Disease of Fear and Palpitation-Anxiety Disorder

Mr. Ram Bahadur is a 25 year male . He is a student. He walking on the road, suddenly saw  death body on the road. He felt discomfort. He developed fearfulness, palpitation, breathing difficulty, fear of going something wrong and  fear of dyeing.  Since then he worries about going to be  stop his heart beat. He thinks that he has  problem of heart  and consulted to  the cardiologist. However he found that his heart was in the normal condition. Now he is treating with psychiatrist and getting better. Now it is known that he has problem  with Generalized anxiety disorder (GAD). Doctor told that he need to  treat  for few months.

What is anxiety disorder? 

Anxiety is a normal part of life. It can even be useful when it alerts us to danger. But for some people, anxiety is a persistent problem that interferes with daily activities such as work, school or sleep called anxiety disorder.. This type of anxiety can disrupt relationships and enjoyment of life, and over time it can lead to health concerns and other problems. In some cases, anxiety is a diagnosable mental health condition that requires treatment. Generalized anxiety disorder, for example, is characterized by persistent worry about major or minor concerns. Other anxiety disorders — such as panic disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) — have more specific triggers and symptoms. In some cases, anxiety is caused by a medical condition that needs treatment.

Whatever form of anxiety you have, medications, counseling or lifestyle changes can generally help. Symptoms of Anxiety

1.             Psychological       -    Fearful anticipation

                                      -    Irritability

                                      -    Restlessness

                                      -    Poor concentration

                                      -    Worrying thoughts

2.             Physical

          Gastro- intestinal -    Dry mouth

                                      -    Difficulty in swallowing

                                      -    Epigastria discomfort

                                      -    Excessive wind

                                      -    Frequent or loose motions

          Respiratory           -    constriction in the chest

                                      -    Difficulty inhaling

                                      -    Over brrathi9ng

          CVS                     -    Palpitations

                                      -    Discomfort in chest

          Genito - urinary    -    urgency of maturation

                                      -    Failure of erection

                                      -    Menstrual discomfort

                                      -    Amenorrhea

          Neuro-muscular

          System                 -    Tremor

                                      -    Prickling sensation

                                      -    Tinnitus

                                      -    Dizziness

                                      -    Headache

                                      -    Aching muscles

3.             Sleep disturbance -    Insomnia

                                      -    Night terror

4.             Other symptoms   -    Obsessions           

                                      -    Depersonalization

Types of anxiety disorder

Anxiety disorders can be divided into three broad categories, although in practice there is considerable overlap between then:

·      Generalized anxiety disorders

·      Panic disorder

·      Phobic anxiety disorders, including agoraphobia, social phobia and specific phobia

1.      Generalized anxiety disorder  (GAD):In GAD,

·      Symptoms of anxiety are present most of the time over a period of at least two weeks and often considerably longer.

·      There does not seem to be a direct cause for the anxiety which is often as severe when the patient is at home or when they are out.

·      This type of anxiety occurring without an obvious stressor is some \times called "free floating anxiety.

·      GAD occurs in about 2% of the population and is more common in women then men with onset usually in early adult life.

·      It tends to occur against a background of chronic social problems, including marital difficulties, unemployment and lack of support.

2.             Panic disorder:

          Panic attack: Panic attacks can occur in any of the anxiety disorders. They are brief but very intense episodes of anxiety. An extreme sense of fear is usually present. It may begin suddenly or build gradually to a crescendo. Hyperventilation is common with shallow and rapid breathing that flushes carbon dioxide from the body resulting in a respiratory alkalosis. This causes symptoms of palpitation, chest pain, sweating, dizziness, and feelings of pins and needles around the mouth dexterities, and muscle spasms. There is often a fear of losing control or, Because of the similarities of symptoms with ischemic heart disease, a fear of dying.

          In panic disorder

·      There are repeated panic attacks occurring over a short period of time.

·      Unlike the panic attacks that can occur in phobic anxiety disorders, they are not predictable of in response to a particular at5ressor.

·      In contrast to generalized anxiety disorder, symptoms are not present between attacks.

·      The disorder occurs in about 0.8% of the population and is slightly more common in women then men.

·      It is most likely to being in early adulthood.

3.             Phobic  disorder: In phobic disorder symptoms of anxiety occur repeatedly and predictably in response to a particular object, situation or thought. The degree of anxiety is quite out of proportion to the circumstances.

          For example, while most people would be wary of approaching a large aggressive looking dog an individual with a phobia about dogs might become anxious if a small well behaved dog passes on the other side of the road or when shown a photograph of a dog. They might stop walking in public places in order to avoid dogs, and therefore lead and extremely restricted life style.

          Avoidance is a characteristic feature of phobias and account for a great deal of disability. Some patients will go to extraordinary lengths to avoid they fear.

          There are three types of phobic disorder:

·      Agoraphobia

·      Social phobia

·      Specific phobia

Agoraphobia:

In agoraphobia

·      Anxiety occurs in a wide range of situations, most commonly crowded places, particularly busy markets, shopping center, and on public transport.

·      There is often fear of losing control in public, by fainting or collapsing, or of being unable to get out of a building.

·      Symptoms tend to gradually escalate over time so that more and more places are avoided until eventually the patient cannot leave their own home. Some can only go out if accompanied by some one. Home is thought of as a safe place, and symptoms of anxiety are less prominent there although often n not entirely absent. 

·      Depressive symptoms are common, and it is important to be alert for a coexisting depressive disorder when assessing these patients.

·      Agoraphobia has a prevalence of 0.6% in the general population.

·      It is more common in women, with symptoms usually beginning in early adulthood.

·      It tends to be chronic disorder that fluctuates in severity.

Social phobia:

In social phobia:

·      The anxiety symptoms are provoked by social situation in which one feels on display in some way, such as speaking to an audience, eating in public, going to the cinema.

·      The impact of the phobia depends upon the job and lifestyle of the individual.

·      For example

·      A teacher who is unable to speak in public will be severely disabled, whereas an office worker may function well despite having a similar fear.

·      Unlike other workers phobias, it occurs as frequently in men as women.

·      Alcohol abuse is a common complication, as alcohol is often in an effort to gain control of the anxiety symptoms.

Specific phobia:

In specific phobias:

·      A particular object arouses anxiety. The object can be virtually anything, although thunderstorms and animals are moat often implicated.

·      This is the commonest, and generally the least serious or disabling of the phobic anxiety disorder.

·      The degree of disability dose depend upon the ease with which phobic object can be avoided.symptomscauses

Causes

As with many mental health conditions, the exact cause of anxiety disorders isn't fully understood. It's thought that anxiety disorders may involve an imbalance of naturally occurring brain chemicals (neurotransmitters) such as serotonin, dopamine or norepinephrine. Life experiences such as traumatic events appear to trigger anxiety disorders in people who are already prone to becoming anxious. Inherited traits also are a factor.

risk-factors

Risk factors

Things that may increase your risk of developing an anxiety disorder include:

·         Being female. Women are more likely than men to be diagnosed with an anxiety disorder.

·         Childhood trauma. Children who endured abuse or trauma or witnessed traumatic events are at higher risk of developing an anxiety disorder at some point in life.

·         Stress due to an illness. Having a chronic health condition or serious illness such as cancer can cause significant worry about the future, your treatment and possibly your finances.

·         Stress buildup. A big event or a buildup of smaller stressful life situations may trigger excessive anxiety — for example, ongoing worry about finances or a death in the family.

·         Personality. People with some personality types are more prone to anxiety disorders than are others. In addition, some personality disorders, such as borderline personality disorder, may be linked to anxiety disorders.

·         Having blood relatives with an anxiety disorder. Anxiety disorders can run in families.

