Anxiety disorder

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Anxiety disorder

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DSMIV-TR-2000 classification of anxiety disorders

• Panic disorder without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without panic disorder
• Specific phobia
• Social phobia
• Obsessive compulsive disorder
• Posttraumatic stress disorder
• Acute stress disorder
• Generalized anxiety disorder
• Anxiety disorder due to medical condition
• Anxiety disorder NOS

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Anxiety disorders

• Sigmund Freud---anxiety neurosis
• Normal anxietyfear vs. anxiety, psychological
  and cognitive sx
• Pathological anxiety
  Psychological theory Id,superego anxiety,
  separation anxiety, castration anxiety
  Behavioral theory conditioned response
  Biological theory NE(panic disorder), serotonin
  (OCD), GABA(general anxiety disorder)
  

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Anxiety disorders

• Brain imaging studies increase size of
  ventricles abnormal in right
  hemisphere functional abnormality in frontal
  cortex, occipital temporal areas
• Genetic studies 1/2 of panic pts1
  affected relatives higher frequency of lst.
  Degree relative
• Neuroanatomical locus ceruleus raphe nuclei
  project to limbic system cerebral cortex

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Panic disorder agoraphobia

• Clinical sx of panic attacks spontaneous
  first attack rapidly increasing sx in 10
  minutes fear and sense of impending death or
  fainting last 20 to 30 minutes rarely more
  than l hr intense anxiety or fear with
  somatic sx of palpitation or tachycardia with
  anticipatory anxiety
• Clinical sx of agoraphobia avoid situations in
  which it would be difficult to obtain help,
  depression,marital discord,loss work,financial
  problem

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• Life time prevalence rate of panic
  disorder1.5-5 (Taiwan 0.2/0.3), panic
  attack3-5.6, agoraphobia 0.6-6 (Taiwan
  1.1/1.5)
• WomenMen2-3/1
• Mean age of onset 25 y/o
• Etiologies Panic-inducing substances
  adrenergic antagonist,serotonin releasing agents,
  GABA receptor antagonist Brain imaging
  studiespathology in temporal, lobes,
  hippocampus mitral valve prolapse?
  Genetic4 to 8x increase in lst. Degree
  rela, higher concordant in monozygotic twin

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Course prognosis of panic disorder

• Onset during late adolescence or early adult
• Chronic, 30-40 symptom free, 50 sx mild, 10-20
  significant sx
• 40-80 with depression, 20-40 substance abuse
• Good prognosis good premorbid function, brief
  duration

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Course prognosis of agoraphobia

• Panic disorder with agoraphobiasx (-) while
  panic disorder (-)
• Agoraphobia without panic---incapacitating,
  chronic
• Depression alcohol dependence often complicated

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Treatment of panic disorder, agoraphobia

• Drugs TCA, MAOI, SSRI, BZD, B-blocker
• Cognitive behavior tx
• Family tx
• Insight-oriented psychotx

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Specific phobia social phobia

• Phobiairrational fear---conscious avoidance of
  feared objects, activity,situation
• Social phobia---excessive fear of humiliation or
  embarrassment in various social settings (public
  speaking,urinating in public rest roomshy
  bladder--)
• Specific phobia animal, storm,height, illness,
  injury, death, narrow closed space
  (claustrophobia), blood (erythrophobia)

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• Specific phobia 6 month prevalence5-10
  (Taiwan 3.6-4.8) Femalemale2/1 pe
  ak age of onset for natural environment type
  blood5-9 y/o,for situational type-mid 20s
• Social phobia 6 month prevalence---2-3
  (Taiwan 0.6/0.5) Femalegtmale peak
  age of onset---teens

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Etiologies of specific phobia

• Behavioral factorsconditional emotional
  reactions (John B. Watson, 1920),
  stimulus-response model of conditioned reflex
  (Pavlov), learning theory
• Psychoanalytic factors--forbidden unconscious
  drive, unressolved childhood oedipal,castration
  anxiety, interaction between genetic factors
  environment (temperament of behavior inhibition
  to the unfamiliar)
• Genetic factors---specific phobia run in
  families, 2/3 to 3/4 of pts with l lst. Degree

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Etiologies of social phobia

• Genetic factors---specific phobia run in
  families, 2/3 to 3/4 of pts with l lst. Degree
• Social phobia---trait of behavioral inhibition,
  parents of persons with social phobialess
  caring, more rejecting, more overprotective
• Neurochemical factorsadrenergic, dopaminergic
  dysfunction
• Genetic factors3x affected in lst. Degree
  relative higher concordance in monozygotic twin

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Clinical features

• Arousal of severe anxiety
• Panic attacks
• Anticipatory anxiety
• Avoidance behavior
• Substance related disorders
• 1/3 of social phobia with major depression

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Course prognosis

• Financial dependence
• Impairment of social life, occupational
  performance, school performance
• Substance related disorders---adversely affect
  the course prognosis

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Treatment

• Insight-oriented psychotx
• Hypnosis
• Supportive tx
• Family tx
• Exposure tx (Joseph Wolpe) for specific phobia
• Behavioral cognitive tx for social phobia
• Pharmacotx---B antagonist, MOAI,xanax,SSRI

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Generalized anxiety disorder (GAD)

• Excessive pervasive worry, with a variety of
  somatic sxsig. Impairment in social or
  occupational function, marked distress in pt
• 1 year prevalence---3-8 (Taiwan 3.7-10.5)
• 50-90 of GAD pts-comorbid with another mental
  disorder
• Women/men2/1

