Anxiety Disorders Back to Basics 2012 Dr. Holly Dornan PGY-4 Psychiatry Resident University of...
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Transcript of Anxiety Disorders Back to Basics 2012 Dr. Holly Dornan PGY-4 Psychiatry Resident University of...
Anxiety DisordersAnxiety DisordersBack to Basics Back to Basics
20122012Dr. Holly DornanDr. Holly Dornan
PGY-4 Psychiatry ResidentPGY-4 Psychiatry Resident
University of OttawaUniversity of Ottawa
LMCC ObjectivesLMCC ObjectivesKey ObjectivesKey Objectives In patients with many other medical complaints and/or In patients with many other medical complaints and/or
excessive utilisation of medical health care, determine excessive utilisation of medical health care, determine whether anxiety co-exists.whether anxiety co-exists.
Differentiate situational stress from true anxiety Differentiate situational stress from true anxiety disorder and from drug and physical causes of anxiety.disorder and from drug and physical causes of anxiety.
ObjectivesObjectives Through efficient, focused, data gathering:Through efficient, focused, data gathering: Review various physical symptoms briefly; elicit history Review various physical symptoms briefly; elicit history
of other non-psychiatric illness, intake of alcohol and of other non-psychiatric illness, intake of alcohol and caffeine, and a brief history of any major life stresses.caffeine, and a brief history of any major life stresses.
Elicit a history of excessive worry about events which Elicit a history of excessive worry about events which is out of proportion to the impact of the event; history is out of proportion to the impact of the event; history present for at least six months (anxiety).present for at least six months (anxiety).
LMCC ObjectivesLMCC Objectives Determine whether there is restlessness, fatigue, Determine whether there is restlessness, fatigue,
inability to concentrate, irritability, muscle tension, inability to concentrate, irritability, muscle tension, sleep disturbance.sleep disturbance.
Determine whether social, occupational, or function Determine whether social, occupational, or function in general has been affected.in general has been affected.
Determine whether co-morbid psychiatric disorders Determine whether co-morbid psychiatric disorders exist, stress, substance abuse, past sexual, physical exist, stress, substance abuse, past sexual, physical and emotional abuse, or neglect.and emotional abuse, or neglect.
Determine whether there is a discrete period of Determine whether there is a discrete period of intense fear, recurrent panic attacks,>1 month of intense fear, recurrent panic attacks,>1 month of concern about more attacks, change in behavior in concern about more attacks, change in behavior in relation to attacks, along with cardiopulmonary, relation to attacks, along with cardiopulmonary, neurologic, psychiatric or other medical symptoms ± neurologic, psychiatric or other medical symptoms ± agoraphobia.agoraphobia.
LMCC ObjectivesLMCC Objectives List and interpret critical clinical and laboratory List and interpret critical clinical and laboratory
findings which were key in the processes of findings which were key in the processes of exclusion, differentiation, and diagnosis.exclusion, differentiation, and diagnosis.
Conduct an effective initial plan of management for Conduct an effective initial plan of management for a patient with anxiety or panic:a patient with anxiety or panic:
Outline supportive therapy (e.g., psychosocial Outline supportive therapy (e.g., psychosocial interventions) and counseling and list indications interventions) and counseling and list indications for drug therapy (e.g., selective serotonin re-for drug therapy (e.g., selective serotonin re-uptake inhibitors).uptake inhibitors).
Select patients in need of specialized care.Select patients in need of specialized care.
LMCC ObjectivesLMCC Objectives
Applied Scientific ConceptsApplied Scientific Concepts
1. Explain that although the 1. Explain that although the pathophysiology of panic disorder/attacks pathophysiology of panic disorder/attacks is incompletely understood, the amygdala, is incompletely understood, the amygdala, locus ceruleus, and hippocampus along locus ceruleus, and hippocampus along with several neurotransmitters have been with several neurotransmitters have been the focus of attention.the focus of attention.
