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AnxietyDisordersPage14of19AnxietyDisordersPhenomenologyMentalstatusexamAnxietyDisordersGeneralVariousphysical__nifestations:restless-appearingpsychomotoragitationshortnessofbreathhyperventilationsto__chupsetchestpaindiaphoresis.__ybeillkemptormeticulouslygroomedOCD.__ydisplayoddritualisticbeh__iors.EmotionalMoodAnxiousfearfulAffectFrightened-appearingcanbeveryintenseThoughtPro__ssCaninvolveobsessiveperseverativethoughtsContentDelusionshallucinationsFearcanbeanor__lappropriatereactiontoaknownsour__ofdanger.“Anxiety”canbedefinedasa“warningsignal”functioningto__keusawareofpresentorpotentialdanger.Withananxietydisorderanindividualisfrightenedbutthesour__ofthedangerisnotknownnotrecognizedorinadequatetoaccountforthesymptoms.Thatistosaytheanxietyresponseisinappropriatetothesituation.Thephysiologic__nifestationsofanxietyaresimilartothe__nifestationsfear.TheyincludesymptomssuchasshakinessandsweatingpalpitationstinglingintheextremitiesnumbnessaroundthemouthdizzinessandsyncopemydriasisandGIorurinarydisturban__s.BydefinitiontheanxietydisordersseeDiagnosissectionofthischapterforcompletelistarepri__rilydisordersofemotion.Howeverlikeothermentaldisordersanxietycanaffectallareasofthementalstatusexam.seeTabletoright.EpidemiologyAnxietydisordersarethemostprevalentofpsychiatricdisorders.Communitysamplesh__eshownsurprisinglyhighlifetimeprevalen__s.TheECAstudydemonstratedthefollowinglifetimeprevalen__s:AnxietyDisordersOverall:15%Generalizedanxietydisorder:
8.5%Phobias:
12.5%Panicdisorder:
1.6%OCD:
2.5%SimilarrateswerefoundbytheNationalComorbiditySurveywhichdemonstratedthefollowinglifetimeprevalen__s:Anyanxietydisorder:25%Generalizedanxietydisorder:5%Agoraphobiawithoutpanic:5%Socialphobia:13%Panicdisorder:
3.5%Additionallyone-monthprevalen__ratesweredeterminedbytheECAstudyasfollows:Allanxietydisorders:
7.3%distributedfairlyequallyacrossagegroupsthoughsomewhatlowerin65+Phobias:6%distributedfairlyequallyacrossagegroupsbutwomentendedtoh__ehigherinyoung_____hoodPanic:
0.5%overalldistributedfairlyequallyacrossagegroupsbutwomentendedtoh__ehigherinyoung_____hoodOCD:
1.3%overalltendedtoh__ehigherinlateadoles__n__andyoung_____hoodClinicalsamplesh__eshownanxietydisorderstobeaverycommonreasonforpresentationtopri__rycaredoctorsERetc.Intermsofgendereffectsanxietydisordersseemmorecommoninwomen.They__ydecreasewithageandcanpresentdifferentlyatdifferentages.Inchildrenananxietydisordercan__nifestasseparationanxiety“schoolphobia”.Elderlypatients__ytendtowardsso__ticpresentations“sto__chproblems”headachessleepproblems.Etiology/PathologyGeneticinfluen__sareafactor.Thereisahighinciden__ofanxietydisorderspassedtosubsequentgenerationsaseviden__dbyfamilystu___s.Inthesestu___sgenerallyallthedisordersaremorecommoninfirst-degreerelativesofaffectedindividualsthanthegeneralpublic.Panicdisorderhasa4-7Xgreaterinciden__infirst-degreerelatives.Specificphobias__yaggregatebytypewithinfamilies.Inadditiontwinstu___sshowstronggeneticcontributiontoPanicDisorder.ForexampleinOCDconcordan__ishigherformonozygoticthandizygotictwins.Thekeyneurotran__ittersseemtobecatecholamines“fightorflightreaction”andserotoninmodulation.InadditiontheGABAre__ptorthepri__ryinhibitorytran__itterinthebrainplaysanimportantroleinthemodulationofarousalandanxiety.SpecificstructuresimportantintheetiologyofanxietydisordersincludetheReticularActivationSystemRASandtheso-called“suffocationresponse.”ThelocuscoeruleussiteofnoradrenergicneuronsraphenucleussiteofserotonergicneuronscaudatenucleusparticularlyinOCDtemporalcortexandfrontalcortexarebrainareaslikelytobeinvolvedinanxietydisorders.Corticalmodulationplaysanimportantrole;keytothisistheroleoflearningclassicalandoperantconditioningaswellastheroleofstressconflictandneurosespsycho____ytictheory.Diagnostictestsh__ebeenusedtoexplorethepathogenesisofanxietydisorders.Forexamplelacticacidinfusionandcarbondioxideinhalationbringoutpanicdisorder.Thisalongwithsometentativedatagivessomecreden__tothesuggestionthatpanicdisorderisa“suffocationresponse”goneawry.DiagnosisTheSyndromesSyndromesaredefinednotasdisordersbutrather“buildingblocksfordisorders”likethe“episodes”inmooddisorders.TheSyndromesincludepanicattacksandagoraphobia.D__-IVDIAGNOSESANDCRITERIAFORPANICATTACKS:Panicattacksmustinclude4ormoreofthefollowingsymptoms:PalpitationspoundingheartorincreasedheartrateSweatingTremblingorshakingSensationsofshortnessofbreathor__otheringFeelingofchokingChestpainNauseaDizzinessDerealizationfeelingsofunrealityordepersonalizationFeelingoflosingcontrol/goingcrazyFearofdyingParesthesiasChillsApanicattackstartsabruptlyandpeaksinabout10minutes.D__-IVCRITERIAFORAGORAPHOBIA:Anxietyaboutbeingapla__orsituationfromwhicheither:escapeisdifficultorembarrassingorifapanicattackoccurredhelpmightnotbe__ailableThesituation:Is__oidedrestrictingtr__elorIsenduredbutwith__rkeddistressoranxietyabouth__ingapanicattackorRequiresacompanionOthermentaldisordersdon’texplainthesymptomsbetter.TheDisordersTheanxietydisordersare:PanicDisorderwithAgoraphobiaPanicDisorderwithoutAgoraphobiaAgoraphobiawithoutaHistoryofPanicDisorderSpecificPhobiaSocialPhobiaObsessive-CompulsiveDisorderPosttrau__ticStressDisorderAcuteStressDisorderGeneralizedAnxietyDisorderAnxietyDisorderduetoaGeneralMedicalConditionSubstan__-Indu__dAnxietyDisorderAnxietyDisorderNotOtherwiseSpecifiedNOSD__-IVCRITERIAFORPANICDISORDERWITHORW/OAGORAPHOBIA:RecurrentunexpectedpanicattacksandAtleast1attackhasbeenfollowedby1month+of:Con__rnabouth__ingadditionalattacksWorryabouttheimplicationsorconsequen__softheattackSignificantchangeinbeh__iorrelatingtotheattackSpecifypresen__orabsen__ofagoraphobiaPanicattacksarenotcausedbysubstan__orgeneralmedicalcondition.PanicattacksarenotpartofanotherAnxietyorMentalDisorder.D__-IVCRITERIAFORAGORAPHOBIAWITHOUTPANICDISORDERThepresen__ofagoraphobia.NohistoryofPanicDisorder.Thefocusofthefearisontheoccurren__ofincapacitatingorextremelyembarrassingpanic-likesymptomsorlimited-symptomattacksratherthanfullPanicAttacks.Thedisturban__isnotcausedbyageneralmedicalconditionorbysubstan__s.Ifanassociatedgeneralmedicalconditionexiststhesymptomsareinex__ssofthatexpectedforthemedicalcondition.D__-IVCRITERIAFORSOCIALPHOBIA__rkedandpersistentfearofoneormoresocialorperfor__n__situations.Thefearisofpossiblehumiliationorembarras__ent.Thephobicstimulusalmostalwayscausesanxiety.Thefearisrecognizedasex__ssiveorunreasonable.Thefearedsituationis__oidedorenduredwithintensedistressoranxiety.TheGlobalCriteriaSPECIFICTYPESOFSPECIFICPHOBIASAni__ltypeNaturalenviro__enttypee.g.heightsstormswateretc.Blood-Injection-InjurytypeSituationaltypee.g.publictransportationtunnelselevatorsflyingdrivingenclosedspa__setc.Othertypee.g.chokingvomitingcontractinganillnesschildren’sfearsofloudsoundsorcostumedcharactersetc.D__-IVCRITERIAFORSPECIFICPHOBIA__rkedpersistentfearthatisex__ssiveorunreasonablecuedbythepresen__oranticipationofaspecifico__ectorsituation.Thephobicstimulusalmostinvariablyprovokesanimmediateanxietyresponse.Thefearisrecognizedasex__ssiveorunreasonablenotneededinchildren.Thephobicstimulusis__oidedorenduredwithintenseanxietyordistress.Personsunderage18musth__ethesymptomsfor6months+.TheGlobalCriteria.D__-IVCRITERIAFOROBSESSIVECOMPULSIVEDISORDEROCDEitherobsessionsorcompulsions:Obsessions:Recurrentpersistentthoughtsorimpulsesexperien__ssometimesasintrusiveandinappropriateandcausedistress.Thethoughtsaren’trealisticworriesaboutrealproblems.Persontriestoignoreorsuppresstheobsessions.Theobsessivethoughtsarerecognizedassuch.Compulsions:Repetitivebeh__iorsormentalactsthataredoneinresponsetoanobsession.Thebeh__iorsaremeanttoredu__distressorpreventafearedeventbutarenotrealistic.Atsomepointthepersonhadgoodinsightintotheunrealisticnatureofthese.TheGlobalCriteria.D__-IVCRITERIAFORPOSTTRAU__TICSTRESSDISORDERThepersonexperien__d/witnessed/wasconfrontedbyanunusuallytrau__ticeventwhich:Involvedactualorthreateneddeath/seriousinjurytothepersonorotherandCausedintensefearhorrororhelplessnessTheeventisreexperien__dthrough1ormoreoffollowing:IntrusiverecurrentrecollectionsRecurrentnight__resFlashbacksIntensedistressinreactiontointernalorexternalcuessymbolizing/resemblingtheeventPhysiologicalreactivityinresponsetothesecues__oidan__ofthestimuliandnumbingofgeneralresponsivenessshownby3+:Effortsto__oidthoughtsfeelingsorconversationsaboutthetrau__Effortsto__oidactivitiespeopleorpla__sassociatedwiththeeventInabilitytorecallimportantaspectsoftheeventLossofinterest/participationinsignificantactivitiesFeelingofdetachmentorestrangementfromothersRestrictedrangeofaffectSenseofforeshortenedfuturePersistentsymptomsofhyperarousal:InsomniaIrritabilityDifficultycon__ntratingHypervigilan__ExaggeratedstartleresponseTheabovesymptomsh__elastedlongerthanonemonth.TheGlobalCriteria.D__-IVCRITERIAFORGENERALIZEDANXIETYDISORDEREx__ssiveanxietyandworryoccurringmoredaysthannotforatleast6monthsinregardtoworkschoolorotheractivities.Itisdifficulttocontroltheseworries.Theanxietyandworryareassociatedwith3+ofthefollowing:RestlessnessorfeelingkeyedupEasyfatigueDifficultycon__ntratingIrritabilityMuscletensionInsomniaorrestlessunrefreshingsleepAspectsofanotherAxisIdisorderdonotprovidethefocusoftheanxietyandworry.TheGlobalCriteria.OtherAnxietyDisorders:AcuteStressDisorderislikePTSDbutlessthan1month.AnxietyDisorderDuetoaGeneralMedicalConditionandSubstan__-Indu__dAnxietyDisordercandemonstrateasgeneralizedanxietypanicattacksOCDsymptomsorphobicsymptomsinthecaseofsubstan__s.AnxietyDisorderNOSisa“wastebasketdiagnosis”foranxietysymptomsnotmeetingthecriteriaforanyspecificdisorder.DifferentialDiagnosisImportantmedicaldisordersthatshouldbeconsideredinthedifferentialforanxietydisordersincludeendocrinedisorderscardiopulmonarydisordersandneurologicdisorders.Substan__-indu__ddisordersmistakenforanxietydisordersincludewithdrawalsyndromesalcoholortranquilizersandintoxication/therapeuticsyndromesstimulantsorothers.Somespecificorganiccausesofsymptomsofanxietyincludeex__ssivecaffeineintakehyperthyroidi__vitaminB12deficiencyhypo-orhypergly__miacardiacarrhythmiasanemiapulmonarydiseaseandpheochromocyto__anadrenalmedullarytumor.Otherpsychiatricsyndromesinthedifferentialincludemooddisordersanxietycanbemisdiagnosedasorcomorbidwithdepressionpsychoticdisorderssleepdisordersso__toformdisordersandeatingdisorders.Adjustmentdisorderoftenmustbedistinguishedfrompost