Anxiety Disorders

Anxiety Disorders Samantha Meltzer-Brody, M.D., M.P.H. Assistant Professor UNC Department of Psychiatry

Anxiety • Nervousness and fear are common human emotions. • Adaptive at lower levels; disabling at high levels. • Physicians must recognize the difference between pathological anxiety and anxiety as a normal or adaptive response.

Features of Pathologic Anxiety • Autonomy: no or minimal environmental trigger • Intensity: exceeds patient’s capacity to bear the discomfort • Duration: symptoms are persistent • Behavior: anxiety impairs coping and results in disabling behaviors

Definition of Anxiety • Diffuse, unpleasant, vague sense of apprehension • Often accompanied by autonomic symptoms such as headache, perspiration, heart palpitations, chest tightness, stomach discomfort and restlessness • Presentation depends on perception of stress, personal resources, psychological defenses, and coping mechanisms

Etiology • Neurophysiology • Central noradrenergic systems– in particular, the locus coeruleus is the major source of adrenergic innervation • GABA neurons from the limbic system • Serotoninergic systems and neuropeptides • Cognitive-Behavioral Formulations • Developmental (Psychodynamic) Formulations

Anxiety Disorders • The most prevalent psychiatric disorders • One-quarter of the U.S. population experiences pathologic anxiety in their lifetime • Presenting problem for 11% of patients visiting primary care physicians • 90% of patients with anxiety present with somatic complaints

Endocrine: thyroid dysfunction, hyper adrenalism Drug Intoxication: caffeine, cocaine Drug Withdrawal: alcohol, narcotics Hypoxia: CHF, angina, anemia, COPD Metabolic: acidosis, hyperthermia Neurological: seizures, vestibular dysfxn Common Medical Conditions Associated with Anxiety Disorders

Major Anxiety Disorders • Panic Disorder • Generalized Anxiety Disorder • Post Traumatic Stress Disorder • Social Phobia • Specific Phobia • Obsessive Compulsive Disorder (OCD) • Substance Induced Anxiety Disorder

Panic Attack • Discrete episodes of intense anxiety • Sudden onset • Peak within 10 minutes • Associated with at least 4 of the 13 other somatic or cognitive symptoms of autonomic arousal

Panic Attack Symptoms • Cardiac: palpitations, tachycardia, chest pain or discomfort • Pulmonary: shortness of breath, a feeling of choking • GI: nausea or abdominal distress • Neurological: trembling and shaking, dizziness, lightheadedness or faintness, paresthesias

Panic Attack Symptoms • Autonomic Arousal: sweating, chills or hot flashes • Psychological: • Derealization (feeling of unreality) • Depersonalization (feeling detached from oneself) • Fear of losing control or going crazy • Fear of dying

Panic Disorder • A syndrome characterized by recurrent unexpected panic attacks (at least 4 in one month) • Attacks are followed for at least one month with: • Concern about having another attack • Worry about implications of the attack • Behavior changes because of the attacks

Agoraphobia • Complication of panic disorder • Means “ fear of the market” • Anxiety or avoidance of places or situations from which escape might be difficult, embarrassing, or help may be unavailable. • Restricts daily activities

Agoraphobia • Agoraphobia • The patient may avoid crowds, restaurants, highways, bridges, movie theaters etc. • In its most severe form, the patient may become dependent on companions to face situations outside the home. • Some individuals become homebound.

Epidemiology of Panic Disorder • Panic disorder has a lifetime prevalence of 1.5-3.5% • 2:1 female/male ratio • ? Of true gender difference versus men tend to self-medicate with alcohol and are less likely to seek treatment. • Onset is late teens through third decade of life.

