Download a anxiety disorders

Anxiety disorders F4x.x
MUDr. Jan Hanka
Prague psychiatric center
Charles University
2012
History of „neurosis“:
• First used in 18th century- symptoms without a
physiological explanation
• End of 19th century: “soldier’s heart“- Da Costa;
“neurastenia“
• Freud (1895) „neurosis“- symptoms of a repressed conflict
• Controversion with DSM-III (1980): psychoanalytical term
“neurosis” as a description of underlying mechanism x
“neurotic disorders” diagnosed by symptoms (criteria)
• Problems with exclusion from affective disorders, when
over 60% of depressed patients suffer from significant
anxiety
• Borderline diagnoses: F34.1 Dysthymia (“depressive
neurosis“); F41.2 Mixed anxiety and depressive disorder
Diagnostic approach
Symptoms
Signs
Anamnestic data
(referred by patient) (from mental state
examination)
Syndromes
(frequently associated
features)
Mental disorders
(definition, criteria, epidemiology,
course and prognosis, treatment)
(including “objective”
information from others)
Diagnostic tests
(laboratory, imaging,
neurophysiological)
A) Syndromes frequently seen
in Anxiety disorders
1.
2.
3.
4.
5.
6.
7.
Anxiety syndrome
Panic attack
Phobia
Obsessive – compulsive syndrome
Somatization
Neurastenia
Derealization and Depersonalization
Anxiety
(anxiety syndrome)
• various forms of fear with non-specific somatic
(autonomic) symptoms
• experienced as unpleasant
• signals of danger
• usually start stress reaction
• intensity: from mild forms to PANIC ATTACK
• leads to avoidant, safety-seeking (neutralizing)
behaviour
Anxiety
(anxiety syndrome)
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Restlessness or feeling on edge
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Fatigue
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Difficulties concentrating or „mind going blank“
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Irritability
•
Muscle tension
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Sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep)
Panic attack
*short episode of intense fear
*sudden onset
*symptoms of autonomic arousal
*secondary fear of death/insanity/loss of control
*duration in minutes
*total exhaustion shortly after
*followed by a constant fear of another panic
attack (without warning) “anticipatory anxiety”
Panic attack - symptoms
Psychological symptoms: derealisation
or depersonalisation, fear of losing
control, going insane, dying
Symptoms of autonomic activation:
1/ G.I.: nausea or abdominal distress,
choking sensation, dry mouth, diarrhea
2/ Respiratory system: dyspnoea
(„can’t get enough air“), chest tightness
3/ Cardiovascular: palpitations
(chest or temples), chest pain /
discomfort
4/ Muscle tension: tremor, muscle pain,
cephalea, inability to move
5/ Consequences of hyperventilation:
feeling dizzy, unsteady, lightheaded, or faint; paraesthesias of
extremities/face (”pins and needles”); cramps; dyspnoe; tinnitus
6/ Sweating, chills, hot flushes
Panic attack – progression in time
High
tension
Normal
tension
time
5 - 25 minutes
TRIGGERS:
excersise
worries
sex
nonREM (30% pac.)
drugs
hangover
COGNITIONS
BIOLOGICAL CHANGES
ANXIETY
SOMATIC REACTION
BEHAVIOUR
ADAPTATION Anticipatory anxiety
EXHAUSTION and cognitions
High arousal
SAFETY-SEEKING
or AVOIDANT behavior
Interpersonal changes
Phobia
• Anxiety provoked by specific objects or
situations (usually not seen as dangerous)
• Secondary fear of losing control, illness, dying
• ANTICIPATORY ANXIETY
• Avoidant behaviour
• Secondary depression
A list of most
prevalent phobias
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Agoraphobia
Acrophobia
Arachnophobia
Aviaphobia
Dysmorfophobia
Entomophobiae
Iatrophobia
Kynophobia
Nyctophobia
Ofidiophobia
Social phobia
Xenofobie
?
•Strangers
•Snakes
•Insects
•Doctors
•Flying
•Open areas
•Spiders
•Dogs
•Darkness
•Heights
•Defect in appearance
•Embarassment
Obsessive – compulsive
syndrome
• OBSESSIONS = repeated intrusive thoughts,
images, impulses, doubts entering patient’s mind
repeatedly in a stereotyped form. They are
distressing, patient tries to resist them. Are
perceived as patient’s own and unwanted.
