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Anxiety Disorders

By

Dr Ejaz Gul

AP and I/C Deptt of Psychiatry


and Behavioural Sciences
BKMC
ANXIETY DISORDER
 Anxiety disorder is characterized by chronic free-floating anxiety with
symptoms such as tension, sweating, trembling, light-headedness
and irritability.

 These disorders are a serious problem for the entire society


because of their interference with patients' work, schooling, and
family life.

 They also contribute to the high rates of alcohol and substance


abuse in the United States. Anxiety disorders are an additional
problem for health professionals because the physical symptoms of
anxiety frequently bring people to primary care doctors or
emergency rooms.
Anxiety disorders,
Obsessive-
Compulsive and
Related disorders, and
Trauma and Stressor-
related Disorders

Heidi Combs, MD
Assistant Professor
University of Washington/HMC
Paul Zarkowski
Assistant Professor

A
Few medical conditions
associated with Anxiety
• Tourette Syndrome
• Stiff-person syndrome
• Delirium
• Joint hypermobility
• Diabetes
• Takotsubo Cardiomyopathy
• IBS
• Fahr's Disease
• Asthma
• Pregnancy
• Epilepsy
• Chronic renal failure
• Parkinson’s disease
• Pheochromocytoma
• SLE
• Stroke
• COPD
• Hypertension
• Eating disorders
• Myocardial Infarction
• Head injury
• Hyperthyroidism
• Hypothyroid
Different aspects of Anxiety
• Phenomenological
– Affective: dread, tension, worry
– Cognitive: expectations of an inability to
cope, impaired cognitive ability
• Behavioural
– Impaired motor functioning and avoidance
• Physiological
– increased blood pressure, heart rate,
breathing; disruptions in GI functioning and
dizziness
Types of Anxiety Disorders
• Panic Disorder
• Generalized Anxiety Disorder
• Phobias
• Posttraumatic Stress Disorder
• Obsessive-Compulsive Disorder
General considerations for anxiety
disorders
• Often have an early onset- teens or early
twenties
• Show 2:1 female predominance
• Have a waxing and waning course over
lifetime
• Similar to major depression and chronic
diseases such as diabetes in functional
impairment and decreased quality of life
Normal versus Pathologic Anxiety

• Normal anxiety is adaptive. It is an inborn


response to threat or to the absence of
people or objects that signify safety can
result in cognitive (worry) and somatic
(racing heart, sweating, shaking, freezing,
etc.) symptoms.
• Pathologic anxiety is anxiety that is
excessive, impairs function.
Focused Neuroanatomy Review
• Amygdala- involved with processing of
emotionally salient stimuli
• Medial prefrontal cortex (includes the
anterior cingulate cortex, the subcallosal
cortex and the medial frontal gyrus)-
involved in modulation of affect
• Hippocampus- involved in memory
encoding and retrieval
Primary versus Secondary Anxiety
Anxiety may be due to one of the primary
anxiety disorders OR secondary to
substance abuse (Substance-Induced
Anxiety Disorder), a medical condition
(Anxiety Disorder Due to a General
Medical Condition), another psychiatric
condition, or psychosocial stressors
(Adjustment Disorder with Anxiety)
The differential diagnosis of anxiety. Psychiatric and Medical disorders. Psychiatr Clin North
Am 1985 Mar;8(1):3-23
Anxiety disorders
• Specific phobia • Anxiety Disorder due
• Social anxiety to a General Medical
disorder (SAD) Condition
• Panic disorder (PD) • Substance-Induced
• Agoraphobia Anxiety Disorder
• Generalized anxiety • Anxiety Disorder NOS
disorder (GAD)
Generalized Anxiety Disorder
• Chronic state of diffuse anxiety
Phobias
• Phobias involve
– intense, persistent fear of something that
poses no real threat
– avoidance of the feared object/situation

Specific Phobia
– fear of circumscribed objects or situations
Phobias
• Algophobia -pain
• Astraphobia -thunderstorms
• Pathophobia -disease
• Monophobia -being alone
• Mysophobia -contamination
• Nyctophobia -darkness
• Ochlophobia -crowds
Phobias: Social Phobia
• Fear of social embarrassment or
humiliation
– public speaking
– eating in public
– using public bathrooms
• Impact on self confidence and restricts
social activity
Posttraumatic Stress Disorder
• Intense fear and helplessness in response
to events involving actual or threatened
death or serious injury.
• Acute Stress Disorder
– symptoms last for 2 days - 4 weeks
• Posttraumatic Stress Disorder
– symptoms last at least 1 month
Obsessive-Compulsive Disorder
• Obsession
– unwanted thought or image that keeps
intruding into awareness
• Compulsion
– an action that a person feels compelled to
repeat again and again despite a lack of
desire to do so
Comorbid diagnoses
• Once an anxiety disorder is diagnoses it is
critical to screen for other psychiatric
diagnoses since it is very common for
other diagnoses to be present and this can
impact both treatment and prognosis.

What characteristics of primary anxiety disorders predict subsequent major depressive


disorder. J Clin Psychiatry 2004 May;65(5):618-25
Epidemiology of anxiety disorders

Damsa C. et al. Current status of brain imaging in anxiety disorders.


Curr Opin Psychiatry 2009;22:96-110
Genetic Epidemiology of
Anxiety Disorders
• There is significant familial aggregation for
PD, GAD, OCD and phobias
• Twin studies found heritability of 0.43 for
panic disorder and 0.32 for GAD.

