ANXIETY DISORDERS Psychiatrické centrum Praha 3. LF UK Praha Centrum neuropsychiatrických studií.

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ANXIETY DISORDERS Psychiatrické centrum Praha 3. LF UK Praha Centrum neuropsychiatrických studií

Transcript of ANXIETY DISORDERS Psychiatrické centrum Praha 3. LF UK Praha Centrum neuropsychiatrických studií.

ANXIETY DISORDERS

Psychiatrické centrum Praha3. LF UK Praha

Centrum neuropsychiatrických studií

Definition of anxiety

Anxiety:

Feelings of fear or dread

Not-concrete content

Inner tension

Autonomic symptoms

Anxiety Disorder = duration-wise and/or intensity-wise out of proportion reactions.

ANXIETY DISORDERS

• Anxiety disorders are the most common mental illnesses: an estimated 13 percent of adults ages 18 – 54 in a given year, or more than 19 million people (USA), are affected by these debilitating disorders. There are several major types of anxiety disorders, each with its characteristics.

AnxietyPrimary human emotion

Adaptation in phylogeny:

Protection against repeated danger

Preparation for fight or flight

Continuum against normal and pathological anxiety

Epidemiology5 % prevalence

SPECIFIC PHOBIA 4.5%

PANIC DISORDER ± AGORAPHOBIA 2%

SOCIAL ANXIETY DISORDER 4%

POST TRAUMATIC STRESS DISORDER 3.5%

OBSESSIVE COMPULSIVE DISORDER 2.5%

GENERALIZED ANXIETY DISORDER 3%

2x higher prevalence in F comp.M (GAD a phobias)

OnsetEarly adulthood

30- 35 y. (GAD)

CourseChronic

Agoraphobia and OCD v 80% chronification

20-25 30-35 y.

intenzity

yearsStress event

MEDICAL CAUSES OF ANXIETY

MEDICAL CONDITIONS (thyreotoxicosis)

BEVERAGES HERBAL TREATMENTS PRESCRIPTION DRUGS STREET DRUGS

Psychology of anxiety

Psychoanalytic and dynamic theories: Unconscious conflicts call for defensive mechanisms

to handle the anxiety. Bringing the unconscious conflicts into awareness

eliminates the need for defensive mechanisms and alleviates the anxiety

Learning and behavioral theories:

Learning of maladaptive behaviors

The cognitive model:

Disordered cognition leads to mental disorders.

The vulnerability-stress model

Abnormal behavior

= Predisposition + Stress

Predisposition due to genetic background.

Stress due to environmental challenge.

Research paradigm: fraternal vs. identical twins.

Neurobiology of anxietyGenetics

Rats: anxiety reactors and non-reactors (fervency of defecation, vocalization during separation)

Offspring (panic disorder): 15-20% (vs. 2-4% in controls)

GAD in monozygotic twins : 20-30% vs. less than 10% in dizygotic (Kendler, 1992)

Neurobiology of anxietyNeuroanatomy

Anxiety: limbic system, amygdala, locus coeruleus, frontal cortex, hyperperfuzion (asymmetric) parahipokampal gyrus in lactate infusion (Panic disord)

(Reiman, 1984)

Ablation of amygdala – anxiety amelioration

(Davis, 1992)

Information processing and anxiaty

Emotional stimulus

Amygdala Hippocampus

mPFC OFC

Thalamus

Autonomic reaction

Behavioral reaction

Endocrinne reaction

Deklarativní paměť

L. Coeruleus (Noradrenaline)

18FDG PET panic disorder versus controls

Horáček, Praško, 2003

18FDG PET panic disorder versus controls

Horáček, Praško, 2003

Neurobiology of anxietyNeurotransmittion

GABAA

Noradrenaline (L.coeruleus)

