Transcript Anxiety disorders - Accra Psychiatric Hospital

Knowledge Fiesta 2012
Ghana College
Anxiety Disorders
Akwasi Osei
09 August 2012
outline
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Introductory remarks
Generalised Anxiety disorders
Obsessive-compulsive disorders
Panic disorders
Introductory remarks
• Psychosis vrs neurosis
• Neurosis vrs Anxiety
• Why ‘Neurosis’ is no longer in use
Anxiety Disorders
• Minor mental disorders of exaggerated or
abnormal fears and anxiety
• Manifests in different amounts and patterns
of four main features:
– Apprehension
– physical tension,
– physical symptoms
– dissociative anxiety.
• Emotions (apprehension) range from simple
nervousness to bouts of terror
• Two groups of Anxiety disorders:
• Continuous symptoms and episodic
symptoms.
• Common condition: 18% of Americans have
one or more of them [Kessler et al, 2005]
Types of Anxiety disorders
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Generalised Anxiety Disorders
OCD
Panic Disorders
Phobic Disorders
PTSD
Separation Anxiety
Other Childhood Anxiety Disorders
Generalised Anxiety Disorders
• Diagnosis followed various descriptions:
DaCosta Syndrome (1871), nervous
tachycardia, neurocirculatory
neurasthenia, irritable heart
cardiovascular symptoms with no organic
basis,
• irritable bowel syndrome
• GIT disorders with no organic basis
• hyperventilation syndrome
• Respiratory features with no organic basis:
• Freud later described Anxiety neurosis
• In 1980 issues resolved and diagnosis of GAD
made in DSM-III and ICD 9 adopted it.
Generalized anxiety disorder
(GAD)
• Anxiety Disorder of excessive, uncontrollable
and often irrational worry about everyday
things like health, finances, relationships,
family, work, etc
• Anxiety disproportionate to any possible
source of worry.
• Pathological worry often interferes with daily
functioning
• Patients typically anticipate disaster
• Key words: Generalised, persistent anxiety
• Not restricted to any particular environmental
setting, free-floating anxiety
• Course tends to be fluctuating
• No organic basis
• But with psychological and physical symptoms
of anxiety
Main features
• Psychological (apprehension)
• Physical:
– Autonomic over-activity
– Motor (muscular tension)
Psychological symptoms Apprehension
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undue worries of future happenings,
fears of personal safety or relative’s safety
feelings of being ‘on edge’,
poor concentration (reported as poor memory)
irritability, poor intermittent sleep, bad dreams,
night terrors
• Easily tearful (from apprehension), can confuse
with depression
Physical symptoms (I)
Autonomic overactivity:
• CNS disturbances: Continuous feelings of
nervousness, sweating, light-headedness,
palpitations, dizziness, tinnitus, blurred vision,
prickling sensation, faintness, weakness, etc.
• GIT symptoms: epigastric discomfort, dry mouth,
dysphagia, borborygmi, flatulence, belching,
frequent or loose stools
• Respiratory symptoms: constriction in chest,
inspiratory distress (as against expiratory distress
of asthma), over-breathing rapid and shallow,
• Cardiovascular symptoms: palpitations,
praecordial pain or discomfort, awareness of
missed beats, throbbing in the neck,
carpopedal spasms,
• Genito-Urinary symptoms: frequency and
urgency of micturitction, erectile
duysfunction, diminshed libido,
dysmenorrhea, amenorrhea,
Physical symptoms (II)
Motor/muscular tension
• Restlessness
• Fidgeting
• tension headaches as constriction or pressure,
bilateral, frontal or occipital
• Tension in other muscles as aching, stiffness,
backache, shoulders
• Trembling of hands impairing delicate
movements, cannot relax
diagnosis
• ICD: several weeks at a time, usually for
several months
• DSM: six months or longer
• The symptoms cause clinically significant
distress or impairment in social, occupational
and other important areas of functioning
• Remember the patient may present with any
of the physical symptoms and not as anxiety
• Careful history is vital
• For breathlessness, may need to watch patient
breathing
• Blood gas analysis may help in acute cases
• Physiological recordings may help, eg.
