Anxiety Disorders

1
Anxiety Disorders

• Brenda Roman, MDProfessor Department of
  Psychiatry

2
Objectives By the end of this presentation,
students will be able to

• Define normal anxiety, fear and anxiety disorder
• Describe and compare the diagnostic criteria and
  features for
• Panic disorder with and without Agoraphobia
• Agoraphobia
• Generalized Anxiety Disorder
• Social Phobia (Social Anxiety disorder)
• Specific Phobia
• Obsessive Compulsive Disorder
• Post Traumatic Stress Disorder
• Acute Stress Disorder

• Explain the known biological correlates for
  anxiety, including regions in the brain and
  neurotransmitters involved
• Describe basic clinical treatment for anxiety
  disorders

3
Anxiety Disorder case

• A 26 year old female presents to the ER with
  complaints of chest pain, difficulty breathing,
  racing heart beat, and feelings of numbness and
  tingling in her fingers. She also feels
  nauseated, dizzy and experiences intense sweating
  during these attacks. She fears a heart
  attack, or that maybe she is going crazy.

4
Anxiety Disorder case

• She has had several episodes like this over the
  last couple of months, but now they are getting
  worse and she fears going out in public because
  of these episodes.
• She also fears that she may die, and is
  incredibly nervous that the doctors may miss
  something.

5
Anxiety Disorder case

• She had been doing well in her new job after
  getting her MBA. Her boyfriend of 3 years had
  recently broken up with her, but she felt the
  break-up was in her best interest, so doesnt
  feel that has anything to do with these episodes.

• Her father is a recovering alcoholic, and she
  knows her paternal grandmother worries a lot,
  fearful of germs and rarely leaves the home.

6
Anxiety Disorder case

• Medical history is unremarkable. No medication
  allergies.
• Medications oral contraceptives, which she has
  taken for six years without side effects, and a
  daily multivitamin with calcium.

• While in college and graduate school, admitted to
  binge drinking on the weekends, but now only
  drinks a couple of beers a week as her job keeps
  her so busy.

7
Anxiety Disorder case
Based on the history presented, what do you think
the most likely diagnosis is?

1. Adjustment Disorder with anxious features
2. Acute Stress Disorder
3. Generalized Anxiety Disorder
4. Panic Disorder with Agoraphobia
5. Social Anxiety Disorder

8
Introduction
Kessler 1994 Kessler 1995 DSM-IV-TR 2000
9
Definitions

• Fear is in response to a known, external,
  definite threat
• Anxiety is a response to an unknown threat, or
  is internal, vague or conflictual
• Fear and anxiety are alerting signals, that
  evolved as part of fight or flight response as
  adaptive for self-preservation by helping to
  avoid danger
• Normal anxiety
• Pathological anxiety
• Anxiety disorders occur when a high level of
  anxiety persists and/or recurs that interferes
  with social and occupational functioning

10
Types of Anxiety Disorders

• Panic Disorder
• With Agoraphobia
• Without Agoraphobia
• Agoraphobia
• Generalized Anxiety Disorder
• Social Phobia (Social Anxiety Disorder)
• Specific Phobia
• Obsessive Compulsive Disorder
• Post Traumatic Stress Disorder
• Acute Stress Disorder

11
1. Panic Disorder
12
1. Panic Disordersymptoms

• A panic attack has at least 4 of the following
  symptoms

• Paraesthesias
• Hot flushes/chills
• DerealizationDepersonalization
• Fear of losing control or of going crazy
• Fear of dying

• Palpitations
• Diaphoresis
• Dyspnea
• Feelings of choking
• Chest pain
• Nausea
• Dizziness

13
1. Panic Disorderdiagnostic criteria

• Discrete period of intense fear or discomfort
• Develops abruptly
• Peaks within 10 minutes, lasts 20 minutes to up
  to 8 hours
• Not induced by a substance/medical illness
• Up to 20 may have syncope during panic attack

14
1. Panic Disorder diagnostic criteria -
DSM-IV-TR

• Need both
• Recurrent unexpected panic attacks
• At least one of the attacks has been followed by
  one month (or more) of
• persistent concern about having additional
  attacks
• worry about the implications of the attack or its
  consequences (e.g., losing control, having a
  heart attack, going crazy)
• a significant change in behavior related to the
  attacks

15
1. Panic Disorder diagnostic criteria -
DSM-IV-TR

• Can be with or without agoraphobia
• The Panic Attacks are not due to the direct
  physiological effects of a substance or general
  medical condition
• The Panic Attacks are not better accounted for by
  another mental disorder