Hetteman J. et al. A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety


disorders. Am J Psychiatry 2001;158:1568-1575
Specific Phobia
Specific Phobia
• Marked or persistent fear (>6 months) that is
excessive or unreasonable cued by the
presence or anticipation of a specific object or
situation
– Anxiety must be out of proportion to the actual danger
or situation
– It interferes significantly with the persons routine or
function
Specific Phobia
• Epidemiology
– Up to 15% of general population
– Onset early in life
– Female:Male 2:1
• Etiology
– Learning, contextual conditioning
• Treatment
– Systematic desensitization
Social Anxiety Disorder
Social Anxiety Disorder
A. Marked and persistent fear of one or more social or
performance situations.
B. Exposure almost invariably provokes anxiety (including
panic attacks).
C. Recognition that the fear is excessive or unreasonable.
D. Situations are avoided or endured with intense anxiety.
E. Symptoms interfere significantly with the person’s
function.
F. Duration is at least 6 months.
G. Not due to medical condition or another mental disorder.

Specify If:
Generalized or Specific
The Life Cycle of Anxiety
Behavioral Stable Childhood Social Panic
Inhibition behavioral anxiety phobia Disorder
inhibition

Reactive infant Peripheral in play Onset of panic


Separation anxiety disorder
Social avoidance

Inhibited Toddler
Retreat from the unfamiliar Social Fears
Shy, tearful Social phobia

Age yrs

.3 2 5 8 13 14-18 20 30
Adapted from: Pollack, et al., Psych Clin NA, 1995;18(4):785-801
Social Anxiety Disorder
• Lifetime prevalence rate: 7 – 13%
• Onset usually in adolescence: mean 15.5 y/o
• Male to female ratio - 2:3
• Chronic course with mean duration of 25 years
with low rates of recovery
• Lifetime rates of comorbid depression near 60%
• Rates of comorbid alcohol dependence near
40%
• Severe educational, occupational and
interpersonal functional impairments
Medication Choice
• Blanco C, Schneier FR, Schmidt A, et al. Pharmacologic
Treatment of Social Anxiety Disorder: A Meta-Analysis
Depression and Anxiety 18 (2003) 29-40
• Medication effect size:
– Phenelzine: 1.02 [0.52-1.52]
– Clonazepam: .97 [0.49-1.45]
– Gabapentin: .78 [0.29-1.27]
– SSRIs: .65 [0.50-0.81]
• No statistical difference between medication groups
• Venlafaxine XR not included due to unpublished data
Social Anxiety Disorder
Social Anxiety Disorder (SAD)
• Marked fear of one or more social or performance
situations in which the person is exposed to the possible
scrutiny of others and fears he will act in a way that will
be humiliating
• Exposure to the feared situation almost invariably
provokes anxiety
• Anxiety is out of proportion to the actual threat posed by
the situation
• The anxiety lasts more than 6 months
• The feared situation is avoided or endured with distress
• The avoidance, fear or distress significantly interferes
with their routine or function
SAD epidemiology
• 7% of general population
• Age of onset teens; more common in
women. Stein found half of SAD patients
had onset of sx by age 13 and 90% by age
23.
• Causes significant disability
• Increased depressive disorders

Incidence of social anxiety disorders and the consistent risk for secondary depression in the first
three decades of life. Arch Gen Psychiatry 2007 Mar(4):221-232
Functional imaging studies in
SAD
• Several studies have found hyperactivity
of the amygdala even with a weak form of
symptom provocation namely presentation
of human faces.
• Successful treatment with either CBT or
citalopram showed reduction in activation
of amygdala and hippocampus

Furmark T et al. Common changes in cerebral blood flow in patients with social phobia treated with
citalpram or cognitive behavior therapy. Arch Gen Psychiatry 2002; 59:425-433
Social Anxiety Disorder treatment

• Social skills training, behavior therapy,


cognitive therapy
• Medication – SSRIs, SNRIs, MAOIs,
benzodiazepines, gabapentin
Panic Disorder
PANIC ATTACK
• Discrete period of intense fear
or discomfort in which four or
more of the following develop
abruptly and reach a peak
within 10 minutes:
1) Palpitations or accelerated 8) Feeling dizzy, unsteady,
heart rate lightheaded or faint
2) Sweating 9) Derealization or depersonalization
3) Trembling or shaking 10) Fear of losing control or going
4) Sensations of shortness of crazy
breath or smothering 11) Fear of dying
5) Feeling of choking 12) Paresthesias
6) Chest pain or discomfort 13) Chills or hot flashes
7) Nausea or abdominal distress
PANIC
• A panic attack doesn’t equal panic disorder.
– Major Depression
– Post Traumatic Stress Disorder
– Social Phobia
– Obsessive Compulsive Disorder
– Specific Phobia
• Panic Disorder
1. Recurrent unexpected panic attacks
2. At least one of the attacks has been followed by one month of 1
or more of the following:
a) Persistent concern about having additional attacks
b) Worry about implications of the attack (losing control, having a
heart attack, “going crazy”)
c) Significant change in behavior related to the attacks
– With or without agoraphobia
Epidemiology
• Lifetime prevalence rate:
– Panic disorder: 1.5 – 5%
– Panic attacks: 3 – 5.6%
• Women 2-3 x more likely to be affected
than men
• Mean age of presentation: 25 years old
Neuroanatomical Pathways of
Viscerosensory Information in the Brain
Medial Prefrontal Cortex, Cingulate Association Bundle Insula

Amygdala Central
Lateral Nucleus Nucleus of Sensory
the Thalamus
Hippocampus Amygdala
Basal

Parabrachial
Hypothalamus Nucleus
Paraventricular Lateral
Nucleus Nucleus
Periaquaductal
Gray Region Nucleus of the
Locus Solitary Tract
Pituitary Autonomic
Ceruleus
Pathways

Adrenal
Pathways Adapted from: Gorman J, et al. AJP 2000;157:493-505 Visceral Pathways
Panic Neurotransmitters
Norepinephrine Serotonin

GABA GABA

1. Brain stem: fires off systemically to create autonomic symptoms


2. Amygdala and Limbic System: generates anticipatory anxiety
3. Pre-frontal cortex: generates phobic avoidance
Differential Diagnosis
• Cardiovascular Disease • Neurological Disease
– Angina – CVA / TIA
– CHF – Epilepsy
– Hypertension – Meniere’s disease
– Mitral valve prolapse – Migraine
– Myocardial Infarction – Tumor
– Paradoxical atrial • Endocrine Disease
tachycardia – Carcinoid syndrome
• Pulmonary Disease – Hyperthyroidism
– Asthma – Perimenopausal
– Pulmonary embolism – Pheochromocytoma
• Drug intoxication or • Other
withdrawal – SLE
– Systemic infection
– Heavy metal poisoning
Course of Illness
• 30 – 40 % become symptom free
• 50 % with mild symptoms with little
impairment of function
• 10 – 20 % continue with significant
impairment

• Depression: 40 – 80 %
• Substance abuse: 20 – 40 %
Treatment
• SSRIs
• Benzodiazepines
• Cognitive Behavioral Therapy

– TCAs
– MAOIs
– Other agents
• Anticonvulsants
• Buspirone
• Atypical neuroleptics
Panic Disorder
• Panic Attack

• Cued (situationally bound) v.s. Uncued


(unexpected) panic attacks

• Panic Disorder
Panic Disorder: Agoraphobia
• Fear of being in a situation where having a
panic attack would be dangerous or where
escape would be impossible
Panic Disorder
• Recurrent unexpected panic attacks and
for a one month period or more of:
– Persistent worry about having additional
attacks
– Worry about the implications of the attacks
– Significant change in behavior because of the
attacks
A Panic Attack is:
A discrete period of intense fear in which 4 of the following
Symptoms abruptly develop and peak within 10 minutes:

• Palpitations or rapid • Chills or heat


heart rate sensations
• Sweating • Paresthesias
• Trembling or • Feeling dizzy or faint
shaking • Derealization or
• Shortness of breath depersonalization
• Feeling of choking • Fear of losing
• Chest pain or control or going
discomfort crazy
• Nausea • Fear of dying
Panic disorder epidemiology
• 2-3% of general population; 5-10% of
primary care patients ---Onset in teens or
early 20’s
• Female:male 2-3:1
Things to keep in mind

• A panic attack ≠ panic


disorder
• Panic disorder often
has a waxing and
waning course
Panic Disorder Comorbidity
• 50-60% have lifetime major depression
– One third have current depression
• 20-25% have history substance
dependence
Panic Disorder Etiology
• Drug/Alcohol
• Genetics
• Social learning
• Cognitive theories
• Neurobiology/condi-
tioned fear
• Psychosocial stessors
– Prior separation
anxiety
Treatment
• See 70% or better treatment response
• Education, reassurance, elimination of
caffeine, alcohol, drugs, OTC stimulants
• Cognitive-behavioral therapy
• Medications – SSRIs, venlafaxine,
tricyclics, MAOIs, benzodiazepines,
valproate, gabapentin
Agoraphobia
Agoraphobia
• Marked fear or anxiety for more than 6
months about two or more of the following
5 situations:
– Using public transportation
– Being in open spaces
– Being in enclosed spaces
– Standing in line or being in a crowd
– Being outside of the home alone
Agoraphobia
• The individual fears or avoids these situations
because escape might be difficult or help might
not be available
• The agoraphobic situations almost always
provoke anxiety
• Anxiety is out of proportion to the actual threat
posed by the situation
• The agoraphobic situations are avoided or
endured with intense anxiety
• The avoidance, fear or anxiety significantly
interferes with their routine or function
Prevalence
• 2% of the population
• Females to males:2:1
• Mean onset is 17 years
• 30% of persons with agoraphobia have
panic attacks or panic disorder
• Confers higher risk of other anxiety
disorders, depressive and substance-use
disorders
Generalized Anxiety Disorder
GAD
• 1 year prevalence: 3 – 8 %
• Lifetime prevalence: 5 %
• Ratio of women to men = 2 : 1
• Comorbidity:
– 50 – 90 % of GAD patients have another
psychiatric disorder
– 25 % develop panic disorder
DSM-IV Criteria for GAD
A. Excessive anxiety and worry occurring more days than not for at
least 6 months, about a number of events or activities
B. Person finds it difficult to control the worry
C. Anxiety and worry are associated with 3 or more of the following:
1) Restlessness or feeling keyed up or on edge
2) Easily fatigued
3) Difficulty concentrating or mind going blank
4) Irritability
5) Muscle tension
6) Sleep disturbance
D. Focus of anxiety or worry not confined to features of another axis I
disorder
E. Causes significant distress or impairment
F. Disturbance not due to substance or general medical condition
Generalized Anxiety Disorder
• Neuroanatomic models poorly developed
• Probably:
– Limbic and paralimbic structures involved as in panic
as well as prefrontal hyperactivity
• Represent attempt to suppress subcortically mediated
anxiety
• Neurochemical
– Reduced CSF serotonin
– m-chlorophenylpiperazine (m-CPP)
• Serotonin agonist, increases anxiety and hostility
– SSRIs appear effective in pharmacotherapy
– Reduced GABA/Benzodiazepine receptor binding
capacity normalizes with treatment
GAD
• Age of onset: “For as long as I can remember.”
– Usually seek treatment in 20s
– Only 1/3 seek psychiatric help
• Often seen by family practitioners and specialists for somatic
complaints of disorder
• Chronic and managed over a lifetime
• Development of Major depression or Panic
disorder often reason for initial presentation
Treatment
• Psychotherapy
– Cognitive behavioral
– Supportive
– Psychodynamic
• Pharmacotherapy
– Benzodiazepines
– SSRIs
– Buspirone
– TCAs
– Anticonvulsants (GABA)
Generalized Anxiety Disorder
Generalized Anxiety Disorder
• Excessive worry more days than not for at
least 6 months about a number of events
and they find it difficult to control the worry.
• 3 or more of the following symptoms:
– Restlessness or feeling keyed up or on edge,
easily fatigued, difficulty concentrating,
irritability, muscle tension, sleep disturbance
• Causes significant distress or impairment
Generalized Anxiety Disorder
Epidemiology

