Anxiety Disorders

    Anxiety Disorders

    • Anxiety is a symptom
    • Anxiety disorders arise from maladaptive activation of alarm system
    • Manifest as inappropriate activation of Sympathetic system.
    • Blood work minimum:
      • CBC, Lytes, Glucose, tox screen, ECG
    • Tx:
      • Meds:  (usually SSRI and benzo for short term) 50-60% success, slow taper q1-2mo
        • B-blockers: only social phobia (Propranolol 20-40mg 30 min prior)
        • Benzos for performance or emergeny tx, not everyone gets tolerance.
        • SSRIs – first line
        • SNRI – 1st line GAD, SAD, panic, 2nd line for OCD
        • TCA, MAOi
      • Psychoeducation
        • General Information
        • Lifestyle advice and non-drug strategies (no caffeine, exercise, no pot, box breathing)
        • Supportive Counselling (coping mechanisms)
      • CBT
        • Change thoughts and behaviours contributing to anxiety.  Overestimate risk and underestimate ability to manage risk.
      • Exposure therapy
        • Systematically approach fear and promote reduction.

     

    Panic Disorder

    • Recurrent, unexpected panic attack accompanied by at lest 1mo of concern of another attack, worry about implications (dying going crazy), or avoiding places to reduce chances of attack.
    • Screening Q’n: “Have you ever had repeated and unexpected ‘attacks’ in which you are suddenly overcome by intense fear for no apparent reason?”

     

     

     

    DSM-IV-TR Panic Attack

    Discrete period of intense fear or discomfort, 4/13 developed abruptly and reached peak in 10min.

    1. S– Sweating
    2. T – Trembling
    3. U – Unsteady/Dizzy
    4. D – Derealization (feel not real)
    5. E – Excessive HR/palpitations
    6. N – Nausea, abdo discomfort
    7. T – Tingling/Numbness
    8. S – Shortness of Breath

          FEAR

    1. Fear of losing control, going crazy,
    2. Fear of dying

          The 3 C’s

    1. Chest Pain,
    2. Choking,
    3. Chills/HotFlashes

     

     

    • Situations provoking anxiety:
      • Standing in line (96%)
      • Having an appointment (91%)
      • Feeling trapped at hairdresser etc.. (89%)
      • Increased distance from home (87%)

     

    Epidemiology

    • 5% of women and 2% of men
    • Onset is mid-20s (alarming, usually ED visit, w/ lab tests and ECG, if all normal psych consulted)
    • Attacks tend to develop suddenly peak in 10min, and last 5-20min.
    • Total remission uncommon, but 70% find improvement.
    • Usually depression and EtOH are comorbid

    Etiology

    • Catecholamine levels increase.  Thought was due to CO2 sensitivity
    • 45% identical and 15% nonidentical twins. (genetics predominate)
    • 20% among first-degree family members

    DDx

    • MDD
    • GAD
    • Schizophrenia
    • Depersonalization Disorder
    • Somatization Disorder
    • Borderline Personality Disorder
    • GMC (hyperthyroidism, pheochromocytoma, vestibular nerve, hypoglycemia, SVT)

    Tx:

    • Combination of meds and psychotherapy
    • NO CAFFEINE!
    • Medication:
      • SSRIs (70-80% effective)  (FDA: fluoxetine, paroxetine, sertraline)
      • (TCA, MAOIs also effective but dangerous)
      • Benzos effective, but habit-forming
      • B-Blockers (Propranolol) [Not as effective]
    • Psychotherapy
    • CBT effective (distraction, breathing exercises, education i.e. panic chest pain will not cause heart attack)
    • Psychodynamic therapy also helpful.
    • Connectingn to resources (Anxiety Disorders Ass. Of Am.)
    • Agoraphobia: exposure therapy

     

     

     

