Anxiety disorders

Dr Jibril Handuleh, MD MPH

Epidemiology
Generalized anxiety Panic disorders Social phobia Agrophobia
disorder (GAD)
Incidences 4.3% General population: General population: Large numbers of
1 year incidence: 10% 1-year incidence: 6% people in the
Patients presenting to community who
emergency departments have agoraphobia
with without panic disorder
‘chest pain’ and 25% may not seek help.
have panic disorder. In the US, about 2/1000
person-years.

Prevalence Lifetime prevalence is Lifetime prevalence: Lifetime prevalence:4%

and lifetime 8.6% in the UK. 6% 6 month prevalence: 3-
risk First degree relatives Children and 6%.
of panic disorder: 8- adolescents:
31%. Children Social phobia: 1%
Simple phobias: 2-9%
Specific phobia: 3%
Person Gender: Women > Men Gender: Women > Men Age: 2 peaks: 5 years Gender: Women > Men
Age: The age of onset is usually in the 20s. Age: Bimodal peak: 15-24 and between 11-15 years. (2:1)
Life events: stressful or years and 45-54 years. Age: 25- 35 years
traumatic life events are important precipitant for Life events: Recent history of divorce or Agoraphobia may occur
GAD and it may lead to separation. before the onset of panic
alcohol misuse. disorder.
Overview of etiology

Noradrenaline (NA)
 GAD: 1) downregulation of 2receptors and increase in autonomic arousal; 2) Electrical
stimulation of locus coeruleus releases noradrenaline and generates anxiety.
 Panic disorder: hypersensitivity of presynaptic 2 receptor and increase in adrenergic
activity Yohimbine has high affinity for the 2-adrenergic receptors and it can induce panic
attacks.
Serotonin (5HT)

 GAD: dysregulation of 5-HT system

 Panic disorder: sub-sensitivity of 5HT1A receptors & exaggerated postsynaptic receptor
response.
 OCD: dysregulation of 5HT system
GABA

 GAD: Decrease in GABA activity.

 Panic disorder: Decrease inhibitory receptor sensitivity and causes panic attack.
Cognitive theories

 GAD: selective attention to negative details, distortions in information processing &

negative views on coping.
 Panic disorder: classical conditioning and negative catastrophic thoughts during attacks.
 Agoraphobia and specific phobias: conditioned fear responses lead to learned avoidance
 OCD: compulsions are learned and reinforced
 GAD: selective attention to negative details, distortions in information processing &
negative views on coping.
 Panic disorder: classical conditioning and negative catastrophic thoughts during attacks.
 Agoraphobia and specific phobias: conditioned fear responses lead to learned avoidance
 OCD: compulsions are learned and reinforced
Psychodynamic theories

 GAD: symptoms of unresolved unconscious conflicts, early loss of parents, separation in

childhood, overprotective parenting, anxious parent or parenting lacking warmth and
responsiveness.
 Panic disorder: arise from unsuccessful attempts to defend against anxiety provoking
impulses.
 Agoraphobia and specific phobias: unconscious conflicts are repressed and may be
transformed by displacement in phobic symptoms
Genetics

 Heritability
 GAD: 30%
 Panic disorder: 30%
 Agoraphobia relatives: increased in social phobia, other neurotic disorders, alcoholism &
depressive disorders.
 OCD: MZ: DZ = 50-80%: 25%; First degree relatives: 10% risk; Heritability: 30%.
 Social phobia: 50% MZ:DZ = 24%:15%
 Animal phobia MZ:DZ = 26%: 11%
Endocrine causes

 GAD: 30% of patients have reduced suppression to dexamethasone suppression test.

 Panic disorder: hypothalamus, amygdala and brainstem are involved.
 PTSD: Low cortisol levels after trauma leads to PTSD increased in glucocorticoid
receptors in hypothalamus and leads to decreased peripheral cortisol) while high cortisol
levels lead to depression.
 Enhanced response to dexamethasone suppression test.
Organic causes

 GAD: cardiac, thyroid, medication such as thyroxine.

