Stress And Anxiety

Disorders

By Heba Essawy
 Definition Of Stress

Set of emotional, physical, and

cognitive (i .e ., thought) reactions to a
change.
Stress as a reaction to change
suggests that it is not necessarily
bad,
Could even be a good thing.
 Causes Of Stress

When person-environment transactions

to:
Perceive a discrepancy.

Whether real or not.

Between the demands of a situation and

the resources of the person's.
Either biological, psychological or social
systems
 Stress
In medical terms:

Stress is the disruption of homeostasis

through physical or psychological stimuli.
Stressful stimuli can be mental,
physiological, anatomical or physical
reactions
Hans Selye, defined the General
Adaptation Syndrome or GAS paradigm in
1936.
 Types of stress
Richard Lazarus(1974) dividing stress into:
- Eustress and - Distress.
Eustress stress :
Enhances function (physical or mental,)
such as through strength training or
challenging work.
Distress stress :
Persistent stress that is not resolved through
coping or adaptation may lead to escape
anxiety or withdrawal depression behavior.
 Types Of Stress
Eustress, or positive stress, has the following
characteristics:
Motivates, focuses energy
Is short-term
Is perceived as within our coping abilities
Feels exciting
Improves performance
In contrast, Distress, or negative stress, has the
following characteristics:
Causes anxiety or concern
Can be short- or long-term
Is perceived as outside of our coping abilities
Feels unpleasant
Decreases performance
Can lead to mental and physical problems
 General Adaptation
Syndrome
Researched mainly by Hans Selye on rats
exposing animals to unpleasant or harmful
stimuli such as injections or extreme
cold .

He found that all animals showed a series

of reactions, broken into three stages. He
describes this universal response to the
stressors as the General Adaption
Syndrome or GAS in 1956.
 Stages Of Stress
Stage one: Alarm
the body's stress response is a state of alarm.
During this stage adrenaline will be produced in
order to bring about the fight-or-flight response.
Activation of the HPA axis producing cortisol.

Stage two: Resistance

If the stressor persists.
Necessary to attempt means of coping with stress.
The body begins to try to adapt ,to the strains or
demands of the environment.
The body cannot keep this up , so its resources are
gradually depleted.
 Stages Of Stress
Stage three: Exhaustion
All the body's resources are depleted.
The body is unable to maintain normal function.
At this point the initial autonomic nervous system
symptoms may reappear
- sweating,
- raised heart rate .

If stage three is extended:

long term damage may result as the capacity of the
adrenal gland.
The immune system is impaired and resulting in
decompensation.
The result can manifest itself in illnesses such as
Ulcers, depression or cardiovascular problems.
 Stages of A Stress Reaction

Stage 1: Recognition of environmental

demand
Stage 2: Appraisal of the demand
by asking : 1 ) Does this event present a
threat ?
2 ) Do we have the resources to
cope with this event?
If we believe that the event is a threat , or if
we we lack the means to effectively respond
to the event, feeling stressed
Stage 3: Mobilization of the
nervous system

Sympathetic nervous system

automatically signals our body to
prepare for action.
The SyNS prepares for fighting or
fleeing by triggering or activating the
hypothalamic-pituitary-adrenal axis,
or HPA axis ( brain's 'stress circuit' ).
 Neurochemistry of General
Adaptation Syndrome
The body reacts to stress first by releasing :
Catecholamine hormones.
Epinephrine and Norepinephrine
Glucocorticoid hormones, cortisol and cortisone.

The hypothalamic-pituitary-adrenal axis (HPA);

Involving the interactions of the hypothalamus, the
pituitary gland, and the adrenal glands.

