Anxiety Disorders

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Anxiety Disorders
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ANXIETY

• Most prevalent psychiatric disorder in the US
  (18.1 of Americans
• (40 million adults 18) Kessler et al., 2005
• Most common psychological problem encountered by
  physicians

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Cultural Issues

• Anxiety expresses itself in ways distinct to the
  culture that a person is from
• Nervios Generalized anxiety symptoms in Latino
  populations (often with somatic features)
• Ataque de nervios Panic symptoms in Latino
  populations (often with behavioral features)
• Shenjing shuairuo Mixed anxiety,
• mood, and physical symptoms in
• Chinese populations
• Taijin kyofusho Social phobia
• symptoms in Japanese populations
• (focus on bodily appearance
• or functioning)

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Adaptive VS Pathological

• Need moderate levels of anxiety for proper
  adaptation ( alertness, attention, arousal)
• Anxiety becomes pathological when a person
  becomes unable to concentrate, problem-solve,
  reason and so on.

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Trait Anxiety

• Trait- Characteristic range of anxiety that is a
  part of a persons core personality.
• fixed and stable over time
• Chronic Anxiety- When trait anxiety is
  consistently highly distressful and maladaptive.

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State Anxiety

• State Anxiety- A brief anxiety response which is
  usually triggered by a particular situation.
• Acute Anxiety- When state anxiety is exaggerated
  or maladaptive. If continues may transition into
  chronic anxiety.

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Healthy to Unhealthy Anxiety
Yerkes-Dodson law
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Psychological Anxiety

• Feelings of apprehension, worry, tension,
  uneasiness that is either vague or free-floating
• Can be an exaggerated response to a particular
  stimuli.
• Hyperviligance to surroundings
• Difficulty concentrating, easy distraction

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Physiological Anxiety

• Psychomotor experiences- tremors, jitters,
  autonomic hyperactivity (sweating, heart racing,
  dizziness).
• The normal flight or fight reactions
• Dry mouth, urinary frequency, swallowing
  difficulties
• NOTE These symptoms can be difficult to
  distinguish at times from medical complaints.
  Frequently people with anxiety problems will seek
  help from their doctors without awareness of the
  origins of their physical complaints

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Maladaptive

• When anxiety is high and maladaptive, functioning
  is impaired because of
• the interference of the physiological symptoms
  or
• because the person is unable to cope with the
  psychological symptoms

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Medical Conditions that Mimic Anxiety

• PANIC DISORDER Cardiopulmonary Disorders
  (embolism, tachycardia, MI, Mitral valve
  prolapse), Temporal lobe epilepsy,
  Pheochromocytoma (rare tumor)
• GAD Hyperthyroism, Hypoglycemia, Post concussion
  syndrome, Delirium, Alcohol/ Hynotic /Anxiolytic
  Withdrawal Caffeine abuse stimulant abuse OTC
  medications (decongestant, inhalers)

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Psychological Etiology

• Psychodynamic- ineffective repression of painful
  memories, unacceptable impulses. A break through
  of such memories will cause a flooding of anxiety
  symptoms and also becomes a mechanism to avoid
  those impulses or thoughts ( OCD)
• Behavioral- Conditioned response to aversive
  stimuli. Body responds physiologically and the
  mind interprets anxiety. Psychological anxiety
  follows recognition of physiological arousal

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Physical Etiology

• Biological- Anxiety occurs when the body
  naturally becomes aroused in fight-flight-freeze
  mode.
• Anxiety disorders are linked with some
  neurotransmitters (norepinephrine) and sites in
  the brain.
• Interesting correlation people with mitral valve
  prolapse/ heart murmur have increased incidence
  of panic disorders.