LMCC ObjectivesLMCC Objectives Causal ConditionsCausal Conditions 1. Panic attack1. Panic attack a. Cardiopulmonary symptoms - 40%a. Cardiopulmonary symptoms - 40% b. Neurologic symptoms - 40%b. Neurologic symptoms - 40% c. Gastrointestinal symptoms - 30%c. Gastrointestinal symptoms - 30% d. Psychiatric symptomsd. Psychiatric symptoms e. Autonomic symptomse. Autonomic symptoms
2. Panic disorder2. Panic disorder a. With agoraphobia/Without agoraphobiaa. With agoraphobia/Without agoraphobia b. With social/Specific phobiab. With social/Specific phobia c. Trauma/Stress related/Post traumatic stress disorderc. Trauma/Stress related/Post traumatic stress disorder
3. Associated with other conditions3. Associated with other conditions a. Depressiona. Depression b. Obsessive compulsive disorderb. Obsessive compulsive disorder c. Substance abusec. Substance abuse
4. Generalized anxiety disorder4. Generalized anxiety disorder
What is anxiety?What is anxiety? A feeling state consisting of physical, A feeling state consisting of physical,
emotional and behavioural responses to emotional and behavioural responses to perceived threatsperceived threats11
Diffuse, unpleasant sense of apprehension Diffuse, unpleasant sense of apprehension accompanied by physical symptoms such accompanied by physical symptoms such as headache, sweating, palpitations, chest as headache, sweating, palpitations, chest tightness, stomach upset, restlessnesstightness, stomach upset, restlessness
Normal and necessary part of everyday Normal and necessary part of everyday lifelife
1 Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Anxiety vs. FearAnxiety vs. FearAnxiety
Fear
Threat
Threat
Response to a threat that is unknown, internal, vague or
conflictual
Response to a known, external, definite threat
Anxiety as a DisorderAnxiety as a Disorder
When does anxiety become a disorder?When does anxiety become a disorder? 1)1) Greater intensity and/or duration than Greater intensity and/or duration than
expected given the circumstancesexpected given the circumstances
2)2) Leads to impairment or disability Leads to impairment or disability
3)3) Daily activities are disrupted by avoidance Daily activities are disrupted by avoidance of of certain situations or objects to decrease certain situations or objects to decrease
anxietyanxiety
4)4) Includes clinically significant unexplained Includes clinically significant unexplained physical physical symptoms, obsessions, compulsions, symptoms, obsessions, compulsions, or intrusive or intrusive recollections of traumarecollections of trauma
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
AnxietyAnxiety
Anxiety =Anxiety =Likelihood x Harm
Ability to cope
Overestimated
Underestimated
Beck et al. 1985
Pathophysiology of Pathophysiology of AnxietyAnxiety
Caudate nucleus has been implicated Caudate nucleus has been implicated in OCDin OCD
fMRI studies have found increased fMRI studies have found increased activity in the amygdala in PTSDactivity in the amygdala in PTSD
Abnormalities in parahippocampal Abnormalities in parahippocampal gyrus in Panic Disordergyrus in Panic Disorder
3 major neurotransmitters involved 3 major neurotransmitters involved are norepinephrine, serotonin, and are norepinephrine, serotonin, and GABAGABA
Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
Limbic cortex
Periaqueductal Gray matter
Brain Stem
Ventral Tegmental Area
Hippocampus
Amygdala
Nucleus accumbens
Orbitofrontal cortex
* Slide courtesy of Dr. Elliott Lee
Locus coeruleus
AnxietyAnxiety Patients try to alleviate Patients try to alleviate
the unpleasant feeling the unpleasant feeling of anxiety by:of anxiety by:
1)1) Avoiding the triggerAvoiding the trigger2)2) Developing a safety Developing a safety
behaviour (i.e. having behaviour (i.e. having someone else someone else accompany them)accompany them)
3)3) Using a substance or Using a substance or medicationmedication
Anxiety Disorders in Anxiety Disorders in DSM-IV TRDSM-IV TR
Panic Disorder with and without agoraphobiaPanic Disorder with and without agoraphobiaAgoraphobia without history of Panic DisorderAgoraphobia without history of Panic DisorderSocial PhobiaSocial PhobiaSpecific PhobiaSpecific PhobiaObsessive Compulsive DisorderObsessive Compulsive DisorderGeneralized Anxiety DisorderGeneralized Anxiety DisorderPost Traumatic Stress DisorderPost Traumatic Stress DisorderAcute Stress DisorderAcute Stress DisorderAnxiety Disorder due to a General Medical ConditionAnxiety Disorder due to a General Medical ConditionSubstance-Induced Anxiety DisorderSubstance-Induced Anxiety DisorderAnxiety Disorder NOSAnxiety Disorder NOS
EpidemiologyEpidemiology
Lifetime prevalence for any anxiety Lifetime prevalence for any anxiety disorder ranges from 10% to 29%disorder ranges from 10% to 29%
12 month prevalence 18%12 month prevalence 18% Common presentation in primary care Common presentation in primary care 1:5 to 1:12 patients presenting to 1:5 to 1:12 patients presenting to
primary care will have an anxiety primary care will have an anxiety disorderdisorder
Suicide rate 10 x higher than general Suicide rate 10 x higher than general populationpopulation
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Initial Assessment of Initial Assessment of Patients with AnxietyPatients with Anxiety
Four scenarios:Four scenarios: 1) Anxiety disorder is primary and there 1) Anxiety disorder is primary and there
is no physical disorder present (any is no physical disorder present (any physical symptoms present are due to the physical symptoms present are due to the anxiety)anxiety)
2) The anxiety is secondary to a physical 2) The anxiety is secondary to a physical illness (e.g. hyperthyroidism)illness (e.g. hyperthyroidism)
3) The anxiety is secondary to a 3) The anxiety is secondary to a medication or substancemedication or substance
4) Both an anxiety and physical disorder 4) Both an anxiety and physical disorder are present by not causally relatedare present by not causally related
