Anxiety disorders



Anxiety disorders

By

Ehsan Fahmy

Professor of Psychiatry

The DSM- IV-TR- lists twelve anxiety disorders:

1 -Panic disorder with agoraphobia

2 -Panic disorder without agoraphobia

3 -Agoraphobia without history of panic disorder

4 -Specific phobia

5 -Social phobia

6 -Obssessive compulsive disorder

7 -Post traumatic stress disorder

8 -Acute stress disorder

9 -Generalized anxiety disorder

10-Anxiety disorder due to general medical condition

11-Substance induced anxiety disorder

12-Anxiety disorder not otherwise specified.

The ICD-10 includes the previous anxiety disorders, the somatoform disorder, the stress related disorder, under one category called neurotic disorders

Definitions of fear, phobia, normal anxiety, and anxiety

Fear: A response to a known external definite threat

Phobia: An excessive, irrational fear of a specific object, circumstance, or situation that produces conscious avoidance of the topic, causing severe distress to the person who usually recognizes that the reaction is excessive.

Normal anxiety: A diffuse , unpleasant ,vague sense of apprehension, proportional to the external stimulus, often accompanied by few autonomic symptoms such as headache, perspiration ,palpitation, tightness in the chest, mild stomach discomfort, and restlessness. The person is focusing on the stimulus more than his feelings.

Pathological anxiety: A diffuse , unpleasant ,vague sense of apprehension, out of proportion to the external stimulus, often accompanied by multiple autonomic symptoms such as headache, perspiration ,palpitation, tightness in the chest, mild stomach discomfort, and restlessness. The person is focusing on the awareness of the physiological symptoms and the awareness of being frightened or nervous.

The anxiety symptoms are divided into two components the psychological and the physical component, the later is responsible of the fact that patients with anxiety seek out a general practitioner or internist. The following table summarizes the psychological and the physical symptoms.

|Psychological |Physical |

|Excessive apprehension | |

|Fearful anticipation | |

|Feeling of dread |awareness of extra systoles |

|Worrying thoughts |Cardiovascular symptoms:‡‡‡ |

|Hyper vigilance (irritability, ease of startle) |palpitation |

|Feeling of restlessness |disturbed appetite |

|Sensitivity to noise |dysphagia |

|Confusion |epigastric discomfort |

|Distortions of perception of time ,space, persons and the |nausea, vomiting , disturbed bowel habits |

|meanings of events |gastritis , heart burn |

|Distortions of perception of time ,space, persons and the |Respiratory symptoms |

|meanings of events | |

|Decrease learning by(↓concentration,↓recall,↓ability to make |chest discomfort |

|association) |difficulty in inspiration |

| |tachypnea |

| |Neurological symptoms |

| |headache, tinnitus , dizziness |

| |tremor, numbness ,blurred vision |

| |Genito-urinary symptoms |

| |↓libido , impotence,↑urinary frequency and urgency ,dysmenorrhea.|

| |Musculoskeletal: |

| |Muscle and joint pain |

| |Sleep |

| |Insomnia, nightmares (bad dreams) |

| |Skin |

| |Sweating ,itching, hot/ cold skin. |

Generalized Anxiety disorder(GAD)

DSM-IV-TR diagnostic criteria

A-It is an excessive worry about several events or activities for a majority of days during at least 6 months duration.

B-Difficult to be controlled

C-Associated with at least 3 of the followings:

1-restlessness or keyed up

2-being easily fatigued

3-difficult concentration

4-irritability

5-muscle tension

6-sleep disturbance

D-Not due to another psychiatric diagnosis(phobia,somatization,post traumatic stress disorder

E- causing distress and dysfunction

F-not due to general medical condition or substance abuse

Epidemiology:

-Life time prevalence 5%

-male to female ratio 1:2

Etiology:

The cause of generalized anxiety disorder is not known. Biological and psychosocial factors probably work together.

Biological factors:

1-Genetic:-25% of first degree relative of patients with GAD are also affected

- Concordance rate of 50% in monozygotic twins and 15% in dizygotic twins

2-Neurotransmitters:- γ amino butyric acid(benzodiazepines)

- Serotonin (Azaspirones)

- Subsensitivity to α 2 adrenergic receptor

-Brain area involved are the occipital lobe(↑ concentration of benzodiazepines),basal ganglia (low metabolic rate), the limbic system, and the frontal cortex.

3- EEG changes:↑ sleep discontinuity, ↓ delta sleep ,↓stage one sleep,and reduced rapid eye movement.

Psychosocial Factors:

- Inaccurate and incorrect response to perceived dangers.

