Anxiety Disorders Back to Basics 2012

1
Anxiety DisordersBack to Basics 2012

• Dr. Holly Dornan
• PGY-4 Psychiatry Resident
• University of Ottawa

2
Anxiety
3
LMCC Objectives

• Key Objectives
• In patients with many other medical complaints
  and/or excessive utilisation of medical health
  care, determine whether anxiety co-exists.
• Differentiate situational stress from true
  anxiety disorder and from drug and physical
  causes of anxiety.
• Objectives
• Through efficient, focused, data gathering
• Review various physical symptoms briefly elicit
  history of other non-psychiatric illness, intake
  of alcohol and caffeine, and a brief history of
  any major life stresses.
• Elicit a history of excessive worry about events
  which is out of proportion to the impact of the
  event history present for at least six months
  (anxiety).
•     

4
LMCC Objectives

• Determine whether there is restlessness, fatigue,
  inability to concentrate, irritability, muscle
  tension, sleep disturbance.
• Determine whether social, occupational, or
  function in general has been affected.
• Determine whether co-morbid psychiatric disorders
  exist, stress, substance abuse, past sexual,
  physical and emotional abuse, or neglect.
• Determine whether there is a discrete period of
  intense fear, recurrent panic attacks,gt1 month of
  concern about more attacks, change in behavior in
  relation to attacks, along with cardiopulmonary,
  neurologic, psychiatric or other medical symptoms
  agoraphobia.

5
LMCC Objectives

• List and interpret critical clinical and
  laboratory findings which were key in the
  processes of exclusion, differentiation, and
  diagnosis.
• Conduct an effective initial plan of management
  for a patient with anxiety or panic
• Outline supportive therapy (e.g., psychosocial
  interventions) and counseling and list
  indications for drug therapy (e.g., selective
  serotonin re-uptake inhibitors).
• Select patients in need of specialized care.

6
LMCC Objectives

• Applied Scientific Concepts
• 1. Explain that although the pathophysiology of
  panic disorder/attacks is incompletely
  understood, the amygdala, locus ceruleus, and
  hippocampus along with several neurotransmitters
  have been the focus of attention.

7
LMCC Objectives

• Causal Conditions
• 1.     Panic attack
• a.     Cardiopulmonary symptoms -
  40
• b.     Neurologic symptoms - 40
• c.     Gastrointestinal symptoms -
  30
• d.     Psychiatric symptoms
• e.     Autonomic symptoms
• 2.     Panic disorder
• a.    With agoraphobia/Without
  agoraphobia
• b.    With social/Specific phobia
• c.    Trauma/Stress related/Post
  traumatic stress disorder
• 3.     Associated with other conditions
• a.    Depression
• b.    Obsessive compulsive disorder
• c.    Substance abuse
• 4.     Generalized anxiety disorder

8
What is anxiety?

• A feeling state consisting of physical, emotional
  and behavioural responses to perceived threats1
• Diffuse, unpleasant sense of apprehension
  accompanied by physical symptoms such as
  headache, sweating, palpitations, chest
  tightness, stomach upset, restlessness
• Normal and necessary part of everyday life

1 Can J Psychiatry Clinical Practice Guidelines
for the Management of Anxiety Disorders July 2006
9
Anxiety vs. Fear
Anxiety
Fear
Threat
Threat
Response to a threat that is unknown, internal,
vague or conflictual
Response to a known, external, definite threat
10
Anxiety as a Disorder

• When does anxiety become a disorder?
• 1) Greater intensity and/or duration than
  expected given the circumstances
• 2) Leads to impairment or disability
• 3) Daily activities are disrupted by
  avoidance of certain situations or objects to
  decrease anxiety
• 4) Includes clinically significant
  unexplained physical symptoms, obsessions,
  compulsions, or intrusive recollections of trauma

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
11
Anxiety
Overestimated
Likelihood x Harm
Anxiety
Ability to cope
Underestimated
Beck et al. 1985
12
Pathophysiology of Anxiety

• Caudate nucleus has been implicated in OCD
• fMRI studies have found increased activity in the
  amygdala in PTSD
• Abnormalities in parahippocampal gyrus in Panic
  Disorder
• 3 major neurotransmitters involved are
  norepinephrine, serotonin, and GABA

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
13
Neurobiology of anxiety
Slide courtesy of Dr. Elliott Lee
Limbic cortex
Nucleus accumbens
Periaqueductal Gray matter
Orbitofrontal cortex
Amygdala
Locus coeruleus
Brain Stem
Ventral Tegmental Area
Hippocampus
14
Anxiety

