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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