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Medical conditions that Medical conditions that mimic or worsen anxiety mimic or worsen anxiety
symptomssymptomsEndocrine Endocrine conditionsconditions
HyperthyroidismHyperthyroidism
HypothyroidismHypothyroidism
PheochromocytomaPheochromocytoma
Cushing’s diseaseCushing’s disease
Addison’s diseaseAddison’s disease
MenopauseMenopause
CardiovascularCardiovascular Acute Coronary SyndromeAcute Coronary Syndrome
ArrhythmiaArrhythmia
CHFCHF
HypertensionHypertension
HypertensionHypertension
Mitral Valve ProlapseMitral Valve Prolapse
Medical conditions that Medical conditions that mimic or worsen anxiety mimic or worsen anxiety
symptoms (con’t)symptoms (con’t)NeurologicalNeurological EpilepsyEpilepsy
Cerebrovascular diseaseCerebrovascular disease
Meniere’s diseaseMeniere’s disease
Multiple SclerosisMultiple Sclerosis
MigraineMigraine
EncephalitisEncephalitis
Early dementiaEarly dementia
MetabolicMetabolic PorphyriaPorphyria
DiabetesDiabetes
PulmonaryPulmonary AsthmaAsthma
COPDCOPD
Pulmonary EmbolismPulmonary Embolism
PneumoniaPneumonia
Medical conditions that mimic Medical conditions that mimic or worsen anxiety symptoms or worsen anxiety symptoms
(con’t)(con’t)OtherOther AnemiaAnemia
UTI (in elderly)UTI (in elderly)
Irritable Bowel SyndromeIrritable Bowel Syndrome
Heavy metal poisoningHeavy metal poisoning
B12 deficiencyB12 deficiency
Electrolyte disturbancesElectrolyte disturbances
MedicationsMedications Anti-cholinergicsAnti-cholinergics
SteroidsSteroids
Stimulants (methylphenidate Stimulants (methylphenidate and amphetamine based)and amphetamine based)
TheophyllineTheophylline
VentolinVentolin
Nasal decongestantsNasal decongestants
SSRIsSSRIs
Substance Abuse and Substance Abuse and AnxietyAnxiety
Substance abuse is often co-morbid with Substance abuse is often co-morbid with anxiety disorders as patients often try to self-anxiety disorders as patients often try to self-medicate to cope with anxiety medicate to cope with anxiety
37% of patients with GAD and 20-40% of 37% of patients with GAD and 20-40% of patients with Panic Disorder have alcohol patients with Panic Disorder have alcohol abuse/dependenceabuse/dependence
Drug intoxication can mimic anxiety:Drug intoxication can mimic anxiety: - - Amphetamines - MarijuanaAmphetamines - Marijuana
- Caffeine - Hallucinogens- Caffeine - Hallucinogens
- Nicotine - Ecstasy- Nicotine - Ecstasy
- Cocaine - Excessive alcohol consumption- Cocaine - Excessive alcohol consumption
- Phencyclidine- Phencyclidine
Substance Abuse and Substance Abuse and Anxiety (con’t)Anxiety (con’t)
Drug withdrawal also associated Drug withdrawal also associated with anxietywith anxiety
AlcoholAlcohol BenzodiazepinesBenzodiazepines OpiateOpiate BarbiturateBarbiturate Anti-hypertensivesAnti-hypertensives
Key features Key features Panic Panic
DisorderDisorder• Fear of losing control, dying or Fear of losing control, dying or going crazygoing crazy• Avoid situations in which attacks Avoid situations in which attacks may occurmay occur
AgoraphoAgoraphobiabia
• Fear of situations from which Fear of situations from which escape may be difficult or help escape may be difficult or help unavailable (crowds, bus, bridge unavailable (crowds, bus, bridge etc.)etc.)
OCDOCD • Intrusive, unwanted thoughts or Intrusive, unwanted thoughts or urges (urges (obsessionsobsessions) and/or ) and/or repetitive behaviours or mental repetitive behaviours or mental acts (acts (compulsionscompulsions))• Fear of harm, uncertainty, Fear of harm, uncertainty, uncontrollable actionsuncontrollable actions
Key features Key features GeneraliGenerali
zedzed
Anxiety Anxiety
• Anxiety regarding a number of Anxiety regarding a number of everyday eventseveryday events• Future and uncertainty difficult to Future and uncertainty difficult to acceptaccept
Social Social AnxietyAnxiety
• Fear of humiliation, Fear of humiliation, embarrassment or scrutiny by embarrassment or scrutiny by othersothers
PTSDPTSD • Re-experiencing of trauma Re-experiencing of trauma through flashbacks, dreams, through flashbacks, dreams, recollectionsrecollections
Specific Specific phobiaphobia
• Fear of a specific object, animal or Fear of a specific object, animal or situationsituation
Generalized Anxiety Generalized Anxiety Disorder – DSM IV TRDisorder – DSM IV TR
Excessive anxiety and worry about a Excessive anxiety and worry about a number of events or activitiesnumber of events or activities, occurring , occurring more days than not for at least more days than not for at least 6 months6 months
Difficult to Difficult to controlcontrol the worry the worry Associated with Associated with three three of the followingof the following
Restlessness, difficulty concentrating, muscle tension, Restlessness, difficulty concentrating, muscle tension, fatigue, sleep disturbances, irritabilityfatigue, sleep disturbances, irritability
Not due to a substance, medical condition Not due to a substance, medical condition or other mental disorderor other mental disorder
Causes clinically significant distress or Causes clinically significant distress or impairment in functioningimpairment in functioning
Generalized Anxiety Generalized Anxiety Disorder Disorder
Lifetime prevalence 6%Lifetime prevalence 6%11
68 % comorbidity with other psychiatric 68 % comorbidity with other psychiatric illness (depression, substance abuse, illness (depression, substance abuse, other anxiety disorder)other anxiety disorder)
Female to male ratio 2:1Female to male ratio 2:111
25% of 125% of 1stst degree relatives also have degree relatives also have GADGAD22
Twin studies show concordance rate of Twin studies show concordance rate of 50%50%22
2Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
1Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Generalized Anxiety Generalized Anxiety DisorderDisorder
Chronic condition, usually lifelongChronic condition, usually lifelong Screening questionsScreening questions
Do others call you a worry-wort?Do others call you a worry-wort? What kinds of things do you worry about?What kinds of things do you worry about?