·         Substance use. Drug or alcohol abuse can cause or worsen anxiety.

complications

Complications

Having an anxiety disorder does more than make you worry. It can also lead to, or worsen, other mental and physical health conditions, including:

·         Depression (which often occurs with anxiety disorder)

·         Substance abuse

·         Trouble sleeping (insomnia)

·         Digestive or bowel problems

·         Headaches

·         Teeth grinding (bruxism)

preparing-for-your-appointment

treatments-and-drugs

Management

Drugs are:

·      Antidepressants, beta blockers   and benzodiazepines 

·         Psychotherapy

-          Reassurance and explanation that "not a life threatening situation"

-       Supportive psychotherapy

-       Relaxation exercise, yoga, massage, mediation etc.

-       Behavioral therapy techniques for phobic anxiety disorders.

-        

Lifestyle and home remedies

While most people with anxiety disorders need psychotherapy or medications to get anxiety under control, lifestyle changes also can make a difference. Here are a few things that you can do:

·         Get exercise. Exercise is a powerful stress reducer; it can improve your mood and keep you healthy. It's best if you develop a regular routine and work out most days of the week. Start out slowly and gradually increase the amount and intensity of the exercise you do.

·         Eat well. Avoid fatty, sugary and processed foods. Include foods in your diet that are rich in omega-3 fatty acids and B vitamins.

·         Avoid alcohol and other sedatives. These can worsen anxiety.

·         Use relaxation techniques. Visualization techniques, meditation and yoga are examples of relaxation techniques that can ease anxiety.

·         Make sleep a priority. Do what you can to make sure you're getting enough quality sleep. If you aren't sleeping well, see your doctor.

·         Quit smoking and cut back or quit drinking coffee. Both nicotine and caffeine can worsen anxiety.

How Can We Be Mentally Healthy?

·      Don’t do deep thinking.

·      Don’t believe traditional false things like witch, ghost, etc

·      Try to be happy whatever you got but don’t forget to do hard working

·      Take as  a good way for your friends success.

·      Don’t abuse Alcohols & Drugs.

·      Do healthy competition on daily life.

·      Don’t be too moral and don’t expect it from other also.

·      Express your problem to other (ventilations).  

·      Make the environment peace and healthy.

·      Break difficult work into different fraction and try to finish one by one.

                                                                Dr C P Sedain,Neuropsychiatrist,                                                                                                                    

                                                                    Chitwan Medical Collage,Chitwan

Drug addiction

A 'Drug' is defined by the World Health Organization (WHO) as any substance that, when introduced into a living organism may alter or modify one or more of its functions. This definition conceptualizes 'drug' in a very board way, including not only the prescribed medications but also all other pharmacologically actives substances.

A 'psychoactive substance' is a substance that is capable of altering the mental functioning of an individual. Such substance when used brings changes in individual's consciousness, behavior, thinking, mood, perception, judgment and insight. The terms 'drug addiction' and 'drug addict' have been dropped from scientific use due to their derogatory connotation. Instead terminologies like 'substance abuse', 'substance dependence', 'harmful use' and ' psychoactive substance use disorder' are used now a days. Licit drug are legal and easily available in the market and their use per se is not legally prohibited, e.g. different medications, tobacco, alcohol, coffee, tea, and solvent. Illicit drug are illegal and not available in the local market. Production, procession, trafficking, buying, selling and use of these drug is illegal, e.g. heroin, cocaine, buprenorphine, cannabis etc

Many mental and behavioral disorders can be cause due to use of one or more psychoactive substances.

·      Substance (Drug) Abuse is a serious public health problem in Nepal.

