Anxiety Disorders

Samantha Meltzer-Brody, M.D., M.P.H.Assistant Professor

UNC Department of Psychiatry

Anxiety Nervousness and fear are common

human emotions. Adaptive at lower levels; disabling

at high levels. Physicians must recognize the

difference between pathological anxiety and anxiety as a normal or adaptive response.

Features of Pathologic Anxiety Autonomy: no or minimal

environmental trigger Intensity: exceeds patient’s

capacity to bear the discomfort Duration: symptoms are persistent Behavior: anxiety impairs coping

and results in disabling behaviors

Definition of Anxiety Diffuse, unpleasant, vague sense of

apprehension Often accompanied by autonomic

symptoms such as headache, perspiration, heart palpitations, chest tightness, stomach discomfort and restlessness

Presentation depends on perception of stress, personal resources, psychological defenses, and coping mechanisms

Etiology Neurophysiology

Central noradrenergic systems– in particular, the locus coeruleus is the major source of adrenergic innervation

GABA neurons from the limbic system Serotoninergic systems and neuropeptides

Cognitive-Behavioral Formulations Developmental (Psychodynamic)

Formulations

Anxiety Disorders The most prevalent psychiatric

disorders One-quarter of the U.S. population

experiences pathologic anxiety in their lifetime

Presenting problem for 11% of patients visiting primary care physicians

90% of patients with anxiety present with somatic complaints

Common Medical Conditions Associated with Anxiety Disorders

Endocrine: thyroid dysfunction, hyper adrenalism

Drug Intoxication: caffeine, cocaine

Drug Withdrawal: alcohol, narcotics

Hypoxia: CHF, angina, anemia, COPD

Metabolic: acidosis, hyperthermia

Neurological: seizures, vestibular dysfxn

Major Anxiety Disorders Panic Disorder Generalized Anxiety Disorder Post Traumatic Stress Disorder Social Phobia Specific Phobia Obsessive Compulsive Disorder (OCD) Substance Induced Anxiety Disorder

Panic Attack Discrete episodes of intense

anxiety Sudden onset Peak within 10 minutes Associated with at least 4 of the 13

other somatic or cognitive symptoms of autonomic arousal

Panic Attack Symptoms Cardiac: palpitations, tachycardia,

chest pain or discomfort Pulmonary: shortness of breath, a

feeling of choking GI: nausea or abdominal distress Neurological: trembling and

shaking, dizziness, lightheadedness or faintness, paresthesias

Panic Attack Symptoms Autonomic Arousal: sweating, chills

or hot flashes Psychological:

Derealization (feeling of unreality) Depersonalization (feeling detached

from oneself) Fear of losing control or going crazy Fear of dying

Panic Disorder A syndrome characterized by

recurrent unexpected panic attacks (at least 4 in one month)

Attacks are followed for at least one month with: Concern about having another attack Worry about implications of the attack Behavior changes because of the

attacks

Agoraphobia Complication of panic disorder Means “ fear of the market” Anxiety or avoidance of places or

situations from which escape might be difficult, embarrassing, or help may be unavailable.

Restricts daily activities

Agoraphobia Agoraphobia

The patient may avoid crowds, restaurants, highways, bridges, movie theaters etc.

In its most severe form, the patient may become dependent on companions to face situations outside the home.

Some individuals become homebound.

Epidemiology of Panic Disorder

Panic disorder has a lifetime prevalence of 1.5-3.5%

2:1 female/male ratio ? Of true gender difference versus

men tend to self-medicate with alcohol and are less likely to seek treatment.

Onset is late teens through third decade of life.

Differential Diagnosis of Panic Disorder Not due to another anxiety disorder Not due to effects of a general medical

condition Cardiovascular disease Pulmonary disease Neurological disease Endocrine disease Drug intoxication or withdrawal Other (lupus, infections, heavy metal

poisoning, uremia, temporal arteritis)

Panic Disorder: Costs 200,000 normal coronary angiograms/yr

in the U.S. at a cost of 600 million dollars: 1/3 of these patients have panic disorder

½ of patients referred for non-invasive testing for atypical chest pain and who have normal tests have panic disorder

1/3 patients undergoing work-up for vestibular disorder with c/o dizziness have panic disorder

Panic Disorder: Comorbidity

Panic disorder patients have an increased personal and family history of other anxiety, mood and substance abuse disorders.