• COMPULSIONS = (RITUALS) = stereotyped
behaviours repeated in order to reduce anxiety,
neutralize obsessions, prevent disaster. They
are not enjoyable, are seen as pointless and
ineffectual. If resisted, anxiety worsens.
THERE CAN BE “MENTAL COMPULSIONS“
Obsessive – compulsive syndrome
• Types of obsessions and compulsions:
1.
2.
3.
4.
5.
6.
7.
Contamination
Catastrophe/harm
Precision, symmerty
Religious
Aggressive/sexual content
Somatic
Good - evil
A.
B.
C.
D.
E.
F.
G.
H.
Washing
Control, checking
Repeating routines
Counting
Organizing items
Touching
Hoarding/collecting
Talking
Somatization
• A tendency to feel and report somatic
symptoms in response to psychosocial
stressors and tendency to seek medical
help for them
• „M.U.S.“ = medically unexplained (physical)
symptoms
• Frequently in patients with alexithymia
(=inability to describe feelings with words)
Neurasthenic syndrome
• Complaint of increased fatigue after
mental effort
• Physical weakness after minimal effort
• Plus somatic symptoms of tension: muscle
aches, dizziness, tension headaches,
sleep disturbances, inability to relax,
irritability
• Relaxation, rest, recreation do not help
Derealization and
depersonalization
• Surroundings seem to be unreal, remote,
automatized. Like on a theatre stage.
• Loss of own feelings. Feeling detached
from their body, emotions or the world. Like
actors in their own lives.
B) Anxiety disorders
*most prevalent mental disorders
*>15 % of population experiences clinically
significant anxiety
*mostly treated by GP’s
*more frequent in patients with chronic somatic
illness (hypertension, COPD, diabetes..)
*and vice versa – anxious patients are more
likely to develop a physical illness
*comorbidity with Anxiety disorder  longer
recovery from physical illness (mortality)
Classification of anxiety disorders
(ICD-10)
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F 40.0 Agoraphobia
F 40.1 Social phobia
F 40.2 Specific phobias
F 41.0 Panic disorder
F 41.1 Generalized anxiety disorder
F 41.2 Mixed anxiety and depressive disorder
F 42 Obsessive- compulsive disorder
F 43.0 Acute stress reaction
F 43.1 Post-traumatic stress disorder
F 43.2 Adjustment disorder
F 44 Dissociative (conversion) disorders
F 45 Somatoform disorders
F 48.0 Neurasthenia
F 48.1 Depersonalization-derealization syndrome
F 40 PHOBIC ANXIETY
DISORDERS
• F 40,0 Agoraphobia
F 40,00 Without panic (5%)
F 40,01 With panic (95%)
• F 40,1 Social phobia
• F 40,2 Specific phobias
(isolated)
•
F 40,8 Other phobic disorders
•
F 40,9 Phobic disorder NOS
AGORAPHOBIA
•
fear not only from open spaces - leaving home,
entering shops, crowds and public places, or
travelling alone in trains, buses or planes (where
escape is not an easy option)
 including
claustrophobia
•
travel, traffic jam, tunnels, bridges, elevators, shopping,
queuing, crowds, leaving home, unknown places, cinemas,
theatres, churches, town squares, home alone
•
„in“  rise of anxiety, fearful thoughts, autonomic
symptoms of stress, tendency to escape
+ anticipatory anxiety and avoidant behaviour
• 3-4 % women; 1-2 % men
• onset mostly at age 20-30
SOCIAL PHOBIA
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fear of social interactions and their possible negative
consequences, tendency to avoid them (extreme shyness)
fear of drawing the attention of others, embarrassment,
criticism, failure
inability to speak, perform, write, eat, make phone calls,
maintain eye contact
Criteria: social anxiety + at least one: blushing, hand tremor,
nausea, or urgency of micturition
Point prevalence 1,5 – 2 % women; 1 - 1,5 % men
(life prevalence 10-15% of population)
Onset in adolescence
Watch for frequent comorbidity with alcohol abuse (selftreatment)!!
