Psychiatry Lecture: Anxiety Disorders

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Psychiatry Lecture: Anxiety Disorders

welcome to this presentation this will be a lecture on anxiety disorders I’ll be attempting to cover the following disorders generalized anxiety disorder or GED panic disorder phobias obsessive-compulsive disorder or OCD post-traumatic stress disorder or PTSD we look at the clinical features anxiety disorders in icd-10 and dsm-5 epidemiology etiology management prognosis as usual we will conclude the lecture with five multiple-choice questions based on the material covered some information about myself I am a consultant psychiatrist based in Chennai which is a city in southern India I have worked for many years in the United Kingdom you we will start with the clinical features of generalized anxiety disorder the patient has persistent prominent and exaggerated worry tension or apprehension about everyday events and problems these could be things like work issues finance etc the patient reports feeling on edge most of the time this is called free-floating anxiety there is usually much muscle tension and eggs an example would be tension headache there is restlessness inability to relax or even irritability the patient has difficulty concentrating and usually reports that their mind goes blank there is initial insomnia but there is a delay in being able to fall asleep because of worrying in depression you have early morning awakening where the patient makes up much earlier than their usual waking time and the patient in generalized anxiety disorder may also report autonomic symptoms like palpitations sweating tremors dry mouth etc there may also be other physical symptoms like nausea abdominal discomfort tingling or numbness hot flashes or cold chills difficulty swallowing due to a feeling of lump in the throat etc you in panic disorder the patient experiences episodes of panic attacks each of which is a discrete event characterized by acute onset of severe anxiety with no obvious trigger so this is called anxiety out of the blue the anxiety reaches a peak over the next few seconds or minutes and then subsides for the following few minutes the autonomic symptoms and physical symptoms seen in panic disorder are much more prominent than those seen in generalized anxiety disorder palpitations sweating tremors dry mouth feeling of choking or difficulty breathing just discomfort or pain abdominal discomfort butterflies in the stomach feeling dizzy faint lightheaded tingling and numbness cold chills and hot flushes and in panic disorder there is typically either fear

of dying due to heart attack or choking or fear of fainting fear of losing control fear of going crazy or bad and depersonalization and derealization so in depersonalization the patient feels detached and unreal in derealization the environment fields detached or unreal but these two usually occur together because the patient does not know when the next panic attack is going to happen in between panic attacks the patient is extremely troubled by anticipatory anxiety we will now look at the clinical features of phobias phobias are characterized by acute episodes of anxiety that are precipitated by exposure to specific triggers these triggers could be objects or situations the anxiety in phobias is predictable this is in contrast to the unpredictable out-of-the-blue anxiety that occurs in panic disorder so in phobias any exposure to the trigger predictably results in acute anxiety a patient with phobia initially demonstrates escape so the patient escapes from the trigger in order to reduce the duration of anxiety in due course the patient exhibits avoidance so the patient avoids exposing oneself to the trigger in order to try not to experience the acute anxiety during acute anxiety in phobias the symptoms that occur are very similar to those seen in panic attacks the main types of phobias are simple phobias also called specific or isolated phobias agoraphobia and social phobia example soft simple phobias include fear of spiders dogs Heights enclosed spaces lips flying needles blood dentists and hospitals and fear of choking Agra phobia is characterized by fear of crowds fear of public places leaving home traveling alone in chronic states the patient may become totally housebound social phobia is characterized by fear of being the focus of attention fear of behaving in an embarrassing way this leads to avoidance of social situations such as public speaking attending parties eating in restaurants using public toilets and even signing documents such as checks in front of others so some features of social phobia such as avoidance of social situations may be similar to schizoid personality or negative symptoms of schizophrenia but in those conditions the patient is not distressed whereas in social phobia the patient is unhappy and acknowledges that the fear is excessive and unnecessary we will now look at the clinical features of OCD OCD is characterized by obsessions and compulsions an obsession is a recurrent intrusive inane unag Noora beliefs dressing ego-dystonic thought impulse or image arising from the subjects mind and

