T3 L3. Anxiety Disorders. Clinical Picture (SBa).pptx

1 2 Anxiety disorders: The clinical picture This lecture will cover: The response to stress including: Acute stress response Adjustment disorder PTSD Generalised anxiety disorder (GAD) including: Symptoms Aetiology-role of parenting Panic disorder and agoraphobia Specific phobias Obsessive Compul...

1 2 Anxiety disorders: The clinical picture This lecture will cover: The response to stress including: Acute stress response Adjustment disorder PTSD Generalised anxiety disorder (GAD) including: Symptoms Aetiology-role of parenting Panic disorder and agoraphobia Specific phobias Obsessive Compulsive Disorder 3 Learning outcomes • Understanding the normal and abnormal response to a stressor • Knowledge of the physical symptoms of GAD and its presentation in primary care • Symptoms of panic disorder and the differential diagnosis • Aetiology of phobias: biological preparedness • Autonomic response in specific phobias 4 Epidemiology Male lifetime prevalence Female lifetime prevalence Age of onset Disability Anxiety disorders Unipolar A.D. Bipolar A.D. Schizophrenia 19% 11% I: 1% II: 5% 0.8% 39% 7% I: 1% II: 5% 0.8% Broad 27 yrs 21 yrs M: 15-40 F: 20-45 Variable / intermittent Moderate 20% recover Mod.severe / Lifelong Severe / lifelong 5 Stress Related & Adjustment Disorders (inc. Post-traumatic Stress Disorder) 6 8 9 Clinical picture of Acute Stress Reaction • Acute stress reaction lasts hours to 3 days • A response to exceptionally stressful events (physical/psychological) • Initial daze • Mixed and usually changing picture • Individual vulnerability 1 0 Typical symptoms of Acute Stress • • • • • • • Feelings of being numb or dazed Insomnia Restlessness Poor concentration Autonomic arousal Anger/anxiety/depression Withdrawal 1 1 ADJUSTMENT DISORDER • • • • Wide range of emotional or behavioural symptoms Stressor not necessarily life threatening Out of proportion to stressor Lasts up to 6 months 1 2 PTSD Response to exceptionally threatening or catastrophic event … experienced ,witnessed … event that involved actual or threatened death or serious injury …. or threat to physical integrity of self or others. … response involved intense fear, helplessness or horror … PTSD symptoms • • • • • • Re-experiencing flashbacks/nightmares Numbness/detachment Avoidance Hypervigilance/startle Insomnia Anxiety/depression 1 4 PTSD course • Usually immediate onset • Most recover within 1 year • Rape victims • 94% at 2 weeks • 65% at 1 month • 42% at 6 months 1 5 Generalised Anxiety Disorders (GAD) 1 6 1 8 Psychological Symptoms of GAD • • • • • • Fearful anticipation Irritability Sensitivity to noise Restlessness Poor concentration Worrying thoughts 1 9 2 0 Additional symptoms of GAD • Sleep disturbances • Insomnia, night terrors • Sadness • Depersonalisation • Fixation with details 2 1 Epidemiology of GAD • Lifetime prevalence: • 8.9% (ICD-10 criteria)1 • Women > men • Estimated to be 3x higher in patients in primary care clinics (indicated increased use of health care services) • High level of co-morbidity (~ 70%), especially simple phobias, social phobia, panic disorder & depression 1. Wittchen HU et al. (1994) DSM-IIIR generalised anxiety disorder in the National Comorbidity Survey. Archives of Gen Psych, 51,355-64 2 2 Aetiology of GAD Genetic Predisposition • Five fold increase in 1st degree relatives1 • 19.5% in relatives of GAD sufferers • 3.5% in relatives of controls • Monozygotic = dizygotic • Shared heritability for GAD and mood disorders • In summary: Genetic factors play a modest role 1. 2. 3. 4. 5. 6. Noyes, R. et al. (1987). Am J Psych, 144, 1019–24 Andrews, G. et al. (1990). J Affective Dis 19,23–9. Torgersen, S. (1983). Arch Gen Psych, 40,1085–9. Kendler, K.S.et al. (1992). Arch Gen Psych, 49, 267–72. Kendler, K.S. et al. (1992). Arch Gen Psych, 49, 716–22. Skre, I. et al. (1993). Acta Psych Scand, 88, 85–92. 2 3 Aetiology of GAD Association with life events Several studies found an association with stressful / traumatic life events The experience of even one very important unexpected negative event was associated with a 3x ↑ in GAD in men and women 2 4 Aetiology of GAD Early environmental factors • Impact on development of anxiety and other negative emotions • Attachment theory: • Parents or other consistent caregivers serve important function in a child’s development • They provide a protective and secure base from which the child can operate • Disruption leads to anxious apprehension and dependency • Severe disruption leads to withdrawal and depression 2 5 Aetiology of GAD Parenting 1 A healthy parent–child relationship fosters a sense of control over events. Responsiveness to child’s efforts at engagement Encouragement of the child to explore and manipulate the environment. A lack of warmth & encouragement leads to a general perception of personal inefficacy which may predispose to negative emotional states Overprotection coupled with a lack of warmth and responsiveness toward the child could lead to anxiety 2 6 Aetiology of GAD Parenting 2 • Mothers of anxious preschool children were: • More critical and intrusive • Less responsive to their children • Compared to controls, adults who rated their parenting as more protective and less caring: • Had higher trait anxiety scores • Met more criteria for GAD & panic disorder 2 7 Aetiology of GAD Parenting 3 One hypothesis is that the relationship of these early parenting experiences to the subsequent development