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 adrenal medulla, and
from the corticosteroid-producing adrenal cortex.
Stress can significantly affect many of the body's
immune systems, as can an individual's perceptions of,
and reactions to, stress.
Biological Systems For Stress
Reactions
The hypothalamus is like a thermostat
that receives inputs about the body's
internal environment.
If body functions are out of balance,
the hypothalamus sends messages to
the ANS and to the pituitary gland to
speed up or slow down relevant
glands and organs to bring the body
back into balance at the set-point
appropriate to each system
 Biological Systems For Stress
Reactions
The main job of the hypothalamus is to
maintain the homeostasis as
Blood pressure,
Body temperature,
Fluid balance,
Body weight,
Sexual activity,
Sleep/wakefulness
Emotions.
 Biological Systems For Stress
Reactions
Some of the hormones secreted by the
hypothalamus and pituitary gland stimulate
the limbic system,
The limbic system is heavily interconnected
with the brain's frontal cortex,
The limbic system and the frontal lobes work
together to make possible the appraisals or
judgments regarding whether or not a
stressor is dangerous or exceeds our coping
ability
. The combined limbic/frontal system also
influences whether we fight, flee, or freeze in
the presence of a stressor.
Factors Influencing the Stress
Response
Arousal Vs Anxiety
Physiological arousal is necessary to prime our
bodies for taking action.
If aroused increased in response to stressors,
alertness increases and attention sharpens.
Increasingly focused on the stressor itself,
while other aspects of the environment fade
into the background.
A narrowed focus of attention towards a
threat is typically adaptive, as it allows to
eliminate some of the available responses .
Factors affecting Arousal

Amount of mental energy .

Baseline level of anxiety ( level of
'trait' anxiety),
level of anticipatory anxiety (how
worried we are in advance of an
upcoming event).
" Yerkes-Dodson Curve".

A diagram suggests, increasing

levels of arousal initially improve
performance, but there quickly
comes a point of diminishing returns.
At high levels of stress, performance
ability declines dramatically.
 Primary and Secondary
Appraisal

Primary Appraisal : A stressor that

is perceived as important will cause
a stress reaction )"Does this matter
for me?").
 Primary and Secondary
Appraisal
In secondary appraisal: evaluate coping
resources (e .g ., how healthy we are, how
much energy we have, whether family
and friends can help, our ability to rise to
the challenge, and how much money or
equipment we have), our available
options, and the possibilities we have for
controlling our situation. If we believe
that we lack the coping resources
necessary to deal with the situation, we
will perceive it as negative stress
 Appraisals Influence How
You Feel: The Cognitive
Model
Beliefs (driven by appraisal process)
strongly influence subsequent mood
state.
Having the ability and resources to
handle the stressors , mood will be
generally positive
 Cognitive Model
the letter "A" stands for an "Activating Event."
Activating Events are the stressors that create
demands and cause potential stress.
letter "B " in the equation stands for "Beliefs."
We come into the world with no preconceived.
letter "C " in the A+B =C equation stands for
"Consequences." Consequences refer to the
feelings that occur as a result of beliefs and
self-talk in response to the activating event .
 Oxidative stress
Causes:
An imbalance between the production of
reactive oxygen and a biological system's
ability to detoxify the reactive intermediates.
Slow repair the resulting damage.

Oxidative stress is involved in :

Atherosclerosis.
Parkinson's disease.
Alzheimer's disease.
Prevention of ageing by induction of a
process named mitohormesis.
 Oxidative stress

Pathophysiology :
All forms of life maintain a reducing
environment within the cells.
Reducing environment is preserved by
enzymes that maintain the reduced state
through a constant input of metabolic
energy.
Disturbances in this normal redox state
can cause toxic effects through the
production of peroxides and free radicals
that damage all components of the cell,
including proteins, lipids, and DNA.
 Stress Scale
To measure stress according to the Holmes and
Rahe Stress Scale
Number of "Life Change Units" that apply to
events in the past year of an individual's life
are added
and final score will give a rough estimate of
how stress affects health.
Score of 300+: At risk of illness.
Score of 150-299+: Risk of illness is moderate
(reduced by 30% from the above risk).
Score 150-: Only have a slight risk of illness.
 Life event Life change
units
Death of a spouse100/Divorce73/Marital separation65
Imprisonment63/Death of a close family member63/Personal
injury or illness53/Marriage50/Dismissal from work47/
Marital reconciliation45/Retirement45/Change in health of family
member44/Pregnancy40/Sexual difficulties39/
Gain a new family member39Business readjustment39Change in
financial state38Change in frequency of arguments35
Major mortgage32Foreclosure of mortgage or loan30Change in
responsibilities at work29Child leaving home29
Trouble with in-laws29Outstanding personal
achievement28Spouse starts or stops work26Begin or end
school26Change in living conditions25Revision of personal
habits24Trouble with boss23Change in working hours or
conditions20Change in residence20Change in schools20Change
in recreation19Change in church activities19Change in social
activities18Minor mortgage or loan17Change in sleeping
habits16Change in number of family reunions15Change in eating
habits15Vacation13Christmas12Minor violation of law11
 Epidemiology Of Anxiety
Disorders

The most common mental illness .

