Anxiety DisordersBack to Basics

Ameneh Mirzaei, M.D.

Resident Department of Psychiatry

April 22, 2009

Definition of anxiety

• a state of fear & apprehension

• everyone experiences anxiety / fear at one time or another

• normal emotions that can be appropriate & even beneficial under certain circumstances

• anxiety disorders: excessive, uncontrollable, & distressing levels of anxiety

Anxiety disorders (DSM-IV)1. panic disorder with/without agrophobia2. agrophobia without panic disorder3. specific phobia (simple phobia)4. social phobia (social anxiety disorder)5. obssessive-compulsive disorder (OCD)6. posttraumatic stress disorder (PTSD)7. generalized anxiety disorder 8. acute stress disorder9. substance-induced anxiety disorder10. anxiety disorder due to general medical condition (GMC)11. anxiety disorder not otherwise specified (NOS)

Panic disorder - epidemiology

• prevalence • life-time: 4.7% • 1/3-1/2 have agrophobia

• F:M ratio 2-3:1 • age of onset: adolescence/early adulthood (17-35)• 20X higher risk of suicide versus general population• 80% first seen by primary care/ER

Panic disorder- diagnosis

• recurrent unexpected panic attacks

• >= 1 month persistent concern about– another attack– implications of attack– significant behavior change related to attacks

• 4/13 symptoms of a panic attack

Panic disorder – diagnosis cont’d

• like any other psychiatric diagnosis – must R/O panic attacks due to

• substance use • physical condition• another psychiatric disorder (including other anxiety

disorders)– symptoms must cause social & functional impairment

• further classified– with agoraphobia– without agoraphobia

Panic attack - diagnosis• >= 4 of 13 (out of the blue, peak W/I 10 min)“STUDENTS Fear the 3 Cs”

– Sweating– Trembling / shaking– Unsteadiness / feeling dizzy– Derealization / depersonalization– Excess HR – Nausea – Tingling– SOB– Fear of death– Fear of going crazy / losing control– Choking– Chills / hot flushes– Chest pain

Agoraphobia – diagnosis

• anxiety about being in places from which escape w/b difficult / embarrassing

– being outside home alone, in a crowd, in line, bridge/tunnel, bus/train/car

• these situations are avoided or endured with + + anxiety

Panic disorder – prognosis

• course– 50 - 70% improve– complete remission is uncommon

• complications– depression: 50%– substance abuse (EtOH): 20%

Panic disorder – treatment

Medications• 1st line: SSRIs, venlefaxine (effexor)• 2nd line: TCA (clomipramine), benzodiazepines (short

term)• continue treatment for 8-12 months

Psychotherapy• CBT: cognitive restructuring, exposure, relaxation• Supportive therapy• Psychoeducation

Cognitive – Behavioral Therapy

• A form of psychotherapy based on the theory that psychological symptoms are related to the interaction of thoughts, behaviors, & emotions

• Goal --- change unhealthy behavior through cognitive restructuring (examining assumptions behind the thought patterns) & the use of behavioral therapy techniques

Generalized anxiety disorder (GAD) - epidemiology

• lifetime prevalence: 5% • F:M = 2:1 • more common in low SES• 50% before age 20 • 90% co-morbidity rates • chronic but may fluctuate during stressful

times

GAD - diagnosis• excessive anxiety & worry most days for at least 6/12• difficult to control

• >= 3 of “BE SKIM” --- (need only 1 in children)

• Blank mind • Easily fatigued • Sleep disturbance • Keyed up / on edge • Irritability• Muscle tension

• focus of worry not confined to another axis 1 d/o• r/o substances & GMC • social & occupational dysfunction

GAD – treatment Medications

• 1st line: SSRIs, Venlefaxine • 2nd line: TCA (imipramine), benzodiazepines (short term),

Bupropion (NE/DA RUI), Buspirone (5HT partial agonist)

Psychotherapy • CBT• relaxational techniques• supportive therapy• psychoeducation: symptoms come & go, avoid caffeine,

EtOH

Social phobia (social anxiety d/o) – epidemiology

• lifetime prevalence: 13% • F:M = 1.5:1• more common in lower SES • 50% generalized (vs performance) • higher rates of substance abuse (EtOH)• 80-90% overlap with avoidant PD

Social phobia - diagnosis

“PERSON” --- same for specific phobia

– Persistent/ marked fear of social/performance situations

– Exposure produces anxiety– Recognition of excess– Social/performance situations avoided / endured w

distress– Occupational / social dysfn.– Not < 6/12 if person <18 yo

Social phobia – treatment

Medications• 1st line: SSRIs, Venlefaxine • 2nd line: benzodiazepines

Psychotherapy • CBT• performance desensitization• social effectiveness training

Avoidant Personality Disorder

• Pervasive pattern of

– social inhibition– feelings of inadequacy– hypersensitivity to negative evaluation

• Beginning by early adulthood

Avoidant Personality Disorder

• 4 or more of the following

– avoids jobs that involve a lot of interpersonal contact ---- fears of criticism, disapproval, rejection