 Panic disorder: hypoglycemia, thyrotoxicosis,phaeochromocytoma
 CO2 act as a panic stimulant as an indicator for lack of O2 in the brain. Hence, breathing
in –out of the paper bag makes panic attack worse. CCK and sodium lactate induce
symptoms of panic disorder.
 There is increase in nocturnal melatonin production.
 OCD: cell-mediated autoimmune factors against basal ganglia are involved
Neuroimaging findings

 In OCD, there is an increase in resting blood flow and glucose metabolism in the orbital
cortex and caudate nucleus.
 Dysfunction of the cortico-striatal-thalamic-cortical circuitry is found in patients with
OCD.
Investigations:

1. Thyroid function test: thyrotoxicosis.

2. Blood glucose: hypoglycemia.
3. ECG or cardiac echocardiogram: atrial fibrillation, arrhythmias and other cardiac problems.
4. Urine drug screen in cases of suspected stimulant use.
5. Lung function test: suspected COPD.
6. 24 hour urine catecholamine (to rule out phaeochromocytoma especially hypertension and
panic attacks coexist)
 When to treat anxiety disorders?
 Pharmacological treatment is indicated when symptoms are severe, there is significant impairment of social,
occupational and role functioning, or there is concurrent moderate or severe depressive disorder.
 Antidepressants are recommended as effective agents for the treatment of panic disorders, social phobia,
obsessive compulsive disorders, generalized anxiety disorder and post-traumatic stress disorder.
 Selective serotonin reuptake inhibitors (SSRIs) are recommended as the first line drug treatment for
anxiety disorder.
 For benzodiazepine, the lowest effective dose to achieve symptom relief should be used over a limited period.
The dose should be gradually tapered off. Long term use should be closely supervised for adverse effects,
abuse, tolerance, dependency and withdrawal symptoms. Cognitive behaviour therapy (CBT) may facilitate the
tapering of benzodiazepines.
 Antidepressants have good anti-anxiety properties and should be the medication of choice in comorbid
depression and anxiety. Some selective serotonin reuptake inhibitors (SSRIs) such as paroxetine and
venlafaxine have demonstrated efficacy for treatment of co-morbid depression and anxiety.
 Relapse is common after discontinuation of medication for most anxiety disorders. Maintenance therapy may
be indicated for individuals who frequently relapse.
 Generalized anxiety is commonly described as a sensation of persistent worry and apprehension about common day
problems and events, associated with symptoms involving the chest / abdomen, mental state symptoms, general symptoms
and other symptoms.
 Common signs and symptoms of generalized anxiety disorder.

Autonomic arousal symptoms Symptoms involving chest/ abdomen Mental symptoms General
symptoms
- Palpitation/increased HR. - Difficulty breathing. - Giddiness / fainting. - Hot flushes/cold
- Sweating. - Choking sensation. - Derealization or chills.
- Trembling/Shaking. - Chest pain. depersonalization. - Numbness /
- Dry mouth. - Nausea/ stomach churning. - Fear of losing control. tingling.
- Fear of dying or “going - Muscle
crazy”. tension/aches.
- Restlessness.
- Feelings of
keyed up,
on the edge.
- Lump in the
throat.
 Generalized anxiety disorder

 The DSM-5 specified that individuals would fulfill the diagnostic criteria if they have been experiencing
excessive anxiety and worries for most everyday events for at least 6 months in duration.
 The DSM-5 further specified that these excessive worries are difficult to control, and that these worries are
associated with at least 3 of the following symptoms:
a. Restlessness
b. Easily tired
c. Attentional and concentration difficulties
d. Feeling irritable
e. Muscle tension
f. Sleep difficulties
 These worries must have caused significant impairments in an individual’s level of functioning.
Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959)

