Anxiety Disorders - Treatment and Management
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Transcript of Anxiety Disorders - Treatment and Management
Anxiety Spectrum Disorders
F- 40, 41, 42 & 43– Agoraphobia– Social Phobia– Specific (isolated) Phobias– Panic Disorder– Generalized Anxiety Disorder– Obsessive Compulsive Disorder– Acute Stress Disorder– Post Traumatic Stress Disorder
» DSM-IV-TR
Ms. Jinu Abraham, IMHANS, Calicut 2
Fear and Anxiety
Fear– acute, immediate response to suddenly appearing,
imminent danger (proximal threats) Anxiety– sustained, insidious response to danger, as might manifest
when degree to which threat is present remains ambiguous (distal threats)
E.g. – Rodent in a cage Impairment– Disruption in normal functioning– Presence of “clinically significant” distress
» CTP, 9th Edition
Ms. Jinu Abraham, IMHANS, Calicut 3
Psychophysiological Aspects
Anxiety – physiological activity (cardiovascular activity and
electrodermal system)
– subjective reports (feelings of increased muscle tension, heart racing, perspiration, shortness of breath and palpitations)
– overt behaviors (increased reflexes and enhanced muscle tension)
» CTP, 9th Edition
Ms. Jinu Abraham, IMHANS, Calicut 4
Analyzing the Details
8 primary anxiety disorders, distinguished from one another by– Focus of anxiety– Specific symptoms
Panic Disorder– Recurrent unexpected panic attacks with anxiety about
having another attack or concerns about consequences of such attacks for one's well-being
– Fear of fear Agoraphobia– Individual's attempt to avoid experiencing another panic
attack
Ms. Jinu Abraham, IMHANS, Calicut 5
Analyzing the Details…contd
Post Traumatic Stress Disorder– Fear of recollections and reminders of previously
experienced life-threatening event Social Phobia– Fear of embarrassment and rejection
Obsessive Compulsive Disorder– Fear of an idiosyncratic concern (contamination, fire, being
an evil or harmful person, etc.) Generalized Anxiety Disorder– Worry about specific future outcomes
Specific (isolated) Phobias– Fear circumscribed to specific situation or object
Ms. Jinu Abraham, IMHANS, Calicut 6
Global Burden of Disease (GBD)
13% of GBD – Mental Disorders Treatment Gap (Severe Mental Disorders)– 76-85% , low and middle-income countries– 35-50%, high-income countries
» WHO, 2012
Ms. Jinu Abraham, IMHANS, Calicut 7
Medical Etiologies of Anxiety
Neurological– Delirium
– Dementia
– Huntington's Disease
– Migraines
– Multiple Sclerosis
– Other degenerative neurological diseases (e.g., Creutzfeldt–Jakob disease)
– Seizure Disorders
– Sleep Disorders
– Transient Ischemic Attacks
Endocrine– Addison's Disease
(hypocortisolism)
– Cushing's s Syndrome (hypercortisolism)
– Hypoglycemia
– Hyperparathyroidism
– Hyperthyroidism
– Hypothyroidism
– Pheochromocytoma
Ms. Jinu Abraham, IMHANS, Calicut 8
Medical Etiologies of Anxiety…contd Toxins/Poisons
– Lead – Mercury – Manganese – Organophosphates
Cardiopulmonary – Angina – Asthma – Cardiac Arrhythmias – Chronic Obstructive Pulmonary
Disease – Mitral Valve Prolapse – Pulmonary Embolus
Infections – Meningitis – Neurosyphilis
Medications and Drugs – Antidepressants – Antihypertensives – Cough/cold medication (may
contain ephedrine or caffeine) – Corticosteroids – Insulin – Monosodium Glutamate – Oral Contraceptive Pill – Sympathomimetics – Thyroid Supplements – Weight Loss Products – Stimulants
(intoxication/withdrawal) – Alcohol intoxication/withdrawal – Benzodiazepine withdrawal – Marijuana
Ms. Jinu Abraham, IMHANS, Calicut 9
Treatments
Until middle 20th Century – Psychoanalysis
– Barbiturates
Current Trend– Pharmacotherapy
– Psychotherapy
– Combination of both