Usually seek treatment for somatic Usually seek treatment for somatic symptoms rather than anxietysymptoms rather than anxiety
Only 1/3 seek psychiatric treatmentOnly 1/3 seek psychiatric treatment Often see specialists (GI, cardiology, Often see specialists (GI, cardiology,
internists)internists)Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
GAD - treatmentGAD - treatment Pharmacotherapy:Pharmacotherapy:
11stst line SSRI or SNRI line SSRI or SNRI 22ndnd line Benzodiazepine line Benzodiazepine
Only recommended for short term use Only recommended for short term use due to side effects (cognitive due to side effects (cognitive impairment, ataxia, sedation) and impairment, ataxia, sedation) and dependence and withdrawal)dependence and withdrawal)
Avoid in substance abuse and the Avoid in substance abuse and the elderlyelderly
33rdrd line Adjunctive olanzapine or risperidone line Adjunctive olanzapine or risperidone MirtazapineMirtazapine
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
GAD - treatmentGAD - treatment
An optimal trial involves 8-12 weeksAn optimal trial involves 8-12 weeks If there is not an adequate response, If there is not an adequate response,
switch to another 1switch to another 1stst line agent line agent Reasonable to try another 1Reasonable to try another 1stst line line
agent with a different mechanism of agent with a different mechanism of actionaction
Treatment resistant patients should Treatment resistant patients should be assessed for comorbid medical and be assessed for comorbid medical and psychiatric conditionspsychiatric conditionsCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
GAD - treatmentGAD - treatment Psychological treatment:Psychological treatment: CBT as effective as medication (also 1CBT as effective as medication (also 1stst
line)line) CBT involves:CBT involves:
PsychoeducationPsychoeducation Cognitive interventions (addressing cognitive Cognitive interventions (addressing cognitive
distortions, unrealistic beliefs)distortions, unrealistic beliefs) ExposureExposure Relaxation strategiesRelaxation strategies Problem SolvingProblem Solving Assertiveness trainingAssertiveness training Relapse PreventionRelapse Prevention
Panic Attack – DSM-IV Panic Attack – DSM-IV criteriacriteria
A discrete period of intense fear or discomfort, in A discrete period of intense fear or discomfort, in which 4 or more develop abruptly and reach a peak which 4 or more develop abruptly and reach a peak within ten minutes:within ten minutes:
Palpitations, increased heart ratePalpitations, increased heart rate SweatingSweating Tremor or shakingTremor or shaking Shortness of breath or smothering sensationShortness of breath or smothering sensation Feeling of chokingFeeling of choking Chest painChest pain Nausea or abdominal distressNausea or abdominal distress Feeling dizzy, lightheaded, or faintFeeling dizzy, lightheaded, or faint DerealizationDerealization DepersonalizationDepersonalization ParasthesiasParasthesias Chills or hot flushesChills or hot flushes Fear of losing control or going crazyFear of losing control or going crazy Fear of dyingFear of dying
Panic Disorder with or Panic Disorder with or without agoraphobia – without agoraphobia –
DSM-IV criteriaDSM-IV criteria The person has experienced both :The person has experienced both :
Recurrent, unexpected panic attacksRecurrent, unexpected panic attacks One or more of the attacks has been followed by One or more of the attacks has been followed by
either either
1) Persistent concern about having another 1) Persistent concern about having another attackattack
2) Worry about the implications of the attack2) Worry about the implications of the attack
3) Significant change in behaviour3) Significant change in behaviour
The presence (or absence of agoraphobia)The presence (or absence of agoraphobia) Not due to a substance, medication or Not due to a substance, medication or
medical conditionmedical condition Not better accounted for by another mental Not better accounted for by another mental
disorderdisorder
Panic DisorderPanic Disorder
Lifetime prevalence of Panic Disorder is Lifetime prevalence of Panic Disorder is 4.7%4.7%
Lifetime prevalence of having a panic Lifetime prevalence of having a panic attack is 15%attack is 15%
1/3 to 1/2 of patients also have 1/3 to 1/2 of patients also have agoraphobiaagoraphobia
More common in women than in menMore common in women than in men Generally begins in late adolescence or Generally begins in late adolescence or
early adulthoodearly adulthoodCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Panic DisorderPanic Disorder
20 X the risk of suicidal ideation and suicide 20 X the risk of suicidal ideation and suicide attempts as the general populationattempts as the general population
Felt to be related to dysregulation of brain Felt to be related to dysregulation of brain noradrenergic systems noradrenergic systems
Abnormalities have been found in the Abnormalities have been found in the autonomic nervous system of some patients autonomic nervous system of some patients (increased sympathetic tone, less adaptive (increased sympathetic tone, less adaptive to repeated stimulit)to repeated stimulit)
Kaplan and Sadock’s Synopsis of Psychiatry 10th edition
Panic DisorderPanic Disorder Initially, panic attacks are unexpectedInitially, panic attacks are unexpected
