ANXIETY DISORDERS
Dr Nesif J. Al-Hemiary M.B.Ch.B F.I.C.M.S(Psych.)Objectives of this lecture
At the end of this lecture students should be able to: Define anxiety and differentiate it from fear List the types of anxiety disorders Define the main features of separation anxiety disorder and selective mutism Enumerate and define the main clinical features, main etiological and epidemiological factors, differential diagnoses ,and main lines of treatment of each of the following disorders: specific phobia , social phobia, panic disorder, agoraphobia, and generalized anxiety disordersIntroduction
Anxiety disorders: include disorders that shares features of excessive fear and anxiety and related behavioral disturbances. They make up one of the most common groups of psychiatric disorders. Epidemiological studies found that 1 in 4 people has met the diagnostic criteria of at least one of the anxiety disorders and that 12-month prevalence rate is 17.7%. Women are more affected than men ( approximately 2:1 ratio).FEAR & Anxiety
Fear : is the emotional response to real or perceived imminent threat . Anxiety : is anticipation of future threat . These two conditions overlap , but they also differ. Fear is more often associated with surge of autonomic arousal necessary for fight or flight reaction, thoughts of immediate danger, and escape behaviors. Anxiety is more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behavior. Panic attacks feature prominently in the anxiety disorders as a particular type of fear response. They are not limited to anxiety disorders but rather can be seen in other mental disorders as wellClassification of anxiety disorders
Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder( Social Phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Substance /Medication Induced Anxiety Disorder Anxiety Disorders due to another Medical ConditionSpecific phobia
The essential feature is that fear or anxiety is circumscribed to the presence of a particular situation or object ,which may be termed the phobic stimulus. This response must be intense or severe and may take the form of full or limited symptoms panic attack.The fear or anxiety is evoked nearly every time the person comes into contact with phobic stimulus.The fear or anxiety is out of proportion to the actual danger that the object or situation poses.Most often, the phobic stimulus is avoided, although it is sometimes endured with dread. this avoidance must interferes significantly with the person’s daily routine ,occupational functioning or social life.The condition must be present for at least 6 months to exclude transient fears.
Subtypes of specific phobia
Animal type :animals or insects.Natural environment type : storms, heights or water.Blood – injection – injury type( needles, medical procedures)Situational type: public transportation, tunnels ,bridges, elevators, flying ,driving or enclosed places.Other types: fear of situations that may lead to choking or vomiting or contracting an illness, etc.Prevalence
Specific phobic is more common than social phobia.It is the most common mental disorder among women and the second among men.Female to male ratio is 2:1.The 12-month community prevalence in US and Europe is about 7-9 %. In Asian and African countries it is lower(2-4%)The peak age of onset for the natural environment & blood –injection-injury type is in the range of 5-9 years, while for situational type is in the mid 30s.Risk factors
Temperamental ( related to personality): negative affectivity or behavioral inhibition. Environmental: parental over-protectiveness, parental loss and separation, physical and sexual abuse, and traumatic events. Genetic and physiologicalDifferential diagnosis
Appropriate fear. Agoraphobia Social anxiety disorder Panic disorder Obsessive compulsive disorder Trauma and stress related disorders Eating disorders Schizophrenia and other psychotic behaviorsTreatment
Behavioral therapy: the most commonly used type is exposure therapy in which the patient is desensitized by using a series of gradual ,self –placed exposure to the phobic stimuli and teaching the patient various techniques to deal with anxiety including relaxation ,breathing control and cognitive approaches.Social Anxiety Disorder(Social phobia)
The essential feature is a marked or intense fear of social situations in which the individual may be scrutinized by others.Exposure to these situations almost invariably provokes an immediate anxiety response.When exposed to social situations ,the individual fears that he or she will be negatively evaluated. The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, etc.The social situations are almost always provoke fear or anxiety.Most often the social or performance situation is avoided, although it is sometimes endured with dread.The fear or avoidance must interferes significantly with the person’s daily routine ,occupational functioning or social life.Prevalence
The 12-month prevalence in US is about 7%. It is lower in other parts of the world. In epidemiological studies females are more than males, but in clinical samples the reverse is often true. The peak age of onset is in the teens, although onset is common as young as 5 years or as old as 35 years. Prevalence decrease with older age
Differential diagnosis
Normal shyness. Agoraphobia Panic disorder Generalized anxiety disorder Specific phobia Major depressive disorder Body dysmorphic disorder Delusional disorder Personality disordersTreatment
PANIC ATTACKSPanic attacks: occur in the context of several different anxiety disorders. The essential features of the panic attack is discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 somatic or cognitive symptoms. The attacks has a sudden onset and builds a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom & an urge to escape.
Symptoms of a panic attack
palpitations, pounding heart or accelerated heart rate , sweating , trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady , lightheaded or faint, derealization or depersonalization, fear of loosing control or going crazy , fear of dying , parasthesia ,chills or hot flushes.Panic disorder
The essential feature of panic disorder is the presence of recurrent, unexpected panic attacks, followed by at least one month of persistent concern about having another panic attack ,worry about possible implication or consequences of the panic attack or significant behavioral change related to the attack. The panic attacks are not due to the direct physiological effects of a substance (e.g. , caffeine intoxication) or a general medical condition (e.g. hyperthyroidism).Panic attacks must not be better accounted for by another mental disorder (e.g. specific or social phobia, obsessive compulsive disorder, PTSD, or separation anxiety disorder.) At least two unexpected panic attacks are required for the diagnosis ,but most individuals have considerably more.
