Adult Anxiety Disorders: Introduction PDF

Adult Anxiety Disorders: Introduction Prof P M Joubert Department of Psychiatry  About the anxiety disorder lectures About the anxiety disorder lectures Generalised anxiety disorder Generalised anxiety disorder management Panic disorder Phobic disorders Other (anxi...

Adult Anxiety Disorders: Introduction Prof P M Joubert Department of Psychiatry  About the anxiety disorder lectures About the anxiety disorder lectures Generalised anxiety disorder Generalised anxiety disorder management Panic disorder Phobic disorders Other (anxiety disorders) Stopping treatment  In this lecture Classification What are the anxiety disorders about? Why do we teach this? Classification of adult anxiety disorders Basic descriptions Normal vs abnormal anxiety Course of the anxiety disorders in general Etiology Case study Classification: Adult Anxiety Disorders Specific phobia Social anxiety disorder (social phobia) Panic disorder Agoraphobia Generalised anxiety disorder Substance/Medication induced anxiety disorder Anxiety disorder due to a general medical condition Other specified anxiety disorder Unspecified anxiety disorder  Why Do We Teach The Anxiety Disorders? They are very common: – 1-4% of the adult population have an anxiety disorder. – More common in women.  Why Do We Teach The Anxiety Disorders? Impairs functioning – Work – Interpersonal – Recreational Demoralising – What’s wrong with me – Avoidance – Misunderstood by others – Subjective suffering  Why Do We Teach The Anxiety Disorders? They have complications – Other anxiety disorders – Mood and depressive disorders – Substance use disorders – Suicide risk is increased although not as high as with MDD and others  Why Do We Teach The Anxiety Disorders? They have wide differential diagnosis (later) – Overlap with other mental disorders – Overlap with other medical conditions Very treatable especially when diagnosed early  The Anxiety Disorders Let’s start with a case…  The Anxiety Disorders: What Are They about? The anxiety disorders is a group of mental disorders where there is excessive anxiety which causes clinically significant distress, or excessive anxiety which causes impairment in general functioning. Description: What is an emotion? A difficult-to-describe subjective feeling-state that is accompanied by – A subjective experience (the feeling) – A physiological change – Behaviour  Description: What is anxiety? An unpleasant feeling state in anticipation of future threat.  Descriptions: What is fear? When the threat or perceived threat is imminent.  Description: What Is Stress? The sum of all the physiological and psychological responses to an event/situation that requires adjustment.  Description: What Is A Stressor? An event/situation that requires adjustment. Normal vs. Abnormal Anxiety / Fear Normal Anxiety / Fear Abnormal Anxiety / Fear Constructive / Destructive no effect on functioning effect on functioning Proportional Excessive subjective distress subjective distress Proportional duration Excessive duration Proportional physical Excessive physical phenomena phenomena  Course of The Anxiety Disorders? Tend to be chronic – Often start during adolescence or young adulthood – Waxing and waning over decades Most will respond to treatment, but most are not cured. – About a third asymptomatic – About a third significantly better – About a third continues with significant symptoms – About 10% do poorly  What about Etiology? There are many theories regarding etiology – Biological – Psychological However, the final cause of the idiopathic anxiety disorders are unknown – Not going to use the lectures to go through etiology. – Own reading: nice to know  Case: Slide 1 of 3 Carol is a 21-year old South African law student. She considers herself “highly strung”. That is, she easily becomes anxious and scared. She feels even more anxious just before she writes a test, but says that after a while her nerves settle, and then she is okay. She actually welcomes all this anxiety and nervousness, because it kind of “wakes her up”, helping her do well.  Case: Slide 2 of 3 When walking the streets alone at night, she is always worried about getting mugged, although it has never happened. She avoids doing that where possible, because, “It is simply stupid for a girl to walk alone those empty streets at night.” When someone accompanies her, preferably someone large and strong, she feels okay. She has no problems walking the streets during daytime, because, “There are so many people on the street that muggers won’t easily try. Off course it could happen, but chances are definitely not as high.”  