 4-7% of general
population
 Median onset=30
years but large range
 Female:Male 2:1
GAD Comorbidity
• 90% have at least one other lifetime Axis I
Disorder
• 66% have another current Axis I disorder
• Worse prognosis over 5 years than panic
disorder
GAD Treatment

• Medications including buspirone,


benzodiazepines, antidepressants (SSRIs,
venlafaxine, imipramine)
• Cognitive-behavioral therapy
OCD
DSM-IV-TR
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), Compulsions as defined by (1) and (2):
(3), and (4):
(1) Repetitive behaviors (e.g., hand
(1) Recurrent and persistent thoughts, washing, ordering, checking) or mental
impulses, or images that are acts (e.g., praying, counting, repeating
experienced, at some time during words silently) that the person feels
the disturbance, as intrusive and driven to perform in response to an
inappropriate and that cause obsession, or according to rules that
marked anxiety or distress must be applied rigidly
(2) The thoughts, impulses, or images (2) The behaviors or mental acts are
are not simply excessive worries aimed at reducing distress or
about real-life problems preventing some dreaded event or
(3) The person attempts to ignore or situation; however, these behaviors or
suppress such thoughts, impulses, mental acts either are not connected in
or images, or to neutralize them a realistic way with what they are
with some other thought or action designed to neutralize or prevent or
(4) The person recognizes that the are clearly excessive
obsessional thoughts, impulses, or
images are a product of his or her
own mind (not imposed from
without as in thought insertion)
DSM-IV-TR
B. At some point in the disorder,
person recognizes obsessions or
compulsions are unreasonable
(Does not apply to children)
C. Obsessions or compulsions cause
marked distress, are time
consuming, or significantly
interfere with functioning
D. If another axis I disorder is
present, the content of the
obsession or compulsion is not
restricted to it (trichotillomania,
body dysmorphic disorder,
hypochondriasis, paraphilia, MDE)
E. Disturbance is not due to a
substance or general medical
condition
Specify if: With poor insight
OCD
• Lifetime prevalence = 2-3%
• Adults: Men = Women
• Adolescents: boys > girls
• Mean age of onset:
– Men – 19 years old
– Women – 22 years old
• Comorbid:
– MDE – 67%
– Social phobia – 25%
OCD
• What did Freud think?
– Lady Macbeth
“The washing was symbolic,
designed to replace by
physical purity the moral purity
which she regretted having
lost”
- “The Rat Man”
- Ernst Lanzer – a prominent
young lawyer in Vienna
- obsessive thoughts of torture
in which a criminal was tied
up and a metal pot filled with
rats was fastened to his
buttocks. The rats would
bore their way into the
victim’s rectum
- Anal = fear of losing control
Conditions Associated With OCD
• Tourette’s Disorder
– Similar age of onset
– 90% of patients with Tourette’s have compulsive
symptoms
– Up to 2/3 of Tourette’s patients meet OCD criteria
– 7% of OCD patients have Tourette’s
• Hypochondriasis
• Body Dysmorphic Disorder
• (Impulse control disorders such as kleptomania
and pathological gambling)
Conditions Associated With OCD
• PANDAS
– “Pediatric Autoimmune Neuropsychiatric
Disorders Associated with Streptococcal
infections”
• Group A B-hemolytic Streptococcus infection
associated with onset of OCD in some children
• Autoantibodies react with basal ganglia in
Sydenham’s chorea which is also associated with
OCD symptoms
– Case reports of elimination of symptoms
following IVIg
Pathophysiology of OCD
• Serotonin Hypothesis
– 1960s: Clomipramine
observed to have
antiobsessional activity
– 50% of OCD patients
challenged with – SSRIs
proserotonergic compounds • Enhance 5-HT release in
experience transient orbitalfrontal cortex
worsening of symptoms • Desensitization of terminal
• Suggest basal hyperactivity of 5-HT autoreceptors
5-HT neurotransmission • Latency of effect (6-8
system, owing to either a
hyperactivity of postsynaptic
weeks)
receptors or to a hypoactivity • High dosages required
of presynaptic, self-regulatory
receptors
• Possible explanation for both
worsening of OCD after acute
5-HT stimulation and clinical
efficacy after chronic
administration of
proserotonergic compounds
Pathophysiology of OCD
• Dopamine Hypothesis
– Correlation between OCD and Tourette’s
– Tourette’s appears to be dopaminergically
mediated and responds to dopamine
antagonists
– Patients with comorbid tics often do not
respond to proserotonergic compounds
– Treatment refractory OCD often aided by
neuroleptic augmentation
Pathophysiology of OCD