·      It is estimated that there are about 70,000-drug user in Nepal and about 35,000 of the total estimated drug are IDUs (Inject able Drug User). 40% of the IDUs are said to be infected with HIV. 90% of the using substances are under the age of 30(population under risk)

Important clinical conditions associated with psychoactive substance use

i.                Acute intoxication: It is the condition following administration of any psychoactive substance, resulting in disturbances in level of consciousness, thinking, perception, mood, behavior or other psycho-physiological function and responses. It may be uncomplicated with bodily injuries, delirium, convulsion or coma.

ii.              Harmful use: It is a pattern as psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis) or (e.g. depression).

iii.             Dependence syndrome: This is the state also commonly know as "drug addiction". It is a condition in which the use of substance taken on a much higher priority for a given individual than all other he/she used to value more. The key feature is a compulsion to use substances. Other features are tolerance; withdrawal and uses of substance to received or avoid withdrawal symptoms. A dependent individual's increasing focus on seeking behavior leads to progressive loss of other interests, focus on drug seeking behavior leads to progressive loss of other interests, neglect of self care and social relationship and disregard for harmful consequences.

iv.            Withdrawal syndrome: Its is a group of symptoms occurring on absolute or relatives withdrawal of a substance after repeated and usually prolonged use in usually high doses. It is time limited, and requires medical treatment. It is one of the indicators of the presence of dependence syndrome.

v.              Substance induced psychiatric disorders: Substance can lead to many of psychiatric disorder including psychosis, depression, anxiety, sleep disturbance, sexual dysfunctions etc.

Types of abused substances

·      Depressants: These substances slow down the activity of the brain. E.g. Alcohol, Barbiturates, Benzodiazepines - diazepam (Valium), nitrazepam etc.

·      Stimulant: They increase the activity of the brain / CNS. E.g. Cocaine, Amphetamine, Tobacco (the active substance in tobacco is nicotine)

·      Narcotic analgesics: These are substances obtained from opium or synthetic (artificial) opium substitute that has opium like effects. E.g.-Opium (ckmLd_, Morphine, Codeine (active component in Phencidyl), Pethidine, Heroin (Brown sugar / white sugar / smack), Pentazocine (Fortwin), Buprenorphin (Tidigesic), Proxyvon etc.

·      Hallucinogens: These substances predominantly produce perceptual disturbances including hallucinations. E.g. LSD, Cannabis - Bhaang (efË), Gaanja (ufFhf), Hashish, Chares (r/];)

·      Volatile inhalants: These substances are inhaled to produce the desired effects. E.g. Adhesive glues (dendrite), paint thinners, correcting fluid, shoe police etc.

Commonly abused substances in Nepal are Alcohol, Nicotine, cannabis, narcotics and benzodiazepines

Few users of any substance become dependent. The estimated proportions of exposed individuals who become dependent on substances are:

·      Nicotine> 30%

·      Opioids --25%

·      Alcohol -- 10-15%

Major risk factors for substance abuse

·      Family disorganization

·      Parental Neglect

·      Parent child conflict

·      Poor discipline

·      Peer group pressure / influence

·      Isolation - lack of emotional support

·      Over protection by parents

·      Repeated failures

·      Personality problems

Why people take psychoactive substances?

·      For excitement and pleasure

·      When in depression

·      To be 'fashionable" / be one among the crowd

·      To be different

·      To escape form problems

·      To see what it is like / curiosity

·      When bored

·      As a break from work

Causes of substance dependence (Drug addiction): Substance dependence is a multifactor and complex phenomenon. Different pharmacological, environmental, social and psychological factors play an important role in one or the other way in the initiation and maintenance of drug seeking behavior:

a.              Pharmacological factors: pain relief, relief from cough, fatigue, obtaining highly pleasurable effects, obtaining intensive sensory and perceptual experiences, enhancing self esteem through "highs" produced y some substances are some of such factors leading to substance seeking behavior and dependence.

b.             Environmental factors: These include-

          Easy availability of substance - Easy availability leads to more frequent use of substances and dependence

             Inverse relationship of price and rate of use -Thus, if the prices of substances are low, the rte of use will be more. Effects of mass media

c.              Social factors:

i.           Home and family environment — Interpersonal or parent child conflicts, parental neglect resulting from large families and (or extensive employment or overtime work of parents), poor parenting skills and family disorganization are of some of the factors which lead to two important weaknesses in the family system:

a)         The unhappy life experiences of the individual, and

b)        Lack of care and supervision for the young ones

          The results in individuals felling dissatisfied, frustrated, anxious, insecure, fearful and even hostile in the home or family.

ii.         Peer group pressure: This is an importance social factoring the beginning of substance use. It initiates substance use because of:

-       Social acceptance

-       Encouragement of friends

-       With friends

-       The desire to go along with crowd

-       Peer values

iii.        Sub-cultural factors: These include characteristics of modern living, integration into the student subculture and "pop culture" of loose morals and declining social values.