• Patients try to alleviate the unpleasant feeling
  of anxiety by
• Avoiding the trigger
• Developing a safety behaviour (i.e. having
  someone else accompany them)
• Using a substance or medication

15
Anxiety Disorders in DSM-IV TR

• Panic Disorder with and without agoraphobia
• Agoraphobia without history of Panic Disorder
• Social Phobia
• Specific Phobia
• Obsessive Compulsive Disorder
• Generalized Anxiety Disorder
• Post Traumatic Stress Disorder
• Acute Stress Disorder
• Anxiety Disorder due to a General Medical
  Condition
• Substance-Induced Anxiety Disorder
• Anxiety Disorder NOS

16
Epidemiology

• Lifetime prevalence for any anxiety disorder
  ranges from 10 to 29
• 12 month prevalence 18
• Common presentation in primary care
• 15 to 112 patients presenting to primary care
  will have an anxiety disorder
• Suicide rate 10 x higher than general population

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
17
Initial Assessment of Patients with Anxiety

• Four scenarios
• 1) Anxiety disorder is primary and there is
  no physical disorder present (any physical
  symptoms present are due to the anxiety)
• 2) The anxiety is secondary to a physical
  illness (e.g. hyperthyroidism)
• 3) The anxiety is secondary to a medication
  or substance
• 4) Both an anxiety and physical disorder are
  present by not causally related

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
18
Medical conditions that mimic or worsen anxiety
symptoms
Endocrine conditions Hyperthyroidism Hypothyroidism Pheochromocytoma Cushings disease Addisons disease Menopause
Cardiovascular Acute Coronary Syndrome Arrhythmia CHF Hypertension Hypertension Mitral Valve Prolapse
19
Medical conditions that mimic or worsen anxiety
symptoms (cont)
Neurological Epilepsy Cerebrovascular disease Menieres disease Multiple Sclerosis Migraine Encephalitis Early dementia
Metabolic Porphyria Diabetes
Pulmonary Asthma COPD Pulmonary Embolism Pneumonia
20
Medical conditions that mimic or worsen anxiety
symptoms (cont)
Other Anemia UTI (in elderly) Irritable Bowel Syndrome Heavy metal poisoning B12 deficiency Electrolyte disturbances
Medications Anti-cholinergics Steroids Stimulants (methylphenidate and amphetamine based) Theophylline Ventolin Nasal decongestants SSRIs
21
Substance Abuse and Anxiety

• Substance abuse is often co-morbid with anxiety
  disorders as patients often try to self-medicate
  to cope with anxiety
• 37 of patients with GAD and 20-40 of patients
  with Panic Disorder have alcohol abuse/dependence
• Drug intoxication can mimic anxiety
• - Amphetamines - Marijuana
• - Caffeine -
  Hallucinogens
• - Nicotine - Ecstasy
• - Cocaine -
  Excessive alcohol consumption
• - Phencyclidine

22
Substance Abuse and Anxiety (cont)

• Drug withdrawal also associated with anxiety
• Alcohol
• Benzodiazepines
• Opiate
• Barbiturate
• Anti-hypertensives

23
Key features
Panic Disorder Fear of losing control, dying or going crazy Avoid situations in which attacks may occur
Agoraphobia Fear of situations from which escape may be difficult or help unavailable (crowds, bus, bridge etc.)
OCD Intrusive, unwanted thoughts or urges (obsessions) and/or repetitive behaviours or mental acts (compulsions) Fear of harm, uncertainty, uncontrollable actions
24
Key features
Generalized Anxiety Anxiety regarding a number of everyday events Future and uncertainty difficult to accept
Social Anxiety Fear of humiliation, embarrassment or scrutiny by others
PTSD Re-experiencing of trauma through flashbacks, dreams, recollections
Specific phobia Fear of a specific object, animal or situation
25
Generalized Anxiety Disorder DSM IV TR

• Excessive anxiety and worry about a number of
  events or activities, occurring more days than
  not for at least 6 months
• Difficult to control the worry
• Associated with three of the following
• Restlessness, difficulty concentrating, muscle
  tension, fatigue, sleep disturbances,
  irritability
• Not due to a substance, medical condition or
  other mental disorder
• Causes clinically significant distress or
  impairment in functioning

26
Generalized Anxiety Disorder

• Lifetime prevalence 61
• 68 comorbidity with other psychiatric illness
  (depression, substance abuse, other anxiety
  disorder)
• Female to male ratio 211
• 25 of 1st degree relatives also have GAD2
• Twin studies show concordance rate of 502

1Can J Psychiatry Clinical Practice Guidelines
for the Management of Anxiety Disorders July 2006
2Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
27
Generalized Anxiety Disorder