recognized as such it usually involves themes of contamination doubt safety symmetry religion illness sex or violence compulsion is a repetitive irresistible time-consuming behavioral or sometimes mental ritual that is performed as an attempt to neutralize the anxiety induced by the obsession despite the patient being aware that the ritual is unnecessary examples of compulsions include washing cleaning checking ordering coding counting and touching we will now look at PTSD in PTSD the symptoms developed after the patient is exposed to an exceptionally threatening or catastrophic event example of such dramas include major physical or sexual assault road traffic accidents natural disasters and terrorism in PTSD the patient V lives that trauma in the form of flashbacks when they are awake and in the form of nightmares while asleep the patient avoids places conversations people etc associated with the trauma the patient exhibits hyper vigilance he or she always appears to be on the lookout for further danger and the patient is easily startled other common features in PTSD include emotional numbing insomnia irritability poor concentration misuse of alcohol or drugs depersonalization and derealization in icd-10 the anxiety disorders are included in a section titled neurotic stress-related and somatoform disorders and in this slide I have listed the codes of the five disorders that we are covering in this lecture in dsm-5 these five disorders are spread across three sections whereas in DSM four they were all in a single section of anxiety disorders so the anxiety disorder section in dsm-5 includes GA D panic disorder specific phobias social phobia and Agra phobia in dsm-5 social phobia is called social anxiety disorder OCD is included in the obsessive-compulsive and related disorder section when PTSD is included in the trauma and stress or related disorder section and in this slide I have listed the duration required for a diagnosis of each disorder in icd-10 and dsm-5 if you are interested you can pause and note down the details we will now move on to the epidemiology of anxiety disorders the lifetime prevalence of any anxiety disorder is about 25% for females and 15% for males all anxiety disorders are more common in females the most common anxiety disorder in females is specific phobia followed by social phobia and the most common anxiety disorder in males is social phobia

the anxiety disorders with a female-to-male ratio of two or more that is these anxiety disorders are at least twice more common in females specific phobia agoraphobic panic disorder and PTSD the anxiety disorders with a female Mane ratio of less than two our GED social phobia and OCD although some studies have suggested almost equal prevalence of both social phobia and OCD in men and women the general consensus from large epidemiological studies is that even these disorders are slightly more common in females than in males you as a group anxiety disorders have a much earlier age of onset than other disorders such as mood or psychotic disorders specific phobias typically have their own certain childhood social phobia characteristically begins in the early teens while OCD begins in the mid to late teens Agra phobia usually begins in the early twenties panic disorder in the mid twenties while generalized anxiety disorder starts around the age of thirty years PTSD onset depends on the age of exposure to trauma for example in post combat PTSD it will be in the 20s as most frontline soldiers are in that age group whereas the age distribution would be different in PTSD after a natural calamity such as an earthquake that devastates a whole city and affects people of different age groups we will now look at the etiology of anxiety disorders anxiety has played a key role in human survival as an evolutionary phenomenon when man was faced with danger so it’s the fight or flight or freeze response when faced with fright anxiety symptoms are common they can be adaptive and so distinguishing normal anxiety from pathological anxiety may be difficult anxiety is likely to be pathological when there is significant avoidance then there is interference with normal functioning when the anxiety is disproportionate to any threat and the anxiety persists even in unthreatening situations some specific phobias such as fear of spiders might reflect an evolutionary phenomenon which has now outlived its usefulness in some cases of social phobia there may have been an episode of being humiliated in public but in most cases the onset is insidious anxiety may be a learned trait for example being brought up by anxious parents in a home environment that is written with anxiety for PTSD there has to be a history of exposure to a severe trauma prior to the onset of symptoms for most other anxiety disorders the exact etiology is not known but is likely to involve a combination of biological psychological and social factors although genetic and biological factors clearly play a role their relative contribution to the etiology of anxiety disorders is less when compared to other disorders like schizophrenia or bipolar among anxiety disorders panic disorder seems to have the highest heritability genes that may play a role in anxiety