-trau__ticstressdisorder.Adjustmentdisorderischaracterizedbyemotionalsymptomse.g.anxietydepressionconductproblemsthatcausesocialschoolorworkimpairmentoccurringwithin3monthsandlastinglessthan6monthsafteraseriousbutusuallynotlife-threateninglifeevente.g.divor__bankruptcychangingresiden__.Generallyadjustmentsdisordersareunderstandableevenseemingly“nor__l”reactionstounusualcircumstan__s.PTSDisanabnor__lreactiontoanabnor__ltrau__andthoughthereaction__ybeunderstandableitisgrossly__ladaptive.ComorbidDisordersCommonlymooddisorderslikedepressioncanpresentcomorbidlywithanxietybringingtoquestiongeneticlinkageordifferentformsofthesamedisorder.Somemedicaldisordersarecommonlycomorbidwithanxietydisorders:forexamplemitralvalveprolapseandPanicDisorder..CourseMostanxietydisorderstendtobechronicdisorders.Panicdisordertendstopresentinlateadoles__n__toearly_____hood.Ithasperhapsabimodaldistributionlateadoles__n__andmid-30’s.Itcanbechronicbutwaxingandwaning.At6-10yearsfollow-up1/3patientsappeartobewellabout1/2h__eimprovedbutarestillsympto__ticand1/5–1/3feelthesameorworse.Thereisahighriskofrelapseafterso__tictreatment.Agoraphobia__yor__ynotimproveifpanicimproves;itcanbecomea“learnedbeh__ior.”SpecificPhobiatendstobegininchildhood.Thesituationtypehasasecondpeakinmid-20’sbimodal.It__yspontaneouslyremitbutifitpersistsuntil_____hooditbecomesverychronicperhaps80%ofthosepersistingto_____hoodwillbechronic.ForSocialPhobiatheonsetisinthemid-teens.Patients__yexhibitapremorbidhistoryofshyness.Usuallysocialphobiaischronicbutitcanfluctuateinseverity.TheonsetofOCDisinadoles__n__orearly_____hood.Itpresentsearlierin__leswho__ybegininchildhood.Thecourseisachronicwaxingandwaningone.15%h__edeteriorationand5%h__eepisodeswithinterepisoderecovery.PTSDcanpresentforthefirsttimeatanyage.HalfofpatientswithPTSDrecoverin3months;therest__ypersistforlongduration.Themostimportantpredictoristheseverityoftrau__.Otherfactorswhich__ymitigateseverity/durationincludesocialsupportfamilyhistorypremorbidpersonalityandpsychologicalhealth.GeneralizedAnxietyDisorderhasanonsetfromchildhoodtoearly_____hood.Itisbydefinitionverychronic.TreatmentSo__ticTreatmentForAnxietyDisorders:ThePsychophar__cologyOfAnxietyCategoriesOfAnxiolyticDrugsAntidepressantsSelectiveSerotoninReuptakeInhibitors_______________5-HT1AagonistsBetaantagonistsBarbiturateshistoricalinthiscontext;h__ebeensupplantedbyotherdrugsThemostcommonmedicationsusedforanxietyaretheantidepressantsand/orsedativehypnotics.Antidepressantsh__egraduallyrepla__dsedativehypnoticsforthefirstlineoftreatmentof__nyanxietydisorders.Severalstu___sshowantidepressantstobeaseffectiveas_______________foravarietyofanxietydisorderse.g.fluoxetine[Prozac]comparedf__orablyagainstalprazolam[Xanax]forpanicdisorder.Theirmechani__ofactionintreatinganxietyispresumedtobesimilartothatfortheirantidepressanteffect.Thispresumptionisreasonableasmonoaminesexertamodulatoryinfluen__onmostotherneurotran__ittersinthebrainincludingGABA.Howeverantidepressantsareusedpreventivelyonaneverydaybasis.Theyarenoteffectivein“asneeded”dosingandthusarenotappropriateforshort-termanxietyorforquickreliefofacuteanxiety.FormoreonantidepressantsseetheirdescriptionunderMoodDisorders.SedativeHypnotics:______________________________h__emultiplepropertieswhichlendthedrugstomultipleclinicalapplications:PropertyOf_______________ClinicalApplicationAnticonvulsanttreatmentofepilepsyMusclerelaxanttreatmentofspasticitymultiplesclerosisand__rebralpalsySedatingsleepinductionAnxiolytictreatmentofanxietyThislastpropertyandapplicationarewhatwearefocusingoninthischapter.Themechani__ofactionfor_______________ispotentiationofGABAactionatGABA-Are__ptorsintheCNS._______________increasetheaffinityofGABAforitsre__ptorandcanpotentiatetheincreaseinchloridepermeabilityandhyperpolarizationofthetargetneuronsnor__llyprodu__dbyGABA.Therearethreeclassesof_______________:2-keto3-hydroxyandtriazolo.2-ketodrugsincludechlordiazepoxidediazepamprazepamclorazepatehalazepamclonazepamandflurazepam.__nyofthesearepro-drugs;theyareoxidizedintheliverusuallytoactivemetabolites.Theythereforetendtoh__elonghalf-livesandaremoresus__ptibletodruginteractionsandageeffects.The3-hydroxydrugsincludeoxazepamlorazepamandtemezepam.Theseareconjugatedinthelivertoinactivesubstan__s;thustheyh__eshorterhalf-livesandarelessaffectedbyageandotherdrugs.Thetriazoloclassincludesalprazolamtriazolamandadinazolam.Theseareoxidizedbutwithmorelimitedactivemetabolites.Thustheyaresomewhatshorter-actingthanthe2-ketodrugs.Themechani__ofactionrelatestospecificre__ptorsonGABAre__ptors.Indicationsforthesemedicationsincludepanicgeneralizedanxietyspecificandsocialphobiasmixedanxietysyndromesinsomniamuscletensionseizuresanesthesiaandalcoholwithdrawal.Sideeffectsandrisksincludeabusepotentialtoleran__withdrawaldependen__andaddiction.Thereisalsoanoverdosepotentialwithraredeathsassingleagents.Othersideeffectsareofthesedativevariety–namelysedationdizzinessweaknessataxiadecreasedmotoricperfor__n__andfallsintheelderly.Inadditionanterogradeamnesianauseahypotensionslightandpossiblydyscontrolh__ebeenshowninpatientstakingthesedrugs.Although_______________canimpairmotorcoordinationtheydon’th__etheacutetoxiceffectsrespiratorydepressionofbarbiturates.However_______________canprodu__respiratorydepressionifcombinedwithothersedativessuchasalcohol.Theseacuteeffectscanbeantagonizedbyflu__zenilacompetitiveGABAantagonist.Ofmostcon__rnarethesideeffectsoftoleran__andwithdrawalandtherelatedbutnotidenticalfearofaddictioninpatientswhotake_______________regularly.Thoughperhapsoverstatedbysomeariskdoesexist.Thebestpredictorofalikelihoodofdevelopingaproblemlikeaddictionwiththesedrugsisaprevioushistoryofaddictiontoothersubstan__s.Arelatedcon__rnisthepossibilityofreboundanxietyon__thesedrugsarestoppedwhichcanbeasseriousastheoriginalanxietythedrugsweremeanttotreat.Becauseoftheseworries_______________areoftenreservedeitherforshort-termtreatmentoftime-limitedanxietye.g.worriedpre__dinganupcomingsurgeryorforintermittentanxietye.g.ifapersongetsinfrequentpanicattackssaylessthanon__amonth.Inbothofthesecasesthey__ybepreferabletoantidepressantsinthatantidepressantstakeweekstoworkandcannotbeusedintermittentlyanditseemsinappropriatetogivedailyantidepressantsforaneventthatonlyhappenson__inawhile.5-HT1AAgonistsBuspironeisanovelagentintheclassofdrugscalledazaspirones.Buspironesmechani__ofactionisverycomplexandsofaritisnottotallyelucidated.Severaldifferentneurophar__cologicpro__ssescanbeinvolved.Buspironehasanaffinityfor5-HT1A-re__ptorsmoderateaffinityforDA2-re__ptorsandweakaffinityfor5-HT2-re__ptorsbutnoaffinityforthebenzodiazepinere__ptorcomplexontheGABAre__ptorinvitro.Itisnotusefulforpanicorotheracuteanxietysyndromesbutit__ybeusefulforgeneralizedanxietydisorder.Itworkslikeanantidepressant;inotherwordsitrequiresregulardosingandtakesseveralweekstowork.Thereislittleabusepotentialandfewsideeffects.Buspironelacksthe_______________’sedativemusclerelaxantoranticonvulsantactionsandhasnoabilitytoaffectbenzodiazepinewithdrawalsymptoms.Itisalsosurprisinglyfreeofsignificantdrug-druginteractions.Howeveritisnotwidelyused;thismeanseitherthatthedrugisn’taseffectiveinclinicalsituationthanin“ideal”drug__rketingstu___sorthatthepatientswhoaremostlikelytobenefit__ynotbethecomplicatedanxietydisordersseenbypsychiatrists.Thusthereisabiasagainstthedrug.Othernoveltreatmentsincludeβantagonists“betablockers”forsocialphobiasandneurosurgeryforOCD.