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Anxiety Disorders Back to Basics


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Title: Anxiety Disorders Back to Basics

Anxiety DisordersBack 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)
  • 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
  • anxiety disorder not otherwise specified (NOS)

Panic disorder - epidemiology
  • prevalence
  • life-time 4.7
  • 1/3-1/2 have agrophobia
  • FM ratio 2-31
  • age of onset adolescence/early adulthood (17-35)
  • 20X higher risk of suicide versus general
  • 80 first seen by primary care/ER

Panic disorder- diagnosis
  • recurrent unexpected panic attacks
  • gt 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 contd
  • 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
  • further classified
  • with agoraphobia
  • without agoraphobia

Panic attack - diagnosis
  • gt 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

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,
  • 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
  • FM 21
  • 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
  • difficult to control
  • gt 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

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Social phobia (social anxiety d/o) epidemiology
  • lifetime prevalence 13
  • FM 1.51
  • 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
  • Exposure produces anxiety
  • Recognition of excess
  • Social/performance situations avoided / endured w
  • Occupational / social dysfn.
  • Not lt 6/12 if person lt18 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,
  • 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

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 substance-related d/o)
  • FM 21
  • 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
  • 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
  • MF in adults, MgtF in adolescents
  • mean age of onset 20
  • less in blacks than whites
  • 10 will develop schizophrenia
  • 50 with Tourettes have OCD

OCD - diagnosis
  • Obsessions or Compulsions
  • O I ignore, suppress, neutralize
  • R recurrent persistent intrusive thoughts
  • O own mind (ego-dystonic)
  • N not simply excessive worries
  • C R repetitive beh./ mental acts
  • R reduce stress
  • R recognition of problem (excessive)
  • O occupational, social dysfn. (take gt 1 hr /
  • N not restricted to another axis I d/o
  • S 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
  • CBT Exposure Response Prevention (ERP)
  • psychoeducation
  • family therapy

Posttraumatic stress disorder (PTSD) -
  • life time prevalence 9
  • FM 21
  • 80 have co-morbid illness
  • 6x completed suicide risk compared to general
  • symptoms fluctuate, get worse with stress

PTSD diagnosis
  • 3 major elements re-experience, avoidence,
  • 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 gt 1/12 (gt3/12 chronic)

PTSD - types
  • Acute
  • symptoms last up to 3 months
  • Chronic
  • symptoms last gt3 months
  • Delayed onset
  • symptoms start gt 6 months after traumatic event

PTSD treatment
  • Pharmacotherapy
  • SSRIs, venlefaxine XR
  • Psychotherapy
  • psychoeducation
  • group therapy
  • formalized stress de-briefing is not recommended

Eye Movement Desensitization Reprocessing
  • 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 () FM Key features Treatment
Social Phobia 13, 1.51 Low SES Anxiety triggered by social/ performance situations PERSON SSRI,effexor, benzo Performance desensitization, social skills training
Specific Phobia 12.5, 21 Young onset 5-12 yo Anxiety triggered by specific object / situation PERSON Beta blockers, benzo systematic desensitization, exposure, supportive therapy
PTSD 9, 21 Hx of trauma--- re-experience, avoidence, arousal TRAPED SSRI,effexor EMDR
GAD 5, 21 Low SES Excessive worry ?6/12 ?3 BE SKIM SSRI,effexor, benzo, imipramine, bupropion, buspirone, relaxatin
Panic Disorder 4.7, 2-31 recurrent attacks (not trigger), gt4/13 STUDENTS Fear the 3 Cs SSRI, Effexor, clomipramine, benzo. 8-12 mos exposure, relaxation
OCD 2-3, MF in adults, MgtF 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?
  • Women have higher rates of almost all anxiety
  • 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?
  • Obsessions are acknowledged as excessive or
  • There are attempts to ignore or suppress
    compulsive thoughts or
  • impulses
  • Obsession or compulsions are time consuming and
    take gt 1hr/day
  • Children need not to recognize their obsessions
    are unreasonable
  • The person recognizes obsessional thoughts as a
    product of outside
  • themselves

  • Anxiety disorders
  • 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
  • All of the above

  • Which one of the following situations are most
    likely to cause PTSD
  • Involvement in an earthquake
  • Being diagnosed with cancer
  • Rape
  • Witnessing a crime
  • Observing a flood

  • The risk of developing anxiety d/os is enhanced
  • Eating disorder
  • Depression
  • Substance abuse
  • Allergies
  • All of the above

  • Isolated panic attacks without functional
  • Are uncommon
  • Occur in lt2 of population \
  • Are part of the criteria for diagnosis of PD
  • Usually involve anticipatory anxiety or phobic
  • None of the above

  • Which of the following statements are true about
    patients with
  • obsessive compulsive personality disorder?
  • 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
  • Onset is typically late adolescence or early
  • Tends to exhibit a fluctuating course
  • Typical patients exhibit a patter of chronic
  • Majority of the pts live relatively normal lives
  • All of the above

  • Tourettes d/o has been shown to possibly have a
    familial genetic
  • Relationship with
  • Panic d/o
  • Social phobia
  • GAD
  • OCD
  • None of the above

  • Isolated panic attacks without functional
  • Are uncommon
  • Occur in lt2 of population \
  • Are part of the criteria for diagnosis of PD
  • Usually involve anticipatory anxiety or phobic
  • None of the above

  • Which one of the following is most common symptom
  • associated with OCD?
  • Obsession of doubt
  • Obsession of contamination
  • Intrusive thoughts
  • Obsession of symmetry
  • Compulsive hoarding

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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

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."

  • "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.

  • "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

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."

  • "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.

  • "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 light-headed. 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!
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