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Genetic Etiology

• Predisposition for anxious reactions ( in
  primates- anxious relatives result in stronger
  reaction to stress (Suomi, 1986)
• Anxious identical twin results in higher chance
  of own anxiety (Hettema et al., 2001 Kendler et
  al., 2002)
• Similar phobias in identical twins, even when
  raised apart (Carey, 1990)

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PANIC ATTACKS

• Can occur within a variety of Anxiety Disorders
  such as Panic Disorders, Phobias, PTSD

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Panic Attacks

• A discrete period of intense fear or discomfort
  in which 4 or more of the following symptoms
  developed ABRUPTLY and reach a peak within 10
  Minutes

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Symptoms

• Palpitations, pounding heart, accelerated heart
  rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort

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• Nausea or abdominal distress
• Dizzy, lightheaded
• Derealization or Depersonalization
• Fear of loss of control or going crazy
• Fear of dying
• Paraesthesias numbness or tingling
• Chills or hot flashes

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• A Panic Attack is not a codable disorder . Code
  the specific diagnosis in which the Panic Attack
  occurs.

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AGORAPHOBIA

• Code the specific disorder in which the
  agoraphobia occurs.
• Example Panic Disorder With Agoraphobia

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Criteria

• Anxiety about being in places or situations from
  which escape may be difficult.
• Fears usually cluster around being outside the
  home alone, being in a crowd, in line, being on a
  bridge, traveling. Because of these fears.
• The situations are avoided

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• Anxiety or phobia is not better accounted for by
  another mental disorder such as Social Phobia,
  OCD, PTSD and so on
• 90 of Panic clients with agoraphobia experienced
  agoraphobia before first panic attack (Fava 1992)

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PANIC DISORDERS
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Incidence

• Begins usually in the 20s
• Rarely after 45
• Occurs 2-3 more in women
• Runs in families
• 8X more likely with 1st degree relative
• 50 of patients with Panic Disorder may develop
  depression.

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Biological Theory 1

• excess of norepinephrine leads to sensitive
  fight-flight-freeze response

locus ceruleus norepinephrine center in
brainstem electrical stimulation results in
panic Removal leads to less anxiety (Redmond,
1977, 1979)
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Biological Theory 2

• CNS constantly monitors for carbon dioxide. If
  increases
• Then the body reacts with a desperate desire for
  air (panic attack)
• If there is a sensitivity or dysfunction in this
  system, then panic attacks could happen more
  easily or
• If there is chronic high levels of Carbon
  dioxicide in ones system (shallow or rapid
  breathers)
• NOTE explains sleep-onset panic attacks

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• first panic attack likely to happen in public
• only 10.6 of first attacks at home (Shulman1994)

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Panic disorder Cycle
Trigger stimulus
Perceived threat
Catastrophic interpretation of sensations
Apprehension or worry
Bodily sensations
Trigger stimulus
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Differential Diagnosis- Phobia

• Unexpected or uncued attacks are associated with
  panic disorder
• Situational or cued attacks are associated with
  phobias
• Some are a combination- situationally
  predisposed- but not consistent more often
  Panic Disorder

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Differential Diagnosis- GAD

• Panic Disorder typically has a feeling of
  anticipatory anxiety between attacks rather than
  returning to a feeling of normality or euthymia.
• While this anxiety mirrors that of GAD, it is
  mostly connected with a fear of having further
  attacks.
• GAD has a more gradual onset and chronic course
  than Panic Disorder

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Differential Diagnosis- GAD

• GAD- hyperarousal of central NS (insomnia,
  restlessness, concentration)
• Panic Disorder- hyperarousal of autonomic NS
  (increased heart rate breathing, dizziness,
  nausea)
• GAD more likely to have GAD first-degree
  relatives than Panic Disorder first-degree
  relatives) (Noyes et al., 1992)

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Differential Diagnosis- Agoraphobia

• May also develop a connected fear of situations
  which may elicit panic attacks.
• Will begin avoiding these situations or ones in
  which they may feel trapped, unable to get help,
  unable to escape.
• When these avoidant behaviors begin to interfere
  with their activities or cause marked distressed,
  then will earn additional specifiers of with
  agoraphobia.