• Chronic condition, usually lifelong
• Screening questions
• Do others call you a worry-wort?
• What kinds of things do you worry about?
• Usually seek treatment for somatic symptoms
  rather than anxiety
• Only 1/3 seek psychiatric treatment
• Often see specialists (GI, cardiology,
  internists)

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
28
GAD - treatment

• Pharmacotherapy
• 1st line SSRI or SNRI
• 2nd line Benzodiazepine
• Only recommended for short term use due to side
  effects (cognitive impairment, ataxia, sedation)
  and dependence and withdrawal)
• Avoid in substance abuse and the elderly
• 3rd line Adjunctive olanzapine or risperidone
• Mirtazapine

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
29
GAD - treatment

• An optimal trial involves 8-12 weeks
• If there is not an adequate response, switch to
  another 1st line agent
• Reasonable to try another 1st line agent with a
  different mechanism of action
• Treatment resistant patients should be assessed
  for comorbid medical and psychiatric conditions

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
30
GAD - treatment

• Psychological treatment
• CBT as effective as medication (also 1st line)
• CBT involves
• Psychoeducation
• Cognitive interventions (addressing cognitive
  distortions, unrealistic beliefs)
• Exposure
• Relaxation strategies
• Problem Solving
• Assertiveness training
• Relapse Prevention

31
Panic Attack DSM-IV criteria

• A discrete period of intense fear or discomfort,
  in which 4 or more develop abruptly and reach a
  peak within ten minutes
• Palpitations, increased heart rate
• Sweating
• Tremor or shaking
• Shortness of breath or smothering sensation
• Feeling of choking
• Chest pain
• Nausea or abdominal distress
• Feeling dizzy, lightheaded, or faint
• Derealization
• Depersonalization
• Parasthesias
• Chills or hot flushes
• Fear of losing control or going crazy
• Fear of dying

32
Panic Disorder with or without agoraphobia
DSM-IV criteria

• The person has experienced both
• Recurrent, unexpected panic attacks
• One or more of the attacks has been followed by
  either
• 1) Persistent concern about having another
  attack
• 2) Worry about the implications of the
  attack
• 3) Significant change in behaviour
• The presence (or absence of agoraphobia)
• Not due to a substance, medication or medical
  condition
• Not better accounted for by another mental
  disorder

33
Panic Disorder

• Lifetime prevalence of Panic Disorder is 4.7
• Lifetime prevalence of having a panic attack is
  15
• 1/3 to 1/2 of patients also have agoraphobia
• More common in women than in men
• Generally begins in late adolescence or early
  adulthood

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
34
Panic Disorder

• 20 X the risk of suicidal ideation and suicide
  attempts as the general population
• Felt to be related to dysregulation of brain
  noradrenergic systems
• Abnormalities have been found in the autonomic
  nervous system of some patients (increased
  sympathetic tone, less adaptive to repeated
  stimulit)

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
35
Panic Disorder

• Initially, panic attacks are unexpected
• Can occur any time (even night)
• Can also develop panic attacks that have triggers
  (situationally-predisposed panic attacks)
• Patients begin to have anticipatory anxiety about
  having another panic attack
• This can lead to avoidance of situations where
  escape or help may not be readily available
  (agoraphobia)

36
Panic Disorder - Treatment

• Pharmacotherapy
• 1st line SSRI or SNRI
• 2nd line Benzodiazepines
• Only recommended for short term use due to side
  effects (cognitive impairment, ataxia, sedation)
  and dependence and withdrawal
• Avoid in substance abuse and the elderly
• Often clinically, a small dose of long acting
  benzodiazepine is started along with SSRI/SNRI to
  provide more immediate relief from distressing
  symptoms
• i.e. 0.5 mg clonazepam BID for 2-3 weeks, then
  tapered until it is stopped

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
37
Panic Disorder - Treatment

• Psychological treatment
• CBT most consistently efficacious psychotherapy
  for Panic Disorder, according to the literature
• Individual or group therapy, bibliotherapy
• CBT for Panic Disorder includes same CBT concepts
  of psychoeducation, cognitive approaches,
  relaxation, problem solving
• Also incorporates interoceptive exposure
  (exposure to feared symptoms ? therapist may ask
  patient to hyperventilate or spin to make
  themselves dizzy)
• Exposure to avoided situations is important