Can occur any time (even night) Can occur any time (even night)
Can also develop panic attacks that have Can also develop panic attacks that have triggers (situationally-predisposed panic triggers (situationally-predisposed panic attacks)attacks)
Patients begin to have anticipatory anxiety Patients begin to have anticipatory anxiety about having another panic attackabout having another panic attack
This can lead to avoidance of situations where This can lead to avoidance of situations where escape or help may not be readily available escape or help may not be readily available (agoraphobia)(agoraphobia)
Panic Disorder - Panic Disorder - TreatmentTreatment
Pharmacotherapy:Pharmacotherapy: 11stst line SSRI or SNRI line SSRI or SNRI 22ndnd line Benzodiazepines line Benzodiazepines
Only recommended for short term use due Only recommended for short term use due to side effects (cognitive impairment, to side effects (cognitive impairment, ataxia, sedation) and dependence and ataxia, sedation) and dependence and withdrawalwithdrawal
Avoid in substance abuse and the elderlyAvoid in substance abuse and the elderly
** Often clinically, a small dose of long acting ** Often clinically, a small dose of long acting benzodiazepine is started along with SSRI/SNRI to benzodiazepine is started along with SSRI/SNRI to provide more immediate relief from distressing provide more immediate relief from distressing symptomssymptoms
i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered until it is stoppeduntil it is stopped
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Panic Disorder - Panic Disorder - TreatmentTreatment
Psychological treatment:Psychological treatment:
CBT most consistently efficacious psychotherapy CBT most consistently efficacious psychotherapy for Panic Disorder, according to the literaturefor Panic Disorder, according to the literature
Individual or group therapy, bibliotherapyIndividual or group therapy, bibliotherapy CBT for Panic Disorder includes same CBT CBT for Panic Disorder includes same CBT
concepts of psychoeducation, cognitive concepts of psychoeducation, cognitive approaches, relaxation, problem solving approaches, relaxation, problem solving
Also incorporates Also incorporates interoceptive exposureinteroceptive exposure (exposure to feared symptoms (exposure to feared symptoms therapist may ask therapist may ask patient to hyperventilate or spin to make patient to hyperventilate or spin to make themselves dizzy)themselves dizzy)
Exposure to avoided situations is importantExposure to avoided situations is important
Obsessive Compulsive Obsessive Compulsive Disorder – DSM IV criteriaDisorder – DSM IV criteria
Either obsessions or compulsionsEither obsessions or compulsions ObsessionsObsessions are defined as: are defined as:
Recurrent and persistent thoughts, images or impulses Recurrent and persistent thoughts, images or impulses that are experienced as intrusive and inappropriate that are experienced as intrusive and inappropriate and cause marked anxiety/distressand cause marked anxiety/distress
Not simply excessive worries about real-life problemsNot simply excessive worries about real-life problems Person attempts to ignore or suppress the obsessions, Person attempts to ignore or suppress the obsessions,
or neutralize them with other thoughts or actionsor neutralize them with other thoughts or actions Recognized as a product of the patient’s own mindRecognized as a product of the patient’s own mind
CompulsionsCompulsions are defined as: are defined as: Repetitive behaviours or mental acts that the person Repetitive behaviours or mental acts that the person
feels driven to perform in response to an obsession, or feels driven to perform in response to an obsession, or according to rigid rulesaccording to rigid rules
Compulsions are aimed at reducing distress or Compulsions are aimed at reducing distress or preventing some dreaded event, however they are not preventing some dreaded event, however they are not connected in a realistic way to what they are meant to connected in a realistic way to what they are meant to neutralize, or are clearly excessiveneutralize, or are clearly excessive
Obsessive Compulsive Obsessive Compulsive Disorder – DSM IV criteria Disorder – DSM IV criteria
(con’t)(con’t) At some point during the course of the disorder, At some point during the course of the disorder,
the the person recognizesperson recognizes that the obsessions that the obsessions and/or compulsions are and/or compulsions are excessive or excessive or unreasonableunreasonable
The obsessions and/or compulsions cause The obsessions and/or compulsions cause marked distressmarked distress, , are time consuming (> 1 are time consuming (> 1 h/dayh/day), or significantly ), or significantly interfere with interfere with functioningfunctioning
Not due to substance, or another medical or Not due to substance, or another medical or mental disordermental disorder
Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder
Estimated lifetime prevalence of 1.6%Estimated lifetime prevalence of 1.6% Median age of onset 19 years (range 14 – Median age of onset 19 years (range 14 –
30 years)30 years) 60% are female60% are female High psychiatric co-morbidity rate (56% -High psychiatric co-morbidity rate (56% -