Major depression is a co-morbid diagnosis in 1/3 of cases presenting for treatment

Untreated patients have high risk of suicide

Panic Disorder: Treatment About 80% of patients will respond

to treatment Antidepressant medications are

effective Serotonin reuptake inhibitors (SSRI)

are first line therapy Tricyclic antidepressants (TCA) and

monoamine oxidase inhibitors (MAOI’s) are also used.

Panic Disorder: Treatment Sedative-Hypnotics: benzodiazepines

are ideally used in the short term before an antidepressant has had time to work

Cognitive Behavioral Therapy (CBT): helps patients overcome a learned pattern of catastrophically misinterpreting the physical symptoms associated with panic attacks.

Generalized Anxiety Disorder (GAD) Patients with GAD suffer from

severe worry or anxiety that is out of proportion to situational factors.

Must last most days for at least 6 months

Described as “worriers” or “nervous”

GAD Symptoms include:

Muscle tension Restlessness Insomnia Difficulty concentrating Easy fatigability Irritability Persistent anxiety (rather than

discrete panic attacks)

GAD Diagnostic Criteria Excessive anxiety and worry that

occurs more days than not for 6 months

Difficult to control the worry 3 out of 6 symptoms Anxiety caused significant distress or

impairment in function Not attributed to another organic cause

GAD Epidemiology 5% prevalence in community

samples 2:1 female/male ratio Age of onset is frequently in

childhood or adolescence Chronic but fluctuating course of

illness (worsened during stressful periods)

GAD Treatment Cognitive Behavioral Therapy Other Psychotherapies Pharmacotherapy

Antidepressants Benzodiazepines Buspirone

Post Traumatic Stress Disorder (PTSD) Patients with PTSD have

experienced a trauma and develop disabling symptoms in response to the event.

Symptoms usually begin within 3 months of the trauma

Syndrome can occur at any age

Definition of Trauma The person experienced, witnessed

or learned of an event that involved actual or threatened death, serious injury, or threat of harm to self or others

The person’s response involved intense fear, helplessness or horror

Types of Trauma Sexual abuse Rape Physical abuse Severe motor vehicle

accidents Robbery/mugging Terrorist attack Combat veteran Natural disasters

Being diagnosed with a life threatening illness

Sudden unexpected death of family/friend

Witnessing violence (including domestic violence)

Learning one’s child has life threatening illness

Diagnosis of PTSD Symptoms must be > one month

duration and include:

Re-experiencing symptoms Avoidance symptoms Emotional numbing Hyperarousal symptoms

Re-experiencing Symptoms There are recurrent, intrusive thoughts

of the event (can’t not think about it) Dreams (nightmares) about the event Acting or feeling the event is recurring,

or sense of living the event (flashbacks) Psychological or Physiological Distress

upon exposure to reminders or cues of the event.

Avoidance/Numbing Symptoms Avoid thoughts, feelings, places or people

that arouse memories of the event Being unable to recall important parts of

the event Decrease interest in activities Feeling detached or estranged from

others Decreased range of affect Sense of foreshortened future

Hyperarousal Symptoms Patient experiences at least two of

the following: Insomnia (falling or staying asleep) Irritability or outbursts of anger Decreased concentration Hypervigilance Increased/exaggerated startle

response

Epidemiology of PTSD Prevalence is 1% in the general

population, and can be as high as 25% in those who have experienced trauma

In combat veterans, prevalence is 20%

Very high prevalence in women who are victims of sexual trauma

PTSD Costs Patients with PTSD are frequent

users of the health care system Patients usually present to primary

care physicians with somatic complaints

After panic disorder, PTSD is the most costly anxiety disorder

PTSD Treatment Psychotherapies

Exposure-based cognitive behavioral therapy Psychotherapy aimed at survivor anger, guilt

and helplessness (victimization) Pharmacological treatment targets the

reduction of prominent symptoms SSRI’s are first line therapy Atypical antipsychotics are being increasingly

used

Social Phobia Fear of being exposed to public

scrutiny Fear of behaving in a way which will

be humiliating or embarrassing Symptomatic resemblance to panic

disorder with anticipatory anxiety (person may be anxious/worrying far in advance of the event)

Extensive phobic avoidance

Social Phobia Distinction: anxiety only occurs

when the patient is subject to the scrutiny of others (public speaking, oral exam, eating in the cafeteria)

Phobic stimulus is avoided or endured with intense anxiety

Fear and avoidant behaviors interfere with person’s normal routine or cause marked distress

Epidemiology: Social Phobia Prevalence rates vary depending on

study; overall range is 3 –13% of the population

Onset in adolescence Prevalence greater in females, but

greater for males in clinical samples Frequent comorbidity with

depression and substance abuse

Social Phobia: Treatment Antidepressants, SSRI’s and MAOI’s High potency benzodiazepines Low doses of beta blockers are

helpful for public speaking (if only an occasional event); this alleviates the autonomic symptoms