16
1. Panic Disorder with Agoraphobia diagnostic
criteria - DSM-IV-TR

• Anxiety about being in places or situations from
  which escape might be difficult or in which help
  may not be available in the event of a panic
  attack
• Situations are avoided or endured with marked
  distress or require the presence of a companion
• Not accounted for by another mental disorders

17
1. Panic Disorder with Agoraphobia situations
that provoke anxiety
Situation
Standing in line 96
Having appointment 91
Feeling trapped at a place 89
Increasing distance from home 87
Being at particular places in neighborhood 66
Having cloudy, depressing weather 56
18
1. Panic Disorder with Agoraphobia situations
that relieve anxiety
Situation
Being accompanied by spouse 85
Sitting near door in church 76
Focusing thoughts on something else 63
Taking the dog, baby carriage, etc., along 62
Being accompanied by friend 60
Reassuring self 52
Wearing sunglasses 36
19
1. Panic Disorder diagnostic features
20
1. Panic Disorder diagnostic features

• AgeOnset usually mid 20s

• 80 of panic patients develop it before age 30
• rare after age 60

21
1. Panic Disorder diagnostic features
CourseRecurrent attacks

• vary in frequency and intensity
• panic-free intervals
• total remission is uncommon

22
1. Panic Disorder diagnostic features

• PrevalenceLifetime prevalence 0.5-3.0

• 2-3 women
• 0.5-1.5 of men have Panic disorder
• Rates 3x higher in primary care patients

• May be 50 of those seeking cardiology evaluation
• 50 of those with normal cardiac catheterization
• 50-60 have co-morbid psychiatric diagnoses

23
1. Panic Disorder diagnostic features

• commonly reported symptoms

Symptoms
Fearfulness/worry 96
Nervousness 95
Palpitations 93
Muscle tension 89
Trembling 89
Apprehension 83
Dizziness 82
Fear of going crazy/dying 81
Light-headedness 80
Hot flushes/chills 80
Symptoms
Restlessness 80
Trouble breathing 80
Easy fatigability 76
Trouble concentrating 76
Irritability 74
Trouble sleeping 74
Chest pain 69
Numbness/tingling 65
Tendency to startle 57
Choking/smothering sensation 54
24
1. Panic Disorder differential diagnosis

• Drugs
• Caffeine
• Aminophylline related compounds
• Sympathomimetic agents
• Monosodium glutamate

• Stimulants/hallucinogens
• Withdrawal from Etoh, Benzodiazepines, other
  sedative-hypnotics
• Thyroid hormone
• Antipsychotics

25
1. Panic Disorder differential diagnosis

• Medical illness
• Angina
• Cardiac arrhythmias
• Congestive heart failure
• Hypoglycemia
• Hypoxia
• Pulmonary embolism

• Severe pain
• Thyrotoxicosis
• Carcinoid
• Pheochromocytoma
• Ménière's disease

26
1. Panic Disorder differential diagnosis

• Anxiety disorders
• Major depression
• Personality disorders
• Adjustment disorder with anxious mood

27
1. Panic Disorder pathophysiology

• Different substances induce panic
• Isoproterenol (beta-agonist) ()
• Yohimbine (alpha2-blocker)
• CO2
• Sodium Lactate
• Theories of etiology based on inducers, but is
  unknown
• Example 5 CO2 exposure leads to panic in
  susceptible individuals false suffocation
  alarm theory

CO2
28
1. Panic Disorder pathophysiology

• Hereditary component
• Risk is 20 for first degree relatives- Only 2
  in relatives of control subjects
• Twin studies- 45 Concordance rate with
  identical twins - 15 concordance in
  non-identical twins

• Psychological theories
• Psychoanalytical-repression
• Behavioral-conditioned response

29
1. Panic Disorder complications

Specialists are often consulted unnecessarily for
panic attacks
Specialty Target Symptoms
Pulmonology Shortness of breath, hyperventilation, smothering sensation
Dermatology Sweating, cold, clammy hands
Cardiology Palpitations, chest pain
Neurology Tingling, numbness, dizziness, light-headedness, depersonalization, derealization, tremulousness
Otolaryngology Choking sensation, dry mouth
Gynecology Hot flashes, sweating
Gastroenterology Nausea, diarrhea, abdominal pain
Urology Frequent urination
30
1. Panic Disorder treatment

• Medications
• Antidepressants
• SSRIs, SNRIs treatment of choice
• Safe, well tolerated
• Tricyclic antidepressants, MAOIs
• High potency Benzodiazepines
• Clonazepam, alprazolam
• Potentially habit forming

