benzodiazepines: for a
occupational/ or other areas.
limited period (to avoid the
risk of dependence).
G- The disturbance is not due to the
direct physiological effects of a
substance (e.g., a drug of abuse, a
medication) or a general medical
condition (e.g., hyperthyroidism).
 Management :
• Search for a depressive
disorder and treat it.
• Reduce the guilt.

• Medications:
- Recurrent obsessions or 1. Antidepressants with an
compulsions that are severe enough antiobsessional effect;
to be time consuming (> 1 hour a enhancing 5HT activity:
Obsessive day) or causes marked distress or - Clomipramine
Compulsive significant impairment. - SSRIs:
Disorder (OCD) Treatment of OCD often
- The person recognizes that the requires high doses of
obsessions or compulsions are SSRIs.
excessive and unreasonable.
2. Anxiolytics (e.g.
- The disturbance is not due to the lorazepam 1mg) to relief
direct effect of a medical condition, anxiety.
substance or another mental
disorder. • Behavior therapy.

• In-patient behavior
therapy.

A. Exposure to a traumatic 1- Psychological (the

threatening event major approach):
(experienced, or witnessed) &
Acute response with horror or A. Eye movement
Stress intense fear. desensitization and
Disorder reprocessing
(ASD) B. Persistent re-experience of the (EMDR).
& event (e.g. flashback, B. Group therapy.
Post- recollections, or distressing
traumatic dreams.
Stress 2- Pharmacological:
Disorder C. Persistent avoidance of
(PTSD) reminder (activities, places, or Symptomatic treatment:
people). a) Anxiolytics (e.g.
alprazolam).
D. Increased arousal (e.g.
hypervigilance, irritability). b) Serotonin-selective
reuptake inhibitors
E. ≥ 1 month duration of the (e.g. sertraline).
disturbance.
c) Tricyclics (e.g.
imipramine).
 F. The disturbance is not due to
the direct physiological effects
of a substance (e.g., a drug of
abuse, a medication) or a
general medical condition.

Acute stress disorder: a- similar

features to PTSD but a-onset is
within 1 month after exposure to a
stressor (If symptoms appeared
after one month consider post-
traumatic stress disorder(PTSD).

1- Symptoms develop within 3

months of the onset of the stressor. A. Psychological
(treatment of choice).
2- A marked distress that exceeds
what would be expected from B. Medication:
exposure to the stressor.
a) Short course of
Adjustment 3- A significant functional benzodiazepines in case
Disorders impairment. of adjustment disorder
with anxious mood.
4- Once the stressor (or its
consequences) has terminated, the b) Small doses of
symptoms do not persist for more antidepressants might be
than an additional 6 months. beneficial for adjustment
disorder with depressed
5- Adjustment disorder can be: mood.
Acute: if the disturbance lasts less
than 6 months. Or Chronic: if the
disturbance lasts for 6 months or
longer (when the stressors or
consequences continue).
 MCQ's

1. A 32-year-old man presented with intense worries when he becomes in the

middle of a row in the mosque as escape seems difficult. The most likely
diagnosis is:

a. Panic disorder.
b. Specific phobia.
c. Agoraphobia.
d. Social phobia.

2. A 20-year-old college student presented with repeated bouts of palpitation,

sweating, and excessive worries when he uses public transport. The most likely
diagnosis is:

a. Generalized anxiety disorder.

b. Posttraumatic disorder.
c. Agoraphobia with panic attacks.
d. Social phobia.

3. A 37-year-old woman has one-year history of epigastric discomfort, sweating,

dysmenorrhea, feeling of restlessness, sensitivity to noise, tinnitus and dizziness.
The initial management step should be:

a. Citalopram 20 mg.
b. Exclusion of anemia.
c. Brain CT scan.
d. Alprazolam for 2 weeks.

4. A 35-year-old mother of three children recently delivered a baby with

congenital defected. Three weeks later she became excessively worried, crying,
hopeless, agitated, and socially withdrawn. Her husband reported that she
always has low frustration tolerance when she faces moderate stresses. The most
likely diagnosis is:

a. Post-traumatic stress disorder.

b. Acute stress disorder.
c. Brief psychotic disorder.
d. Adjustment disorder.
5. A 30-year-old woman lost her husband ten days ago in a road traffic accident.
She has not showed any emotional reaction. Her condition reflects:

a. A normal adjustment reaction.

b. An abnormal grief.
c. Adjustment disorder.
d. Acute stress disorder.

6. A 28-year-old man witnessed death of his friend in a road traffic accident

(RTA) two weeks ago. Since then, he suffers from bouts of excessive fear of
driving his car, extreme distress on exposure to reminders of that RTA, and bad
dreams. The following is an appropriate management step:

a. Overcome denial.
b. Olanzapine 15 mg.
c. Amitriptyline 50 mg.
d. Crisis intervention.

7. A 19-year-old woman college student failed 3 weeks ago in two subjects. She
came to outpatient psychiatry clinic with 5 days history of lack of sleep, very poor
appetite, excessive crying episodes, lack of pleasure and loss of hope. The most
appropriate management step is:

a. Lorazepam 2mg/day.
b. Crisis intervention.
c. Risperidone 4 mg / day.
d. Behavioral therapy.

8. A 14-year-old boy was brought by his father because of 7 days' history of very
severe distress, intense fear whenever he goes to his uncle's house. Ten days ago,
two of his relatives raped him. The most likely diagnosis is:

a. Agoraphobia.
b. Acute stress disorder.
c. Post traumatic stress disorder.
d. Social phobia.

9. A 23-year-old man presented with extreme fear whenever he enters an

elevator (lift). The most appropriate statement about his treatment is:

a. Psychodynamic therapy.
b. Olanzapine 5 mg.
c. Behavior therapy.
d. Insight-oriented therapy.
10. A 27-year-old woman referred to psychiatry outpatient clinic through ENT
clinic with several months' history of continuous tinnitus, vertigo, and recurrent
unprovoked episodes of palpitation. Her investigations were normal. The most
appropriate statement about her treatment is:

a. Escitalopram 10 mg.
b. Propranolol 100 mg.
c. Haloperidol 10 mg.
d. Procyclidine10 mg.

Answers
1 2 3 4 5
C C B D B
6 7 8 9 10
A B B C A

For any suggestions:

[email protected]