Differential Diagnosis of Panic Disorder • Not due to another anxiety disorder • Not due to effects of a general medical condition • Cardiovascular disease • Pulmonary disease • Neurological disease • Endocrine disease • Drug intoxication or withdrawal • Other (lupus, infections, heavy metal poisoning, uremia, temporal arteritis)

Panic Disorder: Costs • 200,000 normal coronary angiograms/yr in the U.S. at a cost of 600 million dollars: 1/3 of these patients have panic disorder • ½ of patients referred for non-invasive testing for atypical chest pain and who have normal tests have panic disorder • 1/3 patients undergoing work-up for vestibular disorder with c/o dizziness have panic disorder

Panic Disorder: Comorbidity • Panic disorder patients have an increased personal and family history of other anxiety, mood and substance abuse disorders. • Major depression is a co-morbid diagnosis in 1/3 of cases presenting for treatment • Untreated patients have high risk of suicide

Panic Disorder: Treatment • About 80% of patients will respond to treatment • Antidepressant medications are effective • Serotonin reuptake inhibitors (SSRI) are first line therapy • Tricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOI’s) are also used.

Panic Disorder: Treatment • Sedative-Hypnotics: benzodiazepines are ideally used in the short term before an antidepressant has had time to work • Cognitive Behavioral Therapy (CBT): helps patients overcome a learned pattern of catastrophically misinterpreting the physical symptoms associated with panic attacks.

Generalized Anxiety Disorder (GAD) • Patients with GAD suffer from severe worry or anxiety that is out of proportion to situational factors. • Must last most days for at least 6 months • Described as “worriers” or “nervous”

GAD • Symptoms include: • Muscle tension • Restlessness • Insomnia • Difficulty concentrating • Easy fatigability • Irritability • Persistent anxiety (rather than discrete panic attacks)

GAD Diagnostic Criteria • Excessive anxiety and worry that occurs more days than not for 6 months • Difficult to control the worry • 3 out of 6 symptoms • Anxiety caused significant distress or impairment in function • Not attributed to another organic cause

GAD Epidemiology • 5% prevalence in community samples • 2:1 female/male ratio • Age of onset is frequently in childhood or adolescence • Chronic but fluctuating course of illness (worsened during stressful periods)

GAD Treatment • Cognitive Behavioral Therapy • Other Psychotherapies • Pharmacotherapy • Antidepressants • Benzodiazepines • Buspirone

Post Traumatic Stress Disorder (PTSD) • Patients with PTSD have experienced a trauma and develop disabling symptoms in response to the event. • Symptoms usually begin within 3 months of the trauma • Syndrome can occur at any age

Definition of Trauma • The person experienced, witnessed or learned of an event that involved actual or threatened death, serious injury, or threat of harm to self or others • The person’s response involved intense fear, helplessness or horror

Sexual abuse Rape Physical abuse Severe motor vehicle accidents Robbery/mugging Terrorist attack Combat veteran Natural disasters Being diagnosed with a life threatening illness Sudden unexpected death of family/friend Witnessing violence (including domestic violence) Learning one’s child has life threatening illness Types of Trauma

Diagnosis of PTSD • Symptoms must be > one month duration and include: • Re-experiencing symptoms • Avoidance symptoms • Emotional numbing • Hyperarousal symptoms

Re-experiencing Symptoms • There are recurrent, intrusive thoughts of the event (can’t not think about it) • Dreams (nightmares) about the event • Acting or feeling the event is recurring, or sense of living the event (flashbacks) • Psychological or Physiological Distress upon exposure to reminders or cues of the event.

Avoidance/Numbing Symptoms • Avoid thoughts, feelings, places or people that arouse memories of the event • Being unable to recall important parts of the event • Decrease interest in activities • Feeling detached or estranged from others • Decreased range of affect • Sense of foreshortened future

Hyperarousal Symptoms • Patient experiences at least two of the following: • Insomnia (falling or staying asleep) • Irritability or outbursts of anger • Decreased concentration • Hypervigilance • Increased/exaggerated startle response

Epidemiology of PTSD • Prevalence is 1% in the general population, and can be as high as 25% in those who have experienced trauma • In combat veterans, prevalence is 20% • Very high prevalence in women who are victims of sexual trauma

PTSD Costs • Patients with PTSD are frequent users of the health care system • Patients usually present to primary care physicians with somatic complaints • After panic disorder, PTSD is the most costly anxiety disorder

