Download Anxiety

ANXIETY DISORDERS
Psychiatrické centrum Praha
3. LF UK Praha
Centrum neuropsychiatrických studií
Definition of anxiety
Anxiety:
Feelings of fear or dread
Not-concrete content
Inner tension
Autonomic symptoms
Anxiety Disorder = duration-wise and/or
intensity-wise out of proportion
reactions.
ANXIETY DISORDERS
• Anxiety disorders are the most common
mental illnesses: an estimated 13
percent of adults ages 18 – 54 in a
given year, or more than 19 million
people (USA), are affected by these
debilitating disorders. There are several
major types of anxiety disorders, each
with its characteristics.
Anxiety
Primary human emotion
Adaptation in phylogeny:
Protection against repeated danger
Preparation for fight or flight
Continuum against normal and pathological
anxiety
Epidemiology
5 % prevalence

SPECIFIC PHOBIA

PANIC DISORDER ± AGORAPHOBIA 2%

SOCIAL ANXIETY DISORDER 4%

POST TRAUMATIC STRESS DISORDER 3.5%

OBSESSIVE COMPULSIVE DISORDER 2.5%

GENERALIZED ANXIETY DISORDER
4.5%
3%
2x higher prevalence in F comp.M (GAD a phobias)
Onset
Early adulthood
20-25
30- 35 y. (GAD)
30-35 y.
Course
Chronic
Agoraphobia and OCD v 80% chronification
intenzity
years
Stress event
MEDICAL CAUSES OF
ANXIETY

MEDICAL CONDITIONS (thyreotoxicosis)




BEVERAGES
HERBAL TREATMENTS
PRESCRIPTION DRUGS
STREET DRUGS
Psychology of anxiety
Psychoanalytic and dynamic theories:
 Unconscious conflicts call for defensive mechanisms
to handle the anxiety.
 Bringing the unconscious conflicts into awareness
eliminates the need for defensive mechanisms and
alleviates the anxiety
Learning and behavioral theories:
Learning of maladaptive behaviors
The cognitive model:
Disordered cognition leads to mental disorders.
The vulnerability-stress model
Abnormal behavior
= Predisposition + Stress
Predisposition due to genetic background.
Stress due to environmental challenge.
Research paradigm: fraternal vs. identical
twins.
Neurobiology of anxiety
Genetics
Rats: anxiety reactors and non-reactors
(fervency of defecation, vocalization
during separation)
Offspring (panic disorder): 15-20% (vs. 2-4%
in controls)
GAD in monozygotic twins : 20-30% vs. less
than 10% in dizygotic (Kendler, 1992)
Neurobiology of anxiety
Neuroanatomy
Anxiety: limbic system, amygdala, locus
coeruleus, frontal cortex, hyperperfuzion
(asymmetric) parahipokampal gyrus in
lactate infusion (Panic disord)
(Reiman, 1984)
Ablation of amygdala – anxiety amelioration
(Davis, 1992)
Information processing and anxiaty
mPFC
OFC 
Deklarativní
paměť
Thalamus
Amygdala
Hippocampus
Autonomic reaction
Emotional
stimulus
Behavioral reaction
L. Coeruleus
(Noradrenaline)
Endocrinne reaction
18FDG
PET panic disorder
versus controls
Horáček, Praško, 2003
18FDG
PET panic disorder
versus controls
Horáček, Praško, 2003
Neurobiology of anxiety
Neurotransmittion
GABAA
Noradrenaline (L.coeruleus)
2 antagonists (yohimbin) – induction of
anxiety
5-HT agonism acute- anxiogenic effect, chronic
(SSRI) anxiolytic effect
Etiology of pathological anxiety
Biological factors
Dynamic

Intrapsychical conflict
Separation, frustration
Disposition
Strong attachment
GABA,
NADR, 5-HT, LS and
Protectivity
amygdala,
somatic
disease
Stress acute
or chronic
(thyroid gland,
Behavioral and cognitive
feochromocytoma,
mitral valve
Learned (conditioned) behaviour
prolapsus,
arytmia, myocardial
Learned (conditioned) cognition
ischemic Psychogenic
disease … factors