• Cognitive-Behavioral Treatment
• Cognitive/Behavioral Therapy for Panic DO
• Agoraphobia-exposure therapy

31
2. Agoraphobia
32
2. Agoraphobiadiagnostic criteria

• Anxiety about being in places or situations from
  which escape may be difficult or help not
  available
• Situations typically avoided
• Not accounted for by another disorder

33
3. Generalized Anxiety Disorder (GAD)
34
3. Generalized Anxiety Disorder (GAD) diagnostic
criteria - DSM-IV-TR

• Excessive anxiety and worry occurring more days
  than not, for at least 6 months, about a number
  of events or activities.
• It is difficult to control the worry
• The anxiety and worry is associated with gt 3 of
  the following
• restlessness / feeling keyed up / on edge
• being easily fatigued
• difficulty concentrating / mind going blank
• irritability
• muscle tension
• sleep disturbance

35
3. Generalized Anxiety Disorder (GAD)diagnostic
features

• Prevalence
• 4-7 of general population
• More common in women, African-Americans,
  patients younger than 30

• Age
• Onset often early 20s but may occur at any age

36
3. Generalized Anxiety Disorder (GAD)diagnostic
features

• Course
• Usually chronic, with fluctuating severity
• One-quarter go on to develop Panic disorder
• Often co-morbid depression or substance abuse
• Many also meet criteria for social and specific
  phobia
• Often presents with medical, not psychiatric
  complaints

37
3. Generalized Anxiety Disorder
(GAD)pathophysiology

• Cause unknown
• Non-genetic factors (such as life events)
• More important than genetics
• But does tend to run in families
• Several different neurotransmitters may be
  involved
• Norepinephrine, GABA, Serotonin
  in frontal lobe, and limbic
  system

38
3. Generalized Anxiety Disorder
(GAD)differential diagnosis

• Same as for Panic disorder

39
3. Generalized Anxiety Disorder (GAD)treatment

• Medication

• Antidepressants (start low to minimize anxiety)
• SSRIs/SNRI Escitalopram, Paroxetine,
  Venlafaxine
• Tricyclics-work well, risk in overdose, side
  effects
• Buspirone
• Like antidepressants takes weeks to work

• Benzodiazepines
• Work well, but tolerance with long term use
• Sedating tricyclic antidepressants
• Work at low doses, but lots of side effects
• Antihistamines
• May work short term but dangerous in the elderly

40
3. Generalized Anxiety Disorder (GAD)treatment

• Psychotherapy
• Education
• chronic disorder, with waxing and waning of
  symptoms
• Psychodynamic
• increases anxiety tolerance
• Behavior Therapy
• to help recognize and control symptoms
• relaxation techniques, re-breathing exercises,
  progressive muscle relaxationhelpful,
  especially if symptoms mild

41
4. Social Phobia(Social Anxiety Disorder)
42
4. Social Phobia (Social Anxiety Disorder)
diagnostic criteria - DSM-IV-TR

• A marked and persistent fear of one or more
  social or performance situations in which the
  person is exposed to unfamiliar people or to
  possible scrutiny by others. The individual fears
  that he/she will act in a way that will
  humiliating or embarrassing
• Exposure to the feared social situation almost
  invariably provokes anxiety, which may take the
  form of a situationally bound or situationally
  predisposed panic attack

43
4. Social Phobia (Social Anxiety Disorder)
diagnostic criteria - DSM-IV-TR

• The person recognizes that the fear is excessive
  or unreasonable
• The feared social or performance situations are
  avoided or else are endured with intense anxiety
  or distress

44
4. Social Phobia (Social Anxiety Disorder)
diagnostic criteria - DSM-IV-TR

• The avoidance, anxious anticipation, or distress
  in the feared social or performance situation
  interferes significantly with persons routine,
  occupational functioning, or social activities or
  relationships, or there is marked distress about
  having the phobia.

45
4. Social Phobia (Social Anxiety Disorder)
diagnostic features

• Prevalence
• Social phobia affects up to 12 of population
• Females Males

46
4. Social Phobia (Social Anxiety Disorder)
diagnostic features

• Age
• Generally early in life shy
• Mean age at onset is estimated to be in the
  mid-teens, although some report onset in early
  childhood

DSM-IV-TR 2000 Adapted from Schneier 1992
Ballenger 1998.
47
4. Social Phobia (Social Anxiety Disorder)
diagnostic features

• Course
• Social Phobia develops slowly and is chronic
• Avoid public speaking, eating in public, riding
  public transportation, using public toilets
• 1/8 develop substance misuse
• 1/2 develop comorbid psychiatric disorder (like
  depression or another anxiety disorder)

