Anxiety Disorders

Anxiety Disorders Dr Sheila Tighe

Lecture content • Psychology of normal anxiety • Anxiety disorders - general features • Specific disorders • Panic disorder • Generalised anxiety disorder • Phobias • OCD • PTSD

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

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

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

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

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

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

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

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

Benefits of anxiety • Yerkes-Dodson law: • Performance improves as a function of anxiety up to a threshold beyond which there is a fall off in performance

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

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%

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

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

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

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

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

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

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

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%

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

Panic Disorder: The Cognitive Perspective Tendency to interpret a range of bodily sensations in a catastropic fashion. Selective attention to internal cues and avoidance compound the problem.

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

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

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

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

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

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

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.

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”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anxiety Disorders