One of 4 person met the diagnosis for
one the anxiety disorders.
In 12- month prevalence rate of 17.1%.
Women have 30.5 % lifetime prevalence
more affected than men ( 19.2%).
Epidemiology Of Anxiety
Disorder
SEX:
The female-to-male ratio for any lifetime anxiety disorder is 3:2.

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

New-onset anxiety symptoms in older adults :

unrecognized general medical condition.
substance abuse disorder.
Major depression with secondary anxiety symptoms.

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

Anxiety disorders appear to be

caused by an interaction of
biopsychosocial factors.
Genetic vulnerability.
Interaction with situations, stress,
or trauma to produce clinically
significant syndromes.
 Biological Factors
Central nervous system: The major mediators
of the symptoms of anxiety disorders:
Norepinephrine .
Serotonin.

Peptides, such as corticotrophin-releasing

factor.
Peripherally:
the autonomic nervous system, especially
the sympathetic nervous system, mediates
many of the symptoms.
 Causes of Anxiety
Disorders
Personal environment:
- Poverty.
- Early separation from the
mother.
- Family conflict.
- Critical and strict parents.
Personality.
Family dynamics.
Brain chemistry.
Genetic vulnerability .
 Risk Factor For Anxiety

Brain chemistry:
Imbalance of neurotransmitters such
as serotonin, GABA, and epinephrine
may contribute to anxiety disorders.
Abnormalities in the stress hormone
cortisol .
 Risk Factor For Anxiety

Personality traits
People with anxiety disorders often
view themselves as powerless and
the world as a threatening place.
Pessimistic perspective can lead to
low self-confidence and poor coping
skills.
 Risk Factor For Anxiety

Heredity Factor:
Anxiety run in families.

People have a family history of

anxiety disorders, mood disorders,
or substance .
One risk factor may be a biological
vulnerability to stress.
 Risk factors for Anxiety

Major life stressors

Financial difficulties.

Marital problems.

Bereavement

It is important to realize that no single

factor causes an anxiety disorder.
The various anxiety risk factors are
interrelated and can interact with and
impact one another.
 Generalized Anxiety
Disorder
Definition :
GAD is defined as excessive anxiety
and worry about several events or
activities for most days during at
least 6- month period.
Worry is difficult to control and is
associated with somatic symptoms,
such as muscle tension, irritability,
difficulty in sleeping and restlessnes.
 Generalized Anxiety
Disorder
Epidemiology
One year prevalence range from 3 to 8%.
Male : Female is 2 : 1.
Life Time prevalence is 5-8%.
25% of all patients with anxiety is suffering
GAD.
Onset : Late adolescence or early adulthood
GAD patients are seen @ primary care settings.
Separation anxiety in childhood that includes
anxiety related to going to school, is one of the
precursor for adult anxiety disorders
 Generalized Anxiety
Disorder
Characterized by excessive anxiety and worry.
Worrying is difficult to control.
Anxiety and worry are associated with at
least 3 of the following symptoms:
Restlessness or feeling keyed-up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Although not a diagnostic feature, suicidal ideation
and completed suicide have been associated with
generalized anxiety disorder.
 Physiological Symptoms
of GAD
Muscle tension. - Cognitive
Vigilance
Fatigue. - Autonomic
hyperactivity
Restlessness. - Difficulty
sleeping.
Irritability. -Edginess.
Gastrointestinal discomfort or diarrhea.
 Lab Studies
in GAD

CBC count .
Chemistry profile .

Thyroid function tests.

Urinalysis .

Urine drug screen.

 Treatment Of GAD

The most effective treatment is the combination

of psychotherapy , pharmacotherapy and
supportive approaches.

