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1 불안장애 Anxiety Disorder 정신과김종우 신경증의개념을설명한다정상및병적불안을감별한다. 공포성불안장애의종류와특징적증상을요약한다. 공포성불안장애의치료를설명한다. 공황장애의특징적증상을요약한다. 공황장애와감별을요하는신체질환을열거한다. 공황장애의치료를설명한다. 범불안장애의특징적증상을요약한다. 범불안장애와감별을요하는정신및신체질환을열거한다. 범불안장애의치료를설명한다. 강박장애의특징적증상을요약한다. 강박장애의정신병리를파악하고, 방어기제를설명한다. 강박장애의치료를설명한다. 급성및외상후스트레스장애와적응장애의특징적증상을요약한다. 스트레스장애및적응장애의일반치료원칙을설명한다.

2 Overview Anxiety disorder는정신과장애중가장흔한질병중의하나로일반인구중약 15% 이상이평생동안한번이상불안장애를앓는것으로보고 전체인구의 1/4에서최소한한가지이상의불안장애진단기준에부합 - 12개월 prevalence rate 17.7% - 여자 (30.5% lifetime prevalence) > 남자 (19.2% lifetime prevalence) - 낮은사회경제상태 > 높은사회경제상태 Pathological anxiety가있을때환자, 가족, 친지그리고의사의평가에의해 normal anxiety와구분할수있으며, 그런평가는환자가표현하는 internal states, behaviors, abilities to function 등에근거하여이루어진다. 위험상황에 anxiety로반응하는것이유리할경우 normal anxiety라고한다. Normal anxiety의예 infant - threatened by separation from parents or by loss of love. children - first day in school adolescents - first date adults - old age & death등을생각할때질병에직면했을때보이는불안등.. Pathological anxiety 주어지는자극에대한부적절한반응 ( 기간과정도에서 ) 임상적특성 1 자율성 : 발생, 경과가외적요인과관계가적다. 2 intensity : 고통의정도가개인의인내력, 대응전략을압도 3 기간 : 길다. 4 행동 : life limiting하는행동전략을따른다.

3 Peripheral Menifestations of Anxiety

4 Ⅰ. 공황장애 Panic Disorder & 광장공포증 Agoraphobia * 특징적증상 : spontaneous unexpected occurrence of panic attack * Panic attack - short lived period of intense anxiety or fear(1hr) - 최소한 4가지이상의 somatic Sx 동반 (palpitation, tachypnea) other medical Sx (M.I.) or hysterical Sx 가능 * 빈도 : 하루몇차례에서일년에몇차례까지다양하다. 진단기준에는빈도가포함되어있지않다. * Panic disorder에서 agoraphobia가자주동반 ; 미국에서는 agoraphobia가 panic dis. 환자에서거의항상합병증으로나타난다고믿는다. 즉 agoraphobia가 public place에서 panic attack을경험한후 classical conditioning의결과로인해생긴다고하는가설이있으나이러한이론을받아들이지않는나라도있다. * Panic attack 3가지 Types(panic attack은어떤 anxiety dis. 에서도나타날수있는증상이다.) 1. Unexpected (=Uncued) ; panic attack의 onset이 situational trigger와관련이없는경우 (panic dis) 2. Situationally bound (Cued) ; situational trigger에노출되거나예상될때즉시나타나는 panic attack (social phobia, specific phobia가전형적이다.) 3. Situationally predisposed ; situational trigger와관련이있으나반드시노출된직후즉시나타나지는않는다. (panic dr가예. social, specific phobia 일부 ) 1. HISTORY Irritable heart syndrome, Dacosta's syndrome Anxiety neurosis (Freud) : chronic tension, excessive worry, frequent headache 처음으로 panic attack과 agoraphobia의관계에대해서보고. 2. EPIDEMIOLOGY panic disorder : life-time prevalence - 1-4%, 여 > 남 (2-3배높다 ) : mean age - 25세, developed in young adulthood * panic attack : lifetime prevalence 3-5.6%

5 * agoraphobia : life-time prevalence : 2-6% : 정신과 setting 에서는최소한 3/4이 panic disorder가동반되나 community sample에서는약절반정도가 agoraphobia without panic disorder를가지고있다. : traumatic events 이후에 onset하는경우가많다. 3. COMORBIDITY * panic disorder의 91%, agoraphobia의 84% 가최소한 1개이상의다른정신과질환이있다. * major depressive dis. : 10-15% of panic dis. 에서 * Anxiety dis. : social phobia % : specific phobia % : Generalized anxiety disorder % : PTSD % : OCD- up to 30 % * Hypochondriasis, Personality disorder, Substance-related disorder 4. ETIOLOGY 1) Biological Factor * panic disorder의증상은 brain structure, function의 biologic abnormality와관계있고 PNS & CNS dysregulation과관계있다. * ANS의 dysregulation 1 sympathetic tone의증가 2 반복되는자극에대해 slowly adaptation 3 moderate stimuli에대하여 excessive response * major neurotransmitter : norepinephrine, serotonin, GABA 1 Panic dis. 에서 serotonergic dysfunction 보고, Mixed serotonin agonist-antagonist drugs이불안을증가 -> postsynaptic serotonin hypersensitivity이이런반응을나타나게한다. 2 local inhibitory GABAergic transmission in basolateral amygdala, midbrain, hypothalamus의 attenuation -> anxietylike physiologic response 유발 * 주로연관된 brain area 1 brain stem - locus ceruleus의 noradrenergic ueruon - median raphe nucleus의 serotonergic neuron 2 limbic system - anticipatory,anxiety와연관 3 preforntal cortex - phobic avoidance와연관