Case: Slide 3 of 3 Carol has no complaints about her functioning, appetite, or sleep. She relaxes at home and with her friends. She enjoys studying, listening to music, reading a good book, and playing netball. Going out once a week or so with her female friends for some “real girl-talk” is something she always looks forward to. She is physically healthy, on no prescription medication, OTC remedies, and does not abuse elicit substances.  Anxiety Disorders: Generalised Anxiety Disorder Prof P M Joubert Department of Psychiatry  In This Lecture Main purpose Making sense of generalized anxiety disorder Video Next lecture: Management of generalised anxiety disorder  About The Lecture Series What is going to be covered? What is available on Blackboard? Today’s lecture  Main Purpose The main purpose of this lecture is ensure understanding of generalised anxiety disorder. The hope is that by doing it students will find generalised anxiety disorder readily diagnosable and will have to tools to make the other anxiety disorders easier to understand and remember too.  Generalised Anxiety Disorder A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities. B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months. 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 (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. F. The disturbance is not better explained by another mental disorder.  Generalised Anxiety Disorder Core clinical features Characteristic clinical features  Generalised Anxiety Disorder Core clinical features Absolutely necessary Without them one can’t even think about the mental disorder under consideration  Generalised Anxiety Disorder Core clinical features We can say they are essential but on their own they are not sufficient  Generalised Anxiety Disorder Characteristic clinical features Not absolutely necessary Nonetheless required to form the whole picture  Generalised Anxiety Disorder Characteristic clinical features We can say they are not essential on their own, but are required  Generalised Anxiety Disorder A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities. B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months. 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 (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. F. The disturbance is not better explained by another mental disorder.  Generalised Anxiety Disorder Core Clinical Features: A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities. B. The individual finds it difficult to control the worry. Persistent, excessive anxiety and difficult-to-control worry for at least 6 months.  Generalised Anxiety Disorder B. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months. 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 (difficulty falling or staying asleep, or restless, unsatisfying sleep).  Generalised Anxiety Disorder B. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months. 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 (difficulty falling or staying asleep, or restless, unsatisfying sleep).  Generalised Anxiety Disorder Physiological symptoms of anxiety. Psychological symptoms of anxiety.  Generalised Anxiety Disorder D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. F. The disturbance is not better explained by another mental disorder.  Generalised Anxiety Disorder D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Significant distress or functional impairment.  Generalised Anxiety Disorder E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. F. The disturbance is not better explained by another mental disorder.  Generalised Anxiety Disorder Not better accounted for by something else: Mental disorder. Medical Condition. Substances.  Generalised Anxiety Disorder Core clinical features. Persistent, excessive anxiety and difficult-to- control worry for 6 months  Generalised Anxiety Disorder Characteristic clinical features: – Physiological symptoms of anxiety. – Psychological symptoms of anxiety. – Significant distress or impaired functioning. – Not better accounted for by “MMS”.  Generalised Anxiety Disorder Put together: – Persistent, excessive anxiety and difficult-to-control worry for at least 6 months, with physiological and psychological symptoms of anxiety – [that impairs functioning or cause significant distress and is not better accounted for by “MMS”].  Case: Slide 1 of 3 Carol is a 21-year old South African law student. She considers herself “highly strung”. That is, she easily becomes anxious and scared. She feels even more anxious just before she writes a test, but says that after a while her nerves settle, and then she is okay. She actually welcomes all this anxiety and nervousness, because it kind of “wakes her up”, helping her do well.  