• PET studies
– Activation of paralimbic circuits, posterior medial orbitalfrontal cortex,
anterior cingulate and temporal limbic regions associated with all
anxiety conditions
– Activation of anterior orbitalfrontal cortex and caudate nucleus specific
for OCD
• Cortico-strato-thalamo-cortico network
– Probable involvement of glutamate, GABA, DA and 5-HT
OCD Treatment
• Clomipramine and SSRIs
– 40% have no clinical improvement
– 60% with 25 – 35% decrease in symptoms
• (considered a response on Yale-Brown Obsessive
Compulsive Scale {Y-BOCS})
• FDA approved in adults:
– Clomipramine, Fluoxetine, Fluvoxamine, Sertraline,
Paroxetine
• FDA approved in pediatrics:
– Clomipramine, Fluvoxamine, Sertraline
OCD Treatment
• Augmentation:
– Li (?)
– Buspirone (?)
– rTMS (?)
– Trazodone
– Psychosurgery
– Atypicals
– IV clomipramine
– Clonazepam
OCD Treatment

• Cognitive Behavioral
Therapy

• OCFoundation
Obsessive-Compulsive and Related
Disorders
• Obsessive-
Compulsive Disorder
• Body Dysmorphic
Disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation Disorder
Prevalence of Obsessive-
Compulsive Related Disorders
• Body Dysmorphic Disorder-2.4%
– 9-15% of dermatologic pts
– 7% of cosmetic surgery pts
– 10% of pts presenting for oral or maxillofacial
surgery!
• Hoarding Disorder- est. 2-6% F<M
• Trichotillomania 1-2% F:M 10:1!
• Excoriation Disorder 1.4% F>M
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder
(OCD)
Obsessions or compulsions or both defined by:
• Obsessions defined by:
– recurrent and persistent thoughts, impulses or
images that are intrusive and unwanted that cause
marked anxiety or distress
– The person attempts to ignore or suppress such
thoughts, urges or images, or to neutralize them
with some other thought or action (i.e. compulsion)
OCD continued
• Compulsions as defined by:
– Repetitive behaviors or mental acts that the
person feels driven to perform in response to
an obsession or according to rigidly applied
rules.
– The behaviors or acts are aimed at reducing
distress or preventing some dreaded situation
however these acts or behaviors are not
connected in a realistic way with what they
are designed to neutralize or prevent.
OCD continued
• The obsessions or compulsions cause
marked distress, take > 1 hour/day or
cause clinically significant distress or
impairment in function
• Specify if:
– With good or fair insight- recognizes beliefs are
definitely or most likely not true
– With poor insight- thinks are probably true
– With absent insight- is completely convinced the
COCD beliefs are true
– Tic- related
OCD Epidemiology
• 2% of general
population
• Mean onset 19.5
years, 25% start by
age 14! Males have
earlier onset than
females
• Female: Male 1:1
OCD Comorbidities
• >70% have lifetime dx • 12% of persons with
of an anxiety disorder schizophrenia/
such as PD, SAD, schizoaffective
GAD, phobia disorder
• >60% have lifetime dx
of a mood disorder
MDD being the most
common
• Up to 30% have a
lifetime Tic disorder
OCD Etiology
• Genetics
• Serotonergic
dysfunction
• Cortico-striato-
thalamo-cortical loop
• Autoimmune-
PANDAS
Treatment
• 40-60% treatment response
• Serotonergic antidepressants
• Behavior therapy
• Adjunctive antipsychotics, psychosurgery
• PANDAS – penicillin, plasmapharesis, IV
immunoglobulin
Functional imaging studies
• Increased activity in the right caudate is
found in pts with OCD and Cognitive
behavior therapy reduces resting state
glucose metabolism or blood flow in the
right caudate in treatment responders.
• Similar results have been obtained with
pharmacotherapy

Baxter L. et al. Caudate glucose metabolic rate changes with both drug and behavioral therapy for
obessive-compulsive disorder. Arch Gen Psych 1992;49:681-689
Trauma- and Stressor-Related
Disorders

• Acute Stress Disorder


• Adjustment Disorders
• Posttraumatic Stress
Disorder
Post Traumatic Stress
Disorder
Post Traumatic Stress Disorder
Posttraumatic Stress Disorder
• Exposure to actual or threatened death,
serious or sexual violence in one or more
of the following ways:
– Direct experiencing of traumatic event(s)
– Witnessed in person the events as it occurred
to others
– Learning that the traumatic events occurred to
person close to them
– Experiencing repeated or extreme exposure
to aversive details of trauma
PTSD continued
Presence of 1 or more
intrusive sx after the Persistent avoidance by 1
event or both:
• Recurrent, involuntary
and intrusive memories of • Avoidance of distressing
event memories, thoughts or
• Recurrent trauma-related feelings of the event(s)
nightmares • Avoidance of external
• Dissociative reactions reminders of that arouse
memories of event(s) e.g.
• Intense physiologic
people, places, activities
distress at cue exposure
• Marked physiological
reactivity at cue
exposure
Negative alterations in cognitions and mood
associated with the traumatic event(s) as
evidenced by 2 or more of the following:
• Inability to remember an important aspect of the
traumatic event(s)
• Persistent distorted cognitions about cause or
consequence of event that lead to blame of self or others
• Persistent negative emotional state
• Marked diminished interest
• Feeling detached from others
• Persistent inability to experience positive emotions
Marked alterations in arousal
and reactivity with 2 or more of:
• Irritable behavior and and angry outbursts
• Reckless or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance
• Duration of disturbance is more than one
month AND causes significant impairment
in function
• Specifiers:
– With dissociative sx (derealization or
depersonalization)
– With delayed expression (don’t meet criteria
until >6 months after event)
PTSD Epidemiology