6 * Noradrenergic system ( presynaptic α 2-adrenergic R) ; 많은관심 ;α 2- R. agonist clonidine, α 2 -R. antagonist yohimbine - locus ceruleus firing을자극하고 panic dis. 에서 paniclike activity를나타낸다. A. Panic inducing substances (Panicogens) * Respiratory panic - inducing substance : Respiratory stimulation & shift in acid-base balance : peripheral cardiovasuclar baroreceptor에우선작용 Vagan afferents에의해 Nuc tractus soliatrii에 signal전달 Nuc paragigantocellularis of medulla로감 : CO2, sodium lactate, bicarbonate : hypersensitivity suffocation alarm system 으로인해 panic dis. 환자에서 hyperventilation : PCO2 & brain lactate 농도증가 -> prematurely activate a physiological asphyxic monitor * Neurochemical panic-inducing substance : CNS에직접적으로 noradrenergic, serotonergic, GABA R. 에영향을주는것으로알려져있다. : yohimbine(α 2 adrenergic antagonist), mcpp (agent with multiple serotonergic effect), μ-carboline drus, GABA B Rc inverse agonist, flumazenil (GABA B Rc antagonist), CCK, caffeine B. Brain Imaging. * MRI study - temporal lobe (esp. hippocampus) 에 pathological involvement - Rt. cortical atrophy * PET study - dysregulation of CBF (induced by hyperventilation and hypocapnia) cbr. vasoconstriction CNS sx (dizziness) PNS sx C. Mitral Valve Prolapse. * 최근연구에의하면 panic disorder와는전혀연관이없다고한다. * MVP가있는환자나없는환자나 panic disorder의유병율의차이는없다. 2) Genetic Factors * distinct genetic component를가지고있다고결론 * lst degree relative에서 4-8배높다 * twin study: MZ (31%) > DZ (10-15%) * Panic dis. 와 specific chromosomal location or mode of transmission사이의연관성을보이는결과 (-) 3) Psychosocial Factors A. Cognitive behavioral theory (1) learned response : from modeling parental behavior (2) classic conditioning : through the process of classic conditioning

7 noxious stimulus + neutral stimulus (bus ride) avoidance of neutral stimuli B. Psychoanalytic Theories. * panic attack : unsuccessful defense against anxiety-provoking impulse * agoraphobia : loss of a parent & Hx of separation (loss object anxiety) * defense mechanism 1 repression 2 displacement 3 avoidance 4 symbolization * 아동기의 traumatic separation이아이의 developing nervous system에영향을주며이런방법으로성인기에도불안에 susceptible. * Environmental stressors와상호작용을하는 predisposing neurophysiological vulnerability가있어 panic attack을만들어낸다. * panic dis. 는 17세이전의 parental separation or death를경험과강한연관성 * Childhood physical & sexual abuse ; panic dis. 여자환자의 60% 가 childhood sexual abuse Hx. * panic attack의 causes는 stressful events의무의식적의미와관련되며, pathogenesis는 psychological reactions에의해촉진되는신경생리적요소와관련된다. 5. DIAGNOSIS A. Panic Attacks.

8 * panic disorder 와 panic attack을구분 * panic attack은 other mental ds (specific & social phobia, PTSD) 에서도가능 * panic disorder의 panic attack ; unexpected or uncued attack social & specific phobia ; 대개 expected or cued attack some panic attack : expected or unexpected가구별되지않는다. situationally predisposed attack 1) Panic Disorder * DSM-IV-TR Criteria for Panic Disorder without Agoraphobia * DSM-IV-TR Criteria for Panic Disorder with Agoraphobia * DSM-IV-TR : 횟수, 기간은정하지않고 1회의 attack이라도최소 1개월이상지속되는다음 attack에대한 concern 또는행동상의심각한변화가있을때진단, expected or situationally predisposed의경우도포함한다.

9 2) Agoraphobia 3) Agoraphobia without History of Panic Disorder * DSM-IV-TR : medical dis (ex. 심한심장질환을가진환자가 myocardial infrction에대한공포 ) 와관련된상황에대한회피도포함됨 )

10 6. CLINICAL FEATURES 1) Panic Disorder * lst attack : excitement, physical exertion, sexual activity or moderate emotional trauma후에생기기도하나대개는 completely spontaneous 하게발생 * DSM-IV-TR : 첫 attack은 unexpected (uncued) attack이어야만함. * 임상적으로 panic attack을관찰할때는항상선행요인 ( 습관이나상황 ) 을명확히해야한다. - ingestion of caffeine, alcohol, nicotine, other drug - unusual pattern of sleeping/eating - specific environmental setting (harsh lighting) * attack의처음시작 10분간증상이급격히증가한다. * major mental Sx : extreme fear & sense of impending death & doom feel confused, trouble concentration * physical signs : tachycardia, palpitaion, dyspnea, sweating * MSE during attack - rumination, difficulty speaking, impaired memory, depression depersonalization - sx은 quickly or gradually 소실 (20-30분간지속, 한시간을넘기는것은드뭄 ) * attack 사이에 anticipatory anxiety GAD와구별이어렵다. : panic에서는 fear의 focus를말하기도한다. * 심장, 호흡문제로인한죽음에대한 somatic concern이 major focus of patient's attention * 20% 는 attack 중실지로 syncope를일으키기도한다. * hyperventilation : respiratory alkalosis or other symptom을일으킴. 2) Agoraphobia * Panic like Sx이생겼을때도움을받을수없을것같은 situation에대한 rigid avoid * 가족, 친구와함께동반하면나갈수있다. * 동반하지않으면집을나서려하지않는다. * marital discord 유발시킬수있고이것이 primary problem으로오진되기도한다. 3) Associated Symptoms * depressive sx : 종종동반 * risk of suicide : * psychosocial consequence : 가정불화, 직업상실, 재정난, 알코올, 약물남용 7. DIFFERENTIAL DIAGNOSIS 1) Panic Disorder A. Medical Disorders. * complete medical Hx와 physical exam이필수. (thyroid, parathyroid, adrenal function)