48
4. Social Phobia (Social Anxiety Disorder)
complications
Katzelnick 2001
49
4. Social Phobia (Social Anxiety Disorder)
pathophysiology
Social Phobia tends to run in families
50
4. Social Phobia (Social Anxiety Disorder)
pathophysiology
The biology of Social Phobia is not well
understood

• Dopamine may play a role
• Historically patients with social phobia did
  better on MAOI (which have dopaminergic activity)
  than TCA (which have little dopaminergic
  activity)
• Low levels of dopamine in CSF is linked to
  introversion
• Functional brain imaging shows decreased striatal
  dopamine D2 receptors and decreased dopamine
  transporter binding

51
4. Social Phobia (Social Anxiety Disorder)
differential diagnosis

• Other anxiety disorders
• Mood disorders
• Schizoid and avoidant personality disorders

52
4. Social Phobia (Social Anxiety Disorder)
treatment

• Cognitive-Behavioral Therapy
• Social Skills
• Systematic Desensitization
• Teach relaxation with gradually increasing
  anxiety producing situations
• Flooding
• Medication
• Generalized subtype
• SSRIs, SNRIs, M.A.O.I.'s, Benzodiazepines
  (high potency)
• Performance subtype
• Beta Blockers (but does not work in generalized
  type)

53
5. Specific Phobia
54
5. Specific Phobiadiagnostic criteria -
DSM-IV-TR

• Marked or persistent fear that is excessive or
  unreasonable, cued by the presence or
  anticipation of a specific object or situation
• Exposure to the phobic stimulus almost invariably
  provokes an immediate anxiety response, which
  may take the form of a situationally predisposed
  Panic Attack

55
5. Specific Phobiadiagnostic criteria -
DSM-IV-TR

• The person recognizes that the fear is excessive
  or unreasonable
• The phobic situation is avoided or else is
  endured with intense anxiety of distress
• The avoidance, anxious anticipation, or distress
  in the feared situation interferes significantly
  with the persons normal routine, occupational
  functioning, or social activities or
  relationships, or there is marked distress about
  having the phobia

56
5. Specific Phobiadiagnostic features

• Age
• Onset usually childhood before age 12

• Prevalence
• 10-12 (common but rarely significantly
  impairing)
• Females gt Males

57
5. Specific Phobiadiagnostic features

• Course
• Few seek treatment as symptom free when away from
  the feared object/situation, therefore simply
  avoid the feared object or situation
• Patients see phobia as bothersome not
  pathological
• Only 2-3 of psychiatric outpatients
• Improve with advancing age/if chronic, rarely
  causes disability

58
5. Specific Phobiapathophysiology

• Specific Phobia tends to run in families
• Familial
• 68 of Blood-Injury Phobics have relatives with
  the Same Phobia
• The biology of specific phobia is not well
  understood

59
5. Specific Phobiapathophysiology

• Behaviorist feel learning may play an important
  role
• Predisposing Factors
• Observing other undergo trauma/situation
• Traumatic event for patient
• Psychoanalysts feel phobias result from
  unresolved conflicts in childhood
• Displacement and avoidance are the defense
  mechanisms used

60
5. Specific Phobiadifferential diagnosis

• Other anxiety disorders
• Mood disorders
• Schizoid and avoidant personality disorders

61
5. Specific Phobiacommon phobias

• Animals
• Natural Environment (storms, heights)
• Illness / blood-injury / fear of death
• Situational (enclosed spaces, airplanes,
  elevators)
• Other (avoidance of situations were may
  contract an illness or choke)

62
5. Specific Phobiatreatment

• Behavioral Therapyexposure therapy
• Flooding
• Systematic desensitization
• Medications
• Benzodiazepine on prn basis if exposure to the
  stimulus is infrequent, yet predictableand
  causes significant distress if not ameliorated in
  some way.

63
6. Obsessive Compulsive Disorder(OCD)
64
6. Obsessive Compulsive Disorder (OCD)
diagnostic criteria - DSM-IV-TR

• Requires obsessions or compulsions

Obsessions are

• Recurrent and persistent thoughts, impulses, or
  images that are
• Intrusive and inappropriate
• Cause anxiety or distress
• Not excessive worries about real-life problems

• The patient attempts to ignore or suppress the
  thought or to neutralize them with some thought
  or action
• Recognized as a product of their own mind

65
6. Obsessive Compulsive Disorder (OCD)
diagnostic criteria - DSM-IV-TR

• Compulsions are

• Repetitive behaviors or mental acts
• Feels driven to perform in response to an
  obsession or according to rules that must be
  applied rigidly