disorders include comt the catecholamine transferase gene cert serotonin transporter or fire tree transporter gene CRF in fab lofts study on classical conditioning the neutral stimulus bell ringing was able to evoke a physiological response salivation after being repeatedly fed with food similarly fear conditioning refers to the process by which a relatively innocuous stimulus evokes fear after being associated with them aversive stimulus the fear conditioning is commonly studied in animal models in the lab where fear is first induced by pairing a tone auditory tone with electric shock and the fear is then made extinct by untiring some phobias can be easily understood in the context of a previous unpleasant experience in a particular situation for example a panic attack that occurred while driving a car might lead to total avoidance of driving altogether but for most anxiety disorders in humans the explanation is not that straightforward the most important brain structure in relation to anxiety appears to be the amygdala the amygdala is an almond-shaped structure and is part of the limbic system the amygdala one on each side are located within the temporal lobe near the hippocampus the amygdala is activated during anxiety in everyone functional neuroimaging studies have shown greater activation of the amygdala especially on the right side in patients with anxiety disorders compared to controls when the subjects are shown faces with different facial expressions such as fearful harsh or angry or neutral faces and this is the location of the amygdala along with the amygdala two other structures are also important the insula which is a portion of the cortex that is buried under the lateral sulcus like the amygdala the insula is also hyperactive in anxiety disorders the next structure is the anterior cingulate cortex this is a collar shaped portion of the cortex that surrounds the frontal aspect of the corpus callosum this is important for fear appraisal and activation of the anterior cingulate cortex might actually help reduce anxiety these three structures together are said to constitute the fear network in addition the hippocampus which is important for memory also seems to play a role in determining behavior such as avoidance in response to anxiety this is a pictorial representation of the insula located under the lateral sulcus and this is a diagram of the diagram showing the location of the anterior symbol of cingulate cortex in this picture shows the hippocampus and it’s close structural relationship to the amygdala the general scientific consensus regarding the neurophysiology of anxiety disorders include the following that there is hyperactivity of limbic regions such as the amygdala there is inability of higher cortical executive areas to attenuate the limbic

hyperactivity and there is a deficit in sensory gating that is correct related stimuli or not properly processed or filtered out you a number of neurotransmitter neuropeptide and neuro endocrine systems have been implicated in anxiety disorders so among neurotransmitters gaba under activity and 5ht dysfunction as evidenced by reduced by hydroxy indole acetic acid in CSF noradrenaline and dopamine dysfunction has also been suggested neuro peptides that have been implicated include cholecystokinin neuropeptide Y oxytocin arginine vasopressin and hypothalamic-pituitary-adrenal axis over activity has also been implicated in some studies you Minda and family studies indicate a substantial genetic component to the etiology of OCD abnormalities in the CST see circuit the kotteakos trial thalamocortical circuit and the glutamate transporter gene dysfunction of the caudate nucleus may be playing an important role and childhood OCD that occurs as part of Panda syndrome the pediatric autoimmune neuropsychiatric disorders associated with streptococcus is possibly due to and P streptococcal antibodies acting on the basal ganglia hormonal factors may also have a role in women considering increased incidence of OCD during menarche and increased symptom severity following childbirth perinatal trauma may play a part especially in earlier onset OCD subjects and psychological risk factors that may predispose to OCD include personality traits such as excessive doubt guilt perfectionism responsibility etc PTSD is unique among psychiatric disorders in that it needs exposure to a major traumatic event or there are vulnerability and resilience factors that may dictate whether an individual goes on to develop PTSD because not everyone who is exposed to the same trauma goes on to develop PTSD some factors that may increase the risk of PTSD after a trauma include prior exposure to other traumas family history of anxiety disorder personality traits anxious avoidant perfectionist or impulsive traits female gender trauma involving threat to one’s life trauma resulting in actual physical injury traumatic brain injury and trauma which then goes on to cause chronic pain in social and financial difficulties you the rates of PTSD vary depending on the nature of the trauma the traumatic events that are typically associated with subsequent PTSD are for individuals being threatened with a weapon witnessing another person being killed or badly injured being involved in a life-threatening accident combined combat exposure or injuries typically in young male front line soldiers being a victim of sexual assault or domestic violence from partner typically in young females and for whole populations so inhabitants of a town or country that has been invaded or involved in civil war or experiencing a natural disaster such as an earthquake tsunami or hurricane

