Transcript Document
Anxiety Disorders Clinical features and assessment
Dr Babu Mani Specialty Registrar (6) Liaison Psychiatry 27/09/2011
Anxiety Response
Psychological – feelings of dread and apprehension accompanied by Restlessness narrowing of attention focussing on source of danger, worrying thoughts, increased alertness and irritability Somatic – Muscle tension and respiratory rate increase/effects of hyperventilation (e.g. – dizziness) Autonomic – heart rate and sweating increase, dry mouth, urge to urinate or defecate Avoidance of danger – phobia is persistent, irrational fear of a specific object or situation. Fear is out of proportion to objective threat Phobias include animate objects, natural phenomena and situations Anticipatory anxiety – not just exposure to the object or situation but also when thinking about it
Anxiety disorders
Found in many disorders In DSM IV obsessional disorders are classified as anxiety disorder Anxiety disorders are abnormal states in which the striking features are mental and physical symptoms of anxiety occurring in the absence of organic brain disease or another psychiatric disorder
Anxiety disorders
All symptoms can occur in the anxiety disorders but the patterns of occurrence are different GAD – continuous anxiety but fluctuate in intensity Phobic anxiety – intermittent anxiety arising in particular circumstances – Agoraphobia, social phobia, specific phobia Panic disorder – intermittent anxiety but occurrence unrelated to any circumstance
Freud first suggested that cases with mainly anxiety symptoms should be recognised as a separate entity According to Freud, Anxiety neurosis and anxiety hysteria were related to sexual conflicts – later accepted wide range of causes First systematic entry about phobic disorders was by Le Camus in the eighteenth century – early nineteenth century classification assigned the phobias to the group monomania which were disorders of thinking – Freud classified as common phobia and specific phobia
Classification of anxiety disorders
ICD 10 F4 Anxiety disorders F40 Phobic anxiety disorders Agoraphobia with panic disorder Without panic disorder Social phobia Specific phobia DSM IV Agoraphobia With panic disorder Without history of panic disorder Social phobia Specific phobia F41 Other anxiety disorders Panic disorder Generalized anxiety disorder Mixed anxiety and depression Panic disorder without agoraphobia Generalised anxiety disorder
Classification
In ICD 10 anxiety disorders are divided into two named groups Panic disorder is classified differently in two schemes OCD is classified as anxiety disorder in DSM IV ICD 10 contains mixed anxiety depressive disorder but DSM IV does not have similar entity
Generalized anxiety disorder
GAD
Symptoms are persistent and are not restricted to any particular set of circumstances All symptoms of anxiety can occur but a characteristic pattern is Worry and apprehension – widespread worries, not focussed on specific issues – find the ‘widespread’ worries difficult to control Psychological arousal – irritability, poor concentration, sensitive to noise, sometimes poor memory Autonomic overactivity – sweating, palpitatiosn, dry mouth, epigastric discomfort, dizziness Muscle tension – restlessness, trempbling, inability to relax, headache Hyperventilation – dizziness, tingling in extremities Disturbed sleep – intermittent, unrefreshing unpleasant dreams – early morning awakening is not a feature of GAD
The symptoms of general anxiety disorder (GAD) often develop slowly and can vary in severity from person to person. Some people experience only one or two symptoms, while others experience many more.
Psychological symptoms
Psychological symptoms of GAD include: restlessness a sense of dread feeling constantly 'on edge' difficulty concentrating irritability impatience being easily distracted withdrawal from social contact (seeing family and friends) to avoid feelings of worry and dread. difficult and stressful going to work and may take time off sick worry even more increased lack of self-esteem.
