Anxiety Disorders

1. Anxiety Disorders Robert Averbuch, MD Department of Psychiatry

2. What is �anxiety�? Apprehensive anticipation of future danger Experienced as dysphoric (unpleasant)- hence ego-dystonic Often accompanied by somatic/physical symptoms (e.g., muscle tension, elevated heart rate, etc.)

3. Is �Anxiety� Always Pathological? Some anxiety is advantageous Helps in novel situations Helps mobilize individual for quick response- fight or flight response for survival Anxiety can heighten one�s awareness/alertness, prepare a defense to a threatening situation

4. Relationship Between Arousal (anxiety) and Performance

5. What Causes Anxiety?

6. Some Fears are Innate

7. Other fears are learned Some learned fears are adaptive and appropriate; others are not and result from faulty learning� Thru Classical Conditioning: pairing of a threatening stimulus with a non-threatening one Hence, safe or innocuous stimuli (e.g., situations, objects) acquire a meaning of danger When anxiety is excessive, becomes generalized, or is inappropriate for the situation, it becomes pathological�

8. Anxiety Disorders

9. Genetics and Epidemiology Overall, anxiety disorders are among the most prevalent of psychiatric disorders Lifetime prevalence of up to 25% for any anxiety disorder in U.S. Higher incidence in women Strong genetic component

10. Anxiety Disorders Panic disorder (w/wo agoraphobia) Posttraumatic stress disorder (PTSD) Social Phobia (aka Social Anxiety Disorder) Specific phobia Obsessive-compulsive disorder (OCD) Generalized anxiety disorder (GAD)

11. Panic ATTACK Discrete period of intense fear or discomfort accompanied by at least four of the following physical sensations�

12. Panic Attack: Accompanying Symptoms Chest pain Palpitations Sweating Trembling or shaking Paresthesias (numbness, tingling) Dizzy, faint Derealization, depersonalization Fear losing control or going crazy Fear of dying Shortness of breath, choking, smothering Nausea or GI distress Chills or hot flashes

13. Panic Attack Episodes have a sudden onset and peak rapidly (usually in 10 minutes or less) Often accompanied by a sense of imminent danger or doom and an urge to escape May present to ER with fear of catastrophic medical event (e.g., MI or stroke)

14. Panic Attacks: A Symptom Not specific to Panic Disorder Also occur in Social Phobia, PTSD, and OCD Can also be secondary: Due to an underlying medical condition Substance-induced: prescription drug side effect, recreational drug misuse, etc.

15. Panic Disorder

16. Panic Disorder Recurrent unexpected panic attacks Followed by one or more of the following: Anticipation of additional attacks Worry about implications of attacks Ex. �Could I stop breathing?� Change in behavior as a result- ex. avoidance With or without Agoraphobia

17. Agoraphobia Literally fear of market place or open spaces Anxiety about being in situations from which escape might be difficult Often secondary to panic attacks Avoided situations include: driving, bridges, tunnels, elevators, airplanes, malls, long lines, sitting in middle of row, etc.

18. Panic Disorder: Demographics and Epidemiology More common in women Lifetime Prevalence 2-5% Frequently present to primary care setting- often emergently

19. Social Phobia aka �Social Anxiety Disorder�

20. Social Phobia Significant fear of public situations where the person may be scrutinized by others, or embarrassed Exposure to the feared situation almost invariably provokes anxiety (sometimes panic attacks) Hence, feared situations are often avoided

21. Social Phobia Fear is that you�ll do something to cause embarrassment or they�ll �see you sweat� (show anxiety) Can be specific to one situation (�performance�), or Generalized

22. Social Phobia: Subtypes Performance Restricted to things like public speaking, giving a recital, etc. (�stage fright�) Common, and often does not require medical treatment Generalized Involves many different situations Avoidance common (like avoidant P D/O) Greater impact on functioning

23. Social Phobia: Demographics and Epidemiology Lifetime prevalence of 2-3% Women > men High co-morbidity with alcohol abuse and depression

24. Specific Phobia

25. Specific Phobia Persistent, irrational fears of �specific� objects or situations Examples: snakes, closed-in spaces, flying, blood, heights, and bridges Common: 5-10% prevalence Women > men

26. Obsessive-Compulsive Disorder

27. Obsessive Compulsive Disorder (OCD) Recurrent unwanted and distressing thoughts (obsessions) and/or repetitive irresistible behaviors (compulsions) Majority, but not all, have both obsessions and compulsions Compulsions usually reduce anxiety but are not pleasurable Ego-dystonic (in contrast to the personality disorder)

