Anxiety Disorders

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Anxiety Disorders

• Dr Sheila Tighe

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Lecture content

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

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Stress

• Definition Experiencing events that are
  perceived as endangering ones 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

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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

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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

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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

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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

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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

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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

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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

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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
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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

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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

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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

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Aetiology of anxiety disorders

• Genetic
• Family studies
• Linkage studies
• Neurotransmitter abnormalities
• 5HT, NA, GABA
• HPA axis dysregulation

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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

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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

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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

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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

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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

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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

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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

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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.
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Panic disorder - psychological treatments

• Behavioural therapy
• exposure and response prevention
• relaxation techniques
• Cognitive behaviour therapy
• education
• recognition and change of negative thoughts

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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

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GAD - epidemiology

• One year prevalence 3 - 8
• Females more likely 21
• Age of onset 20 - 35
• 50 have another psychiatric diagnosis

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GAD - differential

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

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GAD - Management

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

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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

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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.

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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

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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

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Agoraphobia - Management and Prognosis

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

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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

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Social phobia - epidemiology

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

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Social phobia - management

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

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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

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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 persons own thoughts

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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

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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

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OCD - Management

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

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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

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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

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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

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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

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PTSD continued

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

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PTSD - Mx

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

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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

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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

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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

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Any questions ?