Case: Slide 2 of 3 When walking the streets alone at night, she is always worried about getting mugged, although it has never happened. She avoids doing that where possible, because, “It is simply stupid for a girl to walk alone those empty streets at night.” When someone accompanies her, preferably someone large and strong, she feels okay. She has no problems walking the streets during daytime, because, “There are so many people on the street that muggers won’t easily try. Off course it could happen, but chances are definitely not as high.”  Case: Slide 3 of 3 Carol has no complaints about her functioning, appetite, or sleep. She relaxes at home and with her friends. She enjoys studying, listening to music, reading a good book, and playing netball. Going out once a week or so with her female friends for some “real girl-talk” is something she always looks forward to. She is physically healthy, on no prescription medication, OTC remedies, and does not abuse elicit substances.  Case: Slide 1 of 3 Carol is a 21-year old South African law student. She considers herself “highly strung”. That is, she easily becomes anxious and scared. She feels anxious all the time, but becomes even more anxious just before she writes a test. Her nerves never settle. She finds it difficult to focus properly. She thinks the anxiety negatively impacts her studying an marks.  Case: Slide 2 of 3 When walking the streets alone at night, she is always worried about getting mugged, although it has never happened. She avoids doing that where possible, because, “It is simply stupid for a girl to walk alone those empty streets at night.” The worry persists even when accompanied. Matters are not better during the day even when there are many people around. She simply cannot stop worrying that she will be mugged, or that there will be an accident.  Case: Slide 3 of 3 Carol complains that anxiety impairs he functioning. She is never able to relax completely, because there is always something to worry about. Sleep is not restful, because her mind just won’t switch of. It is difficult to enjoy studying, but she enjoys listening to music, reading a good book, and playing netball. Going out once a week or so with her female friends for some “real girl-talk” is something she always looks forward to. She is physically healthy, on no prescription medication, OTC remedies, and does not abuse elicit substances. Video  Anxiety Disorders: Generalised Anxiety Disorder: Management Prof P M Joubert Department of Psychiatry  In This Lecture You’ve made the diagnosis, generalised anxiety disorder. Now what? Work-Up – Physical Examination – Special investigations – Treatment Next lecture: Panic Disorder  Generalised Anxiety Disorder Work-Up: – (History/MSE) – Physical Examination – Special investigations: Much depends on physical work-up and presentation. At a minimum: TSH UK&E LFT FBC  Generalised Anxiety Disorder Treatment: – Biological: – Psychosocial.  Generalised Anxiety Disorder Biological Treatment. SSRI’s – Citalopram 20 – 50 mg/day – Escitalopram 10 – 20 mg/day – Fluoxetine 20 – 60 mg/day – Fluvoxamine 100 – 300 mg/day – Paroxetine 20 – 60 mg/day – Sertraline 50 – 200mg/day  Generalised Anxiety Disorder Biological Treatment. Other: – Venlafaxine 150 – 300 mg/day – Buspirone 20 – 60 mg/day  Generalised Anxiety Disorder Biological Treatment. Note: – For the anxiety disorders the time to improvement may be longer than for depressive disorders. – 6-8 weeks. – May improve earlier. – May need higher doses.  Generalised Anxiety Disorder Biological Treatment. Benzodiazepines: Advantages: – Responds within days. Disadvantages: – Cognitive side-effects. – Slowing of motor speed. – Withdrawal. – Potentially habit forming.  Generalised Anxiety Disorder Biological Treatment. Benzodiazepines. – Use if quick results are necessary and taper later. – Sometimes for refractory cases.  Generalised Anxiety Disorder Biological Treatment. Benzodiazepines. – Lorazepam 0.5 – 2 mg TDS – Oxazepam 10 – 20 mg TDS – Many others.  Generalised Anxiety Disorder Psychosocial Treatment. Psychoeducation – Informing about the disorder. – Informing about consequences / complications – Informing about course. – Informing about treatment options. – Informing about side-effects.  Generalised Anxiety Disorder Psychoeducation – Informing about the disorder.  Generalised Anxiety Disorder Psychoeducation – Informing about consequences / complications  Generalised Anxiety Disorder Psychoeducation – Informing about course.  Generalised Anxiety Disorder Psychoeducation – Informing about treatment options.  Generalised Anxiety Disorder Psychoeducation – Informing about side-effects.  Generalised Anxiety Disorder Psychosocial Treatment. Cognitive Behaviour Therapy: – Cognitive restructuring. – Relaxation training. – Exposure.  Generalised Anxiety Disorder Decide whom to involve (family, friend, work etc). – Will vary according to circumstances.  