11 * standard lab : CBC, electrolyte, FBS, Ca, LFT, Urea/Cr, thyroid/ U/A, drug screen, ECG -> 이단계까지즉각적인 life-threatening condition 배재한후에 panic dis. 생각! * underlying nonpsychiatric medical condition 주의 1 atypical sx : vertigo, loss of bladder control unconsciousness 2 late onset (>45세이상 ) 3 chest pain : cardiac risk factor (obesity, hypertension) 있을때 24hr holter, stress test, chest X-ray, cardiac enzyme 측정. 4 atypical neurologic sx : EEG, MRI r/o for TLE, Multiple sclerosis, space occupying lesion in brain 5 carcinoid syndrome or pheochromocytoma 24 hr urine (serotonine or catecholamine 농도 ( 삭제 ) 6 hypoglycemia : 다른동반증상없이 panic attack만일으키는경우는드물다. B. Mental Disorders. * malingering * factitious disorder * hypochondriasis * depersonalization disorder * social & specific phobia * PTSD * depressive disorder * schizophrenia * somatoform disorder * Generalized anxiety disorder, personality disorder * unexpected panic attack이 panic disorder의 hallmark가된다. * anxiety의 focus가중요 : panic disorder no focus : social phobia -> tongue-tied 될까불안 2) Agoraphobia without History of Panic Disorder * anxiety 나 depression을일으키는모든 medical disorder * depression, SPR, paranoid PD, avoidance PD, dependent PD 8. COURSE & PROGNOSIS 1) Panic Disorder * onset : late adolescent or early adulthood (20대, 평균 25세 ) * 대개 panic disorder에는 preceding psychosocial provocation이없다고하지만일부에서 onset이전한달간 stressful life event가있다는보고를하고있다. * chronic disorder : course는환자간, 환자내에서도다양하다.

12 * long-term F/U: 30-40% ; Sx free 50% ; mild enough not to affect their lives significantly 10-20% ; significant Sx지속 * 첫 attack시는큰신경을쓰지않지만반복되면 Sx이 major concern이된다 * attack을비밀로숨기는경향 -> 가족이나친구들은설명되지않는행동변화에대해걱정. * frequency와 severity는 fluctuate : 흔히 1-2회 / 주 ( 하지만하루에도여러번가능하고일년에한번도가능하다 ) * excessive intake of caffeine, nicotine은증상을악화시킬수있다. * 40-80% 에서 depression이 complicate, OCD가나타나기도한다. 자살사고에대해얘기하지않지만자살위험높다. * 20-40% 에서 alcohol & other drug dependence * good premorbid fx과 brief duration: 예후가좋다. 2) Agoraphobia * 대개 panic disorder로인해생기는것으로생각되며 (3/4) * panic disorder가치료되면, 시간이흐르면서호전됨 * 신속한치료를위해서 behavioral tx도가능 * agoraphobia without panic : often incapacitating and chronic * depression & alcoholism이겹치기쉽다.

13 9. TREATMENT * two most effective Tx 1 pharmarcotherapy 2 cognitive-behavioral Tx 1) Pharmacotherapy A. SSRIs. * 모든 SSRIs가효과적 * panic disorder 환자들은 SSRIs의 activating effect에예민하므로적은용량으로시작하고천천히증량해야한다. B. Benzodiazepines. * dependence, cognitive impairment, abuse 의문제로제한된사용 * most rapid onset (within 1 st week) * 다른약물 (SSRIs) titration하는도중빨리 Sx relief 시켜야할때사용하는것이가장 reasonable한방법. C. Tricyclic & Tetracyclic Drugs. * clomipramine, imipramine : most effective desipramine : efficacy가판명되었다고함. * low dose 시작 : 10mg->2-3일간격 25mg씩천천히증강 * m/c side : overstimulation때문에 noncompliance 원인이되므로따라서천천히올린다.

14 Duration of Pharmacotherapy. * 효과보이면 8-12개월유지 * 성공적으로치료되어도약을끊으면 30-90% 에서재발 * BZD으로치료받은경우에치료받다약을끊은경우재발이잦다. 2) CBT * 약물치료보다효과있다는보고도있고그반대의보고도있음 * 병행치료가 more effective * cognitive-behavior therapy 1 group-format CBT가높은성공률을보임. 2 초기증상에대한약물치료와 CBT치료후점차적인약물감량이제안됨 A. Cognitive Therapy * false belief에대한 instruction - Pt's tendency to misinterpretation * information about panic attack - panic attack은 time limited, not life threatening B. Applied Relaxation * 자신의 anxiety level을스스로통제할수있도록 C. Respiration Training * hyperventilation 조절가능하게한다. D. In Vivo Exposure * 과거노출된자극에초점, 현재내적두려운감정에대한환자의노출에초점. 3) Other Psychosocial Therapies A. Family Therapy. B. Insight-Oriented PT * focus - Ucs meaning of the anxiety -symbolism of the avoided situation -sx's secondary gai * biological component 우세한 pt에서 harmful 할수도 self esteem 의손상, masochistic defense의강화 4) Combined PT & pharmacotherapy * 약물 : primary sx * PT : secondary sx

15 Ⅱ. 범불안장애 Generalized Anxiety Disorder * excessive anxiety & worry about several events/activities, for most days, during at least 6-month * worry는조절이어렵고, 대부분 somatic sx(muscle tension, irritability, difficulty sleeping, restless) 와연관되어있다. * 다른 Axis I 질환에의한것이아니어야한다. * 개인의생활에심각한 impairment를야기한다. 1. EPIDEMIOLOGY * 1 year prevalence : 3-8% * F:M = 2:1 ( 입원환자의경우에는 1:1 정도 ) * life-time prevalence : 5% 2. COMORBIDITY * GAD의 50%-90% 가다른정신과질환을가지고있다. * 특히 social phobia, panic d/o, depressive d/o가많으며, 25% 에서는 panic d/o를경험. * 그외 dysthymic d/o와 substance-related d/o도흔하다. 3. ETIOLOGY (1) Biological factors * unknwon, heterogenous group으로본다. * BZD, azapirones(ex.buspiron) 의치료효과로 GABA & serotonine에대한연구에관심을가진다. BZD receptor BZD(BZD Rc agonist) : anxiety flumazenil(bzd Rc antagonist), β-carbolines(reverse agonist) : anxiety의 * 그러나 GAD pt에서 BZD receptor의이상은밝혀지지않음 * GAD 이상부위 : occipital lobe(bdz Rc 多 ) 또는 basal ganglia, limbic sys, frontal cortex로가정 neurotransmitters * serotonergic sys의 abnormal regulation : buspirone의치료효과 (5-HT 1a receptor agonist) * 그외 NE, glutamate, CCK에대한연구 : clonidine에대한 GH blunted release로보아 subsensitivity of alpha2 adrenergic Rc PET : basal ganglia, white matter의대사감소 genetic study

