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Anxiety Disorders
Back to Basics
Ameneh Mirzaei, M.D.
Resident Department of Psychiatry
April 22, 2009
Definition of anxiety
• a state of fear & apprehension
• everyone experiences anxiety / fear at one
time or another
• normal emotions that can be appropriate &
even beneficial under certain circumstances
• anxiety disorders: excessive, uncontrollable,
& distressing levels of anxiety
Anxiety disorders (DSM-IV)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
panic disorder with/without agrophobia
agrophobia without panic disorder
specific phobia (simple phobia)
social phobia (social anxiety disorder)
obssessive-compulsive disorder (OCD)
posttraumatic stress disorder (PTSD)
generalized anxiety disorder
acute stress disorder
substance-induced anxiety disorder
anxiety disorder due to general medical condition
(GMC)
11. anxiety disorder not otherwise specified (NOS)
Panic disorder - epidemiology
• prevalence
• life-time: 4.7%
• 1/3-1/2 have agrophobia
•
•
•
•
F:M ratio 2-3:1
age of onset: adolescence/early adulthood (17-35)
20X higher risk of suicide versus general population
80% first seen by primary care/ER
Panic disorder- diagnosis
• recurrent unexpected panic attacks
• >= 1 month persistent concern about
– another attack
– implications of attack
– significant behavior change related to attacks
• 4/13 symptoms of a panic attack
Panic disorder – diagnosis cont’d
• like any other psychiatric diagnosis
– must R/O panic attacks due to
• substance use
• physical condition
• another psychiatric disorder (including other
anxiety disorders)
– symptoms must cause social & functional
impairment
• further classified
– with agoraphobia
– without agoraphobia
Panic attack - diagnosis
• >= 4 of 13 (out of the blue, peak W/I 10 min)
“STUDENTS Fear the 3 Cs”
–
–
–
–
–
–
–
–
–
–
–
–
–
Sweating
Trembling / shaking
Unsteadiness / feeling dizzy
Derealization / depersonalization
Excess HR
Nausea
Tingling
SOB
Fear of death
Fear of going crazy / losing control
Choking
Chills / hot flushes
Chest pain
Agoraphobia – diagnosis
• anxiety about being in places from which
escape w/b difficult / embarrassing
– being outside home alone, in a crowd, in
line, bridge/tunnel, bus/train/car
• these situations are avoided or endured with
+ + anxiety
Panic disorder – prognosis
• course
– 50 - 70% improve
– complete remission is uncommon
• complications
– depression: 50%
– substance abuse (EtOH): 20%
Panic disorder – treatment
Medications
• 1st line: SSRIs, venlefaxine (effexor)
• 2nd line: TCA (clomipramine), benzodiazepines (short
term)
• continue treatment for 8-12 months
Psychotherapy
• CBT: cognitive restructuring, exposure, relaxation
• Supportive therapy
• Psychoeducation
Cognitive – Behavioral Therapy
• A form of psychotherapy based on the theory that
psychological symptoms are related to the interaction
of thoughts, behaviors, & emotions
• Goal --- change unhealthy behavior through cognitive
restructuring (examining assumptions behind the
thought patterns) & the use of behavioral therapy
techniques
Generalized anxiety disorder (GAD) epidemiology
•
•
•
•
•
•
lifetime prevalence: 5%
F:M = 2:1
more common in low SES
50% before age 20
90% co-morbidity rates
chronic but may fluctuate during stressful
times
GAD - diagnosis
• excessive anxiety & worry most days for at least 6/12
• difficult to control
• >= 3 of “BE SKIM” --- (need only 1 in children)
•
•
•
•
•
•
Blank mind
Easily fatigued
Sleep disturbance
Keyed up / on edge
Irritability
Muscle tension
• focus of worry not confined to another axis 1 d/o
• r/o substances & GMC
• social & occupational dysfunction
GAD – treatment
Medications
• 1st line: SSRIs, Venlefaxine
• 2nd line: TCA (imipramine), benzodiazepines (short term),
Bupropion (NE/DA RUI), Buspirone (5HT partial agonist)
Psychotherapy
• CBT
• relaxational techniques
• supportive therapy
• psychoeducation: symptoms come & go, avoid caffeine,
EtOH
Social phobia (social anxiety d/o) –
epidemiology
•
•
•
•
•
•
lifetime prevalence: 13%
F:M = 1.5:1
more common in lower SES
50% generalized (vs performance)
higher rates of substance abuse (EtOH)
80-90% overlap with avoidant PD
Social phobia - diagnosis
“PERSON” --- same for specific phobia
– Persistent/ marked fear of social/performance
situations
– Exposure produces anxiety
– Recognition of excess
– Social/performance situations avoided / endured w
distress
– Occupational / social dysfn.
