anxiety disorders

1. Anxiety Disorders Dr Sheila Tighe

4. Stress Definition: Experiencing events that are perceived as endangering one�s physical or psychological well-being. The events are known as stressors and the result as the stress response The response to stressors is influenced by Controllability, predictability and challenge to our limits. Holmes Life Events Scale Different psychological responses to stress include Anxiety Anger and aggression Apathy and depression Cognitive impairment

5. Definition of anxiety A vague unpleasant emotion that is experienced in anticipation of some future misfortune A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation May have emotional, behavioural, cognitive and physical components

6. Structures and neurotransmitters involved in anxiety Structures involved Cerebral cortex Limbic system- hypothalamus, hippocampus, amygdala, cingulum Thalamus, locus ceruleus, raphe nucleus Neurotransmitters NA, 5HT, GABA

7. Fight or flight response Physiological response to a stressor Mediated through the hypothalamus and LC Initial activation of the sympathetic nervous system Subsequent activation of the pituitary adrenal axis Terminated by negative feedback and para sympathetic system

8. Effects of sympathetic stimulation Mediated through noradrenaline and adrenaline Increased heart rate and contractility Increased respiratory rate Sweating Increased glucose availability Shunting of blood to muscles Increased muscle tension Enhanced blood clotting

10. Effects of HPA axis stimulation Mediated through CRH, ACTH and cortisol Promotes breakdown of glycogen to glucose in liver Promotes glucose uptake into cells CRH also activates locus ceruleus

12. Anxiety as a normal adaptive function Evolutionary viewpoint Looks at traits in the context of natural selection and promotion of the species Primitive environment with many physical dangers � anxiety had a protective function as a warning system and in helping escape Anxiety - response to cues of potential danger Protection general or specific depending on nature of threats c.f.. Immune system Avoidance, aggression, freezing or appeasement

13. Anxiety as a normal adaptive function continued Preparedness - We are more likely to become anxious in response to cues that represent ancient dangers e.g.,snakes, strangers, storms, blood. Not flowers, leaves, shallow water Not in response to more evolutionary recent dangers - guns, cars

15. Anxiety disorders - terminology Neurosis � William Cullen General deficiency of nervous system Psychoneurosis � Sigmund Freud 1900 Unreleased sexual tension - hypochondriasis Repressed thoughts - phobias ICD10 � Neurotic, stress related and somatoform disorders. DSM IV � Anxiety disorders

16. Anxiety disorders Anxiety disorders are extremes of normal anxiety Occur when normal anxiety system becomes dysregulated - excessive, inappropriate or deficient Common - ECA lifetime prevalence 15 -20%

17. Shared features of anxiety disorders Substantial proportion of aetiology is stress related. Reality testing is intact. Symptoms are ego dystonic (distressing) Disorders are enduring or recurrent. Demonstrable organic factors are absent

18. Aetiology of anxiety disorders Genetic Family studies Linkage studies Neurotransmitter abnormalities 5HT, NA, GABA HPA axis dysregulation

19. Aetiology of anxiety disorders Psycho-analytic theories - unconscious defence mechanisms Phobia - displacement OCD - reaction formation, undoing PTSD - denial, repression Cognitive theories Selective attention and catastrophic thinking Behaviour - learned behaviour

20. Anxiety disorders - aetiology Social factors Early life adversity Stressful events especially those involving threat Lack of support network Personality factors Some personality traits predispose to certain anxiety disorders � avoidant, perfectionist

21. Panic Disorder Recurrent attacks of severe anxiety Physical symptoms Palpitations, chest pain, choking sensation, dizziness, breathlessness, tingling in the hands and feet, sweating, faintness. Emotional and behavioural symptoms Fear of dying, losing control, going mad Feeling of unreality - depersonalisation Need to exit situation

22. Panic Disorder continued Sudden in onset Not predictable or confined to a given situation Concern about future attacks and secondary avoidance Otherwise relatively free of anxiety between attacks ICD10 criteria - several severe attacks within a month

23. Panic disorder - differential Panic attacks as part of a phobic disorder distinction between panic disorder and agoraphobia controversial Depression PTSD Substance abuse Physical disorders e.g., phaeochromocytoma

24. Panic disorder - epidemiology ECA - 1% of population More prevalent in females Ages 25 - 44 20% have another anxiety disorder Positive family history of panic disorder in 25%

25. Panic disorder - pharmacological treatment Assess and tx comorbid problems SSRIs - paroxetine, citalopram - can initially worsen panic attacks Benzodiazepines - good short term relief but high risk of dependency - alprazolam TCAs - imipramine, clomipramine MAOIs - especially in mixed panic depressive states but use limited by ADR High rate of relapse on cessation of tx

27. Panic disorder - psychological treatments Behavioural therapy exposure and response prevention relaxation techniques Cognitive behaviour therapy education recognition and change of negative thoughts

28. Generalised Anxiety Disorder Anxiety is generalised and persistent Free-floating anxiety � not situational. ICD10 - symptoms present most days for weeks Motor tension Muscle tension, twitching and shaking, restlessness, . Apprehension Feeling on edge,unable to cope, poor concentration, insomnia, irritability Autonomic over-activity Lightheadedness, sweating, tachycardia, dry mouth, epigastric discomfort

29. GAD - epidemiology One year prevalence 3 - 8% Females more likely 2:1 Age of onset 20 - 35 50% have another psychiatric diagnosis

30. GAD - differential Other anxiety disorders Depression Substance abuse Schizophrenia Physical conditions hyperthyroidism, angina Early dementia

31. GAD - Management Biological Benzodiazepines - short-term tx SSRIs - Venlafaxime MAOIs Psychological Anxiety management - based on CBT principle

32. Phobias Anxiety evoked by specific circumstances or situations. Fear is out of proportion to the situation and is beyond voluntary control. Agoraphobia Social phobia Specific phobias Plus or minus panic disorder Avoidance is a characteristic feature Strong association with depression

33. Agoraphobia Fear of open spaces, crowds or public places. Fear of travelling by public transport Fear that it may be difficult to get to a place of safety (home) Situations where an immediately available exit is lacking are avoided.

