* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Anxiety Disorders 2010
Schizoaffective disorder wikipedia , lookup
Obsessive–compulsive personality disorder wikipedia , lookup
Intrusive thought wikipedia , lookup
Psychological trauma wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Mental disorder wikipedia , lookup
Drug rehabilitation wikipedia , lookup
Fragile X syndrome wikipedia , lookup
Conversion disorder wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Conduct disorder wikipedia , lookup
Diagnosis of Asperger syndrome wikipedia , lookup
Asperger syndrome wikipedia , lookup
Treatment of bipolar disorder wikipedia , lookup
Spectrum disorder wikipedia , lookup
Antidepressant wikipedia , lookup
Cognitive behavioral therapy wikipedia , lookup
Selective mutism wikipedia , lookup
History of mental disorders wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Obsessive–compulsive disorder wikipedia , lookup
Externalizing disorders wikipedia , lookup
Child psychopathology wikipedia , lookup
Treatments for combat-related PTSD wikipedia , lookup
Panic disorder wikipedia , lookup
Claustrophobia wikipedia , lookup
Test anxiety wikipedia , lookup
Social anxiety disorder wikipedia , lookup
Anxiety disorder wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
April 16, 2010, 2010 Elliott K. Lee MD, FRCP(C) Staff Psychiatrist Anxiety Disorders Clinic Royal Ottawa Mental Health Centre Anxiety results from an unknown internal stimulus, or is inappropriate or excessive when compared to the existing external stimulus. It is an expected, normal and transient response to stress; may be a necessary cue for adaptation and coping (future event) Different from Fear: sense of dread/foreboding that occurs in response to external threatening event. Pathologic anxiety 1. Autonomy: i.e. Minimal/no recognizable environmental trigger 2. Intensity – exceeds tolerance capacity 3. Duration – persistent, not transient 4. Behaviour – impairs coping: results in disabling behavioural strategies – avoidance, withdrawal Physical symptoms: - autonomic arousal – tachycardia, tachypnea, diaphoresis, diarrhoea, light headedness Affective symptoms: Mild Severe edginess terror, feeling loss of control, dying Behaviour Avoidance, or compulsions (“compensatory”) Cognitions – worry, apprehension, obsessions Anxiety disorders are Prevalent , real, serious, treatable Anxiety disorders are not Signs of personal weakness Nutt et al. In: Handbook of Anxiety and Fear 2008 Neurophysiology Psychodynamic formulation Cognitive behavioural formulation Central noradrenergic system (NE): locus coeruleus (LC)– major source of brain’s adrenergic innervation. E.g. – stimulate LC – get panic attacks; block LC – decrease Gamma Amino Butyric Acid (GABA) system Especially – septohippocampal areas – mediate generalized anxiety, worry, vigilance - BDZ bind to GABA receptors; reduce vigilance Serotonergic system (5-HT) Modulate above 2 systems – explains efficacy of multiple clinical interventions – SSRIs, SNRIs, GABA agents, CBT Psychopharmaology for anxiety disorders is based on those neurotransmitter systems: 1) Norepinephrine TCAs, Prazosin 2) GABA Benzodiazepines, anticonvulsants 3) Serotonergic (5-HT) modulation - SSRIs, SNRIs, TCAs Limbic cortex Nucleus accumbens Periaqueductal Gray matter Orbitofrontal cortex Amygdala Brain Stem Hippocampus Ventral Tegmental Area State anxiety An interruption of one’s emotional state - become restless, agitated, and then may react/overreact to external stimuli - high state anxiety is unpleasant – pts may seek out “adaptive” behaviours to alleviate this. Trait anxiety “Stable aspect of personality” - may worry all the time, even with “normal stimuli”, then when there’s a real threatening stimuli – may worry even more Normal healthy pts vs. Healthy pts with high trait anxiety (Stait Trait Anxiety Inventory (STAI)) Shown - fearful