– Not < 6/12 if person <18 yo
Social phobia – treatment
Medications
• 1st line: SSRIs, Venlefaxine
• 2nd line: benzodiazepines
Psychotherapy
• CBT
• performance desensitization
• social effectiveness training
Avoidant Personality Disorder
• Pervasive pattern of
– social inhibition
– feelings of inadequacy
– hypersensitivity to negative evaluation
• Beginning by early adulthood
Avoidant Personality Disorder
• 4 or more of the following
– avoids jobs that involve a lot of interpersonal
contact ---- fears of criticism, disapproval, rejection
– unwilling to get involved with people unless certain
of being liked
– restraint within intimate relationships for fear of
being shamed or ridiculed
Avoidant Personality Disorder
• preoccupied with being criticized or rejected in social
situations
• inhibited in new interpersonal situations because of
feelings of inadequacy
• views self as socially inept, personally unappealing or
inferior to others
• unusually reluctant to take personal risks or engage
in new activities ---- may prove embarrassing
Avoidant Personality Disorder
• Great deal of overlap between avoidant PD &
social phobia (generalized type)
• If generalized social phobia is present should
also consider diagnosis of avoidant PD
Specific phobia - diagnosis
• Similar to social phobia
Specific phobia - epidemiology
• life time prevalence: 12.5%
• most common mental d/o in women & 2nd
most common d/o in men (after substancerelated d/o)
• F:M = 2:1
• start at a young age (5-12 years)
Specific phobia – types
• animal: childhood onset
• natural environment: childhood onset
– heights, storms, water
• blood-injection-injury: highly familial
• situational type
– airplanes, elevators, enclosed places
• other types
– choking, vomiting, loud sounds, costume
characters
Specific phobia
• order of frequency of fears (most to least)
– animals
– storms
– heights
– illness
– injury
– death
Specific phobia – treatment
• tend to remit spontaneously with age
• can become chronic but rarely disabling
Medications
• limited data on antidepressants
• beta blockers, benzodiazepines for acute
anxiety
Psychotherapy
– CBT: cognitive restructuring
– behavior therapy: exposure (flooding), systematic
desensitization
– supportive therapy
Obsessive-compulsive disorder ( OCD) definition
Obsession (O)
– recurrent & intrusive thought, feeling, idea or
sensation (mental event)
– recognized as irrational
Compulsion (C )
– conscious, standardized, recurrent behavior such
as counting, checking or avoiding (behavior)
– may be carried to  anxiety (not always successful
to do so & may even inc anxiety)
Both O & C ego-dystonic (ie unwanted behavior)
OCD - epidemiology
•
•
•
•
•
•
lifetime prevalence: 2-3%
M=F in adults, M>F in adolescents
mean age of onset: 20
less in blacks than whites
10% will develop schizophrenia
50% with Tourette’s have OCD
OCD - diagnosis
Obsessions or Compulsions
“IRON RRRONS”
O
I ignore, suppress, neutralize
R recurrent persistent intrusive thoughts
O own mind (ego-dystonic)
N not simply excessive worries
C
R
R
R
O
N
S
repetitive beh./ mental acts
reduce stress
recognition of problem (excessive)
occupational, social dysfn. (take > 1 hr / day)
not restricted to another axis I d/o
substances / GMC exclusion
OCD - treatment
Pharmacotherapy
– 1st line: SSRI ; high doses needed for 8-12 wks
– 2nd line: Clomipramine, adjunctive Risperidone
– treat for 6-24 mos after remission
– very low placebo response rate
Psychotherapy
1. CBT: Exposure & Response Prevention (ERP)
2. psychoeducation
3. family therapy
Posttraumatic stress disorder (PTSD) epidemiology
•
•
•
•
life time prevalence: 9%
F:M = 2:1
80% have co-morbid illness
6x completed suicide risk compared to
general population
• symptoms fluctuate, get worse with stress
PTSD – diagnosis
• 3 major elements: re-experience, avoidence, arousal
• “TRAPED”
– Trauma
– Re-experience (1/5)
• via dreams, recurrent intrusive thoughts
– Avoidence (emotional numbing) (3/7)
• feeling detached from others
– Persistent arousal (2/5)
• irritability, exaggerated startle response