Diff.dg.: schizoid personality (not interested), depression,
paranoia, dysmorfophobia
Differential diagnosis
of social phobia
Depression
37 %
Panic
disorder
11 %
Agoraphobia
23 %
Dysthymia
15 %
Spec.
phobias
38 %
SOCIAL
PHOBIA
Avoidant
personality
58 %
GAD
13 %
PTSD
16 %
Alcohol
24 %
Tyrer and
Emmanuel,
1998
SPECIFIC (ISOLATED) PHOBIAS
• Intense fear of a single specific object or situation,
provoking anxiety or panic attacks a leading to
avoidance
• Animals, height, darkness, water, thunder, lightning,
blood (here hypotension – fainting), dentist ect.
• Usually constant severity, mostly not restricting in life
(if can avoid trigger), rarely comorbid mental
disorders
• 7 % women, 4 % men
(life prevalence 10%)
• Exeption- avoiding food in anorexia nervosa is not a
phobia!
F 41 OTHER ANXIETY DISORDERS
Anxiety is not restricted to a
specific situation !
• F 41,0 Panic disorder
• F 41,1 Generalized anxiety disorder
• F 41,2 Mixed anxiety and depressive
disorder
• F 41,3 Other anxiety disorders
Panic disorder F41.0
(recurrent anxiety attacks)
panic attack x panic disorder
*recurrent attacks of extreme anxiety (panic), without detectable triggers –
can’t be predicted (no external threat!)
*life-long prevalence 1,5 – 3,5 %
*10% of cardiology out-patients, 17% of acute admissions due to chest
pain
* approx. 2-3 (up to 10) years until diagnosed!!
*several major panic attacks in a month
*between panic attacks without major symptoms (only anxious anticipation)
*comorbidity with Agoraphobia (50-90%), Major depression (40-80%),
other Anxiety disorder (30%), Personality disorder (25-60%)
*Risk of BZD dependence(!!)
*Panic disorder increases cardiovascular morbidity: hypertension (OR
1,9), MI (OR 4,5), stroke (OR 12) and mortality (twice for the next 35
years)
Etiology of Panic disorder
• Disregulation of autonomic NS (↑ sympatical
tone)
• Psychological theories (fear of abandonement x
fear of dependence)
• Psychoanalytical p.o.v. (loss of a parent,
separation anxiety)
• Hyperventilation hypothesis (unconscious
prolonged hyperventilation)
• Cognitive models (catastrophic interpretation of
normal sensations)
• CBT models (vicious circle)…
Vicious circle of anxiety and panic
Triggers
Automatic
irrational
thoughts
Avoidant
and safety-seeking
behaviors
Emotions
Physical symptoms
(stress reaction)
Consequences:
Short term x Long term
Positive x Negative
F 41.1 GENERALIZED
ANXIETY DISORDER
• Point prevalence 2-4%, life prevalence 5% (but
2/3 of patients with depression and 90% of
pacients with dysthymia fulfill the criteria for GAD)
• Male/female ratio 1:1 (up to 1:2)
• Onset in early adulthood, average age of clinically
significant presentation is 40 years
• Course mostly chronic, only 1/3 are treated
appropriately
• Only ½ fully employed, 1/3 need some form of
social support
F 41.1 GENERALIZED ANXIETY
DISORDER
„free – floating anxiety“- worries about everyday situations and problems
PLUS
• Signs of autonomic activation: palpitations, sweating, tremor, dry
mouth
• Symptoms from chest/abdomen: mild dyspnoea, choking, chest
dyscomfort, nausea or abdominal dyscomfort
• Symptoms regarding mental state: dizziness, restlessness,
derealization, depersonalization, fear of losing control
• General symptoms: hot or cold flushes, numbness, paresthesia
• Signs of tension: muscle aches, inability to relax, irritability or
psychic tension, difficulties swallowing
• Non – specific symptoms: estrong reaction to surprise, „blank
mind“, initial insomnia due to worries
Must not have panic, OCD, hypochondriac disorder, phobias
F 42 OBSESSIVE
COMPULSIVE DISORDER
• Repeated obsessions and compulsion, which distress
the patient mostly by extreme wasting of time
.0 Mostly obsessions or ruminations
.1 Mostly compulsions (rituals)
.2 Mixed obsessions and compulsions
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Life prevalence 2 – 3 %
Gradual onset: men age 6-15, women age 20-29
Chronic or episodic course
Diff.dg.: obsessions/ruminace in depression
in hypochondriac disorder/dysmorfophobia
schizophrenia (+treatment with second generation AP!)