28. OCD Insight present: acknowledged as senseless or excessive at some point during illness Symptoms produce distress and are often time-consuming (occupy>1hr/day)

29. More on Obsessions: the details Can be thoughts, impulses, or images Experienced as intrusive, but the person recognizes it�s their own thoughts (not experienced as hallucinations) Not just excessive worries about real-life events (i.e., not ruminations)

30. Common Obsessions Typical concerns/themes include: Fears of contamination Fears that one will act aggressively Feeling unsafe Sexual perversions Religion (blasphemous thoughts) Somatic fears Need for symmetry or exactness

31. Obsessions Attempts are made to ignore, suppress or neutralize the thoughts with some other thought or action (a compulsion)

32. Compulsions Defined Repetitive behaviors or mental acts the person feels driven to perform either In response to an obsession, OR According to rigid rules Designed to prevent or reduce distress or to prevent some dreaded event from occurring The acts are clearly excessive or senseless- ie, not logical

33. Common Compulsions Typical behaviors include: Cleaning/washing Checking Ordering/arranging Counting Repeating Hoarding/collecting

34. OCD: Prevalence & Course Lifetime prevalence: 2-3% Childhood Onset > 50% Chronic, sometimes disabling Men and women equally affected

35. Biological Underpinnings of OCD Serotonin hypothesis Structural hypotheses Infection-triggered autoimmune process

36. Obsessive Compulsive Disorder- Structural Hypotheses Likely due to excessive activity in the orbitofrontal cortex, cingulate gyrus, and striatum Anterior insular cortex and striatum activated both in the recognition and expression of disgust

37. OCD- Neurotransmitter Pathology Possible excessive glutamatergic activity of neurons in the Orbitofrontal Cortex 5-HT (Serotonin) is a known inhibitor of these neurons

38. Generalized Anxiety Disorder

39. Generalized Anxiety Disorder Excessive worries about real life problems such as school and work performance (�worry wort�) Typically seek help for somatic concerns in primary care setting

40. Generalized Anxiety Disorder Accompanying anxiety symptoms: Muscle tension Restlessness or feeling keyed-up or on edge Easy Fatigability Irritability Trouble Concentrating Sleep disturbance

41. Epidemiology of GAD

42. Post Traumatic Stress Disorder (PTSD) Originally �Shell Shock� or �Combat Fatigue�

43. PTSD- DSM-IV Criteria Exposure to a traumatic event in which there is: Serious risk of death or dismemberment to self or others Their response is key. Must involve: Intense fear Helplessness Horror

44. PTSD- DSM-IV Criteria The traumatic event is persistently reexperienced Person avoids reminders of the trauma May experience a numbing of emotions Chronic state of hyperarousal These things persist for at least 1 month

45. How is the Event Reexperienced? Recurring images, memories, thoughts Misperceptions, hallucinations Dreams/nightmares Flashbacks- reliving the experience

46. What about Avoidance/Numbing? Avoids thinking about it, talking about the trauma Avoids reminders, triggers, cues Inability to recall parts of the trauma Loss of enjoyment in life, sense of no future Feeling detached and emotionally aloof

47. Increased Arousal State Insomnia Irritability or anger outbursts Trouble concentrating Hypervigilance Exaggerated startle

48. Epidemiology of PTSD Lifetime prevalence of 1-3%; far higher in combat veterans (30% of Vietnam vets; 20-30% of Iraq war vets) Common after natural disasters, wars, rape, assault, car accidents Co-morbid substance misuse is common

49. PTSD- Biological Underpinnings Amygdala: key role in attaching fear to the memory of a past threat Amygdala provides the primitive fear response, while the hippocampus and cingulate gyrus facilitate the extinction of this response In PTSD, evidence of hyperactive amygdala with hippocampal atrophy, resulting in a heightened state of arousal

50. Anxiety as a symptom of� Medical Conditions Substance Intoxication or Withdrawal

51. (Secondary) Anxiety Disorders Anxiety Disorder due to a General Medical Condition Anxiety judged to be due to direct physiological effects of a general medical condition such as thyrotoxicosis Substance Induced Anxiety Disorder Anxiety judged to be due to direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure)

52. Medical Conditions that may present with anxiety Tumors (ex. Pheocromocytoma) Hypoxia (from a Pulmonary Embolus, Chronic Obstructive Pulmonary Disease) Hyperthyroidism (thyroid storm) Myocardial infarction, arrhythmias, mitral valve prolapse Hypoglycemia Many more!!!

53. Substanced-Induced Anxiety Alcohol/sedative withdrawal Cocaine/stimulant intoxication Cannabis intoxication Caffeine intoxication

54. The End