    +/- Agoraphobia

    • Agoraphobia is a complication of panic disorder where individual fears being unable to get out of a place or situation quickly in event of a panic attack.
    • Agoraphobia “fear of marketplace”
    • Often fear of panic attack in public place +embarrassment, and unable to get to a physician.  (avoid crowded places b/c they feel trapped)
    • Can fear driving – fear of being away from help.  Often ask others to accompany them.
    • Most Severe: housebound.
    • DSM-IV-TR:

    a.  Anxiety in places or situations escape is difficult or embarrassing,

                i.     (Not Specific phobia – specific situations)

                ii.     (Not Social phobia – social situations)

    b. situations are avoided or endured w/ distress or require companion. 

    c.  Not accounted for by another disorder (see panic disorder DSM)

     

    Panic attacks without agoraphobia

    DSM-IV-TR Panic Disorder w/o Agoraphobia

    A.     Both (1) and (2):

    1. Recurrent unexpected panic attacks
    2. At least one of attacks followed by >=1mo of >=1 of following:

                       i.    Concern of additional attacks

                       ii.   Worry about implications of attack (losing control, heart attack, going crazy)

                       iii.  Change in behavior related to attacks

    B.   No Agoraphobia

    C.   Not substance or GMC

    D.   Panic attacks not from another disorder (Social Phobia, Specific Phobia, OCD, PTSD, Separation Anxiety)

     

    Generalized Anxiety Disorder

    • Screening Qn “Do you normally have excessive worry more days than not – unreasonable worry about events, activities, such as work/school/health?”
    • “Are you normally a worrier? “Are you ‘on-edge’ about things?”

    DSM-IV-TR Generalized Anxiety Disorder

    A.     Excessive anxiety or worry occurring most days for >6mo about many events/activities.

    B.     Difficult to control worry

    C.     Anxiety or worry meets 3/6 (some symptoms present most days >6mo)

    [1/6 for children]

    1.     Restless or feeling keyed up or on edge.

    2.     Irritability

    3.     Muscle Tension

    4.     Easily fatigued

    5.     Sleep Disturbance

    6.     Difficulty concentrating (or mind going blank)

    D.     Not due to Axis I disorder (Panic Disorder, Social Phobia, OCD, Separation Anxiety, Anorexia Nervosa, Somatization Disorder)

    E.     Cause significant distress or impairment of function (social/occupational)

    F.     Not due to substance or GMC and not during mood disorder or psychotic disorder or pervasive developmental disorder.

    • Generally GAD worry excessively about life circumstances (Health, finance, social, job, marriage)
    • Epidemiology
      • Incidence 4-7%
      • Onset early 20’s
      • Often coupled with MDD and substance use
      • Often use substance to deal with anxiety
    • Etiology: cause unknown,
    • DDx (same as panic disorder)
      • Need to r/o drug induced (caffeine), stimulate, EtOH/Benzo withdrawal.
    • Tx:

      • psychotherapy and meds
      • Meds:
        • Guidelines:
          • 1st line: escitalopram, paroxetine, sertraline, venlafaxine XR
          • 2nd line: benzodiazepines, buproprion XL, buspirone, imipramine, pregabalin.
          • 3rd line: mirtazapine, citalopram, trazodone, hydroxyzine, adjunctive olanzapine
        • Drugs by class:
          • SSRI: paroxetine (20-50mg/day) escitalopram (10-20mg/day)
          • SNRI: venlafaxine (75-225 mg/day) duloxetine (60-120 mg/day)
          • (buspirone 10-40mg/day non-benzo anxiolytic)
          • Benzos good for short acting, but tolerance and dependence.
          • B-blockers not recommended
          • TCA, Antihistamines
      • Psychotherapy
        • Behaviour therapy (recognize + control sx)
        • Relaxing, breathing exercises, meditation.

     

    Phobic Disorders

    • Phobia: irrational fear of specific objects, places, or situations, or activities
    • Fear is adaptive, but in phobias it’s irrational and excessive.
    • DSM-IV-TR Social phobia:

    A. marked and persistent fear of social or performance situations where they are exposed to unfamiliar people with possible scrutiny.  Fear of humiliating or embarrassing.  For children: must be age appropriate, and with peers not just adults.

    B.  Exposure to situation causes anxiety or panic attack.   (In children crying, temper tantrums etc..)

    C.  Person recognizes fear of excessive/unreasonable (In children may be absent)

    D.  Feared situations avoid or endured with anxiety.

    E.  Avoidance or anxiousness interferes with function

    F.  If <18yo, duration must be >6mo.

    G. Not due to substance or GMC or mental disorder (Panic disorder, separation anxiety, etc…)

    H.  If a GMC or mental condition present, fear not related to it.

    Types of Phobia

    • Agoraphobia
    • Social Phobia: fear of humiliation or emarrassement
    • Specific Phobia: irrational specific (fear of snakes)
    • Epidemiology:
      • Social phobia: 13% begin in adolescence (rare before age 25)
      • Specific phobia: 11% begin in childhood before age 12
    • Impact depends on whether it impacts job, and varies person to person.
    • DDx:
      • Panic Disorder +/- agoraphobia
      • OCD
      • GAD
      • Schizophrenia
      • Personality Disorders: (Schizoid, avoidant personality disorders)
      • Separation Anxiety Disorder
      • Pervasive Developmental Disorder
    • Note: schizoid vs avoidant personality disorders vs social phobia
      • Avoidant personality disorder: does not fear social situations but feels insecure about relationships
      • Schizoid personality disorder: little interest in social situations, no fear.
    • Etiology: Tends to run in families (dopaminergic pathways play a role
      • May arise from traumatic events (falling etc..)

    Tx

    • Meds
      • SSRI: fluoxetine (10-30mg/day) paroxetine (20-50mg/day) sertraline (50-200mg/day), or long acting venlafaxine (75-225mg/day)
      • MAOIs, benzos effective, but rarely used
      • TCAs NOT effective (b/c jitteriness)
      • B-blockers used in short term performance anxiety (musicians), but ineffective in general social phobia.
      • Relapse when drugs d/c’ed. 
      • Meds are ineffective for specific phobias
    • Behavioral
      • Systematic desensitization: start with least feared
      • Flooding: enter situations until anxiety subsides
        • (Patient must be willing to do this!)
      • CBT: correct thoughts of failure, humiliation, embarrassment (i.e. tell them they don’t receive any more scrutiny than others) restore morale, self confidence.

    OCD

    • Characterized by obsessions and compulsions
      • Obsessions: intrusive unwanted thoughts that cause marked anxiety/distress

    (recurrent, persistent ideas, thoughts, impulses, or images that are experienced as intrusive or inappropriate and cause marked anxiety or distress.)

    • Compulsions: repetitive intentional behaviours in response to obsessions according to rigid rules.

    (Obsessions create anxiety that is relieved by compulsive rituals)

    • Must recognize obsessions and compulsions are unreasonable, not due to Axis I disorder, and not caused by substance or GMC.

    DSM-IV-TR OCD

    A.  Either obsessions or compulsions

    Obsessions: (all)

    1.     Recurrent thoughts that at some time during disturbance experienced as inappropriate and cause marked anxiety/distress.

    2.     Not simply excessive worries about real-life problems

    3.     Person attempts to ignore these thoughts or neutralize with another thought or action.

    4.     Recognizes that they are acts of their own mind (Not insertion)

    Compulsions (all)

    1.     Repetitive behaviours that person feels driven to perform in response to obsession according to rigid rules.

    2.     Must be aimed at preventing/reducing distress or some bad situation.  Compulsions don’t need to be connected to obsessions in a realistic way??  Clearly excessive.

    B.  At some point recognized that obs/comp are unreasonable (Except kids)

    C.  Cause marked distress, time consuming (>1hr/day), or interfere w/ functioning.

    D.  If Axis I disorder present, content of obs/comp not restricted to it.

    E.  Not Substance use of GMC

    Specify if “With Poor Insight” if mostly doesn’t recognize them as unreasonable.

    Epidemiology

    -       Starts late teens or early 20’s, most people develop it by age 30.

    -       2-3% prevalence

    -       MDD in 70-80% of OCD patients.