- Innacuracy is generated by

a-selective attention to negative details in the environment

b-distortion in information processing

c- overly negative view of the person’s own ability to cope.

- unresolved unconscious conflicts

- Fear of fusion with the other or loss of the other

- Castration anxiety

- Super ego anxiety

Differential diagnosis:

1-Medical disorders : hyperthyroidism, hypocalcaemia, hypoglycemia, anemia

2-Substance abuse: caffeine intoxication, stimulants, withdrawal of CNS depressants(alcohol&benzodiazepines)

3- other anxiety disorders

4- depressive disorder (often co exist with each other)

5-adjustment disorder with anxiety

6-hypochondriasis

7-Adult ADHD

8-somatization disorder

9- Personality disorders

Management:

A-treatment of the organic causes

B-psychotherapy

1-reassurance

2-explanation

3-behaviour therapy(relaxation training)

4-cognitive therapy:

Correction of distorted thoughts,it is the most effective non pharmacological treatment.

C-medications:

1-Benzodiazepines

2-Azaspirones

3-antidepressant SSRI

4- Beta antagonist

Duration of treatment: 6-12 months and may be long life

Benzodiazepines cause tolerance and dependence

Start with benzodiazepine simultaneously with Azaspirone than gradually withdraw diazepine after 2 to 3 weeks at which point the azaspirone reaches its maximum effect..

PANIC DISORDER

DSM-IV-TR criteria

A- both (1) and (2):

1) recurrent unexpected panic attacks

2) at least one of the attacks has been followed by 1 month or more by one or more of the following:

a)persistent concern about next coming attack

b)worry about the implication of the attack , or its consequences(having heart attack, losing control. or going crazy)

c)a significant change in behaviour related to attacks

B-Absence of agarophobia

C-The panic attacks are not due to medication, general medical condition, or a drug of abuse.

D-the panic attacks are not due to social phobia, specific phobia. OCD.PTSD, separation anxiety.

DSM-IV-TR criteria of panic attack:

A discrete period of sudden onset of intense fear or discomfort reching the peak in 10 minutes and at least 4 of the following symptoms:

1- palpitation 8-dizzy, unsteady,lightheaded,faint

2-sweating 9-chills or hot flushes

3-trembling or shaking 10-derealization or depersonalization

4-sensation of shortness of breath 11-fear of losing control,going crazy

5-feeling of choking 12-fear of dying

6-chest pain or discomfort 13-parasthesias

7-nausea or abdominal distress

The ICD-10 requires 3 attacks in 3 weeks(moderate)or 4 attacks in one month for (severe)

Onset is usually spontaneous, but can be triggered by:

• Excitement

• Hyperventilation

• Emotional trauma

• Substances abuse (cannabis)

• Sleep disturbance

Epidemiology:

Life time prevalence is 1.5%-5%

Female 2 to3 times male

Mean age of onset 25 years

Aetiology:

Biological factors:

1. Genetic : 4-8 fold in first degree relatives of patient with panic disorder

2. Neurotrasmitters:norepinephrine,serotonin,and GABA

3. Locus coeruleus is essential for anxiety expression

4. Temporal lobe (hippocampus)

5. Mitral valve prolapse(all recent research found no association between them)

6. Panic inducing substances(yohimbine,flumazenil, caffeine)

Psychological factors:

Cognitive- behaviour theories

1-modeling parental behaviour

2-classic conditioning

Psychoanalytic theory

1. physical or emotional separation from significant people

2. situation of ↑work responsibility

3. the parents perceived as contolling ,critical, brutal, and demanding

4. internal representations of relationships involving physical or sexual abuse

5. typical defense mechanisms are :reaction formation,undoing, somatization and externalization.

Differential Diagnosis:

1. Medical causes (see table)

2. phobias

3. PTSD

4. Somatoform disorder

|Cardio vascular diseases | |

|Anemia | |

|Angina |Hypertension |

|Congestive heart failure |Mitral valve prolapse |

|Hyperactive β adrenergic state |Myocardial infarction |

| |Paradoxical atrial tachycardia |

|Pulmonary disease | |

|Asthma |Pulmonary embolus |

|Hyperventilation | |

|Neurological diseases | |

|Cerebrovascular disease |Migraine |

|Epilepsy |Multiple sclerosis |

|Huntington’s chorea |Transient ischemic attack |

|Infection |Tumor |

|Meniere’s disease |Wilson’s didease |

|Endocrine diseases | |

|Addisson’sdisease |Hypoparathyroidism |

|Carcinoid syndrome |Hypoglycemia |

|Cushing’s syndrome |Menopausal disorder |

|Diabetes |Pheochromocytoma |

|Hyperthyroidism |Premenstrual syndrome |

|Drug intoxication | |

|Amphetamine |Hallucinogens |

|Amyl nitrite |Marijuana(cannabis) |

|Anticholinergics |Nicotine |

| |Theophylline |

|cocaine | |

|Drug withdrawal | |

|Alcohol |Opiates and opioids |

|antihypertensives |Sedatives-hypnotics |

|Other conditions | |

|Anaphylaxis |Systemic infections |

|B12 deficiency |Systemic lupus erythromatosus |

|Electrolyte disturbances |Temporal arteritis |

|Heavy metal poisoning |uremia |

Treatment:

1-Treat the organic causes

2-Support and reassurance

3-Cognitive therapy:is focusing on instruction about the patient’s false belief and information about panic attack.

4-Behaviour therapy: applied relaxation, respiratory training, in vivo exposure.

Cognitive and behaviour therapy are equal to pharmacotherapy,combination of both is better than each alone.

Pharmacotherapy

Tricyclic antidepressant (imipramine and clomipramine) the dose must be titrated gradually clinical benefit requires full dose which may need 8-12 weeks.

Selective serotonin re-uptake inhibitorsSSRI(paroxetine,fluvoxamine,citalopram) titrate the dose slowly to avoid initial anxiety induced by SSRI

Benzodiazepines(Alprazolam,lorazepam)are the most rapid and effective treatment against panic attack,however the risk of dependence, cognitive impairment and abuse,lead most of clinician to use them initially withSSRI then gradually withdraw the benzodiazepines.

Duration of treatment is 8to 12 month after improvement, after cessation of treatment the majority of cases tend to have a chronic course and long life treatment.Prognosis is good with therapy.

AGORAPHOBIA

Rigid avoidance of situations in which it would be difficult to obtain help.It is a disabling disorder making the patient very dependent on others to the extent of never leaving his home

The most common feared situation are:overcrowding(super markets,shops, social situation),travelling away, elevators, bridges, public transport

DSM-IV-TR criteria for agarophobia

A-Anxiety about being in place from which escape is difficult,the cluster of situation are(going alone outside home ,be in line,on a bridge,traveling in a bus,train ,automobile)

B-the situation are avoided

C- not due to other anxiety disorders

Associated symptoms:

Depressive symptoms,suicide,alcohol and substance abuse.

Course and prognosis:

Agarophobia without panic disorder tends to have a bad prognosis and chronic course,and depressive disorders and alcohol dependence complicate the course.

Treatment:

Cognitive behaviour therapy

Gathering detailed information about the situation that provoke anxiety

Hierarchy of stimulus from the least to the most

Relaxation training

Exposure

Pharmacotherapy :similar to panic disorder.

Social phobia

DSM-IV-TR criteria of social phobia

A- A marked and persistent fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way that will be humiliating or embarrassing.

B- Exposure to feared social situation provokes anxiety, situationally bound or situational predisposed panic attack

C- The person recognizes that the fear is excessive or unreasonable

D- The feared social performance is avoided or endured with intense anxiety

E- The avoidance, anxious anticipation,or distress of the feared situation interferes with the person’s routine,occupational functioning, or social activities

F- In individuals under 18 years the duration is at least 6 months

G- Not due to substance or general medical condition not due to another mental condition(panic disorder with or without agarophobia,separation anxiety disorder,a pervasive developmental disorder or schizoid personality disorder.

H- If a general medical condition or another mental disorder the fear in criterion A is not related to it(stuttering,tremors of parkinson’s disease)

The most common feared situations

-Gatherings

-Speaking to authority figures or in public

-Performing under scrutiny

Complications:

1. depression

2. substance abuse

3. deterioration in functioning

Epidemiology

Life time prevalence is 3-13%

Age: in teens

Females are more than male but in clinical settings male are more than female.

Aetiology

Genetic factors:

Monozygotic twins more than dizygotic twins

First degree relatives of patients are three fold more than normal

Social factors:

Excessive demands for social conformity

Concern about how to be impressive

Arab cultures are judgmental and impressionistic

Behavioural factors :conditioning

Cognitive factors:exaggerated fear of negative evaluation and criticism

Differential diagnosis:

-Other phobias

-GAD

-Panic disorder

-depressive disorder

-Psychotic disorder

-avoidant personality disorder.

