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Anxiety Disorders New Insights Dr.R.V.S.N.Sarma., M.D., M.Sc., Consultant Physician visit : www.drsarma.in What is anxiety ? It is a mood-state with Marked Negative effects Bodily symptoms of tension Apprehensions about future Its consequence is ‘worry’ What is physiological worry ? Worry is a normal response to stressful situations limited to particular situations Should not exceed the duration of event Should not spread to other topics Excessive worry should not be seen as a normal response, as part of one’s personality What is pathological worry ? It is a component of anxiety Negative emotional thoughts, images Uncontrollable and they occur in sequence Concern about future threats and danger Their frequency and intensity are more What do people worry about ? Real problems that could be potentially solved, but are not acted on Real problems that probably cannot be solved (at least not by the individual), but can be coped with “Imagined problems” that do not yet exist and probably will never exist Worry about worry and its consequences Pathological v/s normal anxiety Autonomous responses Greater intensity Longer duration Behavior significantly affected Stressor may be minimal or absent Origin of anxiety Protective response Normal/protective anxiety Fear and pathological anxiety Common underlying neuro-physiology Two categories of fear/anxiety Acute and Chronic Negative effects of worry 1. Unreasonable fear 2. Anxiety Disorder 3. Panic Disorder 4. Substance abuse 5. Depression What cause Anxiety Disorders ? No single cause Several possible causes genetics, other biological factors physiology, infection, injury, trauma temperament, life experiences upbringing, family, school, peers, society in general, Doctors in particular stress - chronic or acute What cause Anxiety Disorders ? Importance of Anxiety Disorders Accurate Dx and Rx of anxiety disorders is essential Reduction of secondary psychiatric conditions Depression Substance abuse problems Anxiety Disorders - DSM-IV 1. Generalized Anxiety Disorder (GAD) 2. Panic Disorder (PD) with Agoraphobia (AG) 3. PD sans Agoraphobia 4. Specific Phobia (SP) 5. Social Phobia (SoP) 6. Obsessive Compulsive Disorder (OCD) 7. Post traumatic Stress Disorder (PTSD) 8. Acute Stress Disorder 9. SAD, CAD (ASD) 10. Substance-Induced Anxiety disorder (SIAD) 11. Anxiety disorder due some medical illness Dual Diagnosis Disorders Lifetime Prevalence (%) Prevalence of Anxiety Disorders 27 24 21 18 15 24.9 14 12 9 6 3 0 6.8 5.7 4.7 1.6 Any Anxiety Disorder Social Anxiety Disorder PTSD Generalized Anxiety Disorder Panic Disorder OCD Kessler et al. Arch Gen Psychiatry. 1995;52:1048. Kessler et al. Arch Gen Psychiatry. 1994;51:8. Sex differences in Anxiety Disorders Are women more ‘Nutty’ ? Spectrum of Anxiety Disorders SpecPHOB SocPHOB PTSD GAD Percent OCD AGORAPH PANIC D 0 1 2 3 4 5 http://www.nimh.nih.gov/publicat/anxiety.cfm What is Gen. Anxiety Disorder ? Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long. The “What if?” disorder Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress. Domains of anxiety Physical Affective Cognitive Behavioral Physical domain Anorexia Hyperventilation Butterflies in stomach Light-headedness Chest pain/tightness Muscle tension Diaphoresis Nausea, Vomiting Dry mouth Pallor Dyspnoea Palpitations Faintness Paresthesias Flushing Sexual dysfunction Physical domain contd.. Headache Shortness of breath Stomach pain Tachycardia Tremulousness Urinary frequency Diarrhea Affective domain Edginess Uneasiness Terror Panic Behavioral domain Triggers many responses Behavioral in nature Concerned with diminishing And even avoiding the distress Regulation of locus ceruleus Alpha-noradrenergic auto receptors Serotonin receptors GABA-benzodiazepine receptors Opiate receptors Dopamine receptors The amygdala and locus ceruleus Generalized Anxiety Disorder -GAD Pathological anxiety, which is excessive, chronic and typically interferes with their ability to function in normal daily activities. GAD is distinguished from Phobic anxiety – as it is not triggered by a specific object 1. Restlessness or feeling keyed up or on edge, 2. Being easily fatigued, 3. Difficulty concentrating or mind going blank, 4. Irritability, 5. Muscle tension, 6. Sleep disturbance Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events. The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms Case # 1 Ms. D has a chief c/o “worrying about everything” for the last year. She also c/o frequent headaches, fatigue and insomnia secondary to the anxiety. These symptoms have worsened to the point where she has been distracted and making mistakes at work. GAD – Mr. Fisc Worry that is Excessive, uncontrollable Frequent, multiple topics (not only onetime) More than one day out of two 3 out of 6 other associated physical symptoms Muscle tension, Restlessness Fatigued easily, Irritability Sleep disturbance, Concentration difficulty Acute fear state Response to life-threatening danger Terror, helplessness, Sense of impending disaster/doom Urgency to flee or seek safety Sympathetic/Nor-adrenergic activation Located in locus ceruleus Corresponds to panic attacks Agoraphobia Anxiety in situations where escape might be difficult (or embarrassing) or