Psychotherapy-cognitive restructuring

Specific Phobia Marked and persistent fear that is

excessive and unreasonable of a specific object or situation

Exposure to the phobic stimulus will provoke an anxiety response

Phobia Subtypes Animals or insects Natural environment– storms, water,

heights Blood, injury, injection, medical procedure Situational flying, driving, enclosed places Having a phobia of a specific subtype

increased the chances of having another phobia within that subtype

Epidemiology of Specific Phobias

Lifetime prevalence is 10% of the population

Age of onset varies with subtype Childhood onset for phobias of

animals, natural environments blood and injections

Bimodal distribution (childhood and mid-twenties for situational phobias

Specific Phobia Treatments Flooding-exposing the person to the

feared stimulus Exposure therapy works to

desensitize the patient using a series of gradual, self-paced exposures to the phobic stimulus; uses relaxation, hypnosis, breathing control and other cognitive approaches

Benzodiazepines or Beta blockers are useful acutely

Specific Phobia: Treatment Example: Fear of Flying

Visualize a plane. Look at a plane in the sky. Drive by an airport. Go to a museum that has planes. Same museum—visualize going inside. Go inside. Go to airport and watch planes take off and land. Visualize yourself on a plane flying. Omnimax theater experience. The real thing.

Obsessive Compulsive Disorder (OCD) Obsessions: recurrent, intrusive,

unwanted thoughts (i.e. fear of contamination)

Compulsions: behaviors or rituals aimed at reducing distress or preventing a dreaded event (i.e. compulsive handwashing)

OCD Symptoms Recurrent obsessions and/or

compulsions are severe enough to consume more than one hour/day

Person recognizes the obsession as a “product of his/her own mind”, rather than imposed from the outside, and that they are unreasonable or excessive

OCD Symptoms The obsessions are “ego-dystonic”

(not enjoyable for the ego), as opposed to “ego-syntonic” (the ego likes it)

Common Obsessions Contamination Repeated doubts Order Aggressive or horrific images Sexual/pornographic imagery Scrupulosity

Obsessions and Common Compulsive Responses Contamination: cleaning, hand washing,

showering Repeated doubts: checking, requesting

or demanding reassurances from others, counting

Order: checking, rituals, counting Aggressive or horrific images, checking,

prayers, rituals Sexual/Pornographic imagery:

prayer/rituals

Epidemiology of OCD Lifetime prevalence is 2-3% in the

general population Mean age of onset is mid-twenties,

although men may develop symptoms earlier

Less than 5% of patients develop disease after age of 35 years

Chronic course, stress can exacerbate symptoms

OCD Treatment Serotonin reuptake inhibitors Clomipramine, a serotonergic

tricyclic antidepressant Psychotherapy: exposure and

response prevention

OCD is not OCPD Obsessive-Compulsive Disorder is

different from obsessive compulsive personality disorder (OCPD)

OCPD: a pervasive pattern of preoccupation with orderliness, perfectionism and control that begins by early adulthood

Substance Induced Anxiety Disorder Prominent symptoms of anxiety

that are judged to be the direct physiological consequence of a drug or abuse, a medication or toxin exposure

Summary and Review of Anxiety Disorders

Panic Attacks and Panic Disorder

Panic Attacks Agoraphobia without a history of

panic disorder Panic Disorder without

agoraphobia Panic Disorder with agoraphobia

Generalized Anxiety Disorder Characterized by at least 6 months

of persistent and excessive anxiety and worry

Post Traumatic Stress Disorder Characterized by the re-experiencing of

an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma

Symptoms present for at least one month If event just occurred and/or symptoms

present for less than one month, a diagnosis of Acute Stress Disorder is given

Social Phobia Clinically significant anxiety

provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior

Specific Phobia Clinically significant anxiety

provoked by exposure to a specific feared object or situation, often leading to avoidance behavior

Obsessive Compulsive Disorder Characterized by obsessions that

cause marked anxiety or distress and/or compulsions that serve to neutralize anxiety

Substance Induced Anxiety Disorder

Anxiety Disorder not otherwise specified

Anxiety Disorder Association of American (ADAA) The ADAA brings together professionals

from many disciplines including psychiatrists, psychologists, social workers, physicians, nurses, etc. Through networks, the ADAA increases awareness about anxiety disorders, provides education resources, offers access to care, and supports research.

www.adaa.org