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Etiologies of GAD

• Biological factors GABA or serotonergic or
  NA dysregulation lower metabolic rate in basal
  ganglia white matter 25 of lst.
  Degree relative of pt-GAD higher(50)
  concordance rate of monozygotic twin
• Psychosocial factors cognitive-behavioral
  theory, psychoanalytic theory

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Clinical features of GAD

• Primary txanxiety,motor tension,ANS
  hyperactivity,cognitive vigilance
• Excessive anxiety, interfere life
• Motor tensionshakiness,restless,headache
• ANS hyperactivity-SOB,sweating,palpitation, G-I
  sx
• Cognitive vigilanceirritability, ease to be
  startled

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Course prognosis of GAD

• High incidence of comorbid mental disorders 25
  with panic disorder, many with Major depression
• Chronic, may be lifelong

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Treatment of GAD

• Psychotxcognitive-behavior (relaxation
  biofeedback), supportive, insight-oriented
  psychotx
• PharmacotxBZD, buspirone, B-antagonist, TCA

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Obsessive compulsive disorder(OCD)

• Obsession---recurrent intrusive thought,
  feeling, idea or sensation
• Compulsion---conscious, standardized, recurrent
  thought or behavior (counting, checking,
  avoiding)
• Obsessive increase anxiety---compulsions
• Realize the irrationalityego-dystonic
  (sometimes ego-syntonic)
• Disabling time-consuming

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• 2-3 in general population (Taiwan 0.9/0.5)
• 10 of psychiatric outpatients
• Malefemale in adults,boysgtgirls
• Mean age of onset---20 y/o
• Comorbid with major depression (67), social
  phobia (25), alcohol use disorder, specific
  phobia, panic disorders, eating disorders

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Etiologies of OCD

• Biologicaldysregulation of serotonin
• Brain imaging---increased activity in frontal
  lobe,basal ganglia (caudate nucleus),cingulum
• Genetics---35 of lst. Degree relative, higher
  concordance for monozygotic twin
• Psychosocial---15 to 35 of OCD ptsobsessional
  trait
• Psychodynamic---defense mechanism---isolation,
  undoing, reaction formation

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Clinical features of OCD

• 75 with both obsession compulsion
• Feelings of anxiouscountermeasures against the
  idea of impulse
• Recognize it irrational, strong desire to resist
• Four major sx patterns obsession of
  contamination-wash,avoidance obsession of
  doubt-checking obsession without
  compulsion-sexual,aggressive need for symmetry
  or precision-compulsion slowness

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Course and prognosis

• 50-70--onset after a stressful event
• Delay 5 to 10 years to psychiatric attention
• Chronic,variable, fluctuating,or constant
• 20-30 sig. improved,40-50mod.improve, 20-40
  remain same or worse
• 1/3 with major depression
• Poor pxyielding to compulsion,childhood
  onset,bizarre compulsion,need hosp.,with MD,
  delusional, schizotypal PD
• Good pxgood social occupational adjustment,
  ppt(), episodic nature

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Treatment of OCD

• Pharmacotx---SSRI or anafranil
• Behavior tx---exposure response
  prevention,desensitization,thought
  stopping,flooding, aversive conditioning
• Psychotxinsight-oriented psychotx,supportive
  psychotx
• Family tx, group tx, ECT, psychosurgery

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Posttraumatic stress disorder (PTSD) acute
stress disorder

• Emotional stress with a magnitude that would be
  traumatic for anyone---combat, natural
  catastrophes, assault, rape, serious accidents
• Reexperiencing of traumadreams, thoughts
• Persistent avoidance of reminders of trauma,
  numbing of responsive to such reminders
• Persistent hyperarousal
• Depression,anxiety cognitive difficulties
• Minimal duration of one month (PTSD)
• Sx occur within 4 wks of events, last for 2 days
  to 4 wks (acute stress disorder)

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• Lifetime prevalence of PTSDF---1-3 of general
  population, 5-15 of subclinical forms
• High risk group experience traumatic
  eventslifetime prevalence 5-75
• 30 Vietnam veteransPTSD, 25 subclinical
• Single, divorced, widowed, economically
  handicapped, or socially withdrawnlikely to occur

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Etiologies of PTSD

• Stressor
• Predisposing vulnerability factors childhood
  trauma borderline,paranoid,dependent,antisoci
  al PD inadequate support system genetic-const
  itutional vulnerability to psychiatric
  illness recent stressful life
  changes perception of external locus of
  control recent excessive alcohol intake

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Etiologies of PTSD

• Psychodynamic factors unresolved
  psychological conflict
• Biological factors noradrenergic,endogenous
  opiate system, hypothalamic-pituitory-adrenal-axis
  hyperactive increased activity of
  ANS similarity with MD panic disorder

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Clinical features

• Painful reexperiencing of events
• Avoidance emotional numbing
• Constant hyperarousal
• Feelings of guilty,rejection,humiliation
• Dissociative states,panic attacks,illusion
  hallucination
• Impairment of memory attention
• Associated sxaggression,violence,poor impulse
  control,depression,substance related disorders

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Course and prognosis

• Onset some time after trauma,sometimes delay as
  30 yrs
• 30 complete recovery,40 mild sx,20 mod.sx,10
  unchanged or worse
• Good-pxrapid onset,short duration of sx
  (lt6m),good premorbid function,strong social
  support,absence of psychiatric, medical,
  substance disorder
• Very young very old more difficulty,
  preexisting psychiatric disability, PD more
  serious

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Treatment

• Support,encourage to discuss,education coping
  mechanisms, behavioral tx, cognitive tx,
  hypnosis, family tx,group tx
• PharmacotxTCA, SSRI, anticonvulsant, inderal,
  propranolol, clonidine