 The HAM-A scale is a clinician-rated scale which quantifies the severity of anxiety
symptoms in a total score.
 HAM-A assess symptoms over the past week and it contains 14 items which assess
anxiety, tension, fear, poor concentration, somatic complaints associated with anxiety and
mood.
 The score of each item ranges from 0 to 4.
 HAM-A can assess baseline anxiety score the response to therapeutic interventions after a
period of time.
 Differential diagnosis

1. Panic disorder, stress-related disorder, phobia, mixed anxiety and depression.

2. Arrhythmia, ischemic heart disease, mitral valve prolapse, congestive heart failure
3. Asthma, COPD
4. Hyperthyroidism, hypoparathyroidism, hypoglycemia, phaeochromocytoma and anemia.
5. Medication: antihypertensive, antiarrhythmics, bronchodilators, anticholinergics, anticonvulsants, thyroxine, and NSAIDS.
 Treatment
1. Psychotherapy: For CBT, it should be offered in weekly or fortnightly sessions of 1-2 hours and be completed within 4-
6 months.
2. For pharmacological therapy, psychiatrist should consider the patient’s age, previous treatment response, risk of deliberate
self harm, cost and patient’s preference. Antidepressants can be considered as first-line agents over benzodiazepines in the
treatment of generalized anxiety disorder over the long term.
3. Inform the patient on the potential side effects, possible discontinuation withdrawal and the time course of treatment. If one
SSRI is not suitable, consider another SSRI. The psychiatrist should review the patient within 2 weeks of starting treatment
and again at 4, 6 and 12 weeks. Then the psychiatrist can review the patient at 8-12 week intervals.
4. For GAD not responding to at least two types of intervention, consider venlafaxine. Before prescribing, the psychiatrist
should consider the presence of pre-existing hypertension.
 Comorbidity: concurrent panic disorder (25%) and depression (80%).
 Prognosis: 70% of patients have mild or no impairment and 9% have severe impairment. Poor prognostic factors include
severe anxiety symptoms, frequent syncope, and derealization and suicide attempts.
 Panic Disorder
 The DSM-5 characterized panic attack as the sudden onset of intense fear that usually peaks within minutes and during which the following symptoms might occur:
Physical symptoms:
 a. Palpitations
 b. Sweating
 c. Tremors
 d. Difficulties breathing
 e. Choking sensations
 f. Chest pain or discomfort
 g. Abdominal discomfort
 h. Dizziness
 i. Feeling hot or cold

 Mental Symptoms:
 a. Derealization
 b. Depersonalization
 c. Feelings of losing control and going crazy
 d. Feelings of death
 The DSM-5 specified that at least one of the attacks has been followed by at least 1 month of either a. Persistent concerns about having additional attacks or b.
Marked changes in behaviour in relation to the attacks.
 Agoraphobia
 The DSM-5 diagnostic criteria states that an individual would fulfill the diagnostic criteria if there has been
significant anxiety and fear in at least 2 of the following situations:
 a. Being alone outside of home
 b. Being in a crowd
 c. Being in enclosed places
 d. Being in open spaces
 e. Using public transport modalities
 During which, the individual has preoccupation of worries that escape might be difficult or help might not be
available when needed.
 These anxieties and worries must have affected an individual’s level of functioning for at least 6 months in duration.
 Clinicians are advised to take note that agoraphobia could be diagnosed in the presence of absence of panic disorder.
 ICD-10 also stresses that people suffering from panic disorder should be free of anxiety symptoms between attacks
 Other DDX for panic disorder include hypoparathyroidism, phaeochromocytoma, COPD, asthma, mitral valve
prolapse, DM, hypoglycemia, thyrotoxicosis and anemia.
Management of Panic attacks