Triggers, changes in
disposition
Anxiety
Versions of anxiety
Generalized
(free floating)
Anxiety:
Panic
(paroxysmal)
Anxiety is unstable and frequently is transformed into
different clinical symptomatic clusters.
Transformation of pathological anxiety
Generalized (free floating)
Panic (paroxysmal)
Anxiety:
concretization
Phobia
grief
Anxiety depressive disorder
dissociation
Dissociative, conversive disorders
compulsiveness
OCD
somatization
Somatophorm disorders
F40-F48 NEUROTIC, STRESS-RELATED AND
SOMATOFORM DISORDERS
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive-compulsive disorder
F43 Reaction to severe stress, and adjustment disorder
F44 Dissociative [conversion] disorder
F45 Somatoform disorders
F48 Other neurotic disorders
Anxiety Disorders
DSM-IV
• Panic disorder (w/wo agoraphobia)
• Agoraphobia (w/o a history of panic
disorder)
• Generalized anxiety disorder (GAD)
• Obsessive-compulsive disorder (OCD)
• Social phobia
• Specific phobia
• Posttraumatic stress disorder
• Acute stress disorder
Panic Disorder
• Discrete, unexpected episodes of intense fear
and alarming physical symptoms (panic
attack)
• Most frequent presentations:
– Neurological…………..44%
– Cardiac………………..39%
– Gastrointestinal..……...33%
• One year prevalence of 1% - 2%
• Twice as common in women than men
• 60% - 90% comorbid depression
Panic disorder
Genotype: predisposition in twin studies.
Biochemical: serotonin deficiency in the
limbic system.
Physiological: chronic hyper-activation of
the limbic system.
Behavioral: hyper-vigilance to external and
internal cues.
Learning: excessive classical acquisition
of fear and operant acquisition of
avoidance.
Cognitive: over-interpretation of
autonomous cues & lack of control.
PANIC ATTACK
Tension
Functional
tension
time
5 - 25 min
Triggers:
excercise
worries
sex
nonREM
panicogens
COGNITION
BIOLOGICAL CHANGES
ANXIETY
SOMATIC REACTIONS
ANXIOUS BEHAVIOUR
ADAPTATIO
N
REACTION
INHIBITION
Anticipation anxiety
and cognition
High arousal
Safeguarding and
avoidance behaviour
Interpersonal
changes
Case: Panic Disorder
It started 10 years ago. I was sitting in a
seminar in a hotel and this thing came out of
the clear blue. I felt like I was dying. For me,
a panic attack is almost a violent experience.
I feel like I'm going insane. It makes me feel
like I'm losing control in a very extreme way.
My heart pounds really hard, things seem
unreal, and there's this very strong feeling of
impending doom. In between attacks there is
this dread and anxiety that it's going to
happen again.
From the National Institute of Mental Health’s Web Site
Panic disorder – a case story
"In between attacks there is this anxiety that it's
going to happen again. I'm afraid to go back to
places where I've had an attack. Soon won't be
anyplace where I can go and feel safe from
panic.“
“For me, a panic attack is a violent experience.
I feel disconnected from reality. I feel like I'm
losing control in a very extreme way. My heart
pounds hard, I feel I can't get my breath, and
that things are crashing in on me.”
Find the autonomic, cognitive, behavioral and emotional
feeling components.
Agoraphobia
• Anxiety about being in situations from which
escape might be difficult or embarrassing
– unexpected or situationally predisposed panic
attack
– panic-like symptoms
• Situations are avoided or endured with
marked distress or anxiety
• Not better accounted for by another mental
disorder like social phobia or specific phobia
Generalized Anxiety
Disorder
• Chronic, excessive worry, with
symptoms of increased motor tension
and arousal
• Typically seek help for somatic
concerns
• Women > men
• One year prevalence of 3 - 4%
• Prevalence in primary care setting of
8%
General Anxiety Disorder
Clinical Example
I always thought I was just a worrier. I'd feel keyed
up and unable to relax. At times it would come and
go, and at times it would be constant. It could go
on for days. I'd worry about what I was going to fix
for a dinner party, or what would be a great present
for somebody. I just couldn't let something go.
There were times I'd wake up wired in the morning
or in the middle of the night. I had trouble
concentrating, even reading the newspaper or a
novel. My heart would race or pound. And that
would make me worry more.
From the National Institute of Mental Health’s Web Site
Generalized anxiety disorder
"I'd have terrible sleeping problems. There