faces - neutral faces - fearful+neutral faces - neutral+neutral faces Etkin A. et al. Neuron, 2004 Analyzed activation of amygdala (fMRI) Conscious awareness of fearful face - dorsal region of amygdala activated in all subjects Unconscious (masked) awareness fearful face - basolateral amygdala activated (high trait anixety pts) Etkin A. et al. Neuron, 2004 Focus on information processing and behavioural reactions Faulty cognitionse.g. Overprediction of likelihood/degree of catastrophe Attempts to neutralize anxiety – e.g. With avoidance, compulsive behaviour, paradoxically “lock in” or reinforce anxiety ►chronic arousal and anticipatory anxiety Single person sees attractive person Automatic thoughts/Feelings: I am foolish, I am incompetent, I am not loveable Automatic thoughts/Feelings: that person is attractive, I am a good person. Maybe we can be a good match. Let’s find out Behaviour: RUN! Behaviour: Initiate conversation*** Reinforcement: I have not dated; good people don’t like me; I am foolish, I am incompetent, I am not loveable Reinforcement: Attractive person seemed to enjoy talking to me. Maybe I have something to offer in a relationship Cognitive Behavioural Therapy (CBT) is based on these notions Replace anxiogenic thoughts and behaviours with positive ones. Anxiety Thought World view Self View • World is dangerous • I am not competent • I can not cope Coping Thought • World is safe • I am competent • I can cope Anxiety = threat to the ego; signals are elicited because current events have similarities (symbolic or actual) to threatening developmental experiences (traumatic anxiety) Object relations theorists emphasize the use of internalized objects to maintain affective stability under stress Ms. Anxietas – 23-year-old engaged grad student complains of periodic episodes of intense anxiety, and chronic fears about dying Ruminates about her own age, and subsequent death, then to her parents. Fears impair her sleep, and ability to function in her studies. In therapy – issues of death are explored – the therapist comments concerns about living contribute to fears of death; “could anything be going on in her life that might contribute to her anxiety?” “It’s not about my fiancee being stationed overseas!”....she cries....therapist offers her a tissue, but she declines Therapist asks “Why did you decline tissue?” She replies – she thought it would be a sign of weakness. They go on to explore, how everyone comes to her for help, but she could not acknowledge she needed help from others. Revealed significant issues with anger – but feared that her anger would explode and drive others away. Further exploration – reveals she had a great deal of anger towards her father, that she had been unable to express Unconscious concern – was that her anger would be so explosive it would destroy him. After 2 months of therapy – Ms. Anxietas gained greater mastery over her fears Began to understand the impact of her anger and her fears of being abandoned and alone. Defensive function of anxiety may be to distract patient form more disturbing or underlying Gabbard, GO. Psychodynamic Psychiatry in concerns. Clinical Practice, 2000 Panic Disorder without Agoraphobia Panic Disorder with Agoraphobia Agoraphobia without history of Panic Disorder Specific Phobia Social Phobia Obsessive-Compulsive Disorder Acute Stress Disorder Posttraumatic Stress Disorder Generalized Anxiety Disorder Anxiety Disorder Due to General Medical Condition or Substance-Induced Anxiety Disorder Anxiety Disorder NOS Somers et al. Can J Psychiatry 2006 9282 pts – english speaking 12 month prevalence of numerous psychiatric disorders Any psychiatric disorder 26.2% Any anxiety disorder 18.1% 10 Percentage (%) Kessler et al. Arch Gen Psychiatry, 2005 5 Specific phobia (8.7%) Social phobia (6.8%) PTSD (3.5%) GAD (3.1%) Panic (2.7%) OCD (1%) Persistent and irrational