 SSRIs have documented efficacy in the treatment of panic disorder. High potency agents like alprazolam and
clonazepam are effective in providing rapid relief. With discontinuation of these agents, however, patients should
be closely monitored for recurrence of symptoms, as the rates of relapse are very high, especially for shorter-acting
agents.
 After improvement with medication, antidepressant treatment for panic disorders should be continued for at least 6
months.
 Psychotherapy: CBT is the psychotherapy of choice for panic disorder. Possible treatment components for panic
disorder,
 with or without agoraphobia include psychoeducation, exposure to symptoms or situations, cognitive restructuring,
 breathing exercise and monitoring for panic attacks.
 Comorbidity: 30% of patients experience major depressive episode and 40% of them meet the criteria for social
phobia.
 Prognosis: Recurrence is common especially when new stressors emerge.
 Social phobia / Social anxiety disorder
 Patients have marked fear which is brought in by social situations (e.g. being the focus of attention or fear of behaving in
a way that will be embarrassing). This has led to marked avoidance of being the focus of attention.
 Society Anxiety Disorder (Social Phobia)
 The DSM-5 specified that individuals must have significant anxiety about one or more social situations, for which
individuals worry about being evaluated negatively by others. Consequently, these social situations are been avoided.
 The DSM-5 specified a time duration of at least 6 months and there must be significant impairments in terms of
functioning. Subtypes - Performance only: Characterized as when social anxiety disorder is restricted to public
performances
Treatment:
 Medications: Selective serotonin reuptake inhibitor (SSRI) antidepressants are effective for the treatment of social
phobia, and their favourable side-effect profile make them the recommended first-line treatment for social phobia.
Paroxetine has been the most extensively studied SSRI for social phobia. After improvement with medication,
antidepressant treatment for panic disorders and social phobias should be continued for at least 6 months.
 Psychotherapy: Cognitive behaviour therapy (CBT) is recommended as effective treatment for social anxiety disorder.
 Exposure to feared situations is a crucial component. Group approaches are useful and often include elements of social
skills training.
Specific phobia
 Specific phobia is considered to be one of the most common type of anxiety disorder and occurs in 10% of the population. It usually starts in childhood and
may persist into adult life. There is an anticipatory fear of an object (e.g. needles, spiders) or situations (e.g. flying) that cannot be explained or reasoned
away. Furthermore, this fear is beyond voluntary control.
 Specific Phobia
 The DSM-5 specified that for an individual to fulfill this diagnostic criteria, there must be:
1. Significant anxiety about a particular object or situation
2. Encounters with the object or situation always cause marked anxiety
3. The specified object or situation is avoided
4. The anxieties and worries are excessively out of proportion in consideration of the actual threat posed.
 The DSM-5 specified a time duration of at least 6 months and there must be significant impairments in terms of functioning. Subtypes include:
 a. Animal
 b. Natural environment
 c. Blood injection injury type
 d. Situational
 e. Others
 Treatment (MOH guidelines)
 Beta-blockers are effective for specific and circumscribed anxiety, especially for patients with prominent sympathetic hyper-arousal such as palpitations and
tremor.
 Propranolol 10-40 mg taken 45-60 minutes before the performance is sufficient for most patients
Obsessive compulsive disorder (OCD)

 Epidemiology [Nestadt et al, 1998]

 Incidence Prevalence Gender ratio Mean age of onset 0.55 per 1000 person-years
 Prevalence: 1%
 Lifetime prevalence: 0.8%
F:M = 1.5:1
Mean age of onset is around 20 years (70% before 25 years; 15% after 35 years).
 Pathology: Lesion in the orbital-frontal cortex and basal ganglia
Obsessions:

 Obsessions are persistent and recurrent Doubts, Impulses, Ruminations and Thoughts
(mnemonics: DIRT).
 This phenomenon is not simply excessive worries about real-life problems. The person attempts to
ignore or suppress them and recognize that this phenomenon is the product of his or her own
mind.
• Doubts: repeating themes expressing uncertainty about previous actions. E.g. Have I turned off the
tap?
• Impulses or images: repeated urges to carry out actions that are usually embarrassing or undesirable
e.g. shout obscenities in church or mentally seeing a disturbed images e.g. seeing one stabs oneself.
• Ruminations: repeated worrying themes of more complex thought e.g. worrying about the end of
the world.
• Thoughts: repeated and intrusive words or phrases.
Compulsions

 Compulsion is a repetitive behaviour or mental act which is usually associated with an obsession as if it has the function
of reducing distress caused by obsession. E.g. cleaning, checking and counting. Carrying out the compulsive act should
not be pleasurable.
The most common obsessions (in descending order)
1. Fear of contamination (45%).
2. Doubting (42%).
3. Fear of illness, germs or bodily fear (36%).
4. Symmetry (31%).
5. Sexual or aggressive thoughts (28%).
The most common compulsions (in descending order)
1. Checking (63%).
2. Washing (50%).
3. Counting (36%).
 DSM-5: (Please note that OCD is now classified under obsessive-compulsive and related disorders in DSM-5 and is no
longer part of the anxiety disorders chapter)
 Obsessive-Compulsive disorder
 The DSM-5 specified that individuals would fulfill the diagnosis only if there is the presence of (a) Obsessions and
(b)Compulsions that have caused much impairments in terms of functioning.

 The DSM-5 defined Obsessions as:

 a. Repetitive thoughts, urges or images that are experienced recurrently, which individuals find them to be intrusive and
have resulted in significant anxieties
 b. Efforts made by individuals to try to suppress these thoughts, urges or images with other thoughts or actions

 The DSM-5 defined Compulsions as:

 a. Repetitive behaviours or even mental acts that individual feels obliged to perform as a response to the underlying
obsessive thoughts
 b. These repetitive behaviours or even mental acts are being performed by individuals in order to reduce the anxiety
experienced, or to prevent some dreadful event from happening.
 It is important for Clinicians to distinguish the 3 subtypes of OCD, which are with good or fair insight, with poor
insight and with absent insight or even delusional beliefs.
 Questionnaire:
 Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (Goodman et al, 1989)
 The Y-BOCS is a clinician-rated semi-structured questionnaire and rates the severity of OCD symptoms. It covers
the week prior to the interview.
 The questionnaire is divided into obsession and compulsion subsets. The questionnaire takes about 15 to 30 minutes
to complete. It is often used to monitor changes over the course of treatment.
 Differential diagnosis:
1. Recurrent thoughts and worries in a normal person.
2. Anankastic or obsessive compulsive personality disorder
3. Generalized anxiety disorder.
4. Schizophrenia.
5. Delusional disorder.
6. Depressive disorder.
7. Organic causes (e.g. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections-
PANDAS).
 Management:
 Inpatient treatment is indicated when patients 1) pose severe Risk to self or others, 2) severe self-neglect (e.g.
poor hygiene or eating) 3) extreme distress or functional impairment, 4) poor response to treatment and the need to
monitor compliance.
 Pharmacotherapy: The recommended first line of pharmacotherapy for OCD is a 10-12 week trial with a
selective serotonin reuptake inhibitor (SSRI) at adequate doses. Fluvoxamine, fluoxetine, citalopram,
sertraline and paroxetine, have all been shown to be effective in adults with OCD. The usual dose of SSRIs to
treat OCD is 2-3 times higher than the dose for treating depression. The minimum mean daily dosage of one
of the SSRI is listed as follows:
 CBT will begin with anxiety management and asking the patient to keep a diary. Then it will move onto response
prevention in excessive washing with cognitive re-structuring and coping strategies. Behaviour therapy using
Exposure-
 Response Prevention (ERP) is the treatment of choice for limiting the dysfunction resulting from obsessions and
compulsions.
 Poor prognostic factors include a strong conviction about the rationality of obsession, prominent depression,
comorbid tic disorder and underlying medical condition, unable to resist the compulsions, childhood onset, bizzare
compulsions, need for hospitalization, presence of over-valued ideas.
 Hoarding disorder
 The DSM-5 specified that individuals afflicted with this condition has marked difficulties with disposing of
items, regardless of their actual value.
 The difficulties with disposing of items has been attributed to a preoccupation with regards to needing to save the
items, and to the distress associated with disposing.
 This behavioral difficulties would have resulted in the accumulation of items that clutter up personal living
spaces. The disorder must have resulted in significant
 impairments in terms of functioning. and not be attributed to another medical disorder such as due to underlying
brain injury, cerebrovascular disease or Prader-willi syndrome.
 The DSM subtypes include:
a. With good or fair insight
b. With poor insight
c. With absent insight or delusional beliefs
 Acute stress reaction/disorder Adjustment disorder
Etiology Severe acute stress such as rape, assault, natural catastrophe, sudden Major change in a life situation e.g. migration,
unemployment or loss of entering university, entering national service, or a
status newly diagnosed chronic illness.