Tourette’s syndrome (tic x compulsion)
anorexia nervosa (just food)
• Comorbidity: depression (50%-80%), bipolar disorder (30%), Tourette’s
(tic + compulsions), misuse of alcohol, exanthemas on hands
F43 REACTION TO SEVERE STRESS
AND ADJUSTMENT DISORDERS
disorders are a direct consequence of an
exceptionally stressful event or important life
change (would not develop without these)
*F 43,0 Acute stress reaction
1/ singular or transient disaster, injury, assault, loss
2/ onset within 1 hour:
3/ symptoms of “anxiety syndrome” + (isolation, anger or
aggression, narrowing of attention, desoriantation, despair,
agitation or over-activity, excessive mourning) OR
dissociative stupor, derealization, depresonalization
4/ symptoms disappear within 48 hours
*F 43,1 Post-traumatic stress disorder
*F 43,2 Adjustment disorders
POST-TRAUMATIC STRESS
DISORDER
*point prevalence 0,5 – 1 % (3 – 58 %)
1/ delayed or protracted reaction to a stressful event or situation
of an exceptionally threatening or catastrophic nature (which is
likely to cause pervasive distress in almost anyone): natural
disaster, war, lethal accidents, torture, terror, crime, rape..
2/ latency period – several weeks to 6 months
3/ symptoms:
*intrusive reliving – of the traumatic event in memories, vivid
images, nightmares (flashback)
*avoidance of the traumatic topic + partial amnesia to the event +
emotional numbness, blunting, withdrawal, insensitivity
*increased irritability: insomnia, problems concentrating
attention, excessive startle reaction
Lack of treatment in the chronic course lead to: depression,
suicidal tendencies, misuse of alcohol/drugs
ADJUSTMENT DISORDERS
•
abnormal reaction (in form or content),
developing within 1 month after a stressful
life event (not of unusual or catastrophic
nature); normal adaptation unsuccessful
(separation, loss, migration, physical illness,
change of roles- school, job, retirement,
marriage..)
• various symptoms: depression, anxiety,
worries, inability to solve the situation, to
make plans, conduct disorder (mostly in
adolescents)
• duration up to 6 months (except for
prolongued depressive reaction which lasts
up to 2 years)
F44 DISSOCIATIVE
(CONVERSION) DISORDERS
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loss of normal integrity (dissociation) of memories, one’s own
identity, immediate feelings and control of bodily movements
associated with unsolved problems, disturbed relationships  affect
is transformed into symptoms (hysterical conversion)
onset and end often sudden
frequent denial of obvious problems
dissociative amnesia on informations regardingstressful topics
(event, time period, person, place..)
dissociative fugue (unplanned traveling, with self-care intact, not
suspcious to strangers, reversible amnesia, sometimes establishing
of new identity)
dissociative stupor (impairment or loss of voluntary movements,
reactions, speech, muscle tonus)
trance and possession disorders (outside religious or culturally
accepted situations- unwanted or disturbing)
dissoc. motor and sensoric disorders (impairment of voluntary
movements, sensitivity/ resembling neurological illness)
dissociative convulsions (resemble grand mal seizures, „hysterical
fit“)- rarely injuries, bruises, incontinence, tongue biting, loss of
consciousness
F45 SOMATOFORM DISORDERS
Patient complains of lasting physical symptoms,
demands further examinations despite sufficient
previous examinations being negative (non-specific,
borderline…). Patient is not calmed by repeated
explanation by a doctor about the problem being of a
psychological origin.