• 7-9% of general population


• 60-80% of trauma victims
• 30% of combat veterans
• 50-80% of sexual assault victims
• Increased risk in women, younger people
• Risk increases with “dose” of trauma, lack
of social support, pre-existing psychiatric
disorder
Comorbidities
• Depression
• Other anxiety disorders
• Substance use disorders
• Somatization
• Dissociative disorders
Post Traumatic Stress Disorder
Etiology
• Conditioned fear
• Genetic/familial vulnerability
• Stress-induced release
– Norepinephrine, CRF, Cortisol
• Autonomic arousal immediately after
trauma predicts PTSD
PTSD Treatment
• Debriefing immediately following trauma is
NOT necessarily effective
• Cognitive-behavioral therapy, exposure
• Group therapy
• Medications – antidepressants, mood
stabilizers, beta-blockers, clonidine,
prazosin, gabapentin

Pharmacotherapy for post


traumatic stress disorder.
Prazosin
• Start at 1mg qhs X 3 nights then
increased by 1mg q 3 nights until
nightmares improve or patient develops
postural hypotension. Some patients can
gain benefit a 1mg and some need
>10mgs!
Functional neuroimaging in
PTSD
• Increased amygdalar activation is seen in
PTSD pts compared to controls
• Hypoactivation of the medial prefrontal
cortex including the orbitofrontal cortex
and anterior cingulate cortex (area
implicated in affect regulation)

Francati V. et al. Functional Neuroimaging Studies in Posttraumatic Stress Disorder:Review of


Current methods and Findings. Depression and Anxiety 2007;24:202-218
• Study found treatment of PTSD with
paroxetine resulted in increased anterior
cingulate cortex function