– Experience distress / impairment
– Duration > 1/12 (>3/12 chronic)
PTSD - types
• Acute
– symptoms last up to 3 months
• Chronic
– symptoms last >=3 months
• Delayed onset
– symptoms start > 6 months after traumatic
event
PTSD – treatment
Pharmacotherapy
• SSRIs, venlefaxine XR
Psychotherapy
• CBT: EMDR
• psychoeducation
• group therapy
• formalized stress de-briefing is not
recommended
Eye Movement Desensitization &
Reprocessing
(EMDR)
• Eye movements are used to engage the
patients’ attention to an external stimulus,
while the they are simultaneously focusing on
internal distressing material
Acute stress disorder
• occurs in response to a traumatic event
• accompanied by dissociative symptoms
– 5 Ds: detachment, dazed, derealization,
depersonalization, dissociative amnesia
• lasts from 2 days to 1 month
Summary of anxiety disorders
Anxiety disorder
Life time prevalence (%) & F:M
Key features
Treatment
Social Phobia
13%, 1.5:1
Low SES
Anxiety triggered by social/
performance situations
“PERSON”
SSRI,effexor, benzo
Performance
desensitization, social skills
training
Specific Phobia
12.5%, 2:1
Young onset: 5-12 yo
Anxiety triggered by
specific object / situation
“PERSON”
Beta blockers, benzo
systematic desensitization,
exposure, supportive
therapy
PTSD
9%, 2:1
Hx of trauma--- reexperience, avoidence,
arousal
“ TRAPED”
SSRI,effexor
EMDR
GAD
5%, 2:1
Low SES
Excessive worry 6/12
3 “BE SKIM”
SSRI,effexor, benzo,
imipramine, bupropion,
buspirone, relaxatin
Panic Disorder
4.7%, 2-3:1
recurrent attacks (not
trigger), >=4/13
“STUDENTS Fear the 3
Cs”
SSRI, Effexor,
clomipramine, benzo. 8-12
mos
exposure, relaxation
OCD
2-3%, M=F in adults, M>F in
adolescents
Presence of obsessions or
compulsions or both “IRON
RRRONS”
SSRI (high dose),
clomipramine, adjunctive
risperidone tx for 6-24 mos
ERP
Sample multiple choice questions
Which of the following statements regarding anxiety and gender
differences is true?
A.
B.
C.
D.
E.
Women have higher rates of almost all anxiety d/os
Gender ratios are nearly equal with OCD
No significant dirrence exists in average age of anxiety onset
Women have a twofold greater lifetime rate of agoraphobia than men
All of the above
Which one of the following is not a component of the DSM-IV
diagnostic criteria for OCD?
A. Obsessions are acknowledged as excessive or unreasonable
B. There are attempts to ignore or suppress compulsive thoughts or
impulses
C. Obsession or compulsions are time consuming and take > 1hr/day
D. Children need not to recognize their obsessions are unreasonable
E. The person recognizes obsessional thoughts as a product of outside
themselves
Anxiety disorders
A.
B.
C.
D.
Are greater among people at lower SES
Are highest amon those with higher education
Are lowest among homemakers
Have shown different prevalences with regard to social class but
not ethnicity
A. All of the above
Which one of the following situations are most likely to cause PTSD
A.
B.
C.
D.
E.
Involvement in an earthquake
Being diagnosed with cancer
Rape
Witnessing a crime
Observing a flood
The risk of developing anxiety d/os is enhanced by
A.
B.
C.
D.
E.
Eating disorder
Depression
Substance abuse
Allergies
All of the above
Isolated panic attacks without functional disturbances
A.
B.
C.
D.
E.
Are uncommon
Occur in <2% of population \
Are part of the criteria for diagnosis of PD
Usually involve anticipatory anxiety or phobic avoidence
None of the above
Which of the following statements are true about patients with
obsessive compulsive personality disorder?
A.
B.
C.
D.
They have obsessions only
They have compulsions only
They have both obsessions & compulsions
None of the above
Which one of the following is not typical of course of panic d/o
A.
B.
C.
D.
E.
Onset is typically late adolescence or early adulthood
Tends to exhibit a fluctuating course
Typical patients exhibit a patter of chronic disability
Majority of the pts live relatively normal lives
All of the above
Tourette’s d/o has been shown to possibly have a familial & genetic
Relationship with
A.
B.
C.
D.
E.