Generalised Anxiety Disorder Decide whom to refer to: – Psychiatrist. – Clinical psychologist. – Sometimes social worker. – Support groups.  Generalised Anxiety Disorder Decide on when to follow-up and how frequently. – Initially frequently (will vary). – Later less frequently. – When stabilized 3 – 6 monthly.  Anxiety Disorders 3: Panic Disorder Prof P M Joubert Department of Psychiatry Panic Disorder  In This Lecture Panic attacks Limited symptoms attacks Panic Disorder: Clinical features Management of panic disorder Next lecture: The phobic disorders  About Panic Attacks First find out what is meant by a panic attack. – A surge of intense fear or discomfort. – Peaks in minutes. – Accompanied by 4 or more physical and psychological symptoms of intense anxiety / intense autonomic arousal.  About Panic Attacks Limited symptoms attacks – Looks just like a panic attack, but with less than 4 characteristic features (criteria).  About Panic Attacks (And Limited Symptom Attacks) Panic attacks – Provoked – Unprovoked  About Panic Attacks (And Limited Symptom Attacks) Panic attacks – Unprovoked / Unexpected Substances Medications Medical conditions Panic disorder  About Panic Attacks (And Limited Symptom Attacks) Panic attacks – Provoked Danger Phobias Obsessions and compulsions Hallucinations Delusions  Panic Disorder What is panic disorder? – Recurrent, unexpected panic attacks. – Followed by continuous worries about the attacks (will there be more? What will they cause?) – Or dysfunctional behaviour due to the attacks.  Panic Disorder Work-UP History Mental status examination Physical examination Special investigations – Largely depend on history and physical findings but the basics: Thyroid functions. FBC LFT UKE Glucose (Hba1c) ECG EEG  Panic Disorder: Management Biological Treatment SSRI – Citalopram, fluoxetine etc. Start low, go slow, end at effective dose.  Panic Disorder: Management Biological Treatment Benzodiazepines – Alprazolam (prophylaxis) – Clonazepam (prophylaxis) – Lorazepam (acute) Used if: – Quick response is needed. – Sometimes to counteract SSRI side-effects. – Refractory cases  Panic Disorder: Management Biological Treatment Tricyclic antidepressants (later line) – Only 2: imipramine and clomipramine – Imipramine is not available in SA anymore  Panic Disorder: Management Psychosocial Treatment Cognitive behaviour therapy – Cognitive restructuring – Exposure therapy – Respiratory control – (Relaxation training)  Panic Disorder: Management Decide whom to involve (family, friend, work etc). – Will vary according to circumstances.  Panic Disorder: Management Decide whom to refer to: – Psychiatrist. – Clinical psychologist. – Sometimes social worker. – Support groups.  Panic Disorder: Management Decide on when to follow-up and how frequently. – Initially frequently (will vary). – Later less frequently. – When stabilized 3 – 6 monthly.  Anxiety Disorders: Other Anxiety Disorders, Differential Diagnosis Prof P M Joubert Department of Psychiatry  In this Lecture Substance/medication induced anxiety disorder. Anxiety disorder due to another medical condition. Other specified anxiety disorder. Unspecified anxiety disorder. Differential diagnosis of the anxiety disorders as a group. Next lecture: Stopping treatment  Substance/Medication Induced Panic attacks or anxiety is the predominant clinical picture. Symptoms developed soon after substance intoxication or withdrawal, or exposure to medicine. The substance or medicine is a known culprit. Not due to another anxiety disorder. Not during delirium.  Substance/Medication Induced Specifiers: – With onset during intoxication. – With onset during withdrawal. – With onset after medication exposure.  Substance/Medication Induced Examples: – Caffeine induced anxiety disorder, with onset during intoxication. – Thyroxine induced anxiety disorder, with onset after medication use.  Another Medical Condition Panic attacks or anxiety is the predominant clinical picture. Evidence that the anxiety symptoms are the direct effect from another medical condition. Not due to another mental disorder. Not during delirium.  Other Specified Anxiety Disorder Persistent, distressing, unprovoked limited symptom attacks without panic attacks Persistent, distressing generalised anxiety not occurring more days than not Persistent, distressing anxiety without worry  Unspecified Anxiety Disorder Chooses not to specify why criteria are not met. Insufficient information.  Differential Diagnoses We shall look at the differential diagnoses of the anxiety disorders as a group.  