Treatment

A- Psychological

Cognitive behaviour therapy

-exposure

Relaxation training

It is the treatment of choice for social phobia

Social skill training

Assertiveness training

B- Pharmacotherapy similar to panic disorder

Prognosis:

Often lasts for several years

Gradually becomes more severe

Good prognosis if treated

Specific phobia

DSM-IV-TR criteria similar to social phobia except for criterion H

Common feared object and situations

• Animal type: insects(spider)

• Environment type : storms and thunder

• Situational type : cars ,aeroplanes

• Blood-injection-injury type

• Other type (fear of chking, vomiting,contrctong an illness, death, loud sounds or costumed character.)

• N.B they are listed in descending frequency of appearance)

Epidemiology:

It is common in the general population more than social phobia

It is the most common mental disorder in women

It is the second most common disorder among men

The 6 month prevalence of specific phobia is about 5 to 10%

The female to male ratio is 2:1

The peak age of onset for the natural environment type and the blood-injection-injury type is 5 to 9 years

The peak age of onset for the situational type except fear of heights is in the mid’s 20 closer to the onset of agoraphobia

Etiology

1-pairing the specific object with emotion of fear

2-modeling

3-information transfer

4-it tends to run in families either environmental or genetic

Differential diagnosis:

1. OCD

2. Depressive disorder

3. Social phobia and agoraphobia

Treatment:

Behaviour therapy(exposure in vivo and vitro+βadrenergic blocker or benzodiazepines before the exposure)

Prognosis:

If started in adult life after stressful events the prognosis is usually good

If started in childhood it usually disappears by adolescence, may be continued for years.

Obsessive Compulsive Disorder(OCD)

DSM-IV-TR criteria

A- either obsessions or compulsions:

Obsessions as defined by (1) (2)(3) and (4)

(1)recurrent and persistent thoughts, impulses, or images that are experienced,at some time during the disturbance as intrusive and inappropriate and that cause marked anxiety or distress.

(2)the thoughts, impulses, or images are not simply excessive worries about real life problems

(3) The person attempts to ignore or suppress such thoughts,impulses, or images, or to neutralize them with some other thought or action

(4) The person recognizes that the obsessional thoughts,impulses, or images are a product of his mind

Compulsions as defined by(1) (2):

1) repetitive behaviors ( hand washing, ordering , checking , ) or mental act(praying , counting , repeating word silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

2) The behavior or mental acts are aimed at preventing or reducing some dreaded event or situation; however these behaviors or mental acts either are not connected realistically to what they are designed to neutralize or are clearly excessive

B- At some point during the course of the disorder,the person has recognized that the obsessions or compulsions are excessive or unreasonable(not applicable to children)

C- The obsessions or compulsions cause much distress,are time consuming(more than one hour per day) or significantly interfere with the person’s normal routine, occupational functioning, or usual social activities or relationships

D- If another axis I disorder is present, the content of the obsessions or compulsions is not restricted to it( preoccupation with food in the presence of an eating disorder, hair pulling in the presence of trchotillomania; concernwith appearance in the presence of body dysmorphic disorder;preoccupation with drugs in the presence of a substance use disorder; preoccupation with having serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder)

E- The disturbance is not due to the direct physiological effects of a substance(drug abuse or medication) or a general medical condition

Specifyif:

With poor insight: if for the most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable.

Epidemiology:

Life time prevalence: 2-3 % of the population

Sex male = female

Mean age of onset 20-25 years

Aetiology:

Biological factors

Genetic factors:

Concordance rate of monozygotic twins more than dizygotic twins

35% of first degree relatives of patients are affected

Serotonergic dysfunction

↑activity in the frontal lobes, cingulum, and cadate nucleus.

Psychological factors:

The obsessions are formed through conditioning, a neutral stimulus is paired with fear, then the neutral stimulus provoke anxiety.

The compulsion is produced differently when a person learns that some actions reduce the anxiety he develops active avoidance strategy in form of compulsion to control the anxiety gradually these avoidance strategy becomes fixed compulsion.

Differential diagnosis:

• Depressive disorders

• Anxiety, panic and phobic disorders

• Hypochondriasis

• Schizophrenia

• Organic disorders

Course and prognosis:

In most cases the onset is gradual

The majority have a chronic course waxing and wanning with exacerbations related to stressful events.

Treatment:

Explain the nature of the illness

Providing hope

The most effective treatment is combination of behaviour therapy with psychopharmacological treatment

Psychopharmacology:

Anti obssessional (clomipramine anf fluoxetine)

Anxiolytic at the start of treatment to reduce the anxiety of the disorder as well as the early induced anxiety by SSRI(fluoxetine)

Technique of behavior therapy:

-Exposure and response prevention

-Thought stopping

Family therapy:

Using one of the family member to act as co- therapist in watching and helping the patient in response prevention

Psycho surgery:

In resistant cases , cingulotomy is done

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