D.        Psychological factors:

i.  Personality disturbances - certain personally make ups or traits predispose an individual to develop substance dependence. E.g.Anxious, always stressed, depressive, fearful of competition, antisocial, always in despair, low self esteem, inability to face the reality of life

ii.Escape mechanism - Substance may be used by an individual as a means of escaping from frustration, problems, from reality and something undesirable

iii.        Satisfying curiosity or becoming adventurous

iv.       Hedonism - using drugs for fun, "kick" or "high"

v.         Symbol of rejection- Substance may be used as a means of rebellion against conventional, social and traditional values, or as a means of expressing hostility against authority and parental figures, instauration or society.

vi.       Substance may be used to achieve a sense of belongingness or to express independence.

Commonly used substances

Opioids

Opium is derived from the Opium poppy plant (Papaver somniferous), containing more than 20 alkaloids. In use for more than 3500 years in the forms of crude opium and alcoholic solutions of opium. Major opioids in use include Morphine, Codeine (active ingredient in phencidyl), Heroin (Brown Sugar/ Smack), Buprenophin (Norphin/ Tidigesic), Pentazocin (Fortwin) and Dextropropoxyphene (Proxyvon)

The most commonly abused opioids is Heroin.

Routes of ingestion:   

·      Oral

·       Chasing (Intranasally)/sniffing

·      Intravenous injections

·      Subcutaneous injections

Effect on use

·      Euphoric rush

·      Feeling of warmth / facial flushing

·      Dry mouth / Heaviness of extremities following by sedation (also called Nodding off)

·      Occasional low mood / Nausea and vomiting

·      Decreased respiratory rate

·      Change in blood pressure and heart rate

Effects of acute opoid withdrawal

·      All opioids have following withdrawal symptoms in common:

·      Pin& muscle cramps, dysphoria, restlessness, craving for opioids, insomnia, papillary dilatation, anxiety, irritation, yawing

·      Nausea, Vomiting, diarrhea, bowel cramps, bone pain

·      Sweating, piloerection (goose flesh), running nose, excessive lacrimation

·      Raised blood pressure, increased heart rate

Withdrawal symptoms usually being within 12 hours of last does, peak in 24-36 hours, subside in 72 hours and disappear in 1-2 weeks, but this may differ according to the type of opioids used.

 Adverse affects of opioids use

·      Potential transmission of hepatitis B and C / HIV

·      Idiosyncratic allergic reactions — anaphylactic shocks, pulmonary edema

·      Skin popper- lesions in skin consisting of circular depressed scars and underlying chronic abscesses

·      Cellulites

·      Thrombophlebitis

·      Endocarditic

·      Septicemia

·      Gangrene

·      Nutritional

·      Overdose (intentional / accidental)

·      Accident / Death

Treatment of opioids use

1.         Detoxification: Medical detoxification deals with withdrawing a patient safely from physical dependence on substances. It takes nearly 10-15 days for a person t recovers physically from the discomfort of substance withdrawal.

2.         Replace prevention: Replace is a process that begins long before a person reuses substances. Relapse shows some failure to develop defective's ways of dealing with daily stress. Majority of substance of substance users go into relapse. Relapse can be prevented by:

·      Understanding and anticipating the possibility of relapse

·      By recognizing and handing risk situations

3.         After Care:             This is designed to maintain the gains, which the patient has made in treatment and rehabilitation. This offers safe environment for continued support until no longer required.