Differential Diagnoses Other anxiety disorders Major depressive disorder / episode Trauma- and stressor-related disorders Obsessive-compulsive disorder Body dysmorphic disorder Somatic symptom and related disorders Schizophrenia spectrum and other psychotic disorders Personality disorder Autism spectrum disorder Medical diseases, substances and Medication  Differential Diagnoses Other anxiety disorders Major depressive disorder / episode Trauma- and stressor-related disorders Obsessive-compulsive disorder Body dysmorphic disorder Somatic symptom and related disorders Schizophrenia spectrum and other psychotic disorders Personality disorder Autism spectrum disorder Medical diseases, substances and medication  Differential Diagnoses Other anxiety disorders  Differential Diagnoses Major depressive disorder / episode  Differential Diagnoses Schizophrenia spectrum and other psychotic disorders  Differential Diagnoses Personality disorder Autism spectrum disorder  Anxiety Disorders: Phobic Disorders Prof P M Joubert Department of Psychiatry  In This Lecture The phobic disorders Social anxiety disorder Agoraphobia Phobic disorders management Next lecture: Other  Phobic Disorders The disorders involving a phobia – Social anxiety disorder (social phobia) – Agoraphobia – Specific phobia  Phobic Disorders An excessive, persistent (6 months +), and unreasonable fear or anxiety for a circumscribed stimulus, which can be: – object, – or situation.  Phobic Disorders The phobic stimulus almost always provokes fear or anxiety. The fear or anxiety is disproportional to the stimulus. The phobic stimulus is: – Avoided, – Endured with much anxious distress.  Phobic Disorders It impairs functioning or causes clinically significant distress. Not better accounted for by another: – Mental disorder. – Substances. – GMC.  Phobic Disorders How do the different phobic disorders of the DSM-5 differ from each other?  Social Anxiety Disorder The fear/anxiety about: – Social situations. – Where exposed to possible scrutiny. – About showing anxiety symptoms that will be negatively evaluated.  Social Anxiety Disorder Consequences: – Leave school early – Leave university early – Do not go for job interviews – Do not got for promotions – Do not go out with partners  Agoraphobia Fears / avoids situations where they may get panic-like symptoms other incapacitating symptoms embarrassing symptoms And then, if they get the above symptoms…  Agoraphobia ….they will not be able to – Escape – Get help  Agoraphobia A fear of being in places where he fear/anxiety about two (+) of: – Using public transport. – Being in open spaces. – Being in enclosed spaces. – Standing in line or being in a crowd. – Being outside the house alone.  Specific Phobia The fear / anxiety is about any: – object, – situation. Not already covered by social anxiety disorder or agoraphobia.  Specific Phobia There are subtypes – Animal type: any animal or insect etc. – Natural Environment Type: heights, thunder etc. – Blood-Injection-Injury Type: often associated with passing out. – Situational Type: public transport, lifts etc. – Other type.  Phobic Disorders: Management Work-Up: See previous generalized anxiety disorder.  Phobic Disorders: Management Psychosocial Treatment: – Cognitive behaviour therapy for all of them. Exposure and response prevention. Relaxation therapy. Cognitive restructuring.  Phobic Disorders: Management Biological Treatment: Social anxiety disorder – SSRI’s and venlafaxine. Agoraphobia. – None. Specific phobia. – None.  Anxiety Disorders: Stopping Treatment Prof P M Joubert Department of Psychiatry  Stopping Drug Treatment in the Anxiety Disorders What if patients want to get off medication?  In This Lecture Stopping treatment in the anxiety disorders Next lecture: Obsessive-compulsive and related disorders  Stopping Drug Treatment in the Anxiety Disorders Most anxiety disorders are chronic with a waxing and waning course. Relapse after stopping medication is very high (e.g. some studies show that relapse after stopping medication for panic disorder is about 90%).  Stopping Drug Treatment in the Anxiety Disorders Thus, for many, the treatment is life-long. Therefore, carefully consider whether medication may be reduced. After a first treatment with full response discontinuation can be considered.  Stopping Drug Treatment in the Anxiety Disorders Patients who received cognitive behaviour therapy. – And responded adequately. – Tend to do better in the long run. Booster sessions may be needed every 5 years.  Stopping Drug Treatment in the Anxiety Disorders 1. 1 Year of complete remission (symptom free). 2. Full functional restoration. 3. Patient has a sense of well-being. 4. It is the right time in the patient’s life. 5. Do it slowly over months. 6. Reinstitute treatment if relapses.  Case Studies Case studies in handouts Additional cases studies Work on them in on your own.