prevalence
The 12-month prevalence of panic disorder is between 2-3% Female to male ratio is 2:1. The only social factor associated ( or contributing to the occurrence of panic disorder) is a recent history of divorce or separation. Age of onset is typically between late adolescence and the mid 30s . A small number of cases begin in childhood , and onset after age of 45 years is unusual but can occur. The usual course is chronic but waxing and waning.DIFFERENTIAL DIAGNOSIS
Other anxiety disorders Anxiety disorders due to another medical condition Substance/medication related anxiety disorders Psychotic disordersAgoraphobia
The essential feature of agoraphobia is marked or intense fear or anxiety triggered by the real or anticipated exposure to wide range of situations. Diagnosis requires the endorsement of symptoms occurring in at least 2 of the following 5 situations: using public transportation, being in open places, being in enclosed spaces, standing in line or being in crowd, and being outside of home alone. When experiencing fear or anxiety cued by such situations ,individuals typically experience thoughts that something terrible might happen.Some people are able to expose themselves to the feared situation but with considerable dread ,often an individual is better able to confront a feared situation when accompanied with a companion.Individual’s avoidance of situations may impair their ability to travel to work or to carry out home making responsibilities( e.g., grocery, shopping, taking children to the doctor, etc)Most cases of agoraphobia are thought to be due to panic disorder. When the panic disorder is treated ,the agoraphobia often improve with time.Depressive disorder & alcohol dependence often complicate its course.There is also a risk of suicide which accompany panic disorder & agoraphobia.
Individuals frequently believe that escape from such situations might be difficult, or help might be unavailable when panic like symptoms occur. Other incapacitating symptoms include vomiting, and inflammatory bowel syndrome, as well as , fear of falling,
Treatment
The two most effective treatments are: a- pharmacotherapy b- cognitive-behavioral therapy.A- pharmacotherapy: Serotonin-specific reuptake inhibitors( SSRI): paroxetine ,fluoxetine ,sertraline and fluvoxamine.Benzodiazepines : they have the most rapid onset of action against panic ,often within the first week. Alprazolam has been the most widely used for panic disorder although studies found equal efficacy for lorazepam and clonazepam. They are used as the first agent for treatment of panic disorder while a serotonergic drug is being slowly titrated to a therapeutic dose. After 4-12 weeks , the BDZ can be slowly titrated (over 4-10weeks) while the serotonergic drug is continued. The main restrictions for their use are potential for dependence ,cognitive impairment and abuse.Tricyclic and tetracyclic antidepressants,Monoamine oxidase inhibitors (MAOIs),Other drugs(nefazodone , venlafaxine , buspirone, …)Medical treatment should be continued for at least 8- 12 months.Psychotherapy Cognitive therapy which include instructions about a patient’s false beliefs & information about panic attacks.Applied relaxation.Respiratory training.In vivo exposure: the technique involves sequentially greater exposure of the patient to the feared stimulus ;over time the patient become sensitized to the experience.
Generalized anxiety disorder
GAD is an excessive anxiety & worry about several events or activities for majority of days during at least a 6-month period. The worry is difficult to control and is associated with somatic symptoms such as muscle tension , irritability, difficulty sleeping and restlessness. The anxiety is not focused on features of other mental disorders, is not caused by a substance use or a general medical disorder and does not occur only during a mood or a psychiatric disorder.Symptoms of GAD
A- Psychological symptoms: fearful anticipation , irritability, sensitivity to noise , restlessness, poor concentration and worrying thoughts.B- Physical symptoms: GI symptoms :nausea ,vomiting ,abdominal pain, diarrhea, distension Respiratory: chest oppression , tachypnea , chest pain CVS: tachycardia , palpitations, chest pain Genito-urinary: frequency, urgency, dysuria Neuro-muscular: aches and pains, spasms ,tension headacheC-Sleep disturbance: insomnia , night mares.D –Other symptoms: depression, obsessions and depersonalization.Epidemiology
GAD is a common condition. 1-year prevalence range from 3-8%. It is commonly coexist with other mental disorders like social phobia ,specific phobia, panic disorder & depressive disorder. Women to men is 2:1 The age of onset is difficult to specify but is mostly at the 20s.Course & prognosis
GAD is a chronic condition that may be life-long. As many as 25% eventually GAD is a chronic condition that may be life-long. As many as 25% eventually experience panic disorder. An additional high percentage are likely to have major depressive disorder.Differential diagnosis
A. Medical disorders :Cardio-vascular diseases: anemia , angina , congestive heart failure ,mitral valve prolapse, MI, paradoxical atrial tachycardia.Pulmonary disease :asthma ,hyperventilation, and pulmonary embolism.Neurological diseases: CVA, epilepsy, Huntington’s disease, infections, Menier’s disease, migraine, tumors, MS,…. Endocrine diseases: Addison’s disease, carcinoid syndrome, Cushing disease, DM, hyperthyroidism, hypoglysemia, hypoparathyroidism, pheochromocytoma, premenstrual syndrome.5. Drug intoxication: amphetamine , anticholinergics, coccaine , hallucinogens, marijuana, theophylline , nicotine. 6. Drug withdrawal: alcohol , , opiates, sedatives. 7. Other conditions: anaphylaxis ,B12 deficiency, electrolyte disturbances, heavy metal poisoning, uremia, systemic infections.
B. Mental disorders: Hypochondriasis. Social & specific phobia. Posttraumatic stress disorder (PTSD). Depressive disorder. Schizophrenia. Malingering . Factitious disorder. Depersonalization disorder.