83%)83%) Common co-morbidities include Common co-morbidities include substance substance
abuseabuse, , depression, social phobiadepression, social phobia, , generalized anxiety disorder, panic disordergeneralized anxiety disorder, panic disorder
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder
In 50-70% of patients, onset of In 50-70% of patients, onset of symptoms is following a stressful event symptoms is following a stressful event (i.e. pregnancy, death)(i.e. pregnancy, death)
Course is usually long, can be constant Course is usually long, can be constant or fluctuatingor fluctuating
20-30 % have significant improvement20-30 % have significant improvement 40-50% have moderate improvement40-50% have moderate improvement 20-30% have no improvement or 20-30% have no improvement or
worseningworseningKaplan and Sadock’s Synopsis of Psychiatry 10th edition
Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder
20-30% have tics, 6-7% Tourette’s20-30% have tics, 6-7% Tourette’s
Possible link between a subset of OCD and ticsPossible link between a subset of OCD and tics
PET studies have shown increased activity in the PET studies have shown increased activity in the frontal lobes, basal ganglia (caudate), and cingulum frontal lobes, basal ganglia (caudate), and cingulum in patients with OCDin patients with OCD
PANDAS – Pediatric Autoimmune Neuropsychiatric PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infectionsDisorders associated with Streptococcal infections
Streptococcus infection may trigger an autoimmune Streptococcus infection may trigger an autoimmune response which causes acute onset OCD symptoms response which causes acute onset OCD symptoms and tics in childrenand tics in childrenKaplan and Sadock’s Synopsis of Psychiatry 10th edition
Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder Most common obsessions include:Most common obsessions include:
Contamination (#1)Contamination (#1) Doubt/safety (idea that stove was left on, door unlocked Doubt/safety (idea that stove was left on, door unlocked
etc.) (#2)etc.) (#2) Sexual and aggressive impulses (#3)Sexual and aggressive impulses (#3) Symmetry and exactness (#4)Symmetry and exactness (#4) Somatic and religious preoccupationsSomatic and religious preoccupations
Most common compulsions include:Most common compulsions include: CheckingChecking WashingWashing RepeatingRepeating OrderingOrdering CountingCounting HoardingHoarding
OCD - treatmentOCD - treatment Pharmacotherapy:Pharmacotherapy:
11stst line SSRI (serotonergic response needed) line SSRI (serotonergic response needed) 22ndnd line : Clomipramine (2 line : Clomipramine (2ndnd line due to side line due to side
effects – cardiotoxicity, anticholinergic, drug effects – cardiotoxicity, anticholinergic, drug interactions and lethality in overdose)interactions and lethality in overdose)
Effexor XR, MirtazapineEffexor XR, Mirtazapine Adjunctive RisperidoneAdjunctive Risperidone
Dosages of meds e.g. SSRIs may need to be Dosages of meds e.g. SSRIs may need to be higher than in mood disordershigher than in mood disorders
Response may take 6 wks or longer Response may take 6 wks or longer (Guidelines state adequate trial 6-8 weeks)(Guidelines state adequate trial 6-8 weeks)
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
OCD - treatmentOCD - treatment Psychological Psychological
1) Exposure with Response Prevention 1) Exposure with Response Prevention (ERP) – form of behavioural therapy(ERP) – form of behavioural therapy
2) CBT which combines Exposure and Response 2) CBT which combines Exposure and Response Prevention with cognitive interventionsPrevention with cognitive interventions
Posttraumatic Stress Posttraumatic Stress Disorder DSM-IV criteriaDisorder DSM-IV criteria
The person has been exposed to a traumatic The person has been exposed to a traumatic event which included both:event which included both: 1) The person experienced or witnessed an event 1) The person experienced or witnessed an event
involving actual or threatened death or serious involving actual or threatened death or serious injury, or a threat to personal integrity of self or injury, or a threat to personal integrity of self or othersothers
2) Response was fear, horror, or helplessness2) Response was fear, horror, or helplessness
The traumatic event is re-experienced The traumatic event is re-experienced including at least one of:including at least one of: Distressing memories, dreams, acting or feeling Distressing memories, dreams, acting or feeling
as if event is recurring (illusions, dissociative as if event is recurring (illusions, dissociative flashbacks, hallucinations), intense psychological flashbacks, hallucinations), intense psychological or physiological distress when exposed to cues or physiological distress when exposed to cues that symbolize the traumathat symbolize the trauma
Posttraumatic Stress Posttraumatic Stress Disorder DSM-IV criteriaDisorder DSM-IV criteria
Persistent avoiding of stimuli associated with Persistent avoiding of stimuli associated with the trauma and numbing of responsiveness the trauma and numbing of responsiveness including at least 3 of:including at least 3 of: Efforts to avoid thoughts, feelings, conversations Efforts to avoid thoughts, feelings, conversations
associated with the traumaassociated with the trauma Efforts to avoid people, places and activities Efforts to avoid people, places and activities