you will now move on to assessment it is important to perform a thorough psychiatric assessment anxiety symptoms can occur in most major psychiatric disorders so during the prodrome of a first episode of schizophrenia as part of the behavioral and psychological symptoms of dementia in delirium especially delirium tremens of alcohol withdrawal anxiety is commonly seen in unipolar depression and in nixon states of bipolar disorder it is important to note that many patients have more than one anxiety disorder so even if you are able to diagnose one anxiety disorder be aware of the fact that the patient might have another anxiety disorder as well in this lecture the focus is on primary anxiety disorders and not on anxiety that occurs as a symptom of other disorders you take a comprehensive medical history hyperthyroidism can mimic symptoms of anxiety disorders so check for features of hyperthyroidism like tachycardia or heat intolerance do routine blood tests before initiating treatment do a baseline ECG unless specifically indicated for example highly atypical symptoms there is no need for neuroimaging like CT or MRI EEG or psychometric neuropsychological testing or structured personality questionnaires in a patient presenting with the first episode of acute anxiety example anxiety that is severe enough that the patient attends the A&E or emergency room also considered potential abuse of substances like cocaine or amphetamine cardiac causes like an atypical MI especially if accompanied by severe nausea or vomiting supraventricular tachycardia the association between mitral valve prolapse and panic is no longer considered significant hypoglycemia pheochromocytoma especially if there is accompanying headache – slate or blood pressure orthostatic hypotension severe sweating etc and neurological causes like benign paroxysmal positional vertigo and atypical seizures the number of rating scales are available to hit the different anxiety disorders rating scales are mainly used in clinical research studies they are not needed routinely in clinical practice and are not a substitute for thorough clinical assessment and proper follow-up reviews rating scales can however be useful to quantify severity of a disorder and for measuring response to treatment and in this slide I have listed some rating scales that are used in the different anxiety disorders so those who are interested you can pause and know down the details you will now move on to the management of anxiety disorders the two main modalities of treatment are psychotherapy and medication these treatments are usually used on their own but they can also be used in combination if necessary the type of psychotherapy that is usually used in anxiety disorders is cognitive behavior therapy or CBT the types of medication most commonly used in anxiety disorders are the selective serotonin reuptake inhibitors SSRIs for long-term maintenance treatment and the benzodiazepines for immediate short-term symptomatic treatment if CBT is

available and patient is motivated that should be the treatment of choice as the patient can continue to use the CBT techniques even in future in case of relapse however because of the shortage of qualified therapist medication is overall by far the most commonly used treatment modality for all anxiety disorders except simple phobias an SSRI such as fluoxetine or acetyl Oprah is usually the first-line medication for generalized anxiety disorder one can also consider Lila faxing duloxetine Matassa pain buspirone or pregabalin for OCD you can also consider trauma priming which is a serotonergic tricyclic antidepressant when benzodiazepines are used it is good practice not to prescribe for more than two weeks they may be useful in simple phobias for example taking a small dose of diazepam just before a flight for a patient who has a phobia of flying beta blockers may be useful for somatic symptoms of anxiety such as tachycardia and tremors for treatment-resistant OCD consider augmenting the SSRI with a low dose antipsychotic such as haloperidol or risperidone CBT attempts to correct maladaptive cognitions and behavior that contribute to the origin and maintenance of psychological difficulties like depression and anxiety in anxiety disorders cognitively there is a misinterpretation or misperception of a real or imaginary threat and behaviorally there is escape and avoidance to overcome the anxiety CBT aims to correct these cognitive distortions and maladaptive behaviors depending on the anxiety disorder the CBT techniques have to be modified accordingly specific phobias are the easiest to treat and good results can be achieved with even one session disorders like PTSD especially with comorbid alcohol or substance misuse or chronic OCD with entrance to rituals they are much more difficult to treat we’ll first look at some CBT strategies for generalized anxiety disorder educating the patient about the disorder self-monitoring which helps to improve self-awareness relaxation training in the form of progressive muscular relaxation applied relaxation breathing exercises meditation cognitive restructuring this helps the patient make more realistic estimations of the likelihood of danger and of one’s ability to cope usually patients with anxiety disorders tend to overestimate the likelihood of danger and to underestimate one’s ability to cope worry time this is where the patient is asked to save all their worries for a specific time each day so at the end of the day they can spend about 45 minutes worrying where they can write down all their worries so this helps them not to worry when they are doing other things in the day time problem-solving skills training in both panic disorder and phobias the episodes are characterized by acute anxiety in panic disorder there is no obvious trigger thus it is unpredictable so there is anticipate Liang’s idea about future attacks in phobias the symptoms occur due to exposure to this stimulus thus it is predictable so this leads to escape from the stimulus in the present and avoidance of the stimulus in the future