– unwilling to get involved with people unless certain of being liked

– restraint within intimate relationships for fear of being shamed or ridiculed

Avoidant Personality Disorder

• preoccupied with being criticized or rejected in social situations

• inhibited in new interpersonal situations because of feelings of inadequacy

• views self as socially inept, personally unappealing or inferior to others

• unusually reluctant to take personal risks or engage in new activities ---- may prove embarrassing

Avoidant Personality Disorder

• Great deal of overlap between avoidant PD & social phobia (generalized type)

• If generalized social phobia is present should also consider diagnosis of avoidant PD

Specific phobia - diagnosis

• Similar to social phobia

Specific phobia - epidemiology

• life time prevalence: 12.5%

• most common mental d/o in women & 2nd most common d/o in men (after substance-related d/o)

• F:M = 2:1

• start at a young age (5-12 years)

Specific phobia – types

• animal: childhood onset • natural environment: childhood onset

– heights, storms, water• blood-injection-injury: highly familial• situational type

– airplanes, elevators, enclosed places• other types

– choking, vomiting, loud sounds, costume characters

Specific phobia

• order of frequency of fears (most to least) – animals – storms– heights– illness– injury– death

Specific phobia – treatment

• tend to remit spontaneously with age• can become chronic but rarely disablingMedications

• limited data on antidepressants • beta blockers, benzodiazepines for acute anxiety

Psychotherapy – CBT: cognitive restructuring

– behavior therapy: exposure (flooding), systematic desensitization

– supportive therapy

Obsessive-compulsive disorder ( OCD) - definition

Obsession (O)– recurrent & intrusive thought, feeling, idea or sensation

(mental event)– recognized as irrational

Compulsion (C )– conscious, standardized, recurrent behavior such as

counting, checking or avoiding (behavior) – may be carried to anxiety (not always successful to do

so & may even inc anxiety)

Both O & C ego-dystonic (ie unwanted behavior)

OCD - epidemiology

• lifetime prevalence: 2-3% • M=F in adults, M>F in adolescents• mean age of onset: 20 • less in blacks than whites • 10% will develop schizophrenia• 50% with Tourette’s have OCD

OCD - diagnosis Obsessions or Compulsions

“IRON RRRONS”O I ignore, suppress, neutralize

R recurrent persistent intrusive thoughtsO own mind (ego-dystonic)N not simply excessive worries

C R repetitive beh./ mental acts R reduce stressR recognition of problem (excessive) O occupational, social dysfn. (take > 1 hr / day)N not restricted to another axis I d/o

S substances / GMC exclusion

OCD - treatment

Pharmacotherapy– 1st line: SSRI ; high doses needed for 8-12 wks – 2nd line: Clomipramine, adjunctive Risperidone – treat for 6-24 mos after remission– very low placebo response rate

Psychotherapy 1. CBT: Exposure & Response Prevention (ERP)2. psychoeducation3. family therapy

Posttraumatic stress disorder (PTSD) - epidemiology

• life time prevalence: 9%• F:M = 2:1• 80% have co-morbid illness • 6x completed suicide risk compared to

general population• symptoms fluctuate, get worse with stress

PTSD – diagnosis

• 3 major elements: re-experience, avoidence, arousal

• “TRAPED”– Trauma – Re-experience (1/5)

• via dreams, recurrent intrusive thoughts– Avoidence (emotional numbing) (3/7)

• feeling detached from others– Persistent arousal (2/5)

• irritability, exaggerated startle response– Experience distress / impairment – Duration > 1/12 (>3/12 chronic)

PTSD - types

• Acute – symptoms last up to 3 months

• Chronic– symptoms last >=3 months

• Delayed onset– symptoms start > 6 months after traumatic

event

PTSD – treatment

Pharmacotherapy• SSRIs, venlefaxine XR

Psychotherapy• CBT: EMDR• psychoeducation • group therapy• formalized stress de-briefing is not

recommended

Eye Movement Desensitization & Reprocessing

(EMDR)

• Eye movements are used to engage the patients’ attention to an external stimulus, while the they are simultaneously focusing on internal distressing material

Acute stress disorder

• occurs in response to a traumatic event

• accompanied by dissociative symptoms– 5 Ds: detachment, dazed, derealization,

depersonalization, dissociative amnesia

• lasts from 2 days to 1 month

Anxiety disorder Life time prevalence (%) & F:M Key features Treatment

Social Phobia 13%, 1.5:1

Low SES

Anxiety triggered by social/ performance situations

“PERSON”

SSRI,effexor, benzoPerformance desensitization, social skills training

Specific Phobia 12.5%, 2:1

Young onset: 5-12 yo

Anxiety triggered by specific object / situation

“PERSON”

Beta blockers, benzo

systematic desensitization, exposure, supportive therapy

PTSD 9%, 2:1 Hx of trauma--- re-experience, avoidence, arousal

“ TRAPED”