34. Agoraphobia - symptoms Autonomic symptoms - faintness, palpitations, SOB, sweating Panic attacks marker of severity Psychological symptoms - fear, dread Behavioural symptoms - avoidance to the extent that the person becomes house bound Cognitive symptoms - � I might have died�

35. Agoraphobia - epidemiology (similar to panic disorder) Predominantly females � 75% Age of onset � 15 to 35 Risk factors Stressful life events Family history � 20% relative with agoraphobia Domestic instability � family or marital difficulties History of childhood fears or enuresis Overprotective family members Differential diagnosis Depression, schizophrenia, dementia

36. Agoraphobia - Management and Prognosis Behaviour therapy - graded exposure and systematic desensitisation CBT Family therapy Self help books Pharmacotherapy - as for panic disorder

37. Social Phobia Fear of scrutiny by others in relatively small groups Fear of acting in a way that will be embarrassing or humiliating or appear ridiculous Feared social situation associated with intense anxiety and distress - blushing, tremor,butterflies Leads to avoidance of social situations that involve e.g., eating, public speaking - isolation Differential diagnosis Body dysmorphic disorder, panic disorder, depression, paranoid psychosis

38. Social phobia - epidemiology Roughly equal sex incidence Onset in adolescence Prevalence - 1-2 % Often co-morbid depression or alcohol and substance abuse

39. Social phobia - management Assess and treat co-morbid conditions Pharmacotherapy Behavioural and CBT techniques

40. Specific phobias Anxiety provoked only in response to a specific stimulus or situation Panic attacks can occur Degree of disability is related to ease or difficulty of avoiding the feared object Feared object usually something that posed a threat at some time in history - animals, storms, heights, darkness, blood Behavioural approach most useful

41. Obsessive Compulsive Disorder Repetitive unwanted obsessions or compulsive acts Obsession is recurrent and intrusive thought, feeling, idea, image or impulses Usually distressing e.g., contamination, obscene, violent Sometimes futile e.g., quasi-philosophical Indecision between two alternatives Resisted but this causes tension Recognised as the person�s own thoughts

42. OCD continued Compulsions are stereotyped behaviours repeated again and again Cleaning, checking, tidying, counting, Sometimes marked indecision or slowness Not enjoyable or useful May be thought of as protective in some way and can reduce anxiety Autonomic symptoms present Close links with depression

43. OCD epidemiology Lifetime prevalence 1 -2% Equal sex incidence Age of onset 20 - usually abrupt Often delay of years in seeking tx Course chronic and fluctuating Often co-morbid anxiety disorders, (social phobia 25%), depression (67%), eating disorders

44. OCD - Management Behaviour therapy Exposure and response prevention Paradoxical injunctions CBT - less useful Pharmacotherapy SSRIs, Clomipramine Augmentation with quetiapine or risperidone Clonazepam

45. OCD Psychosurgery - indicated rarely for severe intractable cases Outcome 60% respond to SSRIs but relapse is common on cessation of tx Predictors of poor outcome are male sex, early onset and obsessional slowness

46. Disorders arising as a reaction to stress Acute stress reaction Post traumatic stress disorder Adjustment disorders - mild transient response to stress precipitated by life events within the normal range Clear-cut stressor or trauma without which disorder would not occur

47. Acute stress reaction Overwhelming traumatic experience involving threat to life, physical integrity or social position of individual or a loved one RTA, battle, rape, multiple bereavement Daze, disorientation, mixed picture Withdrawn or agitated Autonomic symptoms Onset within minutes, resolves 48-72 hrs

48. Post traumatic stress disorder PTSD Delayed or protracted response to trauma ( often involving threat to life) Onset usually within 6 months of event Core symptom is �reliving the event� Flashbacks, nightmares, waking dreams Emotional numbness and detachment Avoidance of activities, situations that remind person of trauma

49. PTSD continued Autonomic hyper arousal Hypervigilance, increased startle, insomnia Mood disorder - anxiety or depression Abuse of alcohol or drugs

50. PTSD - Mx SSRIs, Serotinergic TCAS Behavioural tx CBT Family tx Debriefing - no clear evidence base

51. PTSD - outcome Symptoms fluctuate over time Most intense at times of stress 30% complete recovery 10 % do badly Predictors of poor outcome - Hx of childhood trauma, borderline or ontisocial personality traits, poor support network, heavy alcohol intake

52. Dissociative and somatoform disorders Disorders in which person presents with physical symptoms for which there is no medical explanation Psychological explanation or cause often present Diagnosis of exclusion Liaison psychiatry

53. Summary Anxiety disorders are common They are distressing and cause loss of function They occur commonly with other co-morbid psychiatric disorders They are amenable to pharmacological and psychological treatment

54. Any questions ?