so cognitive strategies include helping the patient make a more realistic appraisal of the anxiety without catastrophizing like I am going to die educating the patient that the anxiety will not last forever and will not kill advising that avoiding the anxiety may help in the short term by reducing symptoms but in the long term it perpetuates the problem making the patient aware that pacing the anxiety may worsen symptoms in the immediate term but in due course it would help overcome the anxiety and behavioral strategies for panic disorder include familiarizing the patient with physical symptoms of anxiety by reproducing them in the clinic for example by hyperventilation or by running up a flight of stairs to mimic palpitations this would help the patient realize that these are not ominous signs and for phobias by graded exposure and response prevention so exposure to the feared situation and preventing the patient from escaping or leaving the situation till the anxiety naturally subsides this results in systematic desensitization to the fear trigger by habituation and eventually there is extinction of the fear let us look at an example of graded exposure for spider phobia and for agoraphobic so ask the patient to list situation starting from the least fearful to the most fearful so in spider phobia the least fearful might be seeing a picture of a spider and the most fearful may be having a spider in contact with their body and in agoraphobia the least fearful might be going out of the house to drop something in the dustbin just outside and the most fearful might be doing shopping on a Saturday afternoon in the crowded supermarket so do the exposure and response prevention for each stage of the hierarchy starting with the least fearful as the patient masters each step go to the next feared situation for simple phobias flooding where the patient is exposed to the most feared situation in the beginning itself can also be effective but in general systematic desensitization by graded exposure this preferred you in OCD also exposure and response prevention is used here exposure refers to facing the anxiety inducing obsessional thought for example fear of contamination and response prevention refers to the patient staying with the anxiety without performing their habitual compulsive ritual such as hand washing depending on the patient’s severity this is done gradually so for example for a patient who washes her hand every 10 minutes gradually increase the gap between hand washes by 10 min 10 minutes every week some CBT strategies for PTSD educating the patient about the nature and impact of trauma relaxation training identifying and correcting cognitive distortions discussion of the trauma exposure to trauma reminders such as places activities and people which the patient has been avoiding maybe initially by imagination and then by direct confrontation by visiting those speed races and doing those activities developing skills to be with future trauma this is called a stress inoculation another therapy that has been widely used in PTSD is EMDR which stands for high movement desensitization and reprocessing

other options for anxiety disorders include self-help books so-called bibliotherapy online CBT support groups exercise therapy yoga mindfulness meditation these options are particularly suitable for those with milder forms of anxiety disorders and for patients who are well motivated we will now move on to the prognosis of anxiety disorders anxiety disorders are unlikely to remit spontaneously without treatment the best prognosis is for simple phobias which respond very well to CBT most other anxiety disorders tend to run a chronic course with relapses and remissions overall with treatment there is a remission rate of at least 50% within three years among those who improve about 1 in 3 are likely to relapse within 3 years with a higher rate among those who discontinued trick’d treatment prematurely some patients need long-term maintenance treatment a small but not insignificant subgroup of patients especially those with social phobia OCD and PTSD respond neither to CBT nor medication not to combination factors associated with poor prognosis include earlier onset long delay before seeking treatment chronicity severity comorbid alcohol substance misuse depression personality disorder previous unsuccessful treatment non-compliance with medication or lack of motivation to engage in CBT ongoing social issues such as social isolation unemployment relationship difficulties the anxiety disorder might lead to social isolation and poor performance at work might lead to unemployment and the anxiety symptoms may cause relationship problems but then the consequences of the anxiety disorder might make the prognosis of the original anxiety disorder even worse overall there is an increase in suicidal ideation and attempts in patients with anxiety disorders when compared with matched controls from the general population panic disorder and PTSD seem to have the highest risk among anxiety disorders comorbid alcohol or substance misuse personality disorders will increase the risk substantially there also appears to be increased risk for and morbidity and mortality from coronary artery peripheral artery and cerebrovascular diseases in patients with anxiety disorders you have now come to the end of this lecture before we finish we will go through a set of five multiple-choice questions question 1 which of the following suggests generalized anxiety disorder rather than a panic attack if you want you can pause now and select your choice and the correct answer is see free-floating anxiety the other three options are suggestive of a panic attack question two which of the following is true regarding social phobia if you want you can pause now and select your choice and the correct answer is social phobia is the most common anxiety

disorder in males option a is false because specific or simple phobia is the most common anxiety disorder in females and C and D are also false question 3 which of the following is not part of the fear Network if you want you can pause and select your choice and the correct answer is see cerebellum so the other three are considered to be part of the fear Network question four EMDR is a treatment that is used for if you want you can pause and select your option and the correct answer is a PTSD so EMDR stands for high movement desensitization and reprocessing and this is an established treatment for PTSD the final question which of the following is not a typical feature of anxiety disorders if you want you can pause and select your choice and the correct answer is the early morning awakening so this is not a typical feature of anxiety disorders this is a typical feature of depression the other three are typical features of anxiety disorders and that brings us to the end of this presentation thank you for watching hope you found the information useful