Behavior Therapy
* To modify and gain control over unwanted
behavior.
*The individual learns to cope with difficult
situations, often through controlled exposure
to them.
* Gives the individual a sense of having control
over their life.
 Treatment Of GAD
Cognitive Therapy
The goal of Cognitive Therapy:
To change unproductive or harmful
thought patterns.
The individual examines his feelings
and learns to separate realistic from
unrealistic thoughts.
As with Behavior Therapy, the
individual is actively involved in his own
recovery and has a sense of control.
 Cognitive Behavioral
Therapy
CBT examines distortions in our ways of
looking at the world and ourselves
Negative thoughts lead to negative
emotions, so CBT aims to change those
negative thoughts before they trigger
psychological difficulties.
CBT for generalized anxiety disorder
involves retraining the way you think.
Therapist identify automatic negative
thoughts that contribute to your anxiety.
 Cognitive Behavioral
Therapy
Education:
CBT teaches you about the cognitive, physical, and
behavioral .
Teaches you how to distinguish between helpful
and unhelpful worry.
An increased understanding of anxiety
encourages a more accepting and proactive
response to it.
Monitoring
Learn to monitor anxiety, including what triggers
it.
Specific things you worry about, and the severity
and length of a particular episode.
This get perspective, as well as track your
progress.
 Cognitive Behavioral
Therapy
Physical control strategies:
Deep breathing and progressive muscle relaxation
help decrease the physical over-arousal of the
fight or flight response that maintains the state of
fear and anxiety.
Cognitive control strategies:
Realistically evaluate and alter the thinking
patterns that contribute to anxiety
Challenge these negative thoughts, fears will begin
to subside. CBT also teaches you to test the beliefs
you have about worry itself, such as Worry is
uncontrollable or If I worry, bad things are less
likely to happen.
 Cognitive Behavioral
Therapy
Behavioral strategies:
Instead of avoiding situations you fear.

CBT teaches to tackle them .

Start by imagining the thing youre most

afraid of.
By focusing on your fears without trying
to avoid or escape them.

--------- Feeling more in control and

less anxious.
 Relaxation Techniques

Help to develop the ability to more

effectively cope with the stresses
that contribute to anxiety.
as well as with some of the physical
symptoms of anxiety.
The techniques taught include
breathing re-training and exercise.
 Biofeedback
What Exactly is Biofeedback?
Biofeedback is a self-training, mind-
over-body technique developed in the
1940s.

It's a method in which we consciously

control a body function that normally
is regulated automatically by the body
like skin temperature, heart rate, or
blood pressure.
 Pharmacotherapy
Selective Serotonin Reuptake
Inhibitors : Citalopram
Escitalopram
Fluvoxamine
Paroxetine
Fluoxetine
Sertraline .
Affects the concentration
serotonin linked to anxiety
disorders
 Pharmacotherapy

Tricyclic Antidepressants (TCAs

Affects the concentration and

activity of the neurotransmitters
serotonin and norepinephrine,
chemicals in the brain thought to be
linked to anxiety disorders .
 Pharmacotherapy
Monoamine Oxidase Inhibitors (MAOIs
Blocks the effect of an important brain
enzyme, preventing the breakdown of
serotonin and Norepinephrine)
Other Antidepressants
Cymbalta
Desyrel *
Effexor
Remeron
Affects the concentration of the
neurotransmitters serotonin and/or
norepinephrine, chemicals in the brain
thought to be linked to anxiety disorders
 Pharmacotherapy

Azapirones (BuSpar) :Enhances the activity

of serotonin .

* Benzodiazepines: Exact mechanism

unknown.
Some research shown to enhance the
function of gamma aminobutyric acid (GABA).
Antihistamines :Sedative effects through
blockade of histamine receptors in the brain .
 Pharmacotherapy
Beta Blockers: Blocks receptors
associated with physiologic symptoms
of anxiety.
Atypical Antipsychotics :
Augmentation therapy.