38
Obsessive Compulsive Disorder DSM IV criteria

• Either obsessions or compulsions
• Obsessions are defined as
• Recurrent and persistent thoughts, images or
  impulses that are experienced as intrusive and
  inappropriate and cause marked anxiety/distress
• Not simply excessive worries about real-life
  problems
• Person attempts to ignore or suppress the
  obsessions, or neutralize them with other
  thoughts or actions
• Recognized as a product of the patients own mind
• Compulsions are defined as
• Repetitive behaviours or mental acts that the
  person feels driven to perform in response to an
  obsession, or according to rigid rules
• Compulsions are aimed at reducing distress or
  preventing some dreaded event, however they are
  not connected in a realistic way to what they are
  meant to neutralize, or are clearly excessive

39
Obsessive Compulsive Disorder DSM IV criteria
(cont)

• At some point during the course of the disorder,
  the person recognizes that the obsessions and/or
  compulsions are excessive or unreasonable
• The obsessions and/or compulsions cause marked
  distress, are time consuming (gt 1 h/day), or
  significantly interfere with functioning
• Not due to substance, or another medical or
  mental disorder

40
Obsessive-Compulsive Disorder

• Estimated lifetime prevalence of 1.6
• Median age of onset 19 years (range 14 30
  years)
• 60 are female
• High psychiatric co-morbidity rate (56 -83)
• Common co-morbidities include substance abuse,
  depression, social phobia, generalized anxiety
  disorder, panic disorder

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
41
Obsessive-Compulsive Disorder

• In 50-70 of patients, onset of symptoms is
  following a stressful event (i.e. pregnancy,
  death)
• Course is usually long, can be constant or
  fluctuating
• 20-30 have significant improvement
• 40-50 have moderate improvement
• 20-30 have no improvement or worsening

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
42
Obsessive-Compulsive Disorder

• 20-30 have tics, 6-7 Tourettes
• Possible link between a subset of OCD and tics
• PET studies have shown increased activity in the
  frontal lobes, basal ganglia (caudate), and
  cingulum in patients with OCD
• PANDAS Pediatric Autoimmune Neuropsychiatric
  Disorders associated with Streptococcal
  infections
• Streptococcus infection may trigger an autoimmune
  response which causes acute onset OCD symptoms
  and tics in children

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
43
Obsessive-Compulsive Disorder

• Most common obsessions include
• Contamination (1)
• Doubt/safety (idea that stove was left on, door
  unlocked etc.) (2)
• Sexual and aggressive impulses (3)
• Symmetry and exactness (4)
• Somatic and religious preoccupations
• Most common compulsions include
• Checking
• Washing
• Repeating
• Ordering
• Counting
• Hoarding

44
OCD - treatment

• Pharmacotherapy
• 1st line SSRI (serotonergic response needed)
• 2nd line Clomipramine (2nd line due to side
  effects cardiotoxicity, anticholinergic, drug
  interactions and lethality in overdose)
• Effexor XR, Mirtazapine
• Adjunctive Risperidone
• Dosages of meds e.g. SSRIs may need to be higher
  than in mood disorders
• Response may take 6 wks or longer (Guidelines
  state adequate trial 6-8 weeks)

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
45
OCD - treatment

• Psychological
• 
  
  
  
  
  
  
  
  1) Exposure with Response Prevention
  (ERP) form of behavioural therapy
• 2) CBT which combines Exposure and Response
  Prevention with cognitive interventions

46
Posttraumatic Stress Disorder DSM-IV criteria

• The person has been exposed to a traumatic event
  which included both
• 1) The person experienced or witnessed an event
  involving actual or threatened death or serious
  injury, or a threat to personal integrity of self
  or others
• 2) Response was fear, horror, or helplessness
• The traumatic event is re-experienced including
  at least one of
• Distressing memories, dreams, acting or feeling
  as if event is recurring (illusions, dissociative
  flashbacks, hallucinations), intense
  psychological or physiological distress when
  exposed to cues that symbolize the trauma

47
Posttraumatic Stress Disorder DSM-IV criteria

• Persistent avoiding of stimuli associated with
  the trauma and numbing of responsiveness
  including at least 3 of
• Efforts to avoid thoughts, feelings,
  conversations associated with the trauma
• Efforts to avoid people, places and activities
  associated with the trauma
• Inability to recall an important aspect of the
  trauma
• Feeling of detachment or estrangement from others
• Restricted range of affect
• Sense of foreshortened future

48
Posttraumatic Stress Disorder DSM-IV criteria

• Persistent symptoms of increased arousal
  including at least two of
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle reflex
• Duration is more than 1 month
• Causes clinically significant distress or
  impairment in functioning

49
Posttraumatic Stress Disorder

• Key features include exposure to trauma,
  re-experiencing of the trauma, avoidance and
  emotional numbing, and hyperarousal
• Examples of traumas include exposure to war,
  terrorist attacks, natural disasters, accidents
  involving serious injury or death, rape, torture
• If symptoms are present for less than one month,
  then the diagnosis may be Acute Stress Disorder