Ms. Jinu Abraham, IMHANS, Calicut 10
Pharmacotherapy
Commonly used drugs for recurrent anxiety– Fluoxetine - Buspirone
– Fluvoxamine - Azapirone
– Paroxetine - Lorazepam
– Sertraline - Clonazepam
– Citalopram - Benzodiazepines
– Escitalopram - Phenelzine
– Venlafaxine » CTP, 9th Edition
Ms. Jinu Abraham, IMHANS, Calicut 11
Duration
Studies show 20-50% chronic anxiety patients experience recurrence of clinically significant symptoms, several months after discontinuing pharmacotherapy
Guidelines specify – Stable treatment for at least 1-2 years before
consideration of dose reduction or discontinuation–When medication discontinuation instituted,
gradually tapering by 10-25% every 1-2 months while observing for relapse or exacerbation
Ms. Jinu Abraham, IMHANS, Calicut 12
Cognitive Behavior Therapy
CBT endorsed as first-line treatment – UK’s National Institute of Health and Clinical
Excellence
– American Psychiatric Association Treatment Guidelines
Research finds CBT more cost-effective than medication or other treatments in long term
Ms. Jinu Abraham, IMHANS, Calicut 13
Cognitive Behavior Therapy…contd
Thought challenging/Cognitive restructuring– Challenge negative thinking patterns that
contribute to anxiety, replacing them with positive, realistic thoughts
1.Identifying negative thoughts
2.Challenging negative thoughts
3.Replacing negative thoughts with realistic thoughts
Ms. Jinu Abraham, IMHANS, Calicut 14
Exposure Therapy
Encourages systematic confrontation of feared stimuli– external (eg, feared objects, activities, situations)– internal (eg, feared thoughts, physical sensations)– Aim: Reduce fearful reaction to stimulus
4 major theories explain its psychological mechanisms – Habituation– Extinction– Emotional Processing– Self-efficacy
» Kaplan and Tolin, 2011
Ms. Jinu Abraham, IMHANS, Calicut 15
Exposure Therapy…contd
Habituation– Natural reduction in responding with repeated exposure
Extinction– Overwriting previously learned fear associations
Emotional Processing– Developing new interpretations and meanings for feared
stimuli and fearful responses Self-Efficacy– Increased perception that one is capable of tolerating feared
stimuli and responses» Kaplan and Tolin, 2011
Ms. Jinu Abraham, IMHANS, Calicut 16
Exposure Therapy…contd
Guidelines– Develop an exposure hierarchy
Brainstorm external and internal stimuli that are feared and avoidedRate each item using the Subjective Units of Discomfort (SUDs)
Scale– Conduct exposures in gradual and systematic manner
Begin with moderately fear-provoking stimuliAssess patient’s fear during exposure using SUD scaleAddress each exposure collaboratively, in controlled and prolonged
mannerProgress to a higher item after the patient shows a reduced fear
response to lower item– Eliminate safety behaviors– Challenge cognitive distortions
» Kaplan and Tolin, 2011
Ms. Jinu Abraham, IMHANS, Calicut 17
Desensitization Therapy
Based on Reciprocal Inhibition Theory by Joseph Wolpe (1958)
Masserman’s experiment with cats– Counter-conditioning, using one association to run
counter to another
– Reciprocal inhibition, responses of anxiety and eating inhibited or prevented each other
Ms. Jinu Abraham, IMHANS, Calicut 19
Desensitization Therapy…contd
Wolpe’s three-part systematic desensitization procedure:1. The client is trained in deep relaxation
2. The client and therapist construct a list of anxiety-eliciting stimuli, the so-called fear hierarchy, ordered from least to most distressing
3. Starting with the least anxiety-arousing image, the feared stimuli are paired with relaxation, until eventually the most feared stimulus is tolerated calmly
Ms. Jinu Abraham, IMHANS, Calicut 20