These medications may be added when

symptoms only partially respond to
another medication to increase the
overall response to treatment
THANK YOU
Anxiety Disorders:
unpleasant emotional state,
sources of which are less readily
identified.
It is frequently accompanied by
physiological symptoms
lead to fatigue or even exhaustion.
Panic Disorder

By Heba Essawy
 Panic disorder

Background
Panic attacks:
A period of intense fear in which 4 of 13 defined
symptoms.
Develop abruptly and peak rapidly less than 10
minutes .
Cannot result from substance use, medical
conditions, or another psychiatric disorder .
The frequency can vary from several attacks a
day to only a few attacks a year.
Is qualified with the presence or absence of
agoraphobia .
 Panic Disorder With
Agoraphobia

Agoraphobia is:
Anxiety toward places or situations
in which escape may be difficult or
embarrassing.
These anxiety-provoking situations
are avoided or are endured with
anxiety.
Agoraphobia is not a stand-alone
disorder; it is a descriptive term .
 DSM-IV-TR Criteria For
panic Attack
Uncoded , 4 or more symptoms
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sense of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization or depersonalization (feeling detached from
oneself)
Fear of losing control or going crazy
Fear of dying
Numbness or tingling sensations.
Chills or hot flashes.

 Diagnosis Of Panic
Disorder
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision:
Recurrent unexpected panic attacks
One of attacks has been followed for more
than 1 month :
* subsequent persistent worry about
having another attack.
* Consequences of the attack.
* Significant behavioral changes
related to the attack.(Loosing control,
having heart attack.)
Pathophysiology Of Panic :
Biological
Serotonergic model:
5HT system or one of its
subsystems may play a role in the
pathophysiology of panic disorder,
Exaggerated postsynaptic
receptor response to synaptic
serotonin.
Recent studies report
subsensitivity of 5HT1A receptors.
 Pathophysiology Of Panic :
Bio.
Catecholamine model :
* Increased sensitivity to adrenergic
CNS discharges, with hypersensitivity
of presynaptic alpha-2 receptors.
Locus ceruleus model:
* Increased local discharge resulting in
adrenergic neuron stimulation.
* Affects hypothalamic-pituitary-
adrenal axis, which can respond
abnormally to clonidine in patients with
panic disorder.
 Pathophysiology Of Panic :
Bio.
Panic inducing substances Respiratory
stimulation shift acid- base balance
Sodium Lactates : focuses on symptom
production by postulated aberrant metabolic
activity induced by lactate.
Carbon dioxide (False suffocation hypothesis) :
explains panic phenomena by hypersensitive
alarm system by co2 and Lactate activate
asphyxia monitor @ brain stem receptors.
Bicarbonate.
Act through neurotransmitters include yohimbine ,
2- adrenergic , mCPP, cholecystokinine

Pathophysiology Of Panic
: Bio.
GABA model: postulates decreased
inhibitory receptor sensitivity, with a
resultant excitatory effect.
The neuroanatomic model:
* Mediated by a "fear network" in the
brain that involves the amygdala, the
hypothalamus, and the brainstem
centers.
*Cortical atrophy @ rt. Temporal lobe
The genetic hypothesis :MZ>DZ.
Definable genetic loci ??
Pathophysiology Of Panic
: Bio.

Mitral valve prolapse:

Heterogeneous disorder.
Prolapsed one leaflets.
Mid-Systolic click.
 Psychological Factors
Cognitive- Behavioral Theories:
- Learned from parental behavior
- through classic conditioning
Psychoanalytic Theories:
- Unsuccessful defense against anxiety.
- Agoraphobia due to
* loss of a parent in childhood and
history of separation anxiety.
* Parental separation in childhood.
*Death of the parent before 10ys.
 Demographic Data

Prevalence : 1.5-5% for panic disorder .

3-5.6% for panic attacks.
Race: * African Americans presenting with
somatic symptoms .
* seeking help in medical settings.
Sex: One-month prevalence women:men, 0.7%:
0.3% (1: 2-3 folds) .
Age : * Bimodal distribution.
* Highest incidence in late adolescence .
* Second peak in the mid 30s.
Patterns of Panic Attacks

Unexpected panic attacks have no known

precipitating cue panic disorder without
agoraphobia.
Situationally bound (cued) panic attacks recur
predictably in temporal relationship to the trigger
specific phobia-type diagnosis.
Situationally predisposed panic attacks are more
likely to occur in relation to a given trigger, with
inability to escape panic disorder with
agoraphobia.
Use of caffeine, alcohol, nicotine, or other
substances can trigger or potentiate panic
attacks.
 Comorbidities Of Panic