Duration of ICD-10: Exposure to the stressor is followed by an immediate onset of ICD-10: The duration is within 1 month of
illness symptoms within 1 hour and exposure to stressor.
begin to diminish after not more than 48 hours. DSM 5:
DSM-5: The DSM-5 diagnostic criteria specified that there
The DSM-5 Diagnostic criteria specified that the following symptoms must be behavioral or emotional symptoms that
must be fulfilled within a duration of 3 days to 1 month after experiencing have occurred within 3 months from the onset of
the traumatic event. the stressor.
Clinical features Physical: palpitations, chest pain ICD-10 criteria specify
Psychological: withdrawal, inattention, anger, aggression, despair, 1) Brief depressive reaction (< 1 month).
purposeless over-activity, numbness, derealization,depersonalization and 2) Prolonged depressive reaction (< 2 years).
amnesia. 3) Mixed anxiety and depressive episode.
4) With predominant disturbance of other
emotions.
5) With predominant disturbance of
conduct(adolescent grief reaction).
6) With mixed disturbance of emotions and
conduct.

Management Symptomatic relief: short term anxiolytic agents. Counselling.

Crisis intervention and reassurance. Problem solving therapy.
Short duration of anxiolytic and
antidepressant.
Post traumatic stress Disorder

Incidence Prevalence Gender ratio Mean age of onset

On average, about Lifetime prevalence: 1in Women > Men Most prevalent in
10% of 10 (F:M = 2:1) young
people experiencing a in the general adults
significant traumatic population.
event 1 in 5 fire-fighters.
actually go on to 1 in 3 teenager survivors
develop of
PTSD. car crashes.
1 in 2 female rape
victims.
2 in 3 prisoners of war.
 Clinical features
 PTSD is a prolonged response to a traumatic event such as abuse, serious
road traffic accident, disaster, violent crime, torture and terrorism.
 The event should be extraordinary and most people find it traumatic.
 For example, one cannot suffer from PTSD after failure in an
examination because it is not as traumatic as a serious road traffic
accident.
 The development of PTSD symptoms is usually within 6 months after
the traumatic event.
Main symptoms include

 Re-experiencing (e.g. flashbacks in the day time,

nightmare at night), avoidance (e.g. place and objects
associated with the event),
 Hyper-arousal (e.g. increased vigilance, irritability, poor
concentration, exaggerated startle response)
 Emotional numbing (e.g. detachment, lack of interest).
PTSD