Fani N. et al. Increased neural response to trauma scripts in posttraumatic stress disorder
following paroxetine treatment: A pilot study. Neurosci Letters 2011;491:196-201
DSM-IV-TR
A. The person has been
exposed to a traumatic
event in which both of
the following were
present:
1. The person experienced,
witnessed, or was 2. The person’s response
confronted with an event involved intense fear,
that involved actual or helplessness, or horror. Note:
threatened death or In children, this may be
serious injury, or a threat expressed instead by
to the physical integrity of disorganized or agitated
self or others behavior.
DSM-IV-TR
B. The traumatic event is C. Persistent avoidance of stimuli
persistently reexperienced in associated with the trauma and
one or more of the following numbing of general
ways: responsiveness, as indicated by
1. Recurrent and intrusive three or more of the following:
distressing recollections of the 1. Efforts to avoid thoughts, feelings
event or conversations associated with
2. Recurrent distressing dreams of the trauma
the event 2. Efforts to avoid activities, places
3. Acting or feeling as if the or people that arouse
traumatic event were recurring recollections of the trauma
4. Intense psychological distress at 3. Inability to recall important aspect
exposure to internal or external of the trauma
cues that symbolize or resemble 4. Markedly diminished interest in
an aspect of the event significant activities
5. Physiologic reactivity on 5. Feelings of detachment or
exposure to internal or external estrangement from others
cues that symbolize or resemble 6. Restricted range of affect
an aspect of the event
7. Sense of a foreshortened future
DSM-IV-TR
D. Persistent symptoms of E. Duration of the
increased arousal, as disturbance is more than
indicated by two or one month
more of the following: F. Disturbance causes
1. Difficulty falling or staying clinically significant
asleep distress or impairment in
2. Irritability or outbursts of social, occupational, or
anger
other important areas of
3. Difficulty concentrating
functioning
4. Hypervigilance
5. Exaggerated startle
response
PTSD
• Lifetime prevalence
– Approximately 8%
• 10 – 12% women, 5 – 6% men
– Additional 5 – 15% may experience subclinical form
of disorder
• Predisposing vulnerability factors
– Childhood trauma, cluster B personality disorder
traits, inadequate support system, being female,
genetic vulnerability to psych illness, recent stressful
life changes, perception of external locus of control
PTSD
• Biologic considerations
– Noradrenergic system
• Increased 24 hr urine epinephrine concentrations
• Platelet α2 receptors downregulated
– chronically elevated catecholamine
– HPA axis
• Hyperregulation of HPA axis in PTSD
– Low plasma and urinary free cortisol
– Exogenous CRF yields blunted ACTH response
– Suppression of cortisol with dexamethasone is enhanced
in PTSD
PTSD
• Biologic
considerations
– MRI, PET studies
implicate reduced
volume and function of
hippocampus in PTSD
PTSD
• Treatment
– SSRIs
– Atypicals, benzos
– CBT
– (EMDR – eye movement desensitization and
reprocessing)
Acute Stress Disorder
• Similar exposure as in PTSD
• Presence of >9 of 5 categories of
intrusion, negative mood, dissociation,
avoidance, and arousal related to the
trauma.
• Duration of disturbance is 3 days to 1
month after trauma
• Causes significant impairment
Screening questions
• How ever experienced a panic attack? (Panic)
• Do you consider yourself a worrier? (GAD)
• Have you ever had anything happen that still haunts
you? (PTSD)
• Do you get thoughts stuck in your head that really bother
you or need to do things over and over like washing your
hands, checking things or count? (OCD)
• When you are in a situation where people can observe
you do you feel nervous and worry that they will judge
you? (SAD)
Treatment
General treatment approaches
• Pharmacotherapy
– Antidepresssants
– Anxiolytics
– Antipsychotics
– Mood stabilizers
• Psychotherapy- Cognitive Behavior
Therapy
Crank up the serotonin
• Cornerstone of treatment for anxiety
disorders is increasing serotonin
• Any of the SSRIs or SNRIs can be used
How to use them
• Start at ½ the usual dose used for
antidepressant benefit i.e citalopram at
10mg rather than the usual 20mg
• WARN THEM THEIR ANXIETY MAY GET
WORSE BEFORE IT GETS BETTER!!
• May need to use an anxiolytic while
initiating and titrating the antidepressant
Other options
• Hydroxyzine- usually 50mg prn. Helpful for
some patients but has prominent
anticholinergic SEs
• Buspirone-For GAD- 60mg daily
• Propranolol-Effective for discrete social
phobia i.e. performance anxiety
• Atypical antipsychotics at low doses for
augmentation in difficult to treat OCD pts
Anticonvulsants
• Valproic acid 500-750 mg bid (ending
dose)
• carbamazepine 200-600 mg bid (ending
dose)
• Gabapentin 900-2700 mg daily in 3
divided doses (ending dose)
• Atypical antipsychotics at low doses for
augmentation in difficult to treat OCD pts
Psychotherapy
• Please refer to psychotherapy lecture!
Take home points
• Anxiety, Obsessive-Compulsive and Related,
and Trauma and Stressor-related disorders are
common, common, common!
• There are significant comorbid psychiatric
conditions associated with anxiety disorders!
• Screening questions can help identify or rule out
diagnoses
• There are many effective treatments including
psychotherapy and psychopharmacology
• There is a huge amount of suffering associated
with these disorders!
The Psychodynamic Approach
to Anxiety
• Anxiety is a signal that the ego is having a
hard time mediating between reality, id
and superego.
• Different anxiety disorders are the result of
different defense mechanisms used to
cope.
The Psychodynamic Approach
to Anxiety: Attachment Theories
• Bowlby
– disturbances in parent-child bond leads to
“anxious attachment” and a vulnerability to
anxiety disorders later in life
The Behavioural Approach to
Anxiety
• Mowrer (1948) Avoidance learning
– 1) classical (respondent) conditioning
– 2) negative reinforcement
The Behavioural Approach to
Anxiety
• Barlow (1988) Anxiety Sensitivity or “Fear
of Fear”
The Behavioural Approach to
Anxiety
• Treatment:
– systematic desensitization
– exposure
– flooding
The Biological Approach to
Anxiety
• Genetic Component
– family and twin studies suggest a genetic
component in most anxiety disorders
– panic disorder shows the strongest genetic
component and generalized anxiety disorder
the least
The Biological Approach to
Anxiety
• “Suffocation false alarm hypothesis” of
panic disorder
• serotonin and basal ganglia abnormalities
in OCD
• hormonal theory of PTSD
• State-dependent learning
The Cognitive Approach to
Anxiety
• Individuals misperceive and misinterpret
internal and external stimuli
Cognitive Appraisal
• Stimulus--->Appraisal---> Response
– evaluation of stimulus based on memories,
beliefs, and expectations
Information Processing
• Schema
– how we understand the information we take in
from the environment
• Selective Attention
– what information we take in
Cognitive Approach to Panic
Disorder
• Catastrophic interpretations of bodily
sensations
• Feeling of control
• Some Problems:
– panic attacks during sleep
– why do catastrophic interpretations develop
Anxiety and Selective Attention
Phobias
Chapter 4- anxiety disorders
What is a phobia?
• A specific phobia is an
_________________________________
_________________________________
________________________________

– Significantly interferes with ones ability


to function.

• _________________________________
_______________
RUN!!!
• _________________________________
__________is necessary to meet the
criteria for a phobia.

• Most persons with specific phobias


recognize that the fears are
unreasonable and irrational- but try to
escape anyway.
Phobic Disorders
• The
_________________________________
___________
_________________________________
________________
– People with phobias often adapt their lives
and simply work around it.

• The physical symptoms of this type of


anxiety are:
– Increased heart rate
– Blood pressure
– Irregular breathing patterns,
Diagnosing Phobias
• To qualify for a diagnosis of phobic
disorders is that the fear must be
___________
________________________________
________________________________
________________________________

• Unlike generalized anxiety, the anxiety


is focused on some specific object or
Different types of phobias

DSM IV first defined phobias as a


classifiable disorder in 1994
______________________________
______________________________
______________________________
Types of phobias
1. ______________________________
___________
• Unreasonable fear/avoidance of
exposure to
____________________________
____________________________
_____________. These are
typically the people who faint at the
sight of even a drop of blood
(Barlow et al.,1995).

• People with this type of phobia


experience different physiological
reactions than other phobias.
Blood-Injury-Injection Phobias
• This type of phobia runs in families and has a
strong genetic component.