Panic disorder often coexists with mood

disorders.
Alcohol and other substance use disorders are
a sequelae of panic disorder
Medical conditions :
Mitral valve prolapse.
Hypertension.
Cardiomyopathy .
Chronic obstructive pulmonary disorder,
Irritable bowel syndrome.
Migraine headache.
 Pharmacothearapy

Selective serotonin reuptake inhibitors (SSRIs)

are generally used as first-line agents.
followed by tricyclics.
*Benzodiazepines can achieve long-term
control but should be reserved for patients with
refractory panic disorder.
Fluoxetine (Prozac) can be used at very low
starting doses.
*Paroxetine (Paxil) has a more sedating effect,
potentially making its potential aggravation of
anxiety better tolerated initially. Drug alter
metabolism of cytochrome P-450 -2D.
 Cognitive and behavioral
psychotherapy
Cognitive therapy :
Understand false beliefs/distortions .
Provides information about panic attacks.
Behavioral therapy ;
Involves sequentially greater exposure of the
patient to anxiety-provoking stimuli; over
time, the patient becomes desensitized to the
experience.
Relaxation techniques :
Control patients' levels of anxiety.
Respiratory training
Control hyperventilation during panic attacks.
 Specific Phobia

An excessive fear of a specific

object, circumstance , or situation.
Specific phobia is a strong ,
persistent fear of an object or
situation.
Person with specific phobia may
anticipate harm ( bitten by dog,
fainting).
 Social phobia

Intense, irrational and persistent fear of being

criticized or negatively evaluated by others.
Feared social or performance situations
typically provoke an immediate anxious
reaction ranging from diffuse apprehension to
situational panic.
To meet the diagnostic criteria for this
disorder, the symptoms must be severe enough
to cause significant distress or disability .
 Diagnostic Criteria for
Social Phobia
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 possible scrutiny by others.
The individual fears will be humiliating or
embarrassing.
note: In children, there must be evidence of the capacity for
age-appropriate social relationships with familiar people
and the anxiety must occur in peer settings, not just in
interactions with adults.

B. Exposure to the feared social situation almost

invariably provokes anxiety, which may take the form of a
situationally bound or situationally predisposed panic
attack.
note: In children, the anxiety may be expressed by crying,
tantrums, freezing, or shrinking from social situations
with unfamiliar people
 Diagnostic Criteria for
Social Phobia
C. The person recognizes that the fear is excessive or
unreasonable.
NOTE: In children, this feature may be absent.

D. The feared social or performance situations are avoided or

else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation interferes significantly

with the person's normal routine, occupational (academic)
functioning .

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

least six months.
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 condition and is not better accounted for
by another mental disorder .
 Diagnostic Criteria for
Social Phobia
H. If a general medical condition or another
mental disorder is present, the fear in
Criterion A is unrelated to it; (e.g., the fear
is not of stuttering, trembling in Parkinson's
disease or exhibiting abnormal eating
behavior in anorexia nervosa or bulimia
nervosa.)
Specify if:
Generalized: if the fears include most social
situations (also consider the additional
diagnosis of avoidant personality disorder).
 Common Fears in Social
Phobia

Public speaking or performing.

Making "small talk.
*Small group discussion.
*Asking questions in groups.
*Being introduce.
*Meeting or talking with
strangers.
*Being assertiveness.
 Common Fears in Social
Phobia
Being watched doing something (e.g.,
eating, writing).
*Attending social gatherings
*Using the telephone
*Using public restrooms
*Interacting with "important" people
*Indirect evaluation (e.g., test
taking)
 Epidemiology

lifetime prevalence rate of 13.3 percent

.
One-year prevalence rate of 7.9
percent.
It s the third most prevalent psychiatric
disorder, following substance abuse and
depression.
Fears of public speaking or performing
are most prevalent.
 Onset of social phobia

Occurs between 11 and 19 years of age.