16 * 여성에서 GAD와 major depressive disorder 사이의 genetic relation(+) in one study * 남성 relatives : alcohol use disorder가많다. * 25% 에서 lst degree relative에서이환, MZ>DZ : 50%>15% EEG * α rhythm, evoked potential에서 abnormality를보인다. * sleep EEG 의특징 감소 : 1 δ sleep 2 stage I sleep 3 REM sleep 증가 : 4 REM latency 5 sleep discontinuity depression과는다른소견임. (2) Psychosocial Factors A. cognitive-behavioral school * responding to incorrectly & inaccurately perceived * inaccuracy가만들어지는과정 1 환경에서의부정적사건에대한선택적인관심 2 왜곡된 information-processing 3 자신의적응능력에대한지나친부정적견해 B. psychoanalytic school * anxiety = unresolved Uconscious conflicts * anxiety의 hierarchy( 발달단계에따름 ) 1 fear of annihilation or fusion with another person 2 fear of separation from a love object 3 castration anxiety 4 superego anxiety : fear of disappointing one's own idea & values-most mature (derived from internalized parents)

17 4. DIAGNOSIS * normal anxiety와의감별 1 excessive : worry be excessive, pervasive (6개월이상 ) 2 difficult to control 3 significant impairment or distress 4 motor tension과 hypervigilance가두드러짐 5. CLINICAL FEATURES * primary symptom 1 anxiety : excessive & interferes with other aspects of the pt's life 2 motor tension : shakiness, restlessness, headache 3 autonomic hyperactivity : shortness breath, excessive sweating, palpitation, G-I sx 4 cognitive vigilance : irritability & the ease with which the pt is startled * vary in doctor seeking behavior

18 6. DIFFERENTIAL DIAGNOSIS * blood chemistry, EKG, TFT등 medical work-up 必 * caffeine intoxication, stimulus abuse, alcohol withdrawal, sedative-hypnotic-anxiolytic withdrawal의가능성고려해야. * MSE, history taking 통해 DDx * panic disorder의특징 1 더빨리치료를받는다 2 more disabled 3 sudden onset of symptom 4 less troubled by somatic symptom 5 나이가들면줄어든다 * 감별진단 : phobia/ OCD/ major depressive & dysthymic disorder( 구분어렵고자주동반됨 )/ adjustment disorder with anxiety/ hypochondriasis/ adult-adhd/ somatization disorder/ PD 7. COURSE & PROGNOSIS * age of onset을구별하기어렵다. : 기억나는한불안했었다고한다. * 대부분 20대에서정신과적치료에관심보이지만, 어떤나이에서든지치료가시작될수있다. * 1/3만이정신과에서치료, 나머지는 somatic sx의치료를위해일반의나내과전문의를찾아간다. * 동반질환이많기때문에경과를예측하기가어렵다. * GAD의 onset과 life event와의연관성이있다 : negative event가있는경우쉽게발병한다. * 정의에의하면 GAD는 chronic condition이며, may be lifelong! 8. TREATMENT * GAD에서는 psychotherapy + pharmacotherapy + supportive approach가가장효과적이다. (1) Psychotherapy cognitive-behavioral therapy * cognitive approach : cognitive distortions에 directly * behavioral approach : somatic sx에 directly -> relaxation, bio-feedback 한가지보다는두가지를같이병행할때효과좋다. supportive Tx : reassurance, comfort ( 장기적효과는의심 ) insight-oriented PT * uncovering ucs conflict & identifying ego strength * 효과적이라는 case 보고가있으나 large controlled study는부족하다. (2) Pharmacotherapy * 첫방문시처방은피한다.: 만성적인질환이므로신중히고려해서치료를시작한다. * 3 major drug : buspiron, BDZ, SSRI * 25% 에서약끊고첫 1개월내재발하고 60-80% 가 1년이내재발 아마도 life-long treatment가필요하다. * BDZ 치료중일부환자에서는 dependance가생기지만 tolerance는드물다.

19 A. Benzodiazepine * 빠른효과때문에 as-needed basis에서 drug of choice로사용되었다. * several problem : 25-30% fail to respond, tolerance & dependence 가능성, impaired alertness로사고의위험 ( 운전, 기계조작 ) * 고려할점 : 1 진단 2 specific target symptom 3 duration of Tx 환자와정보를공유후투약 * 2-6 week 투약한후에 1-2 week에걸쳐 tapering -> 흔한오류는수동적으로, 무한정처방! * 가장최소용량부터시작 * long half-life 약물보다는 intermediate half life(8-15 hr) 의사용이부작용을줄인다. divided dose 사용하면 high peak plasm level에서나타나는부작용을줄인다. * 항불안효과이외의효과 : 1 상황에대한긍정적인태도 2 alcohol처럼 disinhibition effect B. Buspirone * 60-80% 에서효과 : somatic Sx보다 cognitive Sx에더효과적이다. * 이전에 BDZ으로치료받지않던환자에서효과가있다. BDZ의 muscle relaxation, additional well being sense가없어효과가좋지않다고느낀다. * 처음에 BZD와 buspirone을같이시작 buspirone의효과가나타나는 2-3주후에 BZD를끊는것이 reasonable approach * BZD withdrawal Sx에는효과가없다. C. Venlafaxine * 특히 GAD와동반된 insomnia, poor concentration, restlessness, irritability, excessive muscle tension에효과적이다. D. SSRIs * 특히 depression 동반시에효과적이다. * 그중 fluoxetine은일시적으로불안을증가시키므로 sertraline, paroxetine이더좋다. * BZD와함께시작하고 2-3주후에 BZD를 taper하는것이 reasonable approach E. Other drug * conventional pharmacologic effect가부족할때 : comorbid condition(depression 등 ) 을평가 & 환경적인 stress를고려 * β-blocker : somatic Sx에대해서만효과 (underlying condition에는효과없음 ) performance anxiety 같은 situational anxiety에만제한적으로효과