• This is likely because people who inherit this


phobia
_____________________________________
___________
_____________________________________
_____________________________________
_____________________________________
_

• The average age of onset for this type of


phobia is 9.
Don’t look down!!
Natural/environment
phobias involve the fear of
events in nature, like
heights, storms or water.
• _______________________________
_______________________________
_______________________________
_______________________________
___________
• Example- If you fear deep water, you
are likely to also fear storms

• The age of onset for this type of


Phobias characterized by fear of
public transportation or enclosed
places are called
__________________________
________
Situational phobia

• Situational phobias tend to emerge


in the early to
_____________________________
_
_____________________________
_____________________________
____________________________

• People with situational phobias


never experience a panic attack
outside the context of their phobic
object/situation.
Animal Phobias

4. _________________________________
________________
_________________________________
________________

– particularly dogs, snakes, insects and mice

• The age of onset is 7, like natural


environmental phobias.
Statistics
• The APA reports that in any given year,
__________________________________
_________________

• They are the most common psychiatric


illness among
__________________________________
_________
__________________________________
__________________________________
__________________________________
Since people tend to work around
their phobias, only the most severe
cases tend to seek treatment.
Will I have to live with this
forever?
• Once a phobia develops,
__________________
______________________________
____________________ making
treatment very important.

• With proper treatment, the vast


majority of phobia patients can
completely overcome fears and live
symptom-free.
Treatment
• The treatment for phobias is agreed on by most
of the psychological community.
____________________________
______________________________________
______________________________________
___________________________ exercises.

• This should be done under professional


supervision, so the patients are not exposed to
too much at once, which could lead to escape
and this would only
______________________________________
__________________

• New developments in treatment make it possible


to treat many specific phobias in an intensive,
Treatments
• The results are very interesting because
in these cases not only does the phobia
disappear but the tendency to
experience the
_________________________________
___________
_________________________________
_______________

• It is now clear, based on brain imaging


that these treatments
Where do phobias come
from?

It was once believed that phobias


developed after a traumatic
event.___________________________
________________________________
_____________________________
Where did this come from?

• Traumatic experiences can result in


phobic behavior, developed by
_______________________________
_____________ where danger results
in an alarm response.

• Example- many people who have


choking phobias have experienced
choking at some time.
Developing phobias
Vicarious experience -
__________________________
________________________________
_______________.

• Seeing someone else have a traumatic


experience is enough to instill a phobia
in the watcher.

3. ________________________________
_______________ can sometimes
It’s all in the breeding…
• _________________________________
_________________________________
________________________________
– 31% of first-degree relatives of people with
specific phobias also had a phobia,
compared to only 11% of first relatives of
normal controls.

• This research suggests that relatives


were likely to have that exact type of
phobia (Frye et al. , 1990).
Review Questions
1. Hyperthyroidism should be ruled out as part of the differential diagnosis of which of the
following psychiatric disorders?
a. Cataplexy
b. Panic Disorder
c. Paranoid Schizophrenia
d. Dissociative Identity Disorder
e. OCD

2. Which of the following SSRIs has the longest half-life?


a. Sertraline
b. Paroxetine
c. Fluoxetine
d. Citalopram
e. Fluvoxamine

3. Which of the following benzodiazepines does not have active metabolites?


a. Diazepam
b. Halazepam
c. Lorazepam
d. Chlorazepate
e. Chlordiazepoxide
Review Questions
4. A young adult male patient has thoughts of killing his girlfriend. Whenever he thinks of
her, he is suddenly confronted with images of stabbing her in the face. He is extremely
upset by these images, which he finds contrary to his own beliefs of nonviolence. In
response to these images, he becomes anxious. He relieves his anxiety by pricking his
own face with a pin 10 times. This activity occurs now 20 to 30 times per day, and his
face is sore and red. The medication most likely to reduce these symptoms is:
a. Risperidone
b. Lorazepam
c. Bupropion
d. Buspirone
e. Fluvoxamine

5. A 30-year-old patient has been treated for unreasonable fear of eating in public places,
feeling embarrassment in public places, and anger over the possibility of being
scrutinized. The patient has responded to high doses of paroxetine, citalopram,
buspirone, and alprazolam, each of them administered for 4 to 6 weeks. Which of the
following medications would be appropriate for the psychiatrist to consider prescribing
next?
a. Bupropion
b. Fluoxetine
c. Mirtazapine
d. Phenelzine
Review Questions
6. Which of the following benzodiazepines has an active metabolite?
a. Lorazepam
b. Temazepam
c. Oxazepam
d. Chlordiazepoxide

7. A 25-year-old patient is evaluated for hoarding, intrusive thoughts, and frequent


handwashing, which started 2 years ago and now interferes with daily life. In addition to
psychotherapy, which of the following medications would be most appropriate to begin?
a. Bupropion
b. Olanzapine
c. Clomipramine
d. Mirtazapine
e. Alprazolam

8. Which of the following symptoms would be most commonly associated with Tourette’s
Syndrome?
a. Somatization
b. Panic attacks
c. Violent behavior
d. Psychotic thinking
e. Obsessions and Compulsions
Review Questions
9. Which of the following medications has the least protein binding?
a. Fluoxetine
b. Sertraline
c. Paroxetine
d. Venlafaxine
e. Clomipramine

10. Obsessive-compulsive symptoms are characterized by which of the following


psychological defense mechanisms?
a. Ambivalence and magical thinking
b. Displacement and sublimation
c. Regression and projection
d. Denial and introjection
e. Isolation and undoing

11. Which of the following is a principal goal of the CBT of panic disorder?
a. Learning to use biofeedback techniques
b. Mastering relaxation in the face of flooding
c. Learning more adaptive defenses
d. Using restructured interpretation of disturbing sensations
THANX

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