Physical symptoms
The physical symptoms of GAD can include: dizziness drowsiness and tiredness pins and needles irregular heartbeat (palpitations) muscle aches and tension dry mouth excessive sweating shortness of breath stomach ache nausea diarrhoea headache excessive thirst frequent urinating painful or missed periods difficulty falling or staying asleep (insomnia)
GAD – clinical signs
Face appears strained Tense posture Person is restless Skin is pale and sweating is common Readiness to tears (may suggest depression but could reflect the generally apprehensive state)
GAD - Diagnosis
No dividing line between GAD and normal anxiety Extent and duration of symptoms differentiates GAD from normal Duration – DSM IV and research version ICD 10 – symptoms must have been present for 6 months – ICD 10 criteria is more flexible – present on most days for at least several weeks at a time and usually several months
GAD
Anxiety and depression – Co morbidity Possible to diagnose other anxiety disorders along with Generalized anxiety disorder as per DSM IV
Differential diagnosis - GAD
Depressive disorder Schizophrenia Dementia Substance misuse Physical illness – thyrotoxicosis, phaechromocytoma
Aetiology
Stressful events – involving threat are particularly related to anxiety disorder – loss events are associated with depression Genetic – more frequent among first degree relatives Twin studies – higher concordance for anxiety disorder between monozygotic than dizygotic pairs Early adverse experiences – parental indifference, physical, sexual abuse, separation from mother (women)
Treatment
Counselling Relaxation training CBT Medication – Benzos, SSRIs. TCA, MAO inhibitors
Management of GAD
Check diagnosis and co morbidity Evaluation of psychosocial maintaining factors – persistent social problems, marital conflict Explanation of the evaluation and proposed treatment Psychological help Consider medication Discuss plan with patient, GP and community team (if referred to)
Phobic anxiety disorders
Phobic anxiety disorders
Very similar to generalised anxiety disorder but occus in particular circumstances The situations can be grouped into Situations – eg crowded places Objects – eg living things like spiders Natural phenomena – eg thunder Classification Specific phobias Social phobia agoraphobia
Specific phobias
Four specific phobias are recognised DSM IV Animals Aspects of natural environment Blood, injection, injury Situations and other provoking agents – fear of choking, dental and medical situations Treatment is usually exposure form of behaviour therapy
Social phobia
Social Phobia
Social Phobia (also known as social anxiety disorder) is a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
Aware that their idea is groundless even
though they are preoccupied that they are being observed critically
Social Phobia
The main feature of this disorder is the patient’s fear that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing (American Psychiatric Association, 1994) It is often associated with anticipatory anxiety, leading the patient to avoid situations in which there is the risk of social exposure.
Social phobia
Can be generalized – wide range of social situations Some times in specific situations Can experience any anxiety symptoms but blushing and trembling are frequent
Social phobia
Some patients take alcohol to relieve anxiety – much more common in social phobia Co morbid depression and suicide attempts seem to be more frequent (Schneider et al, 1992) Usually starts in early teenage years First episode occurs in public place Episodes become progressively more severe with increasing avoidance Phobia of excretion/phobia of vomiting
Diagnostic criteria
ICD 10 Marked fear or avoidance of being the focus of attention or of behaving in an embarrassing or humiliating way – manifested in social situations Two general symptoms of anxiety + at least one from Blushing/shaking Fear of vomiting Fear or urgency of micturition or defecation Significant emotional distress recognised as excessive or unreasonable Symptoms restricted to or predominate in feared situations Not secondary to another disorder DSM IV Marked fear or avoidance of situations in which the person is exposed to unfamiliar people or to scrutiny with fear of behaving in an embarrassing or humiliating way Recognises the fear is excessive or unreasonable, interferes with functioning or causes marked distress Not secondary to another disorder Duration at least 6 months if the person is under 18 years of age
Differential diagnosis – social phobia
Agoraphobia and panic disorder – history General anxiety disorder and depressive disorder – history and mental state Schizophrenia Body dysmorphic disorder – History Avoidant personality disorder Normal shyness – feeling ill at ease in company
Aetiology
Genetics Suggested by finding that social phobias are more common among the relatives of social phobics than in the population Conditioning – begin with sudden episode of anxiety in circumstances similar to those becoming the stimulus – subsequent development is partly due to conditioning Cognitive factors Undue concern about other people being critical Excessive high standards for social performance Negative beliefs about oneself Excessive monitoring of their own performances Intrusive negative images of self (supposedly as seen by others) Often develop safety behaviours (like avoiding eye contact)
Neural mechanisms – social phobia
PET study found increased blood flow in Right dorso-lateral prefrontal cortex Left inferior temporal cortex
Left amygdaloid-hippocampal region
Pattern is seen in anticipatory anxiety in healthy individuals except amygdala is not activated and the activation is less widespread Amygdala is a region involved in response to threat Treatment with CBT, Citalopram results in decreased blood flow in amygdala (Fulmark et al, 2002)
Treatment
Psychological CBT Relaxation training – less effective that cognitive therapy Dynamic psychotherapy – may be helpful in those associated with pre-existing problems in personal relationships Drugs SSRIs – continued usually upto a year. MAO inhibitors – Phenelzine /Moclobemide Benzos – short term /avoid in co-morbid alcohol misuse Beta Blockers – short term control of tremor and palpitations – overall effectiveness not greater than placebo
Agoraphobia
Agoraphobia
Get anxious when away from home, in crowds They experience similar symptoms of anxiety but two are very important Panic attacks – response to environmental stimuli or arise spontaneously Anxious thoughts about fainting and loss of control In DSM IV, cases with more than four panic attacks in 4 weeks are not classified as agoraphobia but as panic disorder with secondary agoraphobic symptoms
situation
3 common themes – distance from home, crowding and confinement Examples are buses, trains, shops and supermarkets Progressively patients avoid these situations – in severe cases, they are more or less confined to the house – housebound housewife syndrome Variations can occur in the pattern when symptoms ‘reduce’.