associated with the traumaassociated with the trauma Inability to recall an important aspect of the Inability to recall an important aspect of the
traumatrauma Feeling of detachment or estrangement from Feeling of detachment or estrangement from
othersothers Restricted range of affectRestricted range of affect Sense of foreshortened futureSense of foreshortened future
Posttraumatic Stress Posttraumatic Stress Disorder DSM-IV criteriaDisorder DSM-IV criteria
Persistent symptoms of increased arousal Persistent symptoms of increased arousal including at least two of:including at least two of: Difficulty falling or staying asleepDifficulty falling or staying asleep Irritability or outbursts of angerIrritability or outbursts of anger Difficulty concentratingDifficulty concentrating HypervigilanceHypervigilance Exaggerated startle reflexExaggerated startle reflex
Duration is more than 1 monthDuration is more than 1 month
Causes clinically significant distress or Causes clinically significant distress or impairment in functioningimpairment in functioning
Posttraumatic Stress Posttraumatic Stress DisorderDisorder
Key features include exposure to trauma, re-Key features include exposure to trauma, re-experiencing of the trauma, avoidance and experiencing of the trauma, avoidance and emotional numbing, and hyperarousalemotional numbing, and hyperarousal
Examples of traumas include exposure to war, Examples of traumas include exposure to war, terrorist attacks, natural disasters, accidents terrorist attacks, natural disasters, accidents involving serious injury or death, rape, tortureinvolving serious injury or death, rape, torture
If symptoms are present for less than one If symptoms are present for less than one month, then the diagnosis may be Acute month, then the diagnosis may be Acute Stress DisorderStress Disorder
Posttraumatic Stress Posttraumatic Stress DisorderDisorder
Prevalence in Canada 2.4% (1 month Prevalence in Canada 2.4% (1 month prevalence) and 9.2% (lifetime prevalence) and 9.2% (lifetime prevalence)prevalence)
Higher among women than menHigher among women than men Lifetime prevalence estimates 16-37% in Lifetime prevalence estimates 16-37% in
areas of the world where conflict has areas of the world where conflict has occurredoccurred
Frequent co-morbidity with depression, Frequent co-morbidity with depression, substance abuse, other anxiety disorderssubstance abuse, other anxiety disorders
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Posttraumatic Stress Posttraumatic Stress DisorderDisorder
6X increased risk of suicide attempts6X increased risk of suicide attempts Predisposing factors include:Predisposing factors include:
Childhood traumaChildhood trauma Inadequate support systemInadequate support system FemaleFemale Genetic vulnerability to psychiatric Genetic vulnerability to psychiatric
illnessillness Excessive alcohol use (recent)Excessive alcohol use (recent)
Posttraumatic Stress Posttraumatic Stress Disorder - TreatmentDisorder - Treatment
Guidelines recommend SSRI/SNRI Guidelines recommend SSRI/SNRI as first line treatmentas first line treatment11
Recommended that patients with Recommended that patients with PTSD should continue medication PTSD should continue medication for at least 1 yearfor at least 1 year11
In practice, agents to help with In practice, agents to help with insomnia are often added (i.e. insomnia are often added (i.e. Trazadone)Trazadone)
1Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Posttraumatic Stress Posttraumatic Stress Disorder - TreatmentDisorder - Treatment
Other meds sometimes used include:Other meds sometimes used include: Clonidine (antiadrenergic agent)Clonidine (antiadrenergic agent) Prazosin for nightmares (alpha-1 Prazosin for nightmares (alpha-1
adrenergic antagonist)adrenergic antagonist)
Psychological treatment:Psychological treatment: CBT recommendedCBT recommended
Social Anxiety Disorder Social Anxiety Disorder (Social phobia) – DSM IV (Social phobia) – DSM IV
criteriacriteria Marked and persistent fear of social or Marked and persistent fear of social or
performance situations in which the person is performance situations in which the person is exposed to unfamiliar people or possible exposed to unfamiliar people or possible scrutiny by othersscrutiny by others Fear that they will embarrass or humiliate themselvesFear that they will embarrass or humiliate themselves
Exposure to the feared situation invariable Exposure to the feared situation invariable produces anxiety which may be in the form of a produces anxiety which may be in the form of a panic attackpanic attack
The person recognizes that the fear is excessive The person recognizes that the fear is excessive or unreasonableor unreasonable
Social Anxiety Disorder Social Anxiety Disorder (Social phobia) – DSM IV (Social phobia) – DSM IV
criteria (con’t)criteria (con’t) The feared situations are avoided or endured The feared situations are avoided or endured
with intense anxiety and distresswith intense anxiety and distress The avoidance, anxious anticipation or distress The avoidance, anxious anticipation or distress
interferes with functioning or causes marked interferes with functioning or causes marked distressdistress
In individuals under 18, duration is at least 6 In individuals under 18, duration is at least 6 monthsmonths