Onset after age 25 is rare, until some
new social or occupational demand
forces these persons into social
encounters that trigger the syndrome.
(e.g., meeting new people, public
speaking, promotion).
Slightly more females than males have
social phobia.
 Comorbidity Of social
phobia
* One half of patients with have comorbid
mental, drug or alcohol problems.
70% had comorbid major depression.
Up to 16 % of patients who present with
social phobia have alcohol abuse problems.
Patients presenting for treatment of
substance abuse meet the criteria for
social phobia.
longitudinal data show that social phobia
precedes approximately 70 percent of
these comorbid condition.
 Drugs Used in Treating
Social Phobia
MAOIs
Phenelzine (Nardil) 45 to 90 mg / day

Tranylcypromine (Parnate) 40 to 60 mg / day

SSRIs
Fluoxetine (Prozac) 10 to 100 mg / day..
Paroxetine (Paxil) 20 to 60 mg / day
Sertraline (Zoloft) 50 to 200 mg / day
Fluvoxamine (Luvox) 50 to 150 mg /day
Citalopram (Celexa) 40 mg / day
 Drugs Used in Treating
Social Phobia
Benzodiazepines
Alprazolam (Xanax) 2 to 10 mg / day
Lorazepam (Ativan) 2 to 6 mg /day
Clonazepam (Klonopin) 1 to 3 mg / day
Nonbenzodiazepine, azaspirone
Buspirone (Buspar) 35 to 60 mg /
day

Beta blockers
Propranolol (Inderal) 40 mg as
needed
 Components of Cognitive
Behavior Therapy for Social
Phobia
Anxiety management skills
May involve controlled breathing, relaxation exercise
Social skills training
verbal and nonverbal skills that facilitate social
effectiveness, such as initiating and maintaining
conversation, making appropriate eye contact .
Cognitive restructuring
Involves learning to identify, challenge and change
fearful thinking that overestimates social threat,
underestimates one's ability to manage social
demands and catastrophizes the consequences of
social miscues
Gradual exposure to feared situations
Involves gradual reentry into feared social situations
to reduce the anxiety that they engender
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 Lab Studies in GAD

Initial lab studies might be limited to

the following:
CBC count .
Chemistry profile.

Thyroid function tests.

Urinalysis .

Urine drug screen.

 Pharmacotherapy

Sertraline -- First drug approved by FDA for PTSD.

May be effective in reducing some symptoms in at least
some patients.
Adult Dose : 50-200 mg PO qd .
Pediatric Dose: Not established
Contraindications: Documented hypersensitivity.
Interactions; Increases toxicity of MAOIs, diazepam
and warfarin, due to inhibition of cytochrome P-450
enzymes .
Pregnancy : not established.
Precautions Caution in preexisting seizure disorders,
recent myocardial infarction, unstable heart disease, and
hepatic or renal impairment
 Paroxetine
For PTSD, causing reduction in reexperiencing,
numbing/avoidance, and hyperarousal.
Adult Dose starting dose: 20 mg/d PO; if
indicated, may be increased in 10-mg increments
at intervals >1 wk; doses from 20-50 mg are
effective .
Pediatric Dose: Not established.
Contraindications: MAOIs or
thioridazine.
Precautions: Caution in history of seizures,
mania, renal disease, and cardiac disease; the CR
product should not exceed 50 mg/d for elderly,
debilitated, or severely renally or hepatically
impaired persons
 Paroxetine
Interactions : Avoid alcohol, tryptophan,
and thioridazine; avoid within 14 d of
MAOIs; may inhibit metabolism of TCAs;
- May change concentrations with plasma-
bound drugs; hyperreflexia, weakness, and
incoordination have been reported ;
- Monitor theophylline; caution with
lithium, digoxin, diuretics, cimetidine,
phenobarbital, warfarin, phenytoin,
quinidine, and drugs metabolized by CYP-
450 2D6 (eg, type 1C antiarrhythmics,
phenothiazines, antidepressants)
Pregnancy : - not established.
 Phenelzine
for symptoms of panic disorders.
Adult Dose 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 are slow metabolizers)
Pediatric Dose: Not established
Contraindications : Documented hypersensitivity;
alcoholism, congestive heart failure, and
pheochromocytoma.
Interactions :Co administration with foods containing
tyramine can increase blood pressure; concurrent use with
tryptophan should be approached with caution because
serotonin syndrome may result; may enhance therapeutic and
toxic response of meperidine, and concomitant administration
of these drugs should be avoided.
Pregnancy - not established.
Precautions: monitor for postural hypotension; convulsion
.