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Panic Disorders without Agoraphobia

• Recurrent unexpected Panic Attacks
• Absence of Agoraphobia
• Not due to direct physiological effects of
  Substance or drug abuse or GMC or Social Phobia
  or OCD or PTSD
• At least one of the attacks has been followed by
  1 month or more of one or more of the following
• PERSISTANT CONCERN ABOUT HAVING ADDITIONAL
  ATTACKS
• WORRY ABOUT THE IMPLICATIONS OF THE ATTACK
• A SIGNIFICANT CHANGE IN BEHAVIOR RELATED TO
  ATTACKS

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Panic Disorders

• Panic Disorder With Agoraphobia
• Agoraphobia Without History of Panic Disorder

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PHOBIAS
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Phobias

• An irrational dread of and compelling desire to
  avoid a specific object, situation or activity.
• Often identified by the client as unreasonable or
  excessive.
• Never spontaneous, always within the context of a
  trigger.
• Followed by avoidant
  behavior

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• Usually followed by anticipatory anxiety although
  may be relatively anxiety free between triggers
• Becomes a disorder when anxiety causes
  significant distress and either the avoidance or
  distress impairs functioning

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Types of Phobias
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Study of normal anxieties
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Specific Phobias

• average age of onset- 11-17
• 11 of population
• 2X as common among women
• more common among African-Americans Hispanics
  than other American ethnic groups

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• Often begun in childhood or adolescence and
• Will end within 5 years in half of patients.
• Worse prognosis if continues

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Specific Phobias (Curtis et al., 1998)
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Social Phobia

• Marked and persistent fear of social or
  performance situations in which they feel
  embarrassed.
• Have an irrational fear of being scrutinized
  judged or humiliated in public.
• Can specify as generalized when fears extend to
  most social situations

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Symptoms

• Behavior- avoid social situations, restrict
  choice of activities
• Psychological- low self-esteem, perfectionism
• Physical- blush, sweat, tremble
• vicious cycle insecurities make them prone to
  social rejection, feeding insecurities

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Specific Phobia vs. Social Phobia

• social phobias more pervasive
• Social Phobics fear of broader range of
  situations
• social phobics more impaired
• 92 anxiety interfered with career
• 64 kept from important social events
• 50 used alcohol, tranquilizers to calm self
  in social situations (Turner 1986

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Social Phobia vs. Agoraphobia
Agoraphobia
Social Phobia

• afraid of the anxiety itself
• afraid of screaming, making a scene, passing out,
  having a heart attack, etc.
• comforted by being with others

• afraid of social disapproval
• symptoms arent scary
• idea that someone will see symptoms and think
  poorly of you IS scary
• comforted by avoiding others

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OCD
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Incidence

• 2-3 of worldwide population
• median age of onset 23
• In 50-70 of OCD patients onset after stressful
  event (e.g. pregnancy, relatives death)
• men women at equal risk

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Normal Routines
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• Young men more likely to have checking rituals.
• Married women more likely to have cleaning
  rituals

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Obsessive-Compulsive Disorder

• anxiety disorder characterized by unwanted
  repetitive thoughts (obsessions) and/or behaviors
  (compulsions) with
• no conscious desire for obsession/compulsion and
• Uncontrollable
• Interferes with life substantially

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Etiology

• hyperactivity in anterior cingulate cortex among
  people with OCD- this region monitors our
  actions, checks for mistakes (Ursu et al., 2003)
• SSRIs do inhibit OCD symptoms (Dolberg et al.,
  1996 Pigott, 1996)

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Common Obsessions Compulsions(Rapoport, 1989)
Thought or Behavior Reporting Symptom
Obsessions (repetitive thoughts)
concern with dirt, germs, or toxins 40
something terrible happening (fire, death, illness) 24
symmetry, order, exactness 17
Compulsions (repetitive behaviors)
excessive hand washing, bathing, tooth brushing, or grooming 85
repeating rituals (in/out of a door, up/down from a chair) 51
checking doors, locks, appliances, car brake, homework 46
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OCD- Obsessions

• Obsessions- persistent disturbing, intrusive
  thoughts or impulses which the person finds
  illogical but irresistible.
• Feel uncomfortable and cause distress and
  anxiety. Often will try to avoid them but can
  not.

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Common obsessions

• Contamination
• Doubts
• Needing things in order
• Aggressive impulses
• Sexual imagery

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OCD- Compulsions

• Compulsion- Repetitive behaviors the goal of
  which is to reduce anxiety not provide
  pleasure.
• Either to reduce drive of the obsession or
  prevent some dreaded event. Rising anxiety is
  only relieved by following through with behavior
• Become very rigid and stereotyped. Sometimes no
  logical connection to the fear.