• The behaviors or mental acts are aimed at
• Preventing or reducing distress or preventing
  some dreaded event or situation
• But the behavior or acts are not connected in a
  realistic way with what they are designed to
  neutralize or prevent or are clearly excessive

66
6. Obsessive Compulsive Disorder (OCD)
diagnostic criteria - DSM-IV-TR

• At some point during the course of the disorder,
  the person has recognized that the obsessions or
  compulsions are excessive or unreasonable

• The obsessions or compulsions cause marked
  distress, are time consuming (take more that 1
  hour a day), or significantly interfere with the
  persons normal routine, occupational
  functioning, or usual social activities or
  relationships

• Specify if with poor insight

67
6. Obsessive Compulsive Disorder (OCD)
diagnostic features
Obsessions
Multiple obsessions 72
Contamination 50
Pathological doubt 42
Somatic 33
Need for symmetry 32
Aggressive impulse 31
Sexual impulse 24
Compulsions
Checking 61
Multiple compulsion 58
Washing 50
Counting 36
Need to confess 34
Symmetry/precision 28
Hoarding 18
68
6. Obsessive Compulsive Disorder (OCD)
diagnostic features

• Age
• Onset usually late teens-early 20s
• Most who develop it have it by age 30

• Prevalence
• 2-3 of general population world wide
• MalesFemales

69
6. Obsessive Compulsive Disorder (OCD)
diagnostic features

• Course
• Onset typically gradual but may occur suddenly
  over 1 month in the absence of stressors but men
  have earlier onset
• 70-80 concordance rate with depression

70
6. Obsessive Compulsive Disorder (OCD)
pathophysiology

• 20 of first degree relatives have OCD
• Another 15 have sub-clinical symptoms
• Tourettes is often associated with OCD
• Neurobiological model
• OCD occurs more often in persons with various
  neurological disorders
• Head trauma, epilepsy, Sydenhams chorea,
  Huntingtons chorea
• Liked to
• birth injury, abnormal EEG, Abnormal auditory
  evoked potentials, growth delays, abnormal
  neuro-psych testing, beta-streptococcal infections

71
6. Obsessive Compulsive Disorder (OCD)
pathophysiology

• Biological Theories
• Serotonin System
• Drugs which down regulate the serotonin system
  help in treating the symptoms, but why they help
  is not understood

• Cingulate System
• PET Studies-increased glucose metabolism
• In frontal lobe and basal ganglia (caudate)
• Drugs reverse the hyper metabolism
• Stimulating the Cingulum Produces OCD
• Stereotactic Cingulotomy Effective in 40-50

72
6. Obsessive Compulsive Disorder (OCD)
differential diagnosis

• Schizophrenia
• Major Depression
• PTSD
• Hypochondriasis
• Anorexia nervosa
• Tourettes syndrome

73
6. Obsessive Compulsive Disorder (OCD) treatment

• Behavioral TherapyExposure and response
  prevention
• Most effective for treating compulsions,
  especially in combination with medication

• Medication (10-12 weeks to work)
• Serotonin Re-Uptake Blockers work (need higher
  dose-longer treatment course)
• SSRIs, Clomipramine

• ECT
• Psychosurgery-stereotactic cingulotomy

74
7. Post Traumatic Stress Disorder(PTSD)
75
7. Post Traumatic Stress Disorder (PTSD)
diagnostic criteria - DSM-IV-TR
The person has been exposed to a traumatic event
in which both were present

• The person experienced, witnessed or was
  confronted with an event that involved actual or
  threatened death or serious injury , or threat to
  the physical integrity of self or others
• The persons response involved intense fear,
  helplessness or horror.

76
7. Post Traumatic Stress Disorder (PTSD)
diagnostic criteria - DSM-IV-TR
Re-experiencing Symptoms

• The traumatic event is persistently
  re-experienced in one or more of the following
  ways

• Recurrent intrusive-distressing recollections of
  the event
• Recurrent distressing dreams of the event
• Acting or feeling as if traumatic event were
  recurring
• Intense psychological distress at exposure to
  internal or external cues of the traumatic event
• Physiological reactivity on exposure to internal
  or external cues

77
7. Post Traumatic Stress Disorder (PTSD)
diagnostic criteria - DSM-IV-TR
Avoidance Symptoms

• Persistent avoidance of stimuli associated with
  the trauma and numbing of general responsiveness
• Markedly diminished interest or participation in
  significant activities
• Feeling of detachment or estrangement from others
• Restricted range of affect
• Sense of a foreshortened future

78
7. Post Traumatic Stress Disorder (PTSD)
diagnostic criteria - DSM-IV-TR
Arousal Symptoms

