Anxiety Disorders

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Anxiety Disorders

• Anita S. Kablinger MD
• Associate Professor, Departments of Psychiatry
  and Pharmacology
• LSUHSC-Shreveport

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DSM-IV Anxiety Disorders

• Specific phobias
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder
• Social phobia
• Obsessive-compulsive disorder
• PTSD

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PTSD Presentation Outline

• Introduction/History
• Clinical Presentation/DSM-IV Criteria
• Differential Diagnosis
• Etiology/Risk Factors
• Treatment Issues
• Prevention

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Introduction/History

• First appeared in DSM-III (1980)
• Recognized by Shakespeare in Henry IV
• Civil War descriptions
• WWI- shell shock and soldiers heart
• WWII- operational fatigue and combat neurosis
• Organic origin vs psychogenic derivation

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Diagnostic Criteria for PTSD

• A. Exposed to traumatic event
• The person experienced, witnessed, or was
  confronted with an event involving actual or
  threatened death, serious injury or a threat to
  physical integrity of self or others
• The persons response involved intense fear,
  helplessness or horror

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Diagnostic Criteria for PTSD

• B. The traumatic event is reexperienced in one or
  more of the following ways
• Recurrent images, thoughts or perceptions
• Recurrent distressing dreams of the event
• Acting or feeling as if the event was recurring
• Intense psychological distress OR physiologic
  reactivity at exposure to cues that symbolize or
  resemble an aspect of the event

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Diagnostic Criteria for PTSD

• C. Persistent avoidance of stimuli associated
  with trauma and numbing as indicated by 3 or
  more
• Avoiding thoughts, feelings, or discussion,
  activities, places or people that bring back
  recollections sense of foreshortened future
• Inability to recall restricted affect
• Diminished interest or participation
• Feeling detached or estranged

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Diagnostic Criteria for PTSD

• D. Persistent symptoms of increased arousal by 2
  or more
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response
• E. Duration for more than 1 month

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Diagnostic Criteria for PTSD

• F. Clinically significant impairment in
  functioning
• Acute Less than 3 months
• Chronic Greater than or equal to 3 months
• With delayed onset Onset at least 6 months after
  the stressor

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Diagnostic Criteria for Acute Stress Disorder

• A Exposed to traumatic event
• B. Experiences three or more of
• Subjective sense of numbing, detachment
• Reduction in awareness of surroundings
• Derealization
• Depersonalization
• Dissociative amnesia
• C. Persistent reexperiencing of the event

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Diagnostic Criteria for Acute Stress Disorder

• D. Marked avoidance of stimuli that arouse
  recollections of the trauma
• E. Marked symptoms of anxiety or increased
  arousal
• F. Causes significant impairment
• G. Lasts 2 days to 4 weeks and occurs within 4
  weeks of the trauma

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Epidemiology

• Prevalence of PTSD 1-14 community, 3-58 in
  at-risk populations
• 25-30 lifetime prevalence in Vietnam veterans
• 85 in concentration camp survivors
• May be modulated by cultural differences
• All ages individuals or groups FgtM

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Differential Diagnosis

• Mental disorder secondary to GMC
• (ex. head injury)
• Substance-induced disorder
• Dissociative disorders
• Major depressive episode
• Borderline personality disorder
• Malingering

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Etiological Factors

• Magnitude of the stress exposure
• Cognitive appraisal factors
• Intense fear or helplessness predictive
• Sympathetic hyperactivity
• Psychological factors
• psychodynamic
• cognitive
• behavioral

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Examples of Traumatic Events

• Complicated or unexpected bereavements
• Accidents
• Captivity

• Violent crime
• Sexual trauma
• Chronic physical abuse
• Military combat
• Natural disasters
• Manufactured disasters

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Risk Factors

• Lack of social support
• Family psychiatric history, esp. anxiety
• Previous psychiatric history
• Certain personality traits
• Early separation of parents

• Parental poverty
• Abuse in childhood
• Childhood behavioral problems
• Limited education
• Adverse life-events prior to trauma
• Female

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Six Strongest Predictors of Trauma Exposure

• Male
• Absence of college education
• Extroversion
• Neuroticism
• Early misconduct
• Family psychiatric illness

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Six Strongest Predictors for Risk of PTSD

• Female
• Neuroticism
• Early separation from parents
• Prior anxiety or depression
• Familial anxiety
• Familial antisocial personality disorder

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Associated Symptoms Important for Treatment

• Survival and behavioral guilt
• Somatic distress
• Paranoia
• Interpersonal alienation
• Vegetative changes of depression
• Hopelessness
• Impulsivity

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Course and Prognosis

• 30 recover completely
• 40 continue with mild symptoms
• 20 moderate symptoms
• 10 unchanged or worsen
• Startle, nightmares, irritability and depression
  often worsen with age
• Comorbidity is high (MDD, OCD, Panic, substance
  abuse)

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Treatment ASD

• Talking about the trauma allowing
• confrontation
• acceptance
• process
• integration
• Individual or group therapy, hypnosis
• Followed by support and superficiality

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Treatment PTSD

• Requires multiple modalities
• Initial education, support and referrals
  important to establish trust
• Pharmacotherapy
• Psychotherapy
• Relaxation Training

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Treatment PTSD-Pharmacotherapy

• Duration of at least 8-12 weeks
• Adequate dosages
• Maintenance treatment for at least 1 year
• Antidepressants
• Mood stabilizers
• Propranolol, clonidine
• Atypical antipsychotics

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Drug Treatment of PTSD

• Amitriptyline
• Fluoxetine
• Sertraline
• Paroxetine
• Propranolol
• Clonidine
• Valproic Acid
• Carbamazepine

• 50-300 mg/day
• 20-60
• 50-200
• 20-50
• 40-160
• 0.2-0.6
• 750-1,750
• 200-1,200

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Drug Treatment of PTSD

• Lithium
• Quetiapine
• Risperidone
• Olanzapine

• 300-1,500 mg/day
• 25-700
• 0.5-6
• 2.5-20

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Treatment PTSD- Individual Psychotherapy

• Crisis Intervention
• establish rapport, promote acceptance
• educate, attend to general health
• Trauma-focused psychotherapy
• Implosive therapy
• Systematic desensitization
• Hospitalization may be necessary at times

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Points to Remember

• If a patient has multiple complaints, think PTSD
  or personality disorder up front
• Under-detected because we dont ask the right
  questions
• One of the few DSM disorders defined by its
  cause!

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DREAMS
Detachment Re-experiencing the event Emotional
effects Avoidance Month in Duration Sympathetic
hyperactivity or hypervigilance
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PTSD Questionnaire
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DSM-IV Anxiety Disorders

• Specific phobias
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder
• Social phobia
• Obsessive-compulsive disorder
• PTSD