Different means of aftercare include:

·      Counseling

·      Self help group for abstinence - Alcohol anonymous (AA), Narcotic Anonymous (NA)

Recovery in a patient with substance abuse means signification behavioral change, which include:

·      Change in habits

·      New skills are learnt

·      New social, family and work expectations are defined and met

·      Responsibility taken for change oneself

·      Relapse prevention strategies are developed.

Cannabis

   It is the generic name given to the drugs containing plant product of hemp (Cannabis sativa). Bhaang -efË_, Gaanja-ufFhf_, Hashish, Chares-r/];_ are the derivatives of the same plant.

Psychiatric consequences of cannabis use

i)          Acute intoxication: The features include-

·      Euphoria or apathy

·      Perceptual distortion, illusions hallucination

·      Suspiciousness

·      Increased appetite

·       Dry mouth, red eyes

·      Increased heart rat

ii)              Flashback phenomena:

             Re- experiencing the perceptual symptoms that occurred during acute intoxications even when the person is not using cannabis

iii)            Cannabis induced psychotic disorder

iv)            Cannabis induced anxiety disorder

Benzodiazepines

These include medications like Alprazolam, Lorazepam, Nitrazepam, Which are abused. Tolerance Occurs after a minimum of 3-4 weeks of daily use. The features of benzodiazepine withdrawn are similar to alcohol withdrawal. Treatment is gradual Withdrawal of the drug and counseling

 

Evaluation of substance use disorder:

Objectives when taking a history of substance use:

Its is necessary to determine:

·      What substance a patient currently use

·      What substance a patient has used in the past

·      How the patient has used these substances

·      If this patient is dependent upon these substances

·      If the substance use is causing problems (Medical, Family, social relationship, employment, financial)

·      How to patient feels about their substances use

How t identify a person abusing substances

·      Physical evidence:

·      Order of marijuana (like burnt rope) in room

·      Use of room deodorizers

·       Marijuana cigarettes (rolled and twisted at each end)

·      Butt or "roach" (end of marijuana cigarettes)

·      Power, seeds, leaves, plants

·      Capsules or tables

·      Cigarette rolling paper

·      Small spoons, razor blades

·      Unfamiliar small containers or locked boxes

·      Small glass vials

·      Used syringes / needles

Physical symptoms:  

·      Acting intoxicated

·      "Blood shade" or red eyes

·      Drooping eyelids

·      Imprecise eye movement

·      Wearing sunglasses at inappropriate times

·      Abnormally pale complexion

·      Frequent persisting illnesses, sniffles, and cough

·      Change in sleep pattern such as insomnia, napping or sleeping at inappropriate times

·      Neglect of personal appearance and grooming

Behavioral changes;

·      Unexplained periods of moodiness, depression, anxiety, irritability, hypersensitivity or hostility

·      Strongly inappropriate over reaction to mild criticism or simple requests

·      Decreased interaction and communication with other

·      Loss of interest in previously important things such as hobbies or sports

·      Loss of motivation and enthusiasm

·      Lethargy and lack of energy

·      Lose of ability to assume responsibility

·      Need for instant to gratification

·      Change in value, ideas and beliefs

·      Change in friends, unwillingness to introduce friends

·      Withdrawal from family and social isolation

·      Spending long times in bathroom

·      Persistent lying and stealing

Change in relation to students:

·      Decrease in academic performance, decline in grades

·      Decreased short term memory, concentration and attention

·      Loss of motivation and interest for participation in activities

·      Frequent absenteeism

·      Less interest in participating in classes and meetings

·      Untidy appearing, dress, personal hygiene

·      Slow to respond, forgetful and apathetic

·      Increased disciplinary and behavioral problems

·      Change the peer group

·      Disappearance of money and other items of value from home.

Tips to parents for preventing substance use:

·      Do not quarrel in front of children

·      Spend more times with children

·      Make your children feel that you are their parents and as wells as a friends

·      Try to know the friends of your children

·      Encourage your children to practice moral values

·      Try to practice what you teach to them

                                                                           Dr C P Sedain,Neuropsychiatrist,

                                                                            Chitwan med college

,                                                                Bharatpur,Nepal