Anticipatory anxiety
Common Severe cases – hours before the person enters the feared situation adding to distress (sometimes misdiagnosed as generalised anxiety)
Other symptoms
Depressive symptoms are common Depersonalization can be severe
Agoraphobia
Most cases begin in early or middle twenties (and another peak in thirties) – these ages are later than the average ages of onset of simple phobias (childhood) and social phobias (teenage years) Some patients clearly able to describe the first episode Pattern of recurrent attacks and gradual development of avoidance Increasingly dependent of friends and family
Diagnostic criteria
ICD 10 Marked, consistent fear in or avoidance of at least two situation
from crowds public places travelling alone travel away from home
Significant distress caused by the avoidance or the anxiety recognised as excessive or unreasonable At least one symptom of autonomic arousal plus one other anxiety symptom in the feared Symptoms restricted to or predominate in the feared situations or contemplations thereof Not the result of another disorder DSM IV Anxiety in situations in which escape may be difficult, or help unavailable were there a panic attack, eg outside the home crowds travel bridges These situations are avoided or endured with distress Criteria for panic disorder never met Not accounted for by another disorder
Differential diagnosis
Social phobia Generalized anxiety disorder Panic disorder Depressive disorder Paranoid disorders
Treatment
Anxiolytic drugs Antidepressant drugs Selective serotonin re-uptake inhibitors MOA inhibitors Psychological Exposure treatment – behavioural treatment – more effective when combined with anxiety management – prognosis better in people with good marital relationships and poor in those experiencing chronic life stress CBT – short term it is as effective as medication and long term it is probably more effective
Panic disorder
Panic disorder
The diagnosis did not appear in the nomenclature until 1980 (introduced in DSM III) Sudden attacks of anxiety in which physical symptoms predominate and are accompanied by fear of a serious medical consequence such as hear attack.
Irritable heart, Da Costa’s syndrome, Neurocirculatory asthenia, disorderly action of heart and effort syndrome (these early terms assumed that patients were correct in fearing a disorder of heart) Wood (1941) showed that the condition was a form of anxiety disorder
Symptoms (DSM IV)
Shortness of breath and smothering sensation Choking Palpitations and accelerated heart rate Chest discomfort or pain Sweating Dizziness, unsteady feelings or faintness Nausea or abdominal distress Depersonalisation or derealization Numbness or tingling sensation Flushes or chills Trembling or shaking Fear of dying Fear of going crazy or doing something uncontrolled
Symptoms due to hyperventilation
Dizziness Tinnitus Headache Feeling of weakness Faintness Numbness Tingling in the hands, feet, face Carpopedal spasms Precordial discomfort
Clinical features
Symptoms as listed before (DSM requires the presence of only four or more symptoms) Important features Anxiety builds up quickly Severe symptoms Person fears a catastrophic outcome Hyperventilation – hypocapnia causing medically unexplained symptoms
Diagnosis
DSM IV – panic attacks occur unexpectedly more than four attacks in 4 week period or one attack followed by 4 weeks of persistent fear of another attack and worry about implications.
ICD 10 – recurrent attacks and not consistently associated with a phobic situation or object, or with marked exertion or exposure to dangerous or life threatening situations
Differential diagnosis
Panic attacks can occur in generalized anxiety disorder, phobia, depression and acute organic disorders Two important criteria – persistent marked concern about having further attacks and worrying about the implications of the attacks
Treatment
Cognitive therapy Benzos Imipramine and clomipramine SSRIs
Mixed anxiety and depressive disorder
Anxiety and depressive symptoms occurring together Overlap is greatest when symptoms are mild Antidepressant with anxiolytic effect
Transcultural variations
Koro Men in Asia – more common among Chinese Similar to panic disorder Suk-yeong (Cantonese) – meaning shrinking of penis Acute anxiety last from 30 minutes to a day or two – person complains of palpitations, sweating, pericardial discomfort, and trembling Convinced that the penis will retract into the abdomen and when complete, he will die. Occur at night, sometimes after sexual activity Parallels the belief in panic disorder that heart is damaged and they will die Variations of social phobia have also been described – taijin-kyofu sho (Japanese) or phobia of interpersonal relations