PTSD Treatment • Psychotherapies • Exposure-based cognitive behavioral therapy • Psychotherapy aimed at survivor anger, guilt and helplessness (victimization) • Pharmacological treatment targets the reduction of prominent symptoms • SSRI’s are first line therapy • Atypical antipsychotics are being increasingly used

Social Phobia • Fear of being exposed to public scrutiny • Fear of behaving in a way which will be humiliating or embarrassing • Symptomatic resemblance to panic disorder with anticipatory anxiety (person may be anxious/worrying far in advance of the event) • Extensive phobic avoidance

Social Phobia • Distinction: anxiety only occurs when the patient is subject to the scrutiny of others (public speaking, oral exam, eating in the cafeteria) • Phobic stimulus is avoided or endured with intense anxiety • Fear and avoidant behaviors interfere with person’s normal routine or cause marked distress

Epidemiology: Social Phobia • Prevalence rates vary depending on study; overall range is 3 –13% of the population • Onset in adolescence • Prevalence greater in females, but greater for males in clinical samples • Frequent comorbidity with depression and substance abuse

Social Phobia: Treatment • Antidepressants, SSRI’s and MAOI’s • High potency benzodiazepines • Low doses of beta blockers are helpful for public speaking (if only an occasional event); this alleviates the autonomic symptoms • Psychotherapy-cognitive restructuring

Specific Phobia • Marked and persistent fear that is excessive and unreasonable of a specific object or situation • Exposure to the phobic stimulus will provoke an anxiety response

Phobia Subtypes • Animals or insects • Natural environment– storms, water, heights • Blood, injury, injection, medical procedure • Situational flying, driving, enclosed places • Having a phobia of a specific subtype increased the chances of having another phobia within that subtype

Epidemiology of Specific Phobias • Lifetime prevalence is 10% of the population • Age of onset varies with subtype • Childhood onset for phobias of animals, natural environments blood and injections • Bimodal distribution (childhood and mid-twenties for situational phobias

Specific Phobia Treatments • Flooding-exposing the person to the feared stimulus • Exposure therapy works to desensitize the patient using a series of gradual, self-paced exposures to the phobic stimulus; uses relaxation, hypnosis, breathing control and other cognitive approaches • Benzodiazepines or Beta blockers are useful acutely

Specific Phobia: Treatment • Example: Fear of Flying • Visualize a plane. Look at a plane in the sky. Drive by an airport. Go to a museum that has planes. Same museum—visualize going inside. Go inside. Go to airport and watch planes take off and land. Visualize yourself on a plane flying. Omnimax theater experience. The real thing.

Obsessive Compulsive Disorder (OCD) • Obsessions: recurrent, intrusive, unwanted thoughts (i.e. fear of contamination) • Compulsions: behaviors or rituals aimed at reducing distress or preventing a dreaded event (i.e. compulsive handwashing)

OCD Symptoms • Recurrent obsessions and/or compulsions are severe enough to consume more than one hour/day • Person recognizes the obsession as a “product of his/her own mind”, rather than imposed from the outside, and that they are unreasonable or excessive

OCD Symptoms • The obsessions are “ego-dystonic” (not enjoyable for the ego), as opposed to “ego-syntonic” (the ego likes it)

Common Obsessions • Contamination • Repeated doubts • Order • Aggressive or horrific images • Sexual/pornographic imagery • Scrupulosity

Obsessions and Common Compulsive Responses • Contamination: cleaning, hand washing, showering • Repeated doubts: checking, requesting or demanding reassurances from others, counting • Order: checking, rituals, counting • Aggressive or horrific images, checking, prayers, rituals • Sexual/Pornographic imagery: prayer/rituals

Epidemiology of OCD • Lifetime prevalence is 2-3% in the general population • Mean age of onset is mid-twenties, although men may develop symptoms earlier • Less than 5% of patients develop disease after age of 35 years • Chronic course, stress can exacerbate symptoms

Anxiety Disorders