help might not be available in the event of having a panic attack or panic-like symptoms Situations are avoided or endured with marked distress May not leave home or may need a companion Can occur with and without panic disorder Agoraphobia Social Phobia Marked, persistent fear of social or performance situations where a person is exposed to unfamiliar situations or people or possible scrutiny by others. The individual fears acting in an embarrassing or humiliating way. The Person recognizes fear as excessive. Exposure causes anxiety symptoms or panic Situations are avoided or endured with anxiety Specific Phobias Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a Panic Attack. The person recognizes that his/her fear is excessive or unreasonable. The phobic situation is avoided or else is endured with intense anxiety or distress Specific Phobias - Examples Acrophobia fear of heights Agoraphobia fear of open places Claustrophobia fear of enclosed places Ailurophobia fear of cats Pathophobia fear of disease Mysophobia fear of dirt and germs Arachnophobia fear of spiders Hematophobia fear of blood Xenophobia fear of strangers Better-halfophobia fear of wife Cynophobia fear of dogs PAN – The Greek God Panic Attack – DSM IV 1. Palpitations 8. Feeling dizzy, fainty 2. Sweating 9. Derealization (feelings of unreality) 3. Trembling or shaking 4. Shortness of breath 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abd. distress 10. Fear of going crazy 11. Fear of dying 12. Paresthesias 13. Chills or hot flushes A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes Case # 2 Mrs. B c/o a long h/o episodes of anxiety, SOB, racing heart, sweating, CP, and fears that she is having a MI and will die. These last 30 minutes and are unexpected. She c/o anxiety while in malls and traveling alone to new places for fear of having another attack. Despite a negative w/u, she still worries about having a MI during an attack. Panic Disorder with Agoraphobia Recurrent unexpected panic attacks: anxiety associated with at least four physical and/or cognitive symptoms cognitive symptoms At least 1 month of worry about having additional attacks or the consequences of an attack (losing control, having a heart attack, “going crazy”). Agoraphobia Panic Disorder – Chest pain Chest pain is a common symptom of panic attacks 22 – 70% of panic attacks are associated with CP 18 – 25% of all patients with chest pain have PD Rates of PD higher among cardiology outpatients with chest pain. Such patients undergo expensive cardiac workups, but their PD remains undiagnosed & untreated. Obsessive Compulsive Disorder - OCD Obsessions Recurrent and persistent thoughts, impulses, or images that are experienced during the disturbance, as intrusive and inappropriate, and cause marked anxiety or distress. The thoughts, impulses, or images are not simply excessive worries about real life problems. The person attempts to ignore or suppress such thoughts impulses or to neutralize them with some other thought or action. The person recognizes that the obsessive thoughts, impulses, or images are a product of his or her own mind Obsessive Compulsive Disorder -OCD Compulsions Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) He/she is driven to perform in response to an obsession, The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event But, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive. Obsessive Compulsive Disorder -OCD Putamen Globus Pallidus Caudate Nucleus Thalamus Orbital frontal cortex Post traumatic Stress Disorder- PTSD Post traumatic Stress Disorder- PTSD Experiential requirements The person has experienced a life-threatening event and has responded with intense fear, hopelessness or horror. The person’s response to the event occurred more than 4 weeks after it was experienced and lasted more than one month. The traumatic event is persistently re experienced in several ways, e.g., by intrusive recollections, dreams, illusions, hallucinations, or flashbacks. Post traumatic stress disorder PTSD Post traumatic Stress Disorder- PTSD Behavioral requirements Thought avoidance, related-activities and/or People-avoidance behavior, Feelings of detachment, Blunted affect, Sense of doom Insomnia, Irritability, Hyper vigilance, Exaggerated startle response Post traumatic Stress Disorder- PTSD Subdivisions Acute – when PTSD is diagnosed between 1 and 3 months after the event occurs it is called acute Chronic - when PTSD continues longer than 3 months, it is considered chronic and long term Delayed Onset PTSD-this term is used to describe those cases where the symptoms do not occur immediately after the experience, but, rather, months or years later Case # 3 Mr. A witnessed a friend die in a MVA six weeks ago and c/o frequent nightmares of the accident, poor sleep, fears of driving, anxiety around highways, anhedonia and decreased affection highways, towards his girlfriend. His girlfriend also notes that he has been very irritable and startles easily since the accident. Post traumatic Stress Disorder- PTSD Exposure to a traumatic event Response involving intense fear, Helplessness and horror Re-experiencing of the traumatic event Avoidance of stimuli/psychological numbing Increased arousal Symptoms greater than 1 month Separation