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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) • Restlessness or feeling on edge • Fatigue • Difficulties concentrating or „mind going blank“ • Irritability • Muscle tension • 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 • • • • • • • • • • • • 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) • • • • • • • • • • • • • • 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 • • • • • • • • 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 • • • • 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 • • • • • • • • • • 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. • • • • 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: • • • • 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 • 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