2 antagonists (yohimbin) – induction of anxiety

5-HT agonism acute- anxiogenic effect, chronic (SSRI) anxiolytic effect

Etiology of pathological anxiety

Anxiety

Biological factors

DispositionGABA, NADR, 5-HT, LS and amygdala, somatic disease (thyroid gland, feochromocytoma, mitral valve prolapsus, arytmia, myocardial ischemic disease …Psychogenic factors

Triggers, changes in

disposition

DynamicIntrapsychical conflict Separation, frustrationStrong attachment ProtectivityStress acute or chronic

Behavioral and cognitive Learned (conditioned) behaviourLearned (conditioned) cognition

Versions of anxiety

Anxiety:

Generalized (free floating)

Panic (paroxysmal)

Anxiety is unstable and frequently is transformed into different clinical symptomatic clusters.

Transformation of pathological anxiety

Anxiety:

Generalized (free floating) Panic (paroxysmal)

concretization Phobia

compulsiveness OCD

dissociation Dissociative, conversive disorders

somatization Somatophorm disorders

grief Anxiety depressive disorder

F40-F48 NEUROTIC, STRESS-RELATED AND SOMATOFORM DISORDERS

F40 Phobic anxiety disorders

F41 Other anxiety disorders

F42 Obsessive-compulsive disorder

F43 Reaction to severe stress, and adjustment disorder

F44 Dissociative [conversion] disorder

F45 Somatoform disorders

F48 Other neurotic disorders

Anxiety DisordersDSM-IV

• Panic disorder (w/wo agoraphobia)• Agoraphobia (w/o a history of panic

disorder)• Generalized anxiety disorder (GAD)• Obsessive-compulsive disorder (OCD)• Social phobia • Specific phobia• Posttraumatic stress disorder• Acute stress disorder

Panic Disorder

• Discrete, unexpected episodes of intense fear and alarming physical symptoms (panic attack)

• Most frequent presentations:– Neurological…………..44%– Cardiac………………..39%– Gastrointestinal..……...33%

• One year prevalence of 1% - 2% • Twice as common in women than men• 60% - 90% comorbid depression

Panic disorderGenotype: predisposition in twin studies.Biochemical: serotonin deficiency in the

limbic system.Physiological: chronic hyper-activation of

the limbic system.Behavioral: hyper-vigilance to external and

internal cues.Learning: excessive classical acquisition

of fear and operant acquisition of avoidance.

Cognitive: over-interpretation of autonomous cues & lack of control.

PANIC ATTACK

Tension

time5 - 25 min

Functional tension

Triggers:excerciseworriessexnonREMpanicogens

COGNITIONBIOLOGICAL CHANGESANXIETYSOMATIC REACTIONSANXIOUS BEHAVIOUR

ADAPTATION REACTION -INHIBITION

Anticipation anxiety and cognitionHigh arousalSafeguarding and avoidance behaviour Interpersonal changes

Case: Panic Disorder

It started 10 years ago. I was sitting in a seminar in a hotel and this thing came out of the clear blue. I felt like I was dying. For me, a panic attack is almost a violent experience. I feel like I'm going insane. It makes me feel like I'm losing control in a very extreme way. My heart pounds really hard, things seem unreal, and there's this very strong feeling of impending doom. In between attacks there is this dread and anxiety that it's going to happen again.

From the National Institute of Mental Health’s Web Site

Panic disorder – a case story"In between attacks there is this anxiety that it's

going to happen again. I'm afraid to go back to places where I've had an attack. Soon won't be anyplace where I can go and feel safe from panic.“

“For me, a panic attack is a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds hard, I feel I can't get my breath, and that things are crashing in on me.”

Find the autonomic, cognitive, behavioral and emotional feeling components.

Agoraphobia

• Anxiety about being in situations from which escape might be difficult or embarrassing– unexpected or situationally predisposed panic

attack – panic-like symptoms

• Situations are avoided or endured with marked distress or anxiety

• Not better accounted for by another mental disorder like social phobia or specific phobia

Generalized Anxiety Disorder

• Chronic, excessive worry, with symptoms of increased motor tension and arousal

• Typically seek help for somatic concerns• Women > men• One year prevalence of 3 - 4%• Prevalence in primary care setting of 8%

General Anxiety Disorder Clinical Example

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. There were times I'd wake up wired in the morning or in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. My heart would race or pound. And that would make me worry more.