    -       80-87% monozygtic twins

    DDx

    -       Schizophrenia

    -       MajorDepression  (tends to focus on only past events)

    -       PTSD

    -       Hypochondriasis

    -       AN  (behavior desirable)

    -       Tourette’sdisorder (vocal and motor tics may coexist)

    -       Obsessivecompulsive personality disorder (desired obs/comp)

    Tx

    -       Behaviour and medications

    -       Medications

    o   SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline).

    o   TCAs (Clomipramine), less frequent use

    o   Typically higher doses of SSRIs required to Tx OCD vs major depression.  Response is often delayed, need lengthy trial (12-16weeks)

    -       Behavioural

    o   Family therapy

    o   Individual psychotherapy (morale, self-esteem, encourage compliance)

    o   Family therapy (Help family cope with rituals)

    -       Psychosurgical

     

    PTSD

    -       Occurs to those who experienced an event involving actual or threatened death or injury.  Lasts >1mo   Three parts

    o   1. Reexperiencing the trauma (dreams, thoughts)

    o   2. Emotional numbing (avoidance or detached from others)

    o   3.  Autonomic hyperarousal (Irritability, incr startle response)

    -       Acute <3mo, Chronic >3mo

    DSM-IV-TR PTSD

    A.     Exposed to traumatic event where both:

    1.     Person experienced event that involved actual or threatened death or threat physical integrity.

    2.     The person’s response involved intense fear/helplessness/horror.

    B.     Traumatic event persistently re-experienced in one of:

    1.     Recurrent, intrusive recollections (child: repetitive play)

    2.     Recurrent distressing dreams of event (child: frequent distressing, no recognizable content)

    3.     Acting or feeling as if event recurring (hallucinations, illusions, flashbacks)

    4.     Distress at exposure to cues that symbolize event

    5.     Physiological reactivity to cues that symbolize event.

    C.     Avoidance of stimuli associated w trauma and numbing of general responsiveness as indicated by 3/7 of following:

    1.     Avoid thoughts, feelings, conversations associated w trauma

    2.     Avoidance of activities/places/people  associated w trauma

    3.     Inability to recall certain aspect of trauma

    4.     Diminished interest in activities

    5.     Feeling estragement/detachment from others

    6.     Restricted range of affect (no loving feelings)

    7.     Sense of foreshortened future (not expecting career, marriage etc)

    D.     Increased arousal 2/5:

    1.     Difficulty falling or staying asleep

    2.     Irritability, outbursts of anger

    3.     Difficulty concentrating

    4.     Hypervigilance

    5.     Exaggerated startle response

    E.     Duration of disturbance >1mo.

    F.     Causes distress or impairment.

    Specify if:

    -       Acute<3mo

    -       Chronic>3mo

    -       +/- With Delayed onset (>6mo after stressor)

    -       Business losses, marital conflicts, and death of a loved one are not considered stressors causing PTSD

    -       Factors:

    o   Younger ages worse (80% of young children w/ burns have sx of PTSD vs. 30% of adults

    o   Previous psych treatments – greater vulnerability to stress

    o   Inadequate social support

    o   5-6% men and 10-14% of women have PTSD at some point.

    -       Etiology: amygdala

    -       DDx:

    o   MD

    o   Adjustment disorder

    o   Panic disorder, GAD, acute stress disorder

    o   OCD, depersonalization disorder.

    -       Tx:

    o   SSRIs: paroxetine (20-50mg/day) and sertraline (50-200mg/day) have been approved by FDA, but others work

    o   SNRIs: venlafaxine shown to be good.

    o   Benzos reduce anxiety in short term, but potential for abuse.

    o   Therapy:

    §  Establish safety and separation from trauma.

    §  CBT effective (control anxiety and dysfunctional thoughts)

    §  Group and family therapy work.

     

    Acute Stress Disorder

    -       (precursor to PTSD)

    -       Occur acutely after traumatic experience, considered precursor to PTSD

    o   Need 3 dissociative sx (emotional numbing, derealization, amnesia)

    o   One or more intrusion, avoidance, or hyperarousal symptom.

    o   Must cause difficulty in functioning and last 2days to 4 wks.

    -       Goal of this Dx is to predict those that are more likely to develop PTSD

    -       Precursor to PTSD (80% of MVAs with acute stress disorder will have PTSD)

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