• Persistent symptoms of increased arousal (not
  present before the trauma), as indicated by two
  (or more) of the following
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

79
7. Post Traumatic Stress Disorder (PTSD)
diagnostic criteria - DSM-IV-TR

• Duration of symptoms gt 1 month
• The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning
• Specify if
• Acute if duration of symptoms is less than 3
  months
• Chronic if duration of symptoms is 3 months or
  more
• Delayed Onset if onset of symptoms is at least 6
  months after the stressor

80
7. Post Traumatic Stress Disorder (PTSD)
diagnostic features

• Prevalence of PTSD
• 7 of general population
• Most common trauma
• For men is combat
• For women is sexual assault
• Chance of developing PTSD after trauma
• Cocoanut Grove fire 1942
• 57 had PTSD one year later
• 9/11 Attacks
• South of 110th street 7.5 with PTSD
• South of Canal street 20 with PTSD

81
7. Post Traumatic Stress Disorder (PTSD)
diagnostic features

• Clinical Findings
• PTSD usually begins soon after the trauma
• Sometimes onset may be delayed months or years,
  and could be triggered by a remembering
• Usually chronic and symptoms may fluctuate
• Worsen during stressful periods

82
7. Post Traumatic Stress Disorder (PTSD)
diagnostic features

• Course
• Good prognostic signs
• rapid onset of symptoms
• good premorbid functioning
• strong social support
• absence of psychiatric and medical comorbidity
• many develop comorbid problems
• Major depression, other anxiety disorders,
  substance abuse problems

83
7. Post Traumatic Stress Disorder (PTSD)
pathophysiology

• The major etiological event is the trauma in PTSD
• Must be outside the range of normal human
  experience
• More severe the stress, the greater chance of PTSD

• Other factors in developing PTSD
• Age more likely in children than adults
• Prior psychiatric treatment increase chance of
  PTSD
• Patients with good social support are less
  likely to develop PTSD than patients with poor
  social support

84
7. Post Traumatic Stress Disorder (PTSD)
pathophysiology

• Biological abnormalities in PTSD
• Decreased rapid eye movement latency in Stage IV
  sleep
• Sustained levels of high emotional arousal can
  lead to dysregulation of the hypothalamic-pituitar
  y-adrenal axis

• Noradrenergic and serotonergic pathways have
  been implicated in the genesis of PTSD
• Brain imaging-reduced hippocampal volume,
  increased metabolic activity in the limbic system
  (amygdala)--may explain disturbed emotional
  memory in PTSD

85
7. Post Traumatic Stress Disorder (PTSD)
differential diagnosis

• Major Depression
• Adjustment disorder
• Other Anxiety disorders
• Panic disorder
• Generalized Anxiety disorder
• Acute stress Disorder
• OCD
• Depersonalization disorder
• Factitious disorder
• Malingering

86
7. Post Traumatic Stress Disorder (PTSD)
treatment

• Medications
• Antidepressants-best medication treatment
• SSRIs helps all three symptom clusters, but
  generally are most effective when depressive
  symptoms accompany the PTSD symptoms
• Benzodiazepines have abuse potential
• Beta blockers immediately after the trauma may
  reduce later PTSD
• Psychotherapy
• Individual and Group developing a sense of
  safety and trust is important
• Cognitive/behavioral is effective
• Dynamic therapy can be helpful

87
8. Acute Stress Disorder
88
8. Acute Stress Disorderdiagnostic criteria -
DSM-IV-TR

• The person has been exposed to a traumatic event
  in which both of the following were present

• The person experienced, witnessed, or was
  confronted with an event that involved actual or
  threatened death or serious injury, or a threat
  to the physical integrity of self of
• The persons response involved intense fear,
  helplessness or horror

89
8. Acute Stress Disorderdiagnostic criteria -
DSM-IV-TR

• Either while experiencing or after experiencing
  the distressing event, the individual has three
  or more of the following dissociative symptoms

• A subjective sense of numbing, detachment, or
  absence of emotional responsiveness
• A reduction in awareness of his or her
  surroundings (e.g., being in a daze)
• Derealization
• Depersonalization
• Dissociative amnesia (i.e., inability to recall
  an important aspect of the trauma)

90
8. Acute Stress Disorderdiagnostic criteria -
DSM-IV-TR

• The traumatic event is persistently reexperienced
  in at least one of the following ways

• recurrent images
• thoughts
• dreams
• illusions
• flashback episodes or a sense of reliving the
  experience or distress on exposure to reminders
  of the traumatic event