From the National Institute of Mental Health’s Web Site

Generalized anxiety disorder"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 lightheaded. 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 stomachache, I'd think it was an ulcer.”

Find the autonomic, cognitive, behavioral and emotional feeling components.

Obsessive-Compulsive Disorder(OCD)

• Obsessions: recurrent uncontrollable thoughts that are

intrusive and senseless• Compulsions: repetitive behaviors (rituals)

to neutralize discomfort or prevent a dreaded event

• Women = men• One year prevalence of 2%

Obsessive-Compulsive Disorder Clinical Example

I couldn't do anything without rituals. They transcended every aspect of my life. Counting was big for me. When I set my alarm at night, I had to set it to a number that wouldn't add up to a "bad" number. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. If I was writing a term paper, I couldn't have a certain number of words on a line if it added up to a bad number. I was always worried that if I didn't do something, my parents were going to die. Or I would worry about harming my parents, which was completely irrational.

From the National Institute of Mental Health’s Web Site

Social Phobia

• Fear of being embarrassed in a social setting• Point prevalence of 5-10%• High co-morbidity with alcohol abuse and

depression• Occurs more frequently among biological

relatives• Epidemiologically, women > men however in

clinical samples men women

Social Phobia Clinical Example

I couldn't go on dates or to parties. For a while, I couldn't even go to class. My sophomore year of college I had to come home for a semester. My fear would happen in any social situation. I would be anxious before I even left the house, and it would escalate as I got closer to class, a party, or whatever. I would feel sick to 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.

From the National Institute of Mental Health’s Web Site

Specific Phobia

• Persistent, irrational fears of certain objects or situations

• Examples: snakes, closed-in spaces, flying, blood/injury, storms, and bridges

• One year prevalence of 9%• Sex ratio varies

– 75-90% animal/natural type are female; 55-70% blood injection type are female

From the National Institute of Mental Health’s Web Site

Specific Phobia Clinical Example

I'm scared to death of flying, and I never do it anymore. It's an awful feeling when that airplane door closes and I feel trapped. My heart pounds and I sweat bullets. If somebody starts talking to me, I get very stiff and preoccupied. When the airplane starts to ascend, it just reinforces that feeling that I can't get out. I picture myself losing control, freaking out, climbing the walls, but of course I never do. I'm not afraid of crashing or hitting turbulence. It's just that feeling of being trapped.

From the National Institute of Mental Health’s Web Site

Posttraumatic Stress Disorder(PTSD)

• Occurs in response to an event in which grave physical harm was threatened or occurred– Event is re-experienced– Persistent avoidance of reminders– Persistent increased arousal

• Symptoms > 1 month (PTSD)• Symptoms < 1 month (Acute Stress Disorder)• Lifetime prevalence of 1 - 14%

Posttraumatic Stress Disorder (PTSD) Clinical Example

I was raped when I was 25 years old. For a long time, I spoke about the rape on an intellectual level, as though it was something that happened to someone else. I was very aware that it had happened to me, but there just was no feeling. "I started having flashbacks. They kind of came over me like a splash of water. Suddenly I was reliving the rape. I would get very flushed or a very dry mouth and my breathing changed. I was held in suspension. I was in a bubble, just kind of floating.

From the National Institute of Mental Health’s Web Site

TYPES OF TREATMENTS

• COUNSELLING / PSYCHOTHERAPY– Cognitive– Behaviour– Interpersonal

• DRUG THERAPIES– Minor Tranquilizers– Antidepressant / Anti anxiety

LENGTH OF TREATMENT

• SHORT TERM

• LONG TERM

Treatment of anxiety disordersTreatment of anxiety disorders

Psychotherapy

Pharmacotherapy

Education and support

Exercise