Anxiety Disorder - SAD Medical conditions causing anxiety Endocrine conditions Cardiovascular conditions Respiratory conditions Metabolic conditions Neurological conditions Substances causing anxiety Alcohol Alcohol Substances that cause Amphetamines anxiety (withdrawal) Caffeine Alcohol Cannabis Cocaine Cocaine Sedatives Hallucinogens Hypnotics Inhalants Anxiolytics Phencyclidine Medications causing anxiety Anesthetics Oral contraceptives Analgesics Antihistamines Sympathomimetics Anti-parkinsonians Bronchodilators Corticosteroids Anti-cholinergics Antihypertensives Insulin Cardiovascular drugs Thyroid hormones Anticonvulsants Anxiety Disorders Current Management Strategies Management of Anxiety Disorders Pharmacotherapy (Medications) Psycho-analytic therapy – PT Behavior Therapy - BT Cognitive Behavior Therapy – CBT Computer therapy - CT Virtual Realty – VR Mood GYM Drug Rx. of Anxiety Disorders Clonazepam How do anxiolytics act ? GABA and Glycine are inhibitory neurotransmitter Serotonin and Noradrenaline are excitatory Anxiety is increased excitatory transmitters BZNs increase GABA and increase inhibition SSRI decrease the serotonin levels and ↓excitation TCAs act by ↓both serotonin and noradrenaline Drug Rx. of Anxiety Disorders Disorder First Choice 2nd Choice Short (p.r.n) GAD BZNCZ, CDZ, ALZ Beta-blockers Buspirone BZNTCAClomipramine ALZ, CZ, LZ Add on Carbamazp Panic Disorder Paroxetine/ Citalopram Phobias Beta-blockers SSRIs BZNALZ, CZ MAOI OCD Clomipramine Fluoxetine CDZ Buspirone PTSD TCAImipra, Amytrp SSRI- FLX Sertaline, CP BZN MAOI MAOI Phenelzine Comparison of Benzodiazepines BZN Sedation Anxiolytic Half life Lipid solu Dose Diazepam +++ + 20-80 h High 5 mg od Alprazolam + +++ 6-20 h Low 0.5 mg qid Clonazapam ++ +++ 22-50 h Low 0.5 mg bid Lorazepam ++ ++ 10-20 h Med 1 mg tid + + 7-30 h Med 15 mg bid Chlordiazepx Different strategies of therapy Behavior therapy Desensitization Behavior modification Behavioral activation Cognitive therapy Rational-emotive therapy Beck’s cognitive therapy Newer approaches Mindfulness meditation Acceptance and commitment therapy Dialectical Behavior Therapy (BPD) Cognitive Behaviour Therapy - CBT CBT is a method used to treat anxiety Recognition of “distorted thinking,” “Cognitive restructuring.” It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder. CBT – Obstacles - Restructuring Hopelessness Self-criticism Fear of getting worse Shame and embarrassment Partial exposure Blaming other people Low motivation Looking for complex solution Depressing ruminations There must be an easier way Computer Therapy Pts are ashamed to seek help, and may fear the consequences at work and home. Therapy is expensive and beyond the reach of many patients. Computer therapy is very cheap and available by comparison. Computer Therapy – Softwares Fearfighter - for phobia/panic Cope - for depression/anxiety Balance - for GAD BTSteps - for OCD These are PC based in a CD-Rom or phone based or Web-based MENTAL OUTSIDE Virtual Reality - VR VR therapy via SD (Systematic Desensitization) is becoming very popular. SD is a process of gradually introducing a disturbing stimulus (e.g. view from a high place) in otherwise pleasant surroundings. This process gradually suppresses the anxiety response. Virtual Reality – VR - Advantages Patients often have difficulty imagining the stimulus themselves. They are often afraid of experiencing it directly – which may also be expensive and time-consuming. VR affords patient privacy and confidentiality during treatment. Very good for phobias Virtual Reality – VR - Imagination “Projection in time” – rationally reconstructing the future “De-catastrophizing an image” – modifying a disturbing image “Image modeling and substitution” – interrupting a negative train of images “Covert conditioning” – subtle conditioning using imagined rather than real stimuli Virtual Reality – VR - Hutchworld Hutchworld is a virtual community attached to the Hutchison Cancer Research Center. Designed to provide social support for cancer patients and their families. Based on Microsoft’s Vworld’s system. Mood GYM on the Internet Few GPs are trained in CBT Clinical psychologists are expensive Young people are not easily reached They may not want them – embarrassment The web is accessible, convenient and popular with young people. Deliver CBT via internet – 5 modules Mood GYM Modules 5 Modules - analysis and results 1. Essentials of CBT with examples and interactive exercises 2. Warpy Thoughts Questionnaire, Identifying dysfunctional thoughts. Methods to contest such thoughts 3. Other methods for overcoming warpy thoughts 4. Life Event Stress, Relaxation, meditation, music Pleasant Events Schedule, parental style 5. Simple problem solving, responses to relationship break-up Web stats summary Sessions Take home points Anxiety disorders are very common Just as fevers these are of different types Accurate Dx. and Rx. by GP is essential Depression and substance abuse potential Minimum of six weeks to see Rx effect Prolonged Rx. is necessary 6 m or more Drug Rx is only a small part of management SSRI, TCAs, BZNs, MAOIs, ß-blockers etc. CBT, Computer treatment, VRs, Mood GYM Thank You All Visit us at : www.drsarma.in This is sponsored by Torrent – Makers of Clonotril (Clonazepam)