20 Ⅲ. 특정공포증 Specific Phobia & 사회공포증 / 사회불안장애 Social Phobia/Social Anxiety disorder 1. EPIDEMIOLOGY * single most common mental dis. in US, 대략 5-10 % * 흔한질환이지만많은사람들이치료를찾지않거나, 다른질환으로잘못진단된다. 1) Specific Phobia * specific phobia > social phobia * 여성중가장흔한 mental disorder : 15.5% * 남성중두번째로흔한 mental disorder : 11.1% (1st : substance-related disorder) * 6-Mo prevalence ; 5-10 % * F : M = 2 : 1 ( fear of blood, injection, injury type의경우엔거의 1:1) * peak age 1 natural environmental type, blood-injection-injury type : 5-9세 2 situational type(fear of height는제외 ) - mid-20s(agoraphobia onset age와유사 ) * Feared objects & situations ; animals, storms, heights, illness, injury, death 2) Social Phobia * Lifetime prevalence : 3-13 % * Peak age of onset ; 10대 (5-35세까지가능 ) * F>M (by epidemiologic study) 그러나 F<M(by clinical sample) : 차이나는이유는모름 2. COMORBIDITY * Social phobia ; other anxiety dis, mood dis, substance-related dis, bulimia nervosa, avoidant PD * Specofoc phobia ; % 의 comorbidity ; anxiety, mood, substance-related dis. 3. ETIOLOGY * causative heterogeneity : 각각의 phobia의종류마다또같은종류의 phobia에서도다르다. * phobia : biological, genetic, environmental factor 사이의 interaction * blood-injection-injury type : strong vasovagal reflex가 inherited됨. 1) Specific Phobia * various mechanism

21 1 specific event + emotional experience permanent emotional association 2 modeling : 다른사람의반응을관찰하거나배우고경고받은것에의해형성 Genetic factors. 1 family Hx (+) 2 blood, injection, injury type: high familial tendency 2/3-3/4 of affected proband : 1st degree relative 에서같은종류의 phobia 3 twin & adoption study 는이루어지지않아 nongenetic transmission R/O 안됨 2) Social Phobia * Trait : consistent pattern of behavioral inhibition 특히 panic disorder 있는부모의아이에서흔하며자라면서 severe shyness보임 * Social phobia를가지는환자는 childhood 동안 behavioral inhibition을보이는데 1 biologically based 2 psychologically based: social phobia의부모군은 i) less caring ii) more rejecting iii) more overprotective 경향이두드러진다. * dominance to submission : 고개를숙이고걷고눈맞추기피하는경향 Cf> dominant human : 고개들고걷고눈을잘맞추는경향 A. Neurochemical factors. * two specific neurochemical hypothesis 1 adrenergic theory β-blocker효과를통해유추 - performance phobia:(ex : public speaking) 에 beta-blocker 이용 - 결과적으로환자들은중추, 말초에서 : Nepi, Epi 의분비증가로설명가능 - sensitive to a normal level of adrenergic stimulation 2 dopaminergic theory - generalized social phobia 에 TCA 보다. MAOI 가 more effective - lower homovanillic acid concentration - SPECT ; striatal dopamine reuptake site density -> dopaminergic dysfunction in social phobia B. Genetic factors. * lst degree relative 에서 social phobia가 3배많다. * twin study MZ>DZ ( 예비적연구 ) 4. DIAGNOSIS 1) Specific Phobia * phobic stimulus 노출에 panic attack 발생가능 (panic disorder와감별요망 ) * Specific phobia에서의 panic attack ; situationally bound to specific phobic stimulus * type 1 animal type

22 2 natural environment type(storms) : 10세이하에서 m/c 3 blood-injection-injury type : initial tachycardia이후에 bradycardia, hypotension이발생 4 situational type(cars) : 20대에서 m/c :childhood onset과 mid-20th onset등 bimodal onset 5 space phobia : 주변의벽이나의자같은방어구조물이없으면떨어질까봐무서워하는것 abnormal right hemisphere function visual-spatial impairment phobias는전통적으로그리스어나라틴어에따라분류. acrophobia fear of heights agoraphobia fear of open places ailurophobia fear of cats hydrophobia fear of water claustrophobia fear of closed spaces cynophobia fear of dogs

23 mysophobia fear of dirt & germs pyrophobia fear of fire xenophobia fear of strangers zoophobia fear of animals amaxophobia ; 사회변화와관련. fear of electromagnetic fields/ microwaves/ society 2) Social Phobia * DSM-IV-TR에 generalized type 추가 : 경과, 예후, 치료반응에서차이 * most social situation에서 fear를가질때다른정신과질환또는신체질환에의한상황과감별해야한다.(avoidant PD와감별 )