91
8. Acute Stress Disorderdiagnostic criteria -
DSM-IV-TR

• Marked avoidance of stimuli that arouse
  recollections of the trauma (e.g., thoughts,
  feelings, conversations, activities, places,
  people)
• Marked symptoms of anxiety or increased arousal
  (e.g., difficulty sleeping, irritability, poor
  concentration, hypervigilance, exaggerated
  startle response, motor restlessness)
• The disturbance lasts for a minimum of 2 days and
  a maximum of four seeks and occurs within four
  weeks of the traumatic event

92
8. Acute Stress Disordermiscellaneous

• Little known about disorder
• Highly correlated to severity of trauma
• Treatment strategies not studied
• Hoped that early ID and treatment may decrease
  PTSD symptoms later

93
8. Acute Stress Disorderdifferential diagnosis

• PTSD
• Brief Psychotic disorder
• Dissociative disorder
• Adjustment disorder

94
8. Acute Stress Disordertreatment

• Early intervention helpful
• Cognitive/behavioral approach
• Fewer patients later met PTSD criteria
• Medication
• A brief course of benzodiazepines may be helpful
  to decrease anxiety and re-establish sleep
• Beta blocker within 4 hours of trauma may be
  helpful
• Epinephrine increases the laying down of memory

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Anxiety Disorders differential diagnosis
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Anxiety Disordersdifferential diagnosis

• Whats the trigger?
• Out of the blue (no trigger) Panic disorder
• Reminder of trauma - PTSD
• During a stressor/trauma - ASD
• Fear of public embarrassment - Social Phobia
• Fear of an event/object/being - Specific Phobia
• Not able to perform compulsion - OCD
• Chronic anxiety without panic attacks - GAD