Not due to substance, medical condition or Not due to substance, medical condition or other mental disorderother mental disorder
If a medical condition is present, the fear is not If a medical condition is present, the fear is not related to it (i.e. trembling in Parkinson’s)related to it (i.e. trembling in Parkinson’s)
Social PhobiaSocial Phobia Most people in the general population Most people in the general population
experience a degree of discomfort with experience a degree of discomfort with certain social situationscertain social situations
Generalized type vs. non-generalizedGeneralized type vs. non-generalized (a (a restricted number of situations i.e. public restricted number of situations i.e. public speaking)speaking)
Differentiate fromDifferentiate from panic disorderpanic disorder (panic (panic attacks in social phobia always occur in feared attacks in social phobia always occur in feared situations)situations)
Differentiate from normal shynessDifferentiate from normal shyness (shyness (shyness should not cause functional impairment or marked should not cause functional impairment or marked distress)distress)
Social PhobiaSocial Phobia
Has significant impact on quality of lifeHas significant impact on quality of life
Lifetime prevalence of 8-12Lifetime prevalence of 8-12% 1 % 1 (one of (one of the most common anxiety disorders)the most common anxiety disorders)
Early onset, usually in childhood Early onset, usually in childhood
Chronic course, usually 20 years or Chronic course, usually 20 years or longerlonger
r
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Social PhobiaSocial Phobia Interferes with career, relationship, goals Interferes with career, relationship, goals ““illness of missed opportunities”illness of missed opportunities” Comorbid conditions include substance Comorbid conditions include substance
abuse, depression, or another anxiety abuse, depression, or another anxiety disorderdisorder
Key symptoms include blushing, Key symptoms include blushing, sweating, palpitations, tremor and sweating, palpitations, tremor and lightheadedness, panic attackslightheadedness, panic attacks
Situations are often avoided as an effort Situations are often avoided as an effort to alleviate distressto alleviate distress
Social Phobia - treatmentSocial Phobia - treatment Pharmacotherapy:Pharmacotherapy:
11stst line SSRI or SNRI line SSRI or SNRI 22ndnd line Benzodiazepine line Benzodiazepine
Only recommended for short term use Only recommended for short term use due to side effects (cognitive due to side effects (cognitive impairment, ataxia, sedation) and impairment, ataxia, sedation) and dependence and withdrawaldependence and withdrawal
Avoid in people with substance abuse Avoid in people with substance abuse and the elderlyand the elderly
33rdrd line Adjunctive Abilify or Risperidone line Adjunctive Abilify or Risperidone Mirtazapine, wellbutrinMirtazapine, wellbutrin
** Although not in guidelines, in practice, ** Although not in guidelines, in practice, beta blockers have been used with effect for beta blockers have been used with effect for non-generalized type performance anxietynon-generalized type performance anxiety
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006
Social Phobia - treatmentSocial Phobia - treatment
Psychological treatmentPsychological treatment CBT (group or individual)CBT (group or individual) CBT for social phobia includes exposure CBT for social phobia includes exposure
to feared situations and social skills to feared situations and social skills trainingtraining
Similar efficacy to pharmacotherapySimilar efficacy to pharmacotherapy In practice, CBT and medications are In practice, CBT and medications are
often combined often combined After discontinuation of CBT or After discontinuation of CBT or
medications, gains with CBT last longermedications, gains with CBT last longer
Specific Phobia – DSM IV Specific Phobia – DSM IV criteriacriteria
Excessive or unreasonable fear cued by the Excessive or unreasonable fear cued by the presence or anticipation of a specific object or presence or anticipation of a specific object or situation (insects, flying, heights, blood)situation (insects, flying, heights, blood)
Exposure provokes an immediate anxiety Exposure provokes an immediate anxiety responseresponse
Fear is recognized as excessive or unreasonableFear is recognized as excessive or unreasonable Situation is avoided or endured with intense Situation is avoided or endured with intense
distressdistress Marked distress or interferes with functioningMarked distress or interferes with functioning Not due to a substance, medical condition or Not due to a substance, medical condition or
other mental disorderother mental disorder
Specific PhobiaSpecific Phobia
Lifetime prevalence of 12%Lifetime prevalence of 12% Most common mental disorder Most common mental disorder Begins at young age, 5-12 years oldBegins at young age, 5-12 years old Treatment is exposure based therapyTreatment is exposure based therapy Graded exposure helpfulGraded exposure helpful Virtual reality or computer programs Virtual reality or computer programs
sometimes used for fear of heights, sometimes used for fear of heights, flying, dentistflying, dentist
Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006