24 5. CLINICAL FEATURES * DSM-IV에서의강조점은 phobia 에서도 panic attack이흔히일어날수있다는점이나이때 panic attack은처음몇번을제외하고는거의예견할수있다는점이다 (phobia에서 panic attack이 panic disorder에서와다른점 ). * try to avoid the phobic stimulus 1 물리적으로피하는것 : 비행기를타지않고버스로대륙을횡단 2 phobic stimulus로인한 stress를피하려고한다. associated feature : substance-related disorder( 특히 alcohol use dis) major depressive disorder (1/3에서) * MSE : irrational and ego-dystonic fear of a specific situation, object, activity 6. DIFFERENTIAL DIAGNOSIS * Specific & social phobia는각각 appropriate fear & normal shyness에대한감별 : DSM-IV-TR에서는적절한기능의장애가감별진단에요구됨 * non-psychotic medical condition 1 use of substance (hallucinogen, sympathomimetics) 2 CNS tumor 3 CVA disease * psychiatric condition 1 schizophrenia : psychosis의일환으로 phobic symptom이있을수있다. 2 panic disorder : breathless, dizziness, a sense of suffocation, fear of dying Cf> social phobia i) phobic stimuli에직면시즉각적인불안 ii) identified stimuli에국한된 sx. iii) blushing, muscle twitching, anxiety about scrutiny 3 agoraphobia : 동반자가있을때는편하게느낀다. Cf> social phobia시동반자가있을때더불안하다. 4 avoidant PD : 감별이어려워 extensive interview, Hx 필요 1) Specific Phobia * hypochondriasis : fear of having a disease Cf> specific phobia of illness type : fear of contracting the disease * OCD : OCD에서칼을피하는것은 compulsive thought about killing their children Cf> specific phobia fear of cutting themselves * paranoid PD generalized fear를보인다는게차이. 2) Social Phobia * 두가지부가적인감별진단적고려사항 1 major depressive disorder : social situation의 avoidance보이지만면담해보면우울증상 2 schizoid PD : not fear of socializing but lack of interest in socializing.

25 7. COURSE AND PROGNOSIS 1) Specific phobia * bimodal age of onset childhood peak for animal phobia/natural environment phobia/ blood-injection-injury phobia early adulthood peak * specific phobia의 course에대한 prospective epidemiology는제한되어있다. * most specific phobia - childhood에시작해서 adulthood로지속된다. * severity - 다른불안장애처럼 waxing & waning course가아니고비교적 constant 2) Social Phobia * Onset ; late childhood, early adolescence * chronic disorder이며수년동안개인의생활을붕괴시킨다. 8. TREATMENT 1) Behavioral Therapy * most studied & most effective Tx. * Systematic desensitization ( Joseph Wolpe) ; 환자를가장작은자극에서부터 most frightening anxiety-provoking stimuli에노출 -> 안정제, 최면, 근육이완을통해환자는그들자신에게서 mental & physical response을어떻게유도하는지배운다. -> 불안을유발하는자극에 relaxation할수있도록배운다. * Intensive exposure to phobic stimulus through imagery or desensitization in vivo. ; imaginal flooding (implosion) 2) Insight-Oriented Psychotherapy * insight-oriented PT는 1 환자로하여금 phobia의원천을이해하도록하고 2 이차적이득의현상, 저항의역할을이해하도록 3 anxiety provoking stimuli를다루는건강한방법을찾도록돕는다. 3) Other Therapeutic Modalities * hypnosis : phobic object가위험한것이아니라는것을암시 self-hypnosis - phobic object에직면시 relaxation하는방법으로교육 * supportive PT * family therapy 4) Specific Phobia * Exposure therapy ; 가장많이이용, 점진적인 self-paced exposure를통해탈감작시킨다. ; 불안을다룰수있도록 relaxation, breathing control, cognitive approaches를포함하는다양한기술을배운다.

26 * β-adrenergic R. antagonist - specific phobia ( 특히 panic attacks과관련 ) 에효과 * 약물치료 (BZD), 정신치료, or combined therapy도효과적 5) Social Phobia * 약물치료 + 정신치료 > 단독치료 * Effective drugs (1) SSRIs ; 1st line Tx choice for generalized social phobia (2) Benzodiazepines ; alprazolam, clonazepam (3) Venlafaxine (4) Buspirone ; SSRI에 augmentation * MAOI ( phenelzine, moclobemide, brofaromine) ; Severe case ; phenelzine mg/D, 효과평가는 5-6주필요, response rate 50-70% * β-adrenergic R. antagonist ; perfomance situation과관련된 social phobia 치료 ; atenolol mg( 매일아침또는실행한시간전 ) propranolol 20-40mg * Cognitive, behavioral, exposure tchniques ; performance situation에유용 * Psychothrapy ; behavioral & cognitive method 와병행하여시행 (cognitive retraining, desensitization, rehearsal during session, homework assignments포함 )

27 Ⅳ. 외상후스트레스장애 POSTTRAUMATIC STRESS DISORDER(PTSD) 어떤 extreme traumatic event를겪었거나목격했던사람에게서나타나며, 이경험을 fear & helpless로느끼며, 그사건에서지속적으로벗어난이후에도이와연관된것들을피하기위해노력한다. trauma의특징 : stress that was of magnitude that would be traumatic for almost anyone ex) war, torture, natural catastrophes, assault, rape, serious accident major features 1 reexperience of the trauma through dreams and waking thoughts 2 persistent avoidance of reminders of the trauma & numbing of responsiveness to such reminder 3 persistent hyperarousal common associated Sx : depression, anxiety, cognitive difficulties (poor concentration) DSM-IV-TR에서의구분 PTSD : Sx duration이 1 month 이상 Acute stress disorder : event 이후 2일-4주간증상의지속, 4주이내 Sx onset 1. HISTORY 1871년 : Jacon DaCosta's paper On Irritable Heart - Civil War 이후군인에게나타나는증상 1900년대초기 : 정신치료의발달로 traumatic neurosis로불림. World War I 이후 : 이러한증상을 shell shock로명명. 1941년 : Boston night club 화재이후 nervousness, nightmare, fatigue World War II : 나치캠프의생존자와일본의 atomic bombing의생존자에서도비슷한증상관찰 combat neurosis, operational fatigue Vietnam War veterans : PTSD의개념정립 2. EPIDEMIOLOGY life time prevalence: 5-15% trauma를경험한 high risk group : 5-75% cf) Vietnam veterans 경우 PTSD가 30% 어느나이에서나발생가능 - young adult에서 mc( 이연령군이위험한상황에많이노출 ) - 어린이에서도발병가능