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Disorder Definition Differential Diagnosis Age / Course Treatment
Panic Disorder Need both 1.Recurrent unexpected panic attacks 2. At least one of the attacks has been followed by one month (or more) of persistent concern about having additional attacks, worry about the implications of the attack or its consequences, or a significant change in behavior related to attacks. Anxiety Disorders Schizophrenia Major Depression Personality Disorders Adjustment Disorder with anxious mood Onset usually mid 20s. Recurrent attacks vary in frequency and intensity panic free intervals total remission is uncommon Medications antidepressants (SSRIs and SNRIs are treatment of choice) and high potency Benzodiazepines. Cognitive-Behavioral Therapy
Agoraphobia Anxiety about being in places or situations from which escape may be difficult or help not available. Situations typically avoided. Not accounted for by another disorder. Most people who develop agoraphobia have had panic attacks. Often become housebound as they are so terrified of not being able to get help should their panic become disabling. Anxiety about being in places or situations from which escape may be difficult or help not available. Situations typically avoided. Not accounted for by another disorder. Most people who develop agoraphobia have had panic attacks. Often become housebound as they are so terrified of not being able to get help should their panic become disabling. Anxiety about being in places or situations from which escape may be difficult or help not available. Situations typically avoided. Not accounted for by another disorder. Most people who develop agoraphobia have had panic attacks. Often become housebound as they are so terrified of not being able to get help should their panic become disabling. Anxiety about being in places or situations from which escape may be difficult or help not available. Situations typically avoided. Not accounted for by another disorder. Most people who develop agoraphobia have had panic attacks. Often become housebound as they are so terrified of not being able to get help should their panic become disabling.
Generalized Anxiety Disorder (GAD) Excessive anxiety and worry occurring more days than not, for at least 6 months, about a number of events or activities. It is difficult to control the worry. The anxiety and worry is associated with 3 of the following restlessness/feeling keyed up/on edge, being easily fatigued, difficulty concentrating/mind going blank, irritability, muscle tension, sleep disturbance Same as Panic Disorder Onset often early 20s but may occur at any age. Usually chronic, w/fluctuating severity ¼ go on to develop panic disorder, Often co-morbid depression or substance abuse, Many also meet criteria for social and specific phobia Often presents with medical, not psychiatric complaints Medications Antidepressants (start low to minimize anxiety), Buspirone (like antidepressants takes weeks to work), Benzodiazepines (work well but tolerance with long term use), Sedating tricyclic antidepressants (work at low doses but lots of side effects), Antihistamines (may work short term but dangerous in the elderly)
Social Phobia (Social Anxiety Disorder) A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he/she will act in a way that will be humiliating or embarrassing. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. Other Anxiety Disorders Mood Disorders Schizophrenia Schizoid and avoidant personality disorders Generally early in life shy, Mean age at onset is estimated to be in the mid-teens, although some report onset in early childhood. Social phobia develops slowly and is chronic, avoid public speaking, riding public transportation, using public toilets. 1/8 develop substance misuse, ½ develop co-morbid psychiatric disorder (i.e. depression or another anxiety disorder) Cognitive-Behavioral Therapy (social skills, systematic desensitization, flooding) Medications Generalized subtype (SSRIs, SNRIs, M.A.O.I.s, Benzodiazepines), Performance subtype (Beta Blockers), TCAs DO NOT work in Social Phobiat
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Disorder Definition Differential Diagnosis Age / Course Treatment
Specific Phobia Marked or persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally predisposed Panic Attack Other anxiety disorders Mood disorders Schizophrenia Schizoid and avoidant personality disorders Onset usually childhood before the age of 12 Few seek treatment as symptom free when away from feared object/situation, therefore simply avoid the feared object or situation, Patients see phobia as bothersome not pathological, Only 2-3 of psychiatric outpatients, Improve with advancing age/if chronic, rarely causes disability Behavioral Therapy exposure therapy (flooding, systematic desensitization) Medications Benzodiazepines (on prn basis if exposure to the stimulus is infrequent, yet predictable and causes significant distress if not ameliorated in some way)
Obsessive-Compulsive Disorder (OCD) Requires obsessions or compulsions Obsessions recurrent and persistent thoughts, impulses or images (that are intrusive inappropriate, cause anxiety or distress, not excessive worries about real-life problems), the patient attempts to ignore or suppress the thought or to neutralize them with some thought or action Compulsions Repetitive behaviors or mental acts (feels driven to perform in response to an obsession or according to rules that must be applied rigidly), The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, But the behavior or acts are not connected in a realistic way with what they are designed to neutralized or prevent or are clearly excessive. The person has recognized that the obsessions or compulsions are excessive, cause marked distress and are time consuming Schizophrenia Major Depression PTSDHypochondriasis Anorexia Nervosa Tourettes Syndrome Onset usually late teens-early 20s. Most who develop it have it by age 30. Onset typically gradual but may occur suddenly over 1 month in the absence of stressors but men have earlier onset. 70-80 concordance rate with depression Behavioral Therapy Exposure and response prevention (Most effective for treating compulsions, especially in combination with medication) Medications (10-12 weeks to work) Serotonin Re-Uptake Blockers work (need higher does-longer treatment course SSRIs, Clomipramine) ECT Psychosurgery-stereotactic cingulotomy
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Disorder Definition Differential Diagnosis Age / Course Treatment
Post-Traumatic Stress Disorder (PTSD) The person has been exposed to a traumatic event in which both were present 1. The person experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others. 2. The persons response involved intense fear, helplessness or horror. Re-experiencing symptoms Avoidance symptoms Arousal symptoms Duration of symptoms 1 month Major Depression Adjustment Disorder Other anxiety disorders (panic disorder, GAD, acute stress disorder, OCD) Depersonalization Disorder Factitious Disorder Malingering Good prognostic signs Rapid onset of symptoms Good premorbid functioning Strong social support Absence of psychiatric and medical comorbidity Man y develop comorbid problems (Major depression, other anxiety disorders, substance abuse problems) Medications Antidepressants (best medication treatment) SSRIs (helps all 3 symptom clusters, but generally are most effective when depressive symptoms accompany the PTSD symptoms), Benzodiazepines (have abuse potential), Beta Blockers (immediately after the trauma may reduce later PTSD) Psychotherapy (individual and group developing a sense of safety and trust is important) Cognitive/behavioral (effective), Dynamic Therapy (can be helpful)
Acute Stress Disorder Same as PTSD numbers 1 and 2. Either while experiencing or after experiencing the distressing event , the individual has three or more of the following dissociative symptoms A subjective sense of numbing, detachment, or absence of emotional responsiveness A reduction in awareness of his or her surroundings (e.g., being in a daze) Derealization Depersonalization Dissociative amnesia (i.e., inability to recall an important aspect of the trauma). The traumatic event is persistently re-experienced in at least one of the following ways (recurrent images, thoughts, dreams, illusions, flashback episodes) Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people) Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness) The disturbance lasts for a minimum of 2 days and a maximum of four seeks and occurs within four weeks of the traumatic event PTSD Brief Psychotic Disorder Dissociative Disorder Adjustment Disorder Early intervention helpful Cognitive/Behavioral approach, Fewer patients later met PTSD criteria. Medications Benzodiazepines ( a brief course may be helpful to decrease anxiety and re-establish sleep), Beta Blockers (within 4 hours of trauma may be helpful epinephrine increases the laying down of memory)
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Questions?