 DSM-5 Diagnostic Criteria (Please note that PTSD is no longer part of anxiety disorders chapter in DSM-5 but
classified together within the trauma and stress related disorders chapter).
 The DSM-5 Diagnostic criteria specified that individuals diagnosed with this condition must have had exposure to a
severe or threatened death, serious injury or even sexual violence.
 To fulfill the diagnosis, the following symptoms must be present:
1. Repetitive, intrusive, and distressing memories of the traumatic events
2. Marked efforts to avoid distressing memories and external reminders
3. Dissociative amnesia towards important aspects of the traumatic event
 These symptoms must have resulted in marked impairments in terms of psychosocial functioning.
 At times, it is important for clinicians to specify whether individual experience persistent or recurrent symptoms of
either
 (a) depersonalization or (b) Derealization.
 DSM-5 has also a delayed expression criteria, for which the typical criteria are not fulfilled until at least 6 months after
the experience of the traumatic event.
 Questionnaire (Horowitz, 1979)
 The Impact of Events Scale (IES) is a 15-item questionnaire assessing symptoms of intrusion and avoidance. It assesses
self-reported levels of distress with regard to a specific life event.
 Management:
 When symptoms are mild and have been present less than 4 weeks after the trauma, doctors can offer reassurance and
close monitoring. If PTSD symptoms persist after 1 month, the following treatment can be offered.
 Pharmacotherapy: SSRIs are generally the most appropriate medication of choice for post-traumatic stress disorder
(PTSD), and effective therapy should be continued for 12 months or longer. Paroxetine, sertraline and fluoxetine all have
well documented evidence of efficacy.
 Psychological treatment: Studies of trauma-focused cognitive behaviour therapy (tf-CBT) have shown the most
effective results in the treatment of post-traumatic stress disorder (PTSD). Tf- CBT involves exposure therapy to
overcome avoidance associated with accident. Eye movement desensitization and reprogramming (EMDR) involves
recalling the traumatic event when the patient performs a dual attention movement such as bilateral hand tapping. The
objective of EMDR is to give new insight to the accident and reduce sensitivity to negative re-experiences.
 Prognosis: 50% will recover within the first year and 30% will run in a chronic course. An initial rapid resolution of
symptoms predicts a good prognosis. Bad prognostic factors include completed rape, physical injury, and perception of
life threat during the accident or assault.
 Depersonalization and Derealization
 Depersonalization and Derealization syndrome refers to the phenomenon when the patient complains spontaneously that
the quality of mental activity, body and surroundings are changed to appear to be unreal and remote.
 This syndrome is a subjective and unpleasant experience with insight retained. This syndrome can be a primary
phenomenon or secondary to sensory deprivation, temporal lobe epilepsy, phobic anxiety disorders and generalized
anxiety disorders.
 DSM-5 Criteria:
 The presence of persistent or recurrent depersonalization, Derealization, or both:
 Depersonalization: experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts,
feelings, sensations, body, or actions(e.g., unreal or absent self, perceptual alterations, emotional and/or physical
numbing, distorted sense of time).
 Derealization: experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are
experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
 During the depersonalization and/or Derealization experiences, reality testing remains intact.
Comparing Depersonalization and
Derealization
Depersonalization
The patient complains of a feeling of being
distant or not really there
e.g. A stressful resident complains of his
emotions and
feelings are detached after the night duty. He
feels that his emotions and movements belong
to someone else.
Derealization
The patient complains of feeling that the
environment is unreal
e.g. A stressful resident complains of feeling
of unreality after the night duty. The ward
looks strange as the color of the wall is less
vivid and the staff look soulless. He feels that
the time passes very slowly on that morning
Management

 Treatment: For short term depersonalization and Derealization, reassurance and relaxation
training are recommended. For long term depersonalization and Derealization, CBT and/or
SSRI may be useful.
 Common hypnotics are used
 Common benzodiazepines include:
 Drowsiness.
 - Uncommon side effects include: irritability, nervousness, insomnia, abnormal dreams,
migraine, headache, hyperactivity, hypertension, dry mouth, nausea, abdominal pain, liver
function abnormalities
 - Mechanism of action: The activity of melatonin at the MT1, MT2 and MT3 receptors has
been believed to contribute to its sleep promoting effects.