SSRI,effexorEMDR

GAD 5%, 2:1

Low SES

Excessive worry 6/12

3 “BE SKIM”

SSRI,effexor, benzo, imipramine, bupropion, buspirone, relaxatin

Panic Disorder 4.7%, 2-3:1 recurrent attacks (not trigger), >=4/13 “STUDENTS Fear the 3 Cs”

SSRI, Effexor, clomipramine, benzo. 8-12 mos

exposure, relaxation

OCD 2-3%, M=F in adults, M>F in adolescents

Presence of obsessions or compulsions or both “IRON RRRONS”

SSRI (high dose), clomipramine, adjunctive risperidone tx for 6-24 mos

ERP

Summary of anxiety disorders

Sample multiple choice questions

Which of the following statements regarding anxiety and gender differences is true?

A. Women have higher rates of almost all anxiety d/osB. Gender ratios are nearly equal with OCDC. No significant dirrence exists in average age of anxiety onsetD. Women have a twofold greater lifetime rate of agoraphobia than menE. All of the above

Which one of the following is not a component of the DSM-IV diagnostic criteria for OCD?

A. Obsessions are acknowledged as excessive or unreasonable B. There are attempts to ignore or suppress compulsive thoughts or impulses C. Obsession or compulsions are time consuming and take > 1hr/dayD. Children need not to recognize their obsessions are unreasonable E. The person recognizes obsessional thoughts as a product of outside themselves

Anxiety disorders

A. Are greater among people at lower SES B. Are highest amon those with higher educationC. Are lowest among homemakersD. Have shown different prevalences with regard to social class but

not ethnicity A. All of the above

Which one of the following situations are most likely to cause PTSD

A. Involvement in an earthquakeB. Being diagnosed with cancerC. RapeD. Witnessing a crimeE. Observing a flood

The risk of developing anxiety d/os is enhanced by

A. Eating disorder B. Depression C. Substance abuseD. Allergies E. All of the above

Isolated panic attacks without functional disturbances

A. Are uncommonB. Occur in <2% of population \C. Are part of the criteria for diagnosis of PDD. Usually involve anticipatory anxiety or phobic avoidence E. None of the above

Which of the following statements are true about patients with obsessive compulsive personality disorder?

A. They have obsessions only B. They have compulsions onlyC. They have both obsessions & compulsions D. None of the above

Which one of the following is not typical of course of panic d/o

A. Onset is typically late adolescence or early adulthoodB. Tends to exhibit a fluctuating courseC. Typical patients exhibit a patter of chronic disabilityD. Majority of the pts live relatively normal livesE. All of the above

Tourette’s d/o has been shown to possibly have a familial & genetic Relationship with

A. Panic d/oB. Social phobiaC. GADD. OCDE. None of the above

Isolated panic attacks without functional disturbances

A. Are uncommonB. Occur in <2% of population \C. Are part of the criteria for diagnosis of PDD. Usually involve anticipatory anxiety or phobic avoidence E. None of the above

Which one of the following is most common symptom pattern associated with OCD?

A. Obsession of doubtB. Obsession of contaminationC. Intrusive thoughts D. Obsession of symmetryE. Compulsive hoarding

Case examples

Panic disorder - I

• "It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying

• "For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds really hard, I feel like I can't get my breath, and there's an overwhelming feeling that things are crashing in on me

Panic disorder - II

• "In between attacks there is this dread and anxiety that it's going to happen again. I'm afraid to go back to places where I've had an attack. Unless I get help, there soon won't be anyplace where I can go and feel safe from panic."

Obsessive-compulsive disorder - I

• "Getting dressed in the morning was tough because I had a routine, and if I didn't follow the routine, I'd get anxious and would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behaviour. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.

Obsessive-compulsive disorder - II

• "I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a "bad" number.

Obsessive-compulsive disorder - III

• "I knew the rituals didn't make sense, and I was deeply ashamed of them, but I couldn't seem to overcome them until I had therapy."

PTSD - I

• "I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling.

• "Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn't aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.

PTSD - II

• "The rape happened the week before Thanksgiving, and I can't believe the anxiety and fear I feel every year around the anniversary date. It's as though I've seen a werewolf. I can't relax, can't sleep, don't want to be with anyone. I wonder whether I'll ever be free of this terrible problem."

Social phobia - I

• "In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick at my stomach-it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.

Social phobia - II

• "When I would walk into a room full of people, I'd turn red and it would feel like everybody's eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn't think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn't wait to get out.

• "I couldn't go on dates, and for a while I couldn't even go to class. My sophomore year of college I had to come home for a semester. I felt like such a failure."

GAD - I

• "I always thought I was just a worrier. I'd feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I'd worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn't let something go.

GAD - II

• "I'd have terrible sleeping problems. There were times I'd wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I'd feel a little light-headed. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomach-ache, I'd think it was an ulcer.

• "When my problems were at their worst, I'd miss work and feel just terrible about it. Then I worried that I'd lose my job. My life was miserable until I got treatment."

Good luck on the exam!