28 남녀 type의차이 : 남자는 combat experience, 여자는 assault, rape 多 single, divorced, widowed, socially withdrawal, low SES group에서多 3. COMORBIDITY * PTSD 환자의 2/3 정도에서적어도두개의다른 d/o를가진다. * common conditions : depressive d/o, substance-related d/o, other anxiety d/o, bipolar d/o * 이런경우에 PTSD에 vulnerable! 4. ETIOLOGY (1) Stressor * stressor는 PTSD의주원인이되지만, stressor를경험한다고해서모두 PTSD가되는것은아니다. -> 환자의 preexisting biologic factor, psychosocial factor, trauma 전후의 event를고려! * stressor 자체의 severity 만큼 subjective experience도중요하다. ( 예 ) 살아남은사람의 guilty feeling(survivor guilt) 는 PTSD 를악화시키기도한다. (2) Risk Factor predisposing vulnerable factor 1 presence of child trauma 2 borderline, paranoid, dependent, antisocial personality trait 3 inadequate family/peer supportive system 4 being female 5 genetic vulnerability to psychiatric illness 6 recent stressful life event 7 perception of an external locus of control(natural cause) > an internal one(human cause) 8 recent excessive alcohol intake (3) Psychodynamic Study * trauma가 UCs에있던소아기의 unresolved psychologic conflict를 reactivating repression 되어있던 childhood의 trauma가 revival 되면서, regression 되어 repression, denial, reaction formation, undoing의 defence mch을사용 ego가 anxiety를 relieve, master, reduce하는것을반복하면서증상의완화와회복 (4) Cognitive-Behavioral Factors cognitive model * PTSD 환자들은 trauma에대해 process/rationalize 하지못한다. * 지속적으로 stress를경험하면 avoidance technique를통해 stress의재경험을회피하려고시도한다. * event를전체적으로인지하는데실패함으로써 event에대한 acknowledging( 승인 ) 과 blocking( 방어 ) 이교대하는 period를경험한다. -> trauma로인해야기된막대한양의

29 information을 process하려는 brain의노력에의해이런 alternating period가생기는것으로생각된다. behavioral model * 1st (classical conditioning) : unconditioned stimulus(trauma) + conditioned stimulus(physical/mental reminders) * 2nd (instrumental learning) : conditioned + unconditioned stimuli를 avoidance하는 pattern을발전시킴 (5) Biologic factors neurotransmitter system 1 preclinical model : learned helplessness, kindling, sensitization in animal NE, DA, endogenous opiate, BDZ receptor, HPA axis 이론을유도 2 clinical population NE, endogenous opiate, HPA axis(hyperactive) 의가설지지 ANS의 activity & responsiveness의증가 증거 : 혈압, 맥박의증가, abnormal sleep architecture(sleep fragmentation, sleep latency 증가 ) PTSD와 major depressive ds & panic ds의유사성제안

30 5. DIAGNOSIS

31 6. CLINICAL FEATURES principal clinical feature 1 painful re-experience of the event 2 a pattern of avoidance & emotional numbing 3 fairly constant hyperarousal MSE * feeling of guilt, rejection, humiliation * dissociative state & panic attack * illusion, hallucination * impairment of memory & attention * ass. sx : aggression, violence, poor impulse control, depression, substance-related d/o Cognitive Test : impaired memory & attention MMPI : Sc, D, F, Ps 증가 Rorschach : aggressive, violent material 7. Differential Diagnosis * trauma 당시의 head trauma의가능성고려 * other organic consideration : epilepsy, alcohol & other substance-related d/o * PTSD 증상의원인이되거나악화요인 : acute intoxication/withdrawal state * commonly misdiagnosis : pain disorder/ substance abuse/ other anxiety disorder/ mood disorder/ BPD/ dissociative disorder/ factitious disorder/ malingering 8. Course & Prognosis onset : 대부분은 trauma 직후대개 3개월이내에발생, delay되어 1주 ~ 30 년이후에발생하기도. fluctuating sx - stress시악화 경과 : 30% 회복 /40% 경미한증상 /20% 중등도의증상 /10% 변화없거나악화 1년후에는약 50% 정도가 recovery good Px predictor 1 rapid onset of sx 2 short duration of sx 3 good premorbid functioning 4 strong social support 5 absence of other psychiatric, medical, substance-related d/o the very young & the very old 경우 : more difficult! * burn injury 1-2년후비교 : young children의 80%, adult의 30% 가 PTSD를가진다. * young children : 적절한 coping mechanism을가지지못하기때문 * older person : more rigid coping mechanism, less able to master a flexible approach to the trauma : physical disability에의해악화 ( 신경계, 심혈관계, CBF감소, failing vision, palpitation, arrhythmia)

32 9. Treatment significant trauma 겪은환자에대한 major approach 1 support( 지지 ) 2 encouragement to discuss the event( 격려-사건에관한이야기 ) 3 education regarding a variety of coping mechanism(ex: relaxation) ( 대처기술교육 ) 4 sedative & hypnotics( 약물 ) education regarding the disorder & treatment ( 약물, 정신치료 ) 지방 & 국가의 support group 통한환자와가족을위한 support 제공 (1) Pharmacology 선택적세로토닌재흡수억제제 (SSRI) : sertraline, paroxetine -> 1st line treatment * PTSD의모든 sx. cluster를호전 : depression이나 anxiety와비슷한증상외에도 PTSD 고유의증상도호전. * buspiron도사용한다. 삼환계항우울제 (TCA) ; imipramine & amitriptyline * 여러연구에의해 efficacy 인정 * depression에준한용량, 최소 8주는써야효과판정 * 효과가있다면최소 1년은유지한후 withdrawal 시도 * 일부연구에서 pharmacotherapy는 avoidance, denial, emotional numbing 등의 sx 보다 depression, anxiety, hyperarousal에더효과적이라고한다. other * MAOI, trazodone, anticonvulsant(carbamazepine, valproate) * clonidine, propranolol : noradrenergic hyperactivity 이론지지 * antipsycotics : (+) data는없음 : severe aggression, agitation 위한단기간의사용을제외하고는사용하지않음 (2) Psychotherapy psychodynamic PT가유용 abreaction( 제반응 ) & catharsis를통하여외상적사건을재구성어떤환자는 trauma의재경험에압도당하므로개별적으로적용 psychotherapeutic intervention : 주로 behavioral Tx. cognitive Tx. hypnosis two major psychotherapeutic approach * 1st : imaginal technique 이나 in vivo exposure를통한 traumatic event exposure * 2nd : stress management에대한교육 : relaxation technique & cognitive approach to coping with stress -> 빠른효과 위기개입 (crisis intervention) EMDR(eye movement desensitization reprocessing) 기법도사용 group therapy family therapy