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Common Compulsions

• 2 common types of compulsions
• 1. cleaning rituals usually hand washing
• 2. checking rituals making sure they did
  something they were supposed to (e.g. checking
  locks 10 times before bed)
• washing, checking, counting, demanding assurance,
  repeating actions, hording.

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PTSD
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PTSD

• Occurs after exposure to a severe and extreme
  traumatic stressor which
• involves the threat of death or serious injury to
  oneself (or the witnessing of same to another)
• during which feelings of intense fear,
  helplessness, horror are experienced.

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AND

• Following the event, there is.
• Intrusion the re experiencing of the event or
• Avoidance- of the stimuli associated with the
  trauma.

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Biological

• certain neurotransmitters, hormones critical to
  memory
• ? norepinephrine ? cortisol facilitated
  learning in animals
• low cortisol predisposition for PTSD in people
  Aardal-Eriksson (2001)

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Symptoms

• haunting memories
• Nightmares
• social withdrawal
• jumpy anxiety
• insomnia
• for 4 or more weeks following a traumatic event

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Symptoms

• Numbing (difficulty responding to affection, loss
  of interest in hobbies)
• heightened physiological arousal (insomnia,
  irritability, exaggerated startle response)
• symptom-free for days or weeks after event, then
  onset

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PTSD

• Reencountering a similar stressor will often
  aggravate or rekindle the syndrome.
• Prognosis is better when stressor is less intense
  and when stressor was related to nature and not
  people.

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Combat-related

• WWII Studies
• 50 years later 25-50 suffer from PTSD
• only 4 showed no symptoms at all
• Op den Velde 1996

• Vietnam Studies
• 15 of all vets with PTSD
• only 7-8 of noncombat vets
• 45 among vets in heavy combat
• anxiety/depression (CDC)

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FYI

• combat exposure 2X as likely to abuse alcohol,
  experience
• More exposure to trauma greater likelihood for
  PTSD

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PTSD

• May initially begin with denial or numbing to the
  significance to the event.
• Also experience persistent symptoms of increased
  arousal (cant sleep, irritable, angry,
  hypervigilant, startle response).

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Continuum of Trauma

• Acute stress disorder - when symptoms develop
  within one month of the of the stressor. If it
  lasts for more then one month becomes.
• PTSD Acute- symptoms lasting one to three months.
  While 50 recover in three months, some continue
  and get a diagnosis of..
• PTSD Chronic When symptoms last more then 3
  months
• With delayed onset If onset is 6 or more months
  after the stressor -- Prognosis is much worse.
  Usually associated with the development of other
  Disorders such as Substance Abuse.

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Prevalence of Trauma and Probability of PTSD
Threat w/ Weapon
Witness
Accident
Rape
Physical Attack
Molestation
Combat
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Comorbidity in PTSD with Adults
AlcoholAbuse/ Dependence
Major Depressive
GAD
Panic Disorder
Social Anxiety
Agora phobia
DrugAbuse
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Class Issues in PTSD

• People living in poor, urban environments are at
  heightened risk for PTSD because they are
• More likely to experience trauma
• More likely to have additional risk
• factors for PTSD (low social support,
• high psychological stress)
• Those living near the poverty line are also at
  heightened risk for GAD

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GENERALIZED ANXIETY DISORDER
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Generalized Anxiety Disorder

• Excessive anxiety and worry for at least 6
  months. Anxiety is diffuse and free floating. May
  or may not have accompanying physiological
  symptoms.
• Pervasive and impairs functioning.

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Symptoms

• behavioral restless, jittery, insomnia
• psychological difficulty concentrating,
  irritable
• physical increased heart rate, muscle tension,
  easily tired

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Differential- depression

• Difficult differential is with Mood Disorder
  since people with depression typically present
  with complaints of anxiety also.
• If have depression symptoms treat first.

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AND Dont Forget

• Anxiety Disorder Due to GMC
• ( Substance Induced Anxiety )
• Anxiety Disorder NOS

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Treatment

• Prognosis is best the earlier that the anxiety is
  detected. Treatments are highly effective the
  earlier they are started the better the long term
  outcome.
• Treatment is disorder specific- but data tells us
  that a combination of brief medications and
  cognitive behavioral therapies best!