fear of certain objects or situations Exposure provokes anxiety/panic response Recognized as excessive or unreasonable Phobic object/situation avoided or endured with intense anxiety or distress Significant interference or marked distress Types: animals/insects, natural environment, blood/injury, situational, other Most common anxiety disorder Marked and persistent fear of clearly discernible circumscribed objects or situations Exposure almost invariably provokes anxiety Fear is recognized as excessive or unreasonable (though children may not) Phobic stimulus is avoided, or tolerated with dread Avoidance/fear leads to significant distress or interference with social/occ functioning In children – should persist >6 m Biopsychosocial - Bio - Medications – generally not helpful. BDZs – may provide some temporary relief (e.g. For flying etc.) Psychosocial - Exposure therapy – has shown the most benefit Novel methods - internet based - virtual reality Age Development conditioned fears Psychological Sx DSM-IV Corresponding d/o 0-6 months Fear of loss of caregiver - - 6-8 months Shyness with stranger 8m-3yrs Separation anxiety, fear of lightening, thunder, animals, nightmares 4-5 yrs Fear of death, dead people 5-12yrs Nightmares, Fear of fantasy objects, animals, physical thingsnatural disasters, germs, getting a serious illness Shyness, timidity Avoidant PD, Specific phobias. OCD 13-17 yrs Fear of inadequacy, performance, rejection by peers Fear of negative evaluation Overanxious disorder, social phobia 17-21 yrs Fear of personal loss, failing personal standards Separation anxiety disorder Crying, clinging, withdrawal, freezing GAD, Panic disorder Panic disorder, agoraphobia Classified as “Other disorder of infancy and childhood” in DSM-IV-TR Excessive anxiety beyond that expected for the child’s developmental level related to: - Separation - Impending separation from attachment figure NB Must be in children <18 yrs old, and lasting at least 4 wks. Fear of social or performance situations due to anticipated scrutiny, humiliation or embarrassment Exposure provokes anxiety/panic Considered excessive or unreasonable Situations avoided or endured with anxiety Significant interference or suffering Duration > 6 months if age < 18 Generalized or circumscribed Epidemiology: - 6.8% of the population - Onset - by age 11, 50% have symptoms; - by age 20, 80% have symptoms - Children – may refuse to go to school; - Associated with early drop out from school - Selective mutism – highly likely becomes social anxiety disorder (severe variant) Etiology -Familial, with recurrence risk ratio 2<x<6 i.e. Moderate heritability (chromosome 16 implicated –NE transporter) - Heritable behavioural trait = behavioural inhibition (strong association) Consequences: - Reduced work productivity - Financial costs - Reduced quality of life Despite these issues – only half seek treatment, and usually after 15-20 years of suffering ALCOHOL /SUBSTANCE ABUSE/DEPENDENCE - Strongly consider underlying social phobia in pts with a history of alcohol abuse/dependence » ¼ of pts may have comorbid abuse Parkinsons pts – may frequently develop social anxiety – suggesting striatal involvement Biopsychosocial approach Bio – SSRIs* SNRIs* RIMAs+MAOIs AntiCon BDZs Escitalopram Venlafaxine Moclobemide Gabapentin Clonazepam Phenelzine Pregabalin Alprazolam Sertraline Divalproex Bromazepam Paroxetine Topiramate Fluvoxamine Citalopram Fluoxetine 1st line: SSRI, SNRI 2nd line: BDZ, AntiCon, MAOIs Other alternatives with evidence of benefit Antidepressants Bupropion (NDRI) Mirtazapine (NaSSa) Clomipramine (TCA) Antipsychotics Olanzapine Risperidone Quetiapine Aripiprazole Cognitive restructuring Trigger Perception of Danger Reduced Anxiety Beliefs & Assumptions - Escape - Avoidance - Safety behaviours Increased Anxiety Exposure therapy CBT - 12-15 sessions – lasting 50-90 minutes (individual or group therapy) Correcting distorted cognitions – e.g. Everyone laughing at me – come up with alternative explanations Exposure therapy – may be integrated in CBT - e.g. Returning item, going to crowded mall Social skills training - making small talk, looking at tone, posture, active listening, assertiveness Epidemiology - 3.1% of the population affected (F:M = 2:1) - Onset (median US age=31 yrs, but often childhood) - 25% have onset by 20 yrs old - 50% have onset b/w 20-47 yrs old - Children - may be “overanxious disorder of childhood” Kessler RC et al. Arch Gen Psychiatry, 2005 Elderly – - may be associated with social isolation, trauma, migration, illness in spouse, bereavement - left untreated – may be associated with medical/psychiatric complications - Cardio/cerebrovascular disease - COPD - Malnutrition - Depression - Dementia - Alcohol abuse Weisberg R.B. J Clin Psychiatry, 2009 Etiology - Multiple neurotransmitters likely involved - 5-HT, NE, CCK - Genetic factors likely involved - Some twin studies – show 50% concordance rate in monozygotic twins, and 15% in dizygotic twins - Behavioural, psychosocial factors involved Excessive, wide-spread and uncontrollable anxiety and worry ( 6 months) Symptoms of tension and exhaustion (3/6) restlessness, muscle tension, tiredness, irritability, insomnia, difficulty concentrating NB – children only need ≥1 Worry not confined to another Axis I disorder Significant distress or impairment Not due to the effects of substance of GMC Often – do not present with anxiety initially - May be Pain Fatigue Sleep disturbances Poor concentration Depression - Frequently associated with disabilities in work, education, and/or social interactions Comorbidities common – mood disorders, anxiety disorders, substance abuse Biopsychosocial approach - Bio SSRIs* SNRIs* TCAs AntiCon BDZs Escitalopram* Venlafaxine* Imipramine Pregabalin Lorazepam Alprazolam Sertraline* Bromazepam Paroxetine* Diazepam Citalopram 1st line: SSRI, SNRI x 8-12 wks 2nd line: BDZ, NDRI, Buspar, Pregabalin, TCA Other alternatives with evidence of benefit Antidepressants Bupropion (NDRI) Mirtazapine (NaSSa) Antipsychotics Olanzapine Risperidone Other Buspirone (Buspar) With discontinuation of treatment - 20-40% relapse within 6-12 m, suggesting long term treatment is necessary CBT – most evidence for efficacy Efficacy is comparable to pharmacologic therapy, but may have higher remission rates Other therapies that may be effective: - Short term psychodynamic therapy - Interpersonal therapy Cognitive restructuring Trigger Perception of Danger Reduced Anxiety Beliefs & Assumptions - Escape - Avoidance - Safety behaviours Increased Anxiety Exposure therapy Panic attacks (PA) Recurrent and unexpected, acute, time-limited symptoms (at least 4/13) Not caused by substance or GMC Anticipatory anxiety Concern about additional attacks, their implications and consequences or change in behaviour 1 month Agoraphobia Avoidance/distress/anxiety in places or situations difficult to escape or get help in case of PA Panic attacks – may come from a dysfunction of the fear circuitry Amygdala – central involvement - Consists of several distinct nuclei in the brain Yohimbine Lactate CO2 Caffeine Isoproterenol 5HT agonists (fenfluramine, m-CPP) Choleocystokinin (CCK-4, CCK-5) Stimulants – nicotine, amphetamines Biopsychosocial approach - Bio SSRIs* SNRIs* TCAs AntiCon BDZs Escitalopram Venlafaxine Imipramine Gabapentin Lorazepam Clomipramine Divalproex Alprazolam Fluoxetine Sertraline Paroxetine Diazepam Citalopram Clonazepam Fluvoxamine 1st line: SSRI, SNRI 2nd line: BDZ, NaSSA, TCA 3rd line: Anticon, MAOI, Atypical Antipsych, RIMA, pindolol Other alternatives with evidence of benefit Antidepressants Bupropion (NDRI) Mirtazapine (NaSSa) Other: Pindolol Antipsychotics Olanzapine Risperidone Quetiapine SSRI Benefits – may be seen within 