33 Special Considerations World Trade Center, Pentagon terror 로 3500 명이사망함 이후 psychological sequelae에대해조사.* 성인 45% 가사건과관련되어한가지이상의 substantial sx. 을호소 : stress, insomnia, nightmare, fearfulness, irritability, among others * 성인 90% 에서 minor degree의 sx을호소 * 부모의 80% 가아이들이한가지이사의증상을가진다고보고함. -> susceptibility to sx : 1 female, 2 nonwhite, 3 previous psychological illness, 4 being close to the disaster sites -> level of stress는 disaster에대한 television viewing의정도와비례함 사건 5-8주후 Manhattan resident를대상으로한 survey * 9.8%(90000명 ) 이 PTSD or depression, 그중 3.7%(34000명 ) 이 both! * both 인경우 : 1 ground zero( 사고지역 ) 가까운곳에거주, 2 사고로인한 personal losses, 3 사고이전 12개월내에다른 stressful event를겪은경우, 4 Hispanic > whites, blacks, asians 5 women 6 low SES 사건 9개월이후 NewYork에서 10-13세사이의 8000명을대상으로연구 * 11% 가 PTSD 진단에합당 * 추가로 15% 정도에서 agoraphobia 증상 (fear of taking public transportation) * Hispanic students & girl에서많았다. 향후 longitudial study가필요할것이다.

34 Ⅴ. 급성스트레스장애 ACUTE STRESS DISORDER 극심한외상에노출된후 1개월이내에특징적인불안, 해리증상및기타증상들이나타나는것 외상후스트레스장애의증상과유사 증상은최소 2일이상지속, 4주이상을넘지않아야한다. Ⅵ. 일반적의학적상태로인한불안장애 Anxiety Disorder Due to a General Medical Condition Disorders associated with anxiety Hyperthyroidism, hypothyroidism, hypoparathyroidism, vit B 12 deficiency, pheochromocytoma : paroxysmal episodes of anxiety symptoms certain lesions of the brain & postencephalitic state : OCD cardiac arrhythmia : physiological symptoms of panic disorder hypoglycemia : anxiety disorder * common mechanism : noradrenergic system을통해서증상유발 Clinical features * most common : syndrome similar to panic disorder * least common : similar to phobia

35 A. Panic Attacks * cardiomyopathy pt( 이식수술을기다리는 ) 의 83% 에서증상보임 * increased noradrenergic tone * Parkinosn's disease & chronic obstructive pulmonary disease의 25% * Panic disorder와연관된그외질환 1 chronic pain 2 primary biliary cirrhosis 3 epilepsy(esp. Rt parahippocampal gyrus에 focus) B. Generalized anxiety disorder * Sjogren's syndrome : cortical & subcortical fx과 thyroid fx에영향을주어증상유발. * Graves' disease : 가장높은빈도를보이는질환으로환자의 2/3에서 GAD의진단기준에맞는다. C. Obsessive-Compulsive Sx. * Sydenham's chorea & multiple sclerosis D. Phobias * uncommon, Parkinsosn's disease의 17% 에서증상보임 Treatment * 일차적으로원인질환을치료 * 물질남용질환이같이있는경우 : 동시에치료 * 원인질환치료후에도불안이계속될경우 : BM(behavior modification), anxiolytic agents, serotonergic antidepressants Ⅶ. 물질에의한불안장애 Substance-Induced Anxiety Disorder Etiology * sympathomimetics (ex, amphetamine, cocaine, caffeine) : most association * serotonergic drugs (ex, LSD & MDMA)

36 Diagnosis * 증상의발생은 substance의이용하는동안이나 substance를중단한지 1달이내 * 진단구성 : 1 물질규명 ( 예 :cocaine) 2 상태규명 ( 예 :intoxication) 3 특정증상규명 ( 예 :panic attack) Clinical features * 사용한물질에따라다양 * cognitive impairments in comprehension, calculation, memory 물질사용중단하면 reversible * alcohol user의대부분이가끔은 anxiety를감소하려는목적으로음주 anxiety에대한 alcohol의효과는다양 (gender, amounts, cultural attitude 등의영향 ) * 그럼에도불구하고 alcohol & substance-related d/o는흔히 anxiety d/o와연관 alchol use d/o가 panic d/o에서는 4배, OCD에서는 3.5배, phobia에서는 2.5배많다. * 일부가족에서는 alcohol & anxiety d/o의 genetic diathesis이발견된다. Differential Diagnosis * Primary anxiety disorders/ anxiety disorder due to a general medical condition/ mood disorders/ personality disorder/ malingering Course & Prognosis * substance use를그만두는것과얼마동안사용하지않을수있느냐에따라결정 * anxiogenic effects of most drugs : reversible * irreversible할경우 : 1 진단을재고하거나 2 substance causes irreversible brain damage Tx * 일차적으로원인물질제거 * 물질에노출되지않도록 * 증상이지속될경우 : PT or Drug Tx