Galvanic Skin Response, pulse, muscle blood
flow, EMG (electromyography)
Differential diagnosis
• Panic disorders (but one can have GAD with
panic attacks)
• Depressive illness
• Schizophrenia
• Drug dependence
• Physical illnesses, thyrotoxicosis,
phaeochromocytoma, hypoglycaemia, cardiac
condition
epidemiology
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Commonest anxiety disorder,
4x commoner than panic disorder
3x commoner than phobic disorder
2x commoner in women
prevalence
Country
Australia
Canada
Italy
Taiwan
US
One year prevalence in
US
Ghana
World average
Prevalence
3% adults
3-5% adults
2.9% adults
0.4% adults
3.1% of above 18 years
2.5-8% (American
Catchment Area)
1.8% (hospital based)
3%
• Age of onset is variable - from childhood to
late adulthood
• Median age of onset about 31 (Kessler,
Berguland, et al., 2005).
• GAD generally has earlier and more gradual
onset than the other anxiety disorders
aetiology
• Genetic:
• familial - 15-20% relatives have GAD while
general population is about 3%
• Few twin studies indicate genetic factors,
• Biologic: based on benzodiazepines being
effective, believed GAD patients have GABA
receptor and chloride ionophore abnormalities
which respond to benzodiazepines
• Amygdala:
• The Amygdala is central to the processing of
fear and anxiety, and its function may be
disrupted in anxiety disorders.
• Medialfrontal cortex, adjacent central nucleus
of the amygdala, decreased connectivity with
the insula and cingulate gyri
• All involved in control of general stimulus
salience and suggest dysfunctional amygdala
processing of anxiety
• Personality: anxiety prone personalities:
obessional and asthenic personalities
• Stressful events: stress and social factors
precipitate and perpetuate GAD
• Psychoanalytic theories: Freud believed GAD is a
result of unresolved unconscious conflict between
impulses of libidinal and aggressive gratification and
the ego’s inhibition from recognition of the dangers
of the gratification
• Cognitive theories: GAD patients react to fear
differently in a manner that leads to vicious circle,
their fear leads to more symptoms and the
symptoms precipitate more fear
management
• Pharmacological: anxiolytics, beta-blockers
and antidepressants,
• Psychological: CBT more effective in long term
treatment
• Combination therapy (psycho and pharmaco)
best
• Anxiolytics: Benzodiazepines, 5mg bd – 10 mg
bd for few weeks
• Tricyclic antidepressants: probably because
associated depression. When depression ruled
out, effect not better than placebo.
• B-blockers like atenolol for palpitations and
other autonomic effects
• Azapirones, like buspirone, on serotonin
system, 30-60mg dly in divided doses
• SSRIs (Selective Serotonin Reuptake Inhibitor)
which are Antidepressants blocking the
reabsorption of serotonin:
• Fluoxetine (Prozac, Sarafem)
• Paroxetine (Paxil, Aropax)
• Citalopram (Celexa, Cipramil) or
Escitalopram(Lexapro, Cipralex)
• Sertraline (Zoloft)
• Pregabalin, anticonvulsant and also used in
neuropathic pain, designed as a more potent
successor to gabapentin, is an adjunct therapy
for partial seizures with or without secondary
generalization in adults
• Acts on pre-voltage dependent calcium
channel to decrease the release of
neurotransmitters like glutamate,
noradrenaline and substance P.
• Therapeutic effect appears after 1 week of use
• Found effective for GAD
• As of 2007, approved for GAD in the European
Union.