1 wk; - up to 6-8 wks Continued benefits may be seen after 12 m Treatment time of 8 -12 m is suggested, to prevent relapse risk. CBT – most evidence for efficacy Efficacy is comparable to pharmacologic therapy, but may have higher remission rates Other therapies that may be effective: (BUT – INSUFFICIENT evidence to recommend) - Psychodynamic therapy - Eye Movement Desensitization and Reprocessing (EMDR) Epidemiology - 1% of population (F:M= 3:2) - Onset – median age 19 yrs old, though can be childhood onset (NB – in childhood, F:M= 1:2) - Children Etiology: - Dysregulation of 5-HT* - Genetics – significant 35% of 1st degree relatives of OCD also have OCD - Neuroimaging studies - show increased metabolism of frontal lobes, caudate and cingulum - Behavioural, psychosocial factors involved Obsessions recurrent, persistent thoughts, urges or images experienced as intrusive and anxiety-provoking, distinct from excessive worry, attempted to be suppressed, ignored or neutralized contamination, harm/aggression, somatic, religious, sexual Compulsions repetitive, excessive behaviours or mental acts and rituals aimed to prevent or decrease anxiety/distress cleaning, checking, counting, repeating, arranging, hoarding Obsessions or compulsions are time consuming (>1 hr/day) or cause clinically significant distress At some point – obsessions/compulsions are recognized as excessive or unreasonable (may not occur in childhood) Not due to medical condition/substance Obsessions – are distressing – e.g. Repeated thoughts about contamination Usual response – compulsion – a behaviour aimed at reducing the anxiety associated with obsession – e.g. wash hands – temporary relief from anxiety of obsession, but then obsession returns. Egodystonic: i.e. “alien”, not within his/her control BUT – recognized as product of the mind (i.e. Not thought insertion) Children - clinical features: - Most frequent compulsion children - Handwashing (75%) - Checking - Sorting May not be egodystonic – often brought by parents Small subset (<5%) – ass with Gp A β-hemolytic streptococcal infection (scarlet fever, “strep throat”) abrupt onset, with motor abnormalities = PANDAS (Paediatric Autoimmune Neuropsychiatric Disorder Ass with Streptococcal infection) Elderly onset – more concerns about morality and washing rituals. Comorbid issues with OCD “Depressing BODY TAASTE”: - Depressive disorder - Body dysmorphic disorder - Trichotillomania and other impulse control d/o - Anxiety Disorders - Autism - Schizophrenia - Tourette’s/Tic disorders - Eating Disorders e.g. Anorexia nervosa Biopsychosocial - Bio SSRIs* SNRIs* Escitalopram Venlafaxine TCAs Fluoxetine Clomipramine Sertraline IV Clomipramine AntiCon AntiPsych Gabapentin Risperidone Topiramate Olanzapine Paroxetine Citalopram Fluvoxamine 1st line: SSRI 2nd line: Clomipramine, SNRI, NaSSA, Risperidone 3rd line: Something else....antipsych, anticon, MAOI Quetiapine Haloperidol Dosages of meds e.g. SSRIs may need to be higher Response may take 6 wks or longer Most recommendations – suggest staying on treatment for 1-2 yrs (reduce relapse risk) Neurosurgical options - deep brain stimulation - anterior cingulotomy - anterior capsulotomy, - subcaudate tractotomy - limbic leucotomy Indicated for severe OCD, refractory to therapy/medications 40-60% of refractory pts may benefit CBT with Exposure Response Prevention (ERP) - the most evidence for efficacy for treatment Individual may be better than gp (individualization of treatment) Anxiety is common – we all experience this Pathological anxiety can also be common, and is not a sign of personal weakness. Important, but sometimes difficult to recognize. There are significant biological underpinnings to anxiety disorders. Psychological approaches are very effective. Treatment can be very effective, but should be tailored to individual patients. Use BIOPSYCHOSOCIAL approach.