Panic d/o
Social phobia
GAD
OCD
None of the above
Isolated panic attacks without functional disturbances
A.
B.
C.
D.
E.
Are uncommon
Occur in <2% of population \
Are part of the criteria for diagnosis of PD
Usually involve anticipatory anxiety or phobic avoidence
None of the above
Which one of the following is most common symptom pattern
associated with OCD?
A.
B.
C.
D.
E.
Obsession of doubt
Obsession of contamination
Intrusive thoughts
Obsession of symmetry
Compulsive hoarding
Case examples
Panic disorder - I
• "It started 10 years ago, when I had just graduated
from college and started a new job. I was sitting in a
business seminar in a hotel and this thing came out
of the blue. I felt like I was dying
• "For me, a panic attack is almost a violent
experience. I feel disconnected from reality. I feel like
I'm losing control in a very extreme way. My heart
pounds really hard, I feel like I can't get my breath,
and there's an overwhelming feeling that things are
crashing in on me
Panic disorder - II
• "In between attacks there is this dread and anxiety
that it's going to happen again. I'm afraid to go back
to places where I've had an attack. Unless I get help,
there soon won't be anyplace where I can go and feel
safe from panic."
Obsessive-compulsive disorder - I
• "Getting dressed in the morning was tough because I
had a routine, and if I didn't follow the routine, I'd get
anxious and would have to get dressed again. I
always worried that if I didn't do something, my
parents were going to die. I'd have these terrible
thoughts of harming my parents. That was completely
irrational, but the thoughts triggered more anxiety and
more senseless behaviour. Because of the time I
spent on rituals, I was unable to do a lot of things that
were important to me.
Obsessive-compulsive disorder - II
• "I couldn't do anything without rituals. They invaded
every aspect of my life. Counting really bogged me
down. I would wash my hair three times as opposed
to once because three was a good luck number and
one wasn't. It took me longer to read because I'd
count the lines in a paragraph. When I set my alarm
at night, I had to set it to a number that wouldn't add
up to a "bad" number.
Obsessive-compulsive disorder - III
• "I knew the rituals didn't make sense, and I
was deeply ashamed of them, but I couldn't
seem to overcome them until I had therapy."
PTSD - I
• "I was raped when I was 25 years old. For a long
time, I spoke about the rape as though it was
something that happened to someone else. I was
very aware that it had happened to me, but there was
just no feeling.
• "Then I started having flashbacks. They kind of came
over me like a splash of water. I would be terrified.
Suddenly I was reliving the rape. Every instant was
startling. I wasn't aware of anything around me, I was
in a bubble, just kind of floating. And it was scary.
Having a flashback can wring you out.
PTSD - II
• "The rape happened the week before Thanksgiving,
and I can't believe the anxiety and fear I feel every
year around the anniversary date. It's as though I've
seen a werewolf. I can't relax, can't sleep, don't want
to be with anyone. I wonder whether I'll ever be free
of this terrible problem."
Social phobia - I
• "In any social situation, I felt fear. I would be anxious
before I even left the house, and it would escalate as
I got closer to a college class, a party, or whatever. I
would feel sick at my stomach-it almost felt like I had
the flu. My heart would pound, my palms would get
sweaty, and I would get this feeling of being removed
from myself and from everybody else.
Social phobia - II
• "When I would walk into a room full of people, I'd turn
red and it would feel like everybody's eyes were on
me. I was embarrassed to stand off in a corner by
myself, but I couldn't think of anything to say to
anybody. It was humiliating. I felt so clumsy, I couldn't
wait to get out.
• "I couldn't go on dates, and for a while I couldn't even
go to class. My sophomore year of college I had to
come home for a semester. I felt like such a failure."
GAD - I
• "I always thought I was just a worrier. I'd feel keyed
up and unable to relax. At times it would come and
go, and at times it would be constant. It could go on
for days. I'd worry about what I was going to fix for a
dinner party, or what would be a great present for
somebody. I just couldn't let something go.
GAD - II
• "I'd have terrible sleeping problems. There were
times I'd wake up wired in the middle of the night. I
had trouble concentrating, even reading the
newspaper or a novel. Sometimes I'd feel a little lightheaded. My heart would race or pound. And that
would make me worry more. I was always imagining
things were worse than they really were: when I got a
stomach-ache, I'd think it was an ulcer.
• "When my problems were at their worst, I'd miss work
and feel just terrible about it. Then I worried that I'd
lose my job. My life was miserable until I got
treatment."
Good luck on the exam!