• Not yet available in Ghana, hopefully soon
Psychological treatment
• Supportive psychotherapy – regular contact
with therapist for support
• CBT: cognitive restructuring, psychoeducation, relaxation, breathing retraining,
exposure, graded practice, flooding, selfinstructional training, etc
• Dynamic psychotherapy – empower patient,
resolve dysfuntional relationships,
maladaptive defenses and patient’s capacity
for introspection and insight
prognosis
• More recent ones recover quickly
• Poorer prognosis with more severe symptoms
and with syncope, agitation, derealisation,
suicidal ideas and hysterical features
• Brief depressive episodes occur with patients,
• Schizophrenic features not different from
general population
Obsessive-compulsive disorder
• Recurrent obsessional thoughts or compulsive
acts
• Obessional thoughts: ideas, images or
impulses that keep intruding against the
patient’s wish
• Involuntary, often repugnant, patient’s own
thoughts
• May be single words, phrases, rhymes, usually
unpleasant and shocking, blasphemous or
obscene, eg ‘God is Satan’
• Compulsive acts or rituals: stereotyped
behaviours repeated time and again
• Not inherently enjoyable
• Often recognised by individual as pointless
Diagnosis
• Must be recognised as one’s own thoughts
• Must be at least one thought or act resisted
unsuccessfully
• The thought or act must not be pleasurable in
itself
• Must be unpleasantly repetitive
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Various features include
obessional ruminations
obsessional doubts
obessional impulses
Obessionnal rituals
Obessional slowness
Anxiety and depression from the obsessions
Depersonalisation
Differential diagnosis
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GAD
Panic disorder
Phobic disorder
Depression
Schizophrenia
Organic cerebral disorders
Obsessional personality
Tourette’s disorder: the two tend to coexist
epidemiology
• Less frequent than GAD
• 0.01-0.23 % one year prevalence
• Lifetime prevalence of 2-3% in recent
American study
• Women and men affected same
• Mean age of onset around 20 yrs
• Less than 5% have onset after 40yrs
aetiology
• Genetic: 5-7% relatives of patients have it,
higher than general population
• Inadequate twin studies to confirm
• Neurobiology: PET scan indicate abnormalities
in frontal lobes, cingulate gyrus and basal
ganglia compared with depressed and normal
controls
• Several high-tech images suggest neurological
hypothesis
• Serotonin: on the basis that Serotonin Specific
Reuptake inhibitors (SSRI) partially help, 5HT
thought to play a role in pathophysiology:
alteration of brain serotonin system
• Organic factors: epidemic encephalitis in one
study, inconclusive in others
Psychodynamic theories
• 3 major psychological defense mechanisms
thought to play a role (Nemiah and Uhde):
• Isolation protects the patient from anxietyprovoking affects and impulses of the OCD
thereby saving the patient from the act
• Undoing: where isolation has not been
complete, undoing results in the compulsive
act in an attempt to undo what the aroused
impulse suggests
• Reaction formation: the third defense
mechanism as the opposite of what the
impulses suggest, as a feature of OCD
management
• Pharmacotherapy:
• Short term anxiolytics, few weeks at a time
• Small doses of tricyclic antidepressants
clomipramine up to 250 mg daily if tolerable
• Supportive Psychotherapy
• CBT
• combinations
Panic disorders
• Episodic paroxysmal anxiety
• Recurrent attacks of severe anxiety (panic) not
restricted to any particular situation or setting
and hence unpredictable.
• Accompanied by several somatic symptoms:
• Sudden palpitations, chest pains, choking
sensations, dizziness and feelings of unreality
(depersonaliatin and derealisatin)
• Secondary fear of dying, losing control, going
mad,
• Individual attacks last for minutes,
• Crescendo of fear and autonomic symptoms
• person rushes out of the situation
• may subsequently avoid that situation or
produce fear of being alone
• Often followed by persistent fear of having
another attack
diagnosis
• Shortness of breath and smothering
sensations
• Choking, Palpitations and tachycardia
• Fear of dying
• Fears of going crazy or not being in control
• Chest discomfort,
• sweating, dizziness, faintness, nausea or
abdominal discomfort
• depersonalisation, derealisation,
• numbness, tingling sensation, flushes or chills,
• trembling or shaking
• With or without agoraphobia, more severe
with agoraphobia
Differential diagnosis
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GAD
Phobic disorder
Depressive disorders
Acute organic disorders
epidemiology
• Life time prevalence of 1.5-2%
• Women 2-3x more than men
aetiology
• Biochemical factors
– Chemicals sodium lactate and yohimbine induce
panic attacks more in patients than in healthy
people
– Panic attacks reduced by imipramine
– Panic attacks more inn relatives
– Proposed theory: inadequate functioning of
presynaptic alpha-adrenoceptors
• Hyperventilation
– Voluntary overbreathing can produce panic
anxiety features in some people
– Thus spontaneous attacks may be from
hyperventilation
• Cognitive abnormality
– Fears about physical or mental illness commoner
in anxious patients without panic attacks
prognosis
• Quite poor though not much studied
• A study shows 90% still having after 20 years
Treatment
• Alprazolam
• Imipramine with small doses initially, eg. 10
mg increased gradually to 150 mg daily over
about two months period
• Cognitive therapy
References
• 1. Kessler RC, Chiu WT, Demler O, Merikangas
KR, Walters EE (June 2005). "Prevalence,
severity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey
Replication". Arch. Gen. Psychiatry 62 (6):
617–627.