βantagonistse.g.propranololareusedespeciallyfortreatmentofphysicalsymptomssuchastremorandtachycardia.Note:epinephrinecancauseskeletalmuscletwitchviaβ2agonisteffects;thiswouldbeblockedbypropranolol.FormoreonneurosurgeryseethechapteronOCD.Psychosocial/Beh__ioralTreatmentsForAnxietyDisorders:Psychotherapiesh__ebeengreatlysuc__ssfulfor__nyoftheanxietydisorderssometimesmoresothanso__tictreatments.Anexampleofawell-stu___deffectivetreatmentforanxietyiscognitivebeh__ioraltreatmentCBT.CBTisbasedonlearningtheory;theideaisthatpeoplelearntodevelopauto__ticresponsesoffearordreadinrelationtoastimulus.WhatislearnedcanbeunlearnedandmuchofCBTisspentteachingthepatienttotoleratethetriggersofanxiety.Inthecaseofphobiasthetriggersareclear;inthecaseofpanicdisorderthetriggerisinasensetheanxietyitselfandthepatientlearnstotoleratetheiranxiety.Thistreatment__ybetheonlythingthathelpsagoraphobiaifitisassociatedwiththepanicwhichotherwiseoftenpersistslongaftermedicationsh__epreventedthepanic.Otherexamplesofpsychotherapyforanxietyincludedesensitizationtechniquesforphobias.Oftenthesearemuchmoreeffectivethananymedicationandcantrulycurethedisorderwhereasmedicationwillonlyprovidesympto__ticrelief.Othertherapies__ybemoregenerale.g.groupsupportisalsoofferedforPTSDpatients.Howeveragainthiscanbeveryeffectiveinacomplicateddiseasethatoftendoesn’trespondwelltomedicationalone.SomedrugscommonlyusedforanxietysedationorforsleepNameTypeApprovedforEquivalentDoseforbenzosHalf-lifeOnsetMetaboli__DiazepamValiumBenzodiazepineanxietyEtOHwithdrawalmusclespa__preopsedationseizures5mg/daylongveryfastoxidationChlordiazepoxideLibriumanxietyalcoholwithdrawalpreopsedation10longfastN-dealkylationOxazepamSeraxanxietyalcoholwithdrawal15shortslowconjugationLorazepamAtivananxietypreopsedation1shortfastconjugationClonazepamKlonopinseizurespanicdisorder
0.25longfastreductionAlprazolamXanaxanxietydisorderspanicdisorder
0.5mediumfastoxidationFlurazepamDal__nesleep15verylongfastoxidationTemezepamRestorilsleep15mediummediumconjugationTriazolamHalcionsleep
0.5shortfastoxidationZolpidemAmbienBenzodiazepineomega-1re__ptoragonistssleep2hrs1/2-1hrZaleplonSonatasleep1hr1/2-1hrBuspironeazapirone5-HT1AagonistanxietyN/AusuallygivenTID1/2-
1.5hrN/ADiphenhydramineBenadrylAntihistaminevarious:allergiescoldremedy.3-10hrHydroxyzineVistarilAtaraxanxietyprurituspreopandpostopsedation2hrAntidepressantsseetheantidepressanttableObsessive-CompulsiveDisorderPhenomenologyObsessive-compulsivedisorderOCDisananxietydisordercharacterizedbyintrusiveobsessionsandrepetitivecompulsionswhichcausedistressorareasignificantburdentothepatient.Obsessionsarerecurrentandpersistentthoughtsthatareexperien__dasintrusiveandinappropriatecausing__rkedanxiety.Compulsionsontheotherhandarerepetitivebeh__iorsormentalactscarriedoutinresponsetoanobsessionandareaimedatpreventingorreducinganxiety.Atsomepointduringthecourseofthedisorderapatienthasrecognizedthattheobsessionsorcompulsionsareex__ssiveorunreasonable.ThesecharacteristicsymptomsofOCDofteninterferewithaperson’snor__lroutineoccupationorsocialactivitiesandrelationships.Typicalobsessions:Fearofgettingdirtyorcontaminatedbypeopleortheenviro__entFearofinfectionincludingAIDSorotherillnessDisgustwithbodilywasteorsecretionsRecurringthoughtsofharmingoneselforothersFearthatadisasterwilloccurFearofcommittingacrimeRecurringdistressing___ualthoughtsori__gesFearofthinkingsinfulorblasphemousthoughtsFearofblurtingoutobs__nitiesorinsultsExtremecon__rnwithordersymmetryorexactnessRecurrentintrusivethoughtsof__rtainsoundsi__geswordsornumbersIntenseneedtoknoworrememberFearoflosing/discardingsomethingimportantTypicalcompulsions:Ex__ssiveorritualizedhandwashingProlongedorritualizedshoweringbrushingteethortoiletroutineRepeateddressingandundressingRepeatedcleaningofhouseholdo__ectsIntenseneedtoorderorarrangethingsinaparticularwayRepeatedlycheckinglocksswitchesfau__tsapplian__sCheckingtoseenoonehasbeenharmedbythepatient’sactionsNeedto____askconfessRepeating__rtainactionse.g.goingthroughdoorsCheckingthatthepatientdidnot__keamistakeConstantseekingofapprovalorreassuran__Touching__rtaino__ectsinaparticularwayRepeatedcountingtoa__rtainnumberoramultipleofthatnumberHoardinguselesso__ectsEpidemiologyOCDhasalifetimeprevalen__of2-3%intheUnitedStates.ThereisabimodalpatternofonsetofOCDoccurringinchildhoodandlateadoles__n__/early_____hood.Two-thirdsofcasesh__etheironsetearlierthanage25andonly15%occurafterage
35.Aboutone-thirdofcasesh__eonsetinchildhoodorearlyadoles__n__.__lestendtoh__eearlieronset.Etiology/PathologyFamilial/GeneticTheories:Twinstu___sh__eshownthatconcordan__ratesformonozygotictwinsarehigherthanthatofdizygotictwins.OCDprevalen__ishigherifa1stdegreerelativehasOCDorTourette’ssyndrome.Thereisalsoeviden__thatinsomefamilieswithTourette’sratesofbothOCDandTourette’sareincreasedinbiologicalrelativeswhichsuggeststhatinthesefamiliesOCDandTourette’s__ybealternativephenotypicexpressionsofthesameunderlyinggeneticdefect.Beh__ioralTheories:Two-stageclassicalinstrumentalconditioningmodelofOCD:Obsessionsresultfrompairingmentalstimuliwithanxiety-provokingthoughts.Compulsionsareneutralbeh__iorsthath__ebeenassociatedwithanxietyreductionandthereforereinfor__d.NeurobiologicalTheories:Convergingeviden__fromi__gingphar__cologicalandbeh__ioralstu___simplicateshyperactivityinfrontal-subcorticalthalamiccircuitsinthepathogenesisofOCD.Thistheoryholdsthathyperactivityinthesecircuitsleadstoex__ssactivityinfrontal-subcorticalsystemsgivingrisetothebeh__ioraldisturban__inOCD.PrefrontalcortexorbitofrontalandanteriorcingulatebasalgangliaglobuspallidusthalamusprefrontalcortexAseriesoffunctionali__gingstu___sPETSPECTfMRIh__edemonstratedincreasedperfusionandmetaboli__intheorbitalfrontalcortexanteriorcingulategyrusandheadofthecaudatenucleusinpatientswithactiveOCD.Somestu___sh__esuggestedthatthehypermetaboli____yh__earight-sidedpredominan__.Thehypermetaboli__inthesecircuitscanbereversedfollowingsuc__ssfulmedicationbeh__ioralorsurgicaltreatmentoftheOCsymptoms.CognitiveFunctionsOfFrontal-SubcorticalStructuresInvolvedInTheDevelopmentOfA“WorryCircuit”InOcd:Prefrontalcortex:responseinhibitionplanningerrordetectionandmoodregulationParalimbiccortexorbitofrontalcortexandamygdala:integratingexternalstimuliwithemotionalstatesandmodulationofarousalandintenseemotionBasalganglia:auto__ticfilteringofstimuliandmediationofstereotypedbeh__iorsThalamus:gatingoftran__issionofstimuliandrefinedinfor__tionbacktothecortexSeveralfindingimplicatetheserotonergicsysteminmodulationofOCDsymptoms:SerotoninReuptakeInhibitorsSRIsareuniquelyeffectiveinOCD.SerotoninpartialagonistsmCPPcanacutelyworsenOCD.SerotoninantagonistsmetergolineritanserincanprovokeOCDsymptomsinSRIresponders.ThereisatentativeassociationbetweensomevariantsingenescodingforserotoninsystemcomponentsandOCD.DiagnosisD__-IVCRITERIAFOROBSESSIVECOMPULSIVEDISORDEROCDEitherobsessionsorcompulsions:Obsessions:Recurrentpersistentthoughtsorimpulsesexperien__ssometimesasintrusiveandinappropriateandcausedistress.Thethoughtsaren’trealisticworriesaboutrealproblems.Persontriestoignoreorsuppresstheobsessions.Theobsessivethoughtsarerecognizedassuch.Compulsions:Repetitivebeh__iorsormentalactsthataredoneinresponsetoanobsession.Thebeh__iorsaremeanttoredu__distressorpreventafearedeventbutarenotrealistic.DifferentialDiagnosisAndComorbidityOCDisoftenassociatedwithotherdisorderssuchasdepression50%dysthymiaanxietydisorderssuchassocialphobiaandpanicdisorderhypochondriasisandeatingdisorders.Obsessive-compulsivesymptomsareoftenseeninschizophreniaaswell.Thereisagreatdealofoverlapwithotherrepetitivebeh__iorssuchasTourette’sSyndrome50%h__eOCDbut25%withOCDh__etics.Obsessive-CompulsivePersonalityDisorderOCPDisapersonalitydisorderseechapteronpersonalitydisorderscharacterizedbyrigidovercon__rnwithrulessometimessomuchthatindividualslosethepointofanactivity.OCPDisusuallyseenwithoutOCDinindividualsandvi__-versabutOCDandOCPD__yruntogetherinfamilies.CourseSymptoms__ybepresentforyearsbeforetreatmentissoughtandthoseaffectedoftensufferinsilen__.Thediseasefollowsachronicwaxingandwaningcoursewhere15%ofpatientsh__edeteriorationand5%h__eepisodeswithinterepisoderecovery.__lestendtoundergoamore__lignantcoursethanfe__les.TreatmentOCDcanbetreatedwithmedicationbeh__ioraltherapyandevensurgicalpro__dures.SelectiveserotoninreuptakeinhibitorsSSRIsaretheonlymedicationscurrentlyapprovedforthetreatmentofOCD.TheseincludetheTricyclicantidepressantClomipramineandalloftheSSRIsseeafullerdiscussionoftheseintheMoodDisorderschapter._________________yhelpbluntinitialanxietyproblemsandinsomnia.Thesearemostoftenusedincombinationwithantidepressants.Ingeneralcombiningmedicationsandbeh__iortherapy__yworkbestespeciallyforpatientswhoareunabletotoleratebeh__ioraltherapyduetosevereanxietymorethan25%insomeseries.Beh__ioraltherapyinvolvesexposingthepatienttosymptom-triggeringsituationsandnotallowingthemtoperformcompulsiveor__oidan__responses.Thisgradualdesensitizationallowsthepatienttobuilduptheabilitytohandleeverydaysituations.Neurosurgeryanteriorcingulotomycapsulotomylimbicleucotomyshouldbeconsideredalastresort.Re__nt____ysisfromMassachusettsGeneralHospitalfoundabout30%ofpatientswithsevererefractoryOCDbenefitedfromcingulotomy.Anteriorcapsulotomyespeciallywiththe“double-shot”gam__-knifetechniquelookspromisingforpatientswithintractableanddisablingOCD.40%ofpatientswereverymuchimprovedontheclinicalglobalimpressionscaleat12monthsafterthepro__dure.Thereisoftenadelayafterthepro__durebeforesymptomsimprove.Deepbrainstimulationisanewapproachdescribedinare__ntLan__tarticleNuttinetal.1999whichisstillearlyindevelopment.Ithas__rkedlyimprovedsymptomsina__allnumberofseverelyaffectedpatientswhowouldotherwisebecandidatesforneurosurgery.Potentialadvantagesoverneurosurgeryarethatnobraintissueisdestroyeditcanbetitratedfor__ximumindividualbenefitanditisreversible.。