Transcript Anxiety disorders

Anxiety disorders
IV year teaching
Christopher Gale
Department of Psychological Medicine
Dunedin School of Medicine
Anxiety is….
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… a subjective experience of unpleasant anticipation,
accompanied by characteristic behavioural and physiological
responses (e.g. avoidance, vigilance and arousal)
Evolutionary value: to protect individuals from danger.
Present in most/?all higher animals – ? universal mechanism
by which organisms adapt to adverse conditions.
Symptoms:
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Cognitive (feelings of apprehension, fear)
Physical symptoms (shortness of breath, trembling, palpitations etc);
Endocrine and physiological changes
Normal Emotion
Pathological State
Spectrum
severe symptoms
& functional
impairment
Panic.
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Overwhelming sense of impending doom or
disaster.
Physical symptoms.
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Tachycardia.
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Shortness of Breath.
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Chest pain.
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Tingling lips and extremities.
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Nausea, vomiting, diarrhoea
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Weakness. Collapse.
If specific → Phobia. If random → Panic
disorder
Anxiety
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Sense of fear around an event or stimulus →
distress, or panic.
May be specific
May be generalized (multiple topics of anxiety,
most of the day, nearly every day)
Can lead to:
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Avoidance
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Self medication with substances.
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Ritualisation of behaviour.
DSM and anxiety
Clustering based on phenomenology; divorcing of depressive vs anxiety components
Obsessions, compulsions.
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Obsession is an unwanted, repeated
distressing thought that is seen as:
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From one's own mind.
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Distressing.
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Not controlled.
Compulsions are a ritualised repeated
behaviour that is seen by the patient as
preventing or minimising risk of feared event
occuring eg hand washing, checking doors
locked.
Traumatic event.
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Out of ordinary life events.
Risk of death or severe injury (including fear of)
or witnessing same.
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Would be seen as distressing by most people.
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Examples
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Living in war zone.
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Physical or sexual assault
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Car crashes
Although panics are not traumatic as such can
have similar post event sequelae.
Following trauma
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Nightmares: of event.
Flashbacks. Like nightmares, full re
experience of event including all senses and the
sense of fear. Can be stimulated by certain
triggers of the trauma (including therapy) or
may occur randomly.
Foreshortened future. Lack of confidence in
planning years, weeks or days at work or
relationships.
Emotional numbness.
Where does anxiety arise in
the brain?
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Multiple components
Amygdala (A) and insular cortex (B)
activation– key structures in
emotional processing/integration
(Etkin Am J Psych 2007)
Prevalence of anxiety &
substance disorders
All anxiety disorders
Panic disorder
agoraphobia w/o panic
Specific phobia
Social phobia
GAD
PTSD
OCD
12 month
14.8%
1.7%
0.6%
7.3%
5.1%
2.0%
3.0%
0.6%
Lifetime
24.8%
2.7%
1.2%
10.8%
9.6%
6.0%
6.0%
1.2%
All substance disorders
Alcohol abuse
Alcohol dependence
Drug abuse
Drug dependence
Marijuana abuse
Marijuana dependence
3.5%
2.6%
1.3%
1.2%
0.7%
0.9%
0.5%
12.3%
11.4%
4.0%
5.3%
2.2%
Rate of disorders: WHO surveys, selected
countries.
Country
Anxiety
Mood
Impulse
control
Subst.
any
Mexico
6.8
4.8
1.3
2.5
12.2
United States
18.2
9.6
6.8
3.8
26.4
France
12.0
8.5
1.4
0.7
18.4
Germany
6.2
3.6
0.3
1.1
9.1
Italy
5.8
3.8
0.3
0.1
8.2
Nigeria
3.3
0.8
0.0
0.8
4.7
Japan
5.3
3.1
1.0
1.7
1.8
Severity of disorders, Te Rau
Hinengaro
Anxiet y (all)
Panic
Specific phobia
Social phobia
GAD
PTSD
OCD
Mood (all)
MDE
dyst hym ia
Bipolar
Subst ances (all)
alcohol abuse
m arijuana abuse
m ild
32.9
20.6
39.6
21.2
7.4
27.2
4.6
9.5
9.4
15.3
8.6
33.4
37.3
26
m oderat e severe
43.3
29.5
34.5
44.9
38.8
21.6
48.3
30.4
58.3
34.3
36.9
35.9
55.3
40.1
50.3
40.2
55.9
34.7
34.1
50.6
36.5
54.9
45.6
22.7
36.8
25.9
26.9
47.1
Factor Analysis of CIDI data from 10,641 participants in the Australian National
Survey of Mental Health and Well-Being, a large-scale community
epidemiological survey of mental disorders
General
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Think of diagnoses, not diagnosis.
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Consider priority of treatment.
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Timing for treatment.
 Use of others – practice nurse, primary mental
health.
 Consider referral
 Opinion
 Management
Positive approach: can minimize disability.
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Treatment
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General techniques.
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Talking therapies
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Medication
Behaviour therapies
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Applied relaxation.
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Education about anxiety.
Activity Scheduling.
Befriending.
Exercise
Relaxation technique & practice.
Bibliotherapy
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“Anxiety and Neurosis handbook” etc.
Internet therapy – via CrufAD (in Australia) and now
integrated in most GP practices (in New Zealand)
Graded exposure.
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Phobias.
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List of stimuli and programmed increase in anxiety
provoking triggers.
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Can expose symptoms panic (exercise, antihistamines).
OCD
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add response prevention (expose and no ritual).
Cognitive therapy.
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More effective in GAD
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Very useful in depression, which is quite co-morbid.
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Common distortions.
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Over responsible
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Perfectionism (“All or nothing”)
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Catastrophization (“Mountains out of molehills”).
USE MANUAL.
Comments medications.
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Generally do not control all symptoms.
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Take six to ten weeks to work.
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Need higher doses SSRI than in depression: 20 –
60 for GAD, 40 – 100 for OCD.
Medications.
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Antidepressants.
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Anticonvulsants
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SSRI, TCA, MAOI
Gabapentin, Pregabalin, Tigiabatine
Aziopirones.
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Buspirone, Gepirone.
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Benzodiazepines. (dependancy)
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Hyoscine & Kava (side effects)
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Low dose antipsychotics esp Quetiapine (side effects ++)