50
Posttraumatic Stress Disorder

• Prevalence in Canada 2.4 (1 month prevalence)
  and 9.2 (lifetime prevalence)
• Higher among women than men
• Lifetime prevalence estimates 16-37 in areas of
  the world where conflict has occurred
• Frequent co-morbidity with depression, substance
  abuse, other anxiety disorders

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
51
Posttraumatic Stress Disorder

• 6X increased risk of suicide attempts
• Predisposing factors include
• Childhood trauma
• Inadequate support system
• Female
• Genetic vulnerability to psychiatric illness
• Excessive alcohol use (recent)

52
Posttraumatic Stress Disorder - Treatment

• Guidelines recommend SSRI/SNRI as first line
  treatment1
• Recommended that patients with PTSD should
  continue medication for at least 1 year1
• In practice, agents to help with insomnia are
  often added (i.e. Trazadone)

1Can J Psychiatry Clinical Practice Guidelines
for the Management of Anxiety Disorders July 2006
53
Posttraumatic Stress Disorder - Treatment

• Other meds sometimes used include
• Clonidine (antiadrenergic agent)
• Prazosin for nightmares (alpha-1 adrenergic
  antagonist)
• Psychological treatment
• CBT recommended

54
Social Anxiety Disorder (Social phobia) DSM IV
criteria

• Marked and persistent fear of social or
  performance situations in which the person is
  exposed to unfamiliar people or possible scrutiny
  by others
• Fear that they will embarrass or humiliate
  themselves
• Exposure to the feared situation invariable
  produces anxiety which may be in the form of a
  panic attack
• The person recognizes that the fear is excessive
  or unreasonable

55
Social Anxiety Disorder (Social phobia) DSM IV
criteria (cont)

• The feared situations are avoided or endured with
  intense anxiety and distress
• The avoidance, anxious anticipation or distress
  interferes with functioning or causes marked
  distress
• In individuals under 18, duration is at least 6
  months
• Not due to substance, medical condition or other
  mental disorder
• If a medical condition is present, the fear is
  not related to it (i.e. trembling in Parkinsons)

56
Social Phobia

• Most people in the general population experience
  a degree of discomfort with certain social
  situations
• Generalized type vs. non-generalized (a
  restricted number of situations i.e. public
  speaking)
• Differentiate from panic disorder (panic attacks
  in social phobia always occur in feared
  situations)
• Differentiate from normal shyness (shyness should
  not cause functional impairment or marked
  distress)

57
Social Phobia

• Has significant impact on quality of life
• Lifetime prevalence of 8-12 1 (one of the most
  common anxiety disorders)
• Early onset, usually in childhood
• Chronic course, usually 20 years or longer

r
Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
58
Social Phobia

• Interferes with career, relationship, goals
• illness of missed opportunities
• Comorbid conditions include substance abuse,
  depression, or another anxiety disorder
• Key symptoms include blushing, sweating,
  palpitations, tremor and lightheadedness, panic
  attacks
• Situations are often avoided as an effort to
  alleviate distress

59
Social Phobia - treatment

• Pharmacotherapy
• 1st line SSRI or SNRI
• 2nd line Benzodiazepine
• Only recommended for short term use due to side
  effects (cognitive impairment, ataxia, sedation)
  and dependence and withdrawal
• Avoid in people with substance abuse and the
  elderly
• 3rd line Adjunctive Abilify or Risperidone
• Mirtazapine, wellbutrin
• Although not in guidelines, in practice, beta
  blockers have been used with effect for
  non-generalized type performance anxiety

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
60
Social Phobia - treatment

• Psychological treatment
• CBT (group or individual)
• CBT for social phobia includes exposure to feared
  situations and social skills training
• Similar efficacy to pharmacotherapy
• In practice, CBT and medications are often
  combined
• After discontinuation of CBT or medications,
  gains with CBT last longer

61
Specific Phobia DSM IV criteria

• Excessive or unreasonable fear cued by the
  presence or anticipation of a specific object or
  situation (insects, flying, heights, blood)
• Exposure provokes an immediate anxiety response
• Fear is recognized as excessive or unreasonable
• Situation is avoided or endured with intense
  distress
• Marked distress or interferes with functioning
• Not due to a substance, medical condition or
  other mental disorder

62
Specific Phobia

• Lifetime prevalence of 12
• Most common mental disorder
• Begins at young age, 5-12 years old
• Treatment is exposure based therapy
• Graded exposure helpful
• Virtual reality or computer programs sometimes
  used for fear of heights, flying, dentist

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
63
Questions