were times I'd wake up wired in the middle
of the night. I had trouble concentrating,
even reading the newspaper or a novel.
Sometimes I'd feel a little lightheaded. My
heart would race or pound. And that would
make me worry more. I was always
imagining things were worse than they really
were: when I got a stomachache, I'd think it
was an ulcer.”
Find the autonomic, cognitive, behavioral and emotional
feeling components.
Obsessive-Compulsive
Disorder
(OCD)
• Obsessions: recurrent uncontrollable
thoughts that are
intrusive and
senseless
• Compulsions:
repetitive behaviors
(rituals) to neutralize discomfort or
prevent a dreaded event
• Women = men
• One year prevalence of 2%
Obsessive-Compulsive
Disorder Clinical Example
I couldn't do anything without rituals. They transcended
every aspect of my life. Counting was big for me.
When I set my alarm at night, I had to set it to a number
that wouldn't add up to a "bad" number. I would wash
my hair three times as opposed to once because three
was a good luck number and one wasn't. If I was
writing a term paper, I couldn't have a certain number
of words on a line if it added up to a bad number. I was
always worried that if I didn't do something, my parents
were going to die. Or I would worry about harming my
parents, which was completely irrational.
From the National Institute of Mental Health’s Web Site
Social Phobia
• Fear of being embarrassed in a social setting
• Point prevalence of 5-10%
• High co-morbidity with alcohol abuse and
depression
• Occurs more frequently among biological
relatives
• Epidemiologically, women > men however in
clinical samples men women
Social Phobia Clinical
Example
I couldn't go on dates or to parties. For a while, I
couldn't even go to class. My sophomore year
of college I had to come home for a semester.
My fear would happen in any social situation. I
would be anxious before I even left the house,
and it would escalate as I got closer to class, a
party, or whatever. I would feel sick to my
stomach—it almost felt like I had the flu. My
heart would pound, my palms would get sweaty,
and I would get this feeling of being removed
from myself and from everybody else.
From the National Institute of Mental Health’s Web Site
Specific Phobia
• Persistent, irrational fears of certain
objects or situations
• Examples: snakes, closed-in spaces,
flying, blood/injury, storms, and
bridges
• One year prevalence of 9%
• Sex ratio varies
– 75-90% animal/natural type are female;
55-70% blood injection type are female
From the National Institute of Mental Health’s Web Site
Specific Phobia Clinical
Example
I'm scared to death of flying, and I never do it
anymore. It's an awful feeling when that airplane
door closes and I feel trapped. My heart pounds
and I sweat bullets. If somebody starts talking to
me, I get very stiff and preoccupied. When the
airplane starts to ascend, it just reinforces that
feeling that I can't get out. I picture myself losing
control, freaking out, climbing the walls, but of
course I never do. I'm not afraid of crashing or
hitting turbulence. It's just that feeling of being
trapped.
From the
National Institute of Mental Health’s Web Site
Posttraumatic Stress Disorder
(PTSD)
• Occurs in response to an event in which
grave physical harm was threatened or
occurred
– Event is re-experienced
– Persistent avoidance of reminders
– Persistent increased arousal
• Symptoms > 1 month (PTSD)
• Symptoms < 1 month (Acute Stress
Disorder)
• Lifetime prevalence of 1 - 14%
Posttraumatic Stress Disorder
(PTSD) Clinical Example
I was raped when I was 25 years old. For a long
time, I spoke about the rape on an intellectual
level, as though it was something that happened
to someone else. I was very aware that it had
happened to me, but there just was no feeling. "I
started having flashbacks. They kind of came
over me like a splash of water. Suddenly I was
reliving the rape. I would get very flushed or a
very dry mouth and my breathing changed. I
was held in suspension. I was in a bubble, just
kind of floating.
From the National Institute of Mental Health’s Web Site
TYPES OF TREATMENTS
• COUNSELLING / PSYCHOTHERAPY
– Cognitive
– Behaviour
– Interpersonal
• DRUG THERAPIES
– Minor Tranquilizers
– Antidepressant / Anti anxiety
LENGTH OF TREATMENT
• SHORT TERM
• LONG TERM
Treatment of anxiety disorders

Psychotherapy

Pharmacotherapy

Education and support

Exercise