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 patients 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

Common Medical Conditions Associated with Anxiety Disorders

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

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 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 (MAOIs) 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 persons response involved intense fear, helplessness or horror

Types of Trauma

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 ones child has life threatening illness

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 (cant 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

SSRIs 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 persons 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, SSRIs and MAOIs 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 midtwenties 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 museumvisualize 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

OCD Treatment

Serotonin reuptake inhibitors Clomipramine, a serotonergic tricyclic antidepressant Psychotherapy: exposure and response prevention

OCD is not OCPD

Obsessive-Compulsive Disorder is different from obsessive compulsive personality disorder (OCPD) OCPD: a pervasive pattern of preoccupation with orderliness, perfectionism and control that begins by early adulthood

Substance Induced Anxiety Disorder

Prominent symptoms of anxiety that are judged to be the direct physiological consequence of a drug or abuse, a medication or toxin exposure

Summary and Review of Anxiety Disorders

Panic Attacks and Panic Disorder

Panic Attacks Agoraphobia without a history of panic disorder Panic Disorder without agoraphobia Panic Disorder with agoraphobia

Generalized Anxiety Disorder

Characterized by at least 6 months of persistent and excessive anxiety and worry

Post Traumatic Stress Disorder

Characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma Symptoms present for at least one month If event just occurred and/or symptoms present for less than one month, a diagnosis of Acute Stress Disorder is given

Social Phobia

Clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior

Specific Phobia

Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior

Obsessive Compulsive Disorder

Characterized by obsessions that cause marked anxiety or distress and/or compulsions that serve to neutralize anxiety

Substance Induced Anxiety Disorder Anxiety Disorder not otherwise specified

Anxiety Disorder Association of American (ADAA)

The ADAA brings together professionals from many disciplines including psychiatrists, psychologists, social workers, physicians, nurses, etc. Through networks, the ADAA increases awareness about anxiety disorders, provides education resources, offers access to care, and supports research. www.adaa.org