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Somatization disorder
Hypochondriac disorder
Somatoform autonomic disorder
Persistent somatoform pain disorder
F45 SOMATOFORM DISORDERS
•life prevalence 3 - 14 %
•6-month prevalence 4 - 6 %
•onset between ages 20 – 30…but possible at any age
•sex ratio 1:1 in Hypochondriac disorder, otherwise M:F 1:3-20
•non-familiar incidence
•10-20% of healthy people experience health related worries (but 45% of people
treated for anxiety)
Differential diagnosis of Somatoform disorders
Somatic (medical) illness - sclerosis multiplex, brain tumor,
hyperparathyroidism, hyperthyroidism, lupus erythematosus, myastenia gravis
Affective (depression) a anxiety disorders – 1 or 2 symptoms - acute onset
and short duration
Hypochondriac disorder – patient is concerned about a specific illness, not just
symptoms
Panic disorder – somatic symptoms during the panic attack only
Persistent somatoform pain disorder– 1 or 2 types of pain without medical
explanation (not polymorphic complaints)
Delusions – schizophrenia with hypochondiacal delusions (bizarre), psychotic
depression with hypochondriacal delusions (mood congruent, exaggerated
fears)
Clinical presentation of Somatoform disorders
•Fear (belief) of a very serious medical disease
•Interpretation of somatic sensations as signs of a serious illness (sinus
tachycardia,tiredness, hangover, overeating, long-term inactivity, somatic signs
of anxiety/stress reaction, lack of sleep…)
•Belief is resistant against repeated explanations by doctors and negative (or
non-specific) results of instrumental/laboratory examinations
•Symptoms can not be controlled by the patient
•Does not have delusional qualities (bizarre, unique,..) and is not a part of
another mental disorder
•Patients with somatoform disorders tend to create counter-transferrence (want
help/advice, then dismiss it as useless)
•Caution: “borderline values, systolic hypertension, hraniční hodnoty,
hyperventilation syndrome, respiration arrhythmia, non-specific changes…”
Cognitive sources of anxiety:
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somatic sensations are perceived as more dangerous than they are
consequences are perceived as more severe
own capacity to resist harm is perceived as inadequate
abilities and willingness of doctors are underestimated
F 45.0 Somatization disorder
*Multiple, repeated and frequently changing somatic symptoms
regarding any organ or system
*onset before age 30
*patient more interested in therapeutic relationship than a diagnosis
*multiple (unnecessary) examinations in pt’s medical history,
including invasive (endoscopy, lumbar puncture, EMG…) or operative
(laparoscopy)
*dramatic and manipulative presentation
F 45.2 Hypochondriac disorder
• fear of one or multiple serious diseases (or dysmorfophobia)
• constant worries about the diseases
• frequent complaints about somatic symptoms
• catastrophic interpretation of normal physiological processes
• refusal to accept advice or reassurance from a doctor about benign nature of the
symptoms
F 45.3 Somatoform autonomic disorder
Da Costa’s syndrome, cardiac neurosis, chronic asthenia, effort syndrome, functional
cardiovascular disease, neurocirculatory asthenia, primary neurasthenia, subacute
asthenia and irritable heart, hiccup, irritable bowel syndrome, gastric neurosis,
psychogenic dysuria
•complaints regarding autonomic disregulation
(cardiovascular, gastrointestinal, respiratory, urogenital..)
• strong preoccupation with these symptoms
• unclear presentation of symptoms
F 45.4 Persistent somatoform pain disorder
•Lasting severe and disturbing pain, without sufficient medical
explanation
•Is in the centre of attention of the patient
•Mostly headaches, low back pain
•Duration > 6 months
F 48 OTHER NEUROTIC DISORDERS
F 48,0 Neurasthenia
• Neurasthenic syndrome > 3 months
• Exclusion criteria: not a post-encephalitic or post-concussion
syndrome, affective (mood) disordes, panic disorder, generalised
anxiety disorder
F 48,1 Depersonalization and derealization
syndrome
• A rare disorder- usually a part of other disorders/diseases
• These syndromes more frequently in: schizophrenic, depressive,
phobic, or obsessive-compulsive disorder
• Other possible causes that must be excluded before diagnosting
F48.1: organic disorders, intoxications, fatigue, hypoglycemia,
pre- and post-epileptic states
Diagnostic algorithm for anxiety disorders
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Symptoms of anxiety which interfere with functioning and/or well-being
•
Must exclude: organic disorder, influence of chemical agents, psychotic
disorder, affective (mood) disorder
TRAUMA
OBSESSIONS
AND
COMPULSIONS
EVERYDAY
WORRIES
EPISODES OF SEVERE
ANXIETY AND
AVOIDANT BEHAVIOUR
OBJECTS SPONTAINEOUS
EMBARRASSMENT
AND
SITUATIONS
Look for
Panic disorder
Look for
PTSD
Look for
OCD
Look for
GAD
Look for
Social phobia
Look for
Specific phobia