of anxiety or depression is mediated by the early formation of cognitive vulnerability best described as a sense of uncontrollability regarding future events in one’s life 2 8 Panic Disorder & Agoraphobia 2 9 The heart beats quickly and violently so that it palpitates and knocks against the ribs…the skin instantly becomes pale… under a great sense of fear…in connection with the disturbed action of the heart, the breathing is hurried…one of the best marked symptoms is the trembling of all the muscles of the body. 3 0 Clinical picture of panic • Psychic: Fear of losing control, going mad, fainting, dying, derealisation, depersonalisation. • Somatic: Palpitations, tachycardia, sweating, trembling, dyspnoea, choking, chest pain, nausea, ‘butterflies’, urgency, dizziness, faintness, paraesthesia, chills/flushes Panic Differential Dx • Endocrine • Hypoglycaemia • Phaeocromocytoma • Carcinoid • Cardiovascular • Arrythmia • Respiratory • Asthma • Drugs • Neurological • Seizures • Vestibular 3 2 Clinical Picture of Agoraphobia • Anxiety in specific context: • Away from home • In crowds • In situations they cannot easily leave • Presents with anxiety symptoms & panic attacks • Anxious cognitions about fainting and loss of control are common • Avoidance is common 3 3 Epidemiology of Panic General Info Panic attacks: 7-9% of the population Panic disorder: 1.5-2.5% lifetime prevalence Onset has two peaks: 15-24 & 45-54 3 4 Aetiology of Panic Genetic Predisposition • Increased risk in 1st degree relatives ~ 7 fold • Increased concordance in all but one monozygotic twin study • Modest inheritability suggested by family & twin studies • At least 50% environmental influences 3 5 Aetiology of Panic Environmental Factors • Precipitating events in 60-96% of cases • Separation / loss • Relationship difficulties • New responsibilities • Traumatic early life events • Early parental separation • Traumatic childhood event – 3 fold increase • Early sexual abuse (<5 years of age) 3 6 Aetiology of Panic Biological Models • Panic attacks may be triggered in the locus coeruleus • ↑ firing associated with ↑ CO2 etc • Noradrenergic agents (yohimbine & isoproterenol) stimulate attacks in sufferers • SSRIs are effective but contradictory findings regarding the role of serotonin 3 7 Aetiology of Panic Biological Models 2 γ-Aminobuyric acid (GABA) has a role: Benzodiazepine agonists are clearly effective Benzodiazepine antagonist (flumazenil) aggravates attacks Cholecystokinin causes panic attacks in animals & pentagastrin causes attacks in panic disorder patients 3 8 Specific Phobias 3 9 Clinical Picture of Specific Phobias • Inappropriate anxiety in the presence of one or more particular objects or situations • Characterised by adding the name of the stimulus (e.g. Spider Phobia) • Avoid jargon (e.g. Arachnophobia) 4 0 4 1 4 2 4 3 4 4 4 5 4 6 Specific Phobias - Subtypes • • • • • Blood, injection, injury – a specific case? Animals & Insects Aspects of the natural environment (e.g. heights) Situational (e.g. flying) Other (e.g. dental/medical procedures, choking, etc.). 4 7 Specific Phobias - Responses • Individuals with blood–injection–injury phobias exhibit a biphasic anxiety reaction: • • • • Initial short-lived sympathetic arousal Followed by parasympathetic arousal May result in vasovagal syncope The subjective experience tends to disgust and repulsion rather than pure apprehension • In other subtypes, exposure to the phobic stimulus evokes intense anxiety that may meet the criteria for a situationally bound panic attack • There is extreme apprehension and desire to escape or avoid the phobic stimulus 4 8 Aetiology of Specific Phobias Genetics • All Specific Phobias: evidence for genetic transmission • 31% of 1st degree relatives affected • Animal phobias: • monozygotic 26% • Dizygotic 11% 4 9 Aetiology of Specific Phobias Psychological Theories • Psychoanalytic approach: Symptoms related to unresolved unconscious conflicts • Classical conditioning: phobias are learned through association of negative experience with an object or situation • Marks’ ‘preparedness’ theory maintains that commonly feared objects are those that historically threatened the survival of the individual or the species • Large number of studies suggest that phobias may be acquired via observational learning 5 0 Social Phobia 5 1 Clinical Picture of Social Phobia • Inappropriate anxiety in: • Situations where the person is observed • Situations where there is potential for criticism • Leads to avoidance of trigger situations • Eating in public • Dinner parties • Committees, seminars, public speaking 5 2 Symptoms of Social Phobia • • • • • Anticipatory anxiety Feeling anxious Blushing Trembling (observed writing is a problem) Relieved by alcohol (potential for abuse) 5 3 5 4 Aetiology of Social Phobia • Both genetics and environmental factors contribute, with genetics contributing < ⅓ of the variance in the transmission • 16% of relatives of probands vs 5% of relatives of controls • Monozygotic > dizygotic 5 5 Obsessive-compulsive Disorder (OCD) 5 6 Clinical Picture of OCD 1 • Obsessional thoughts / images • • • • Words, ideas, beliefs and/or images Recognised as own Intrude forcibly into the mind They are resisted • Compulsions reduce anxiety • Cleaning/checking • Precision – ‘just right’ 5 7 Epidemiology of OCD - 2 • Men = women • Some reports suggest a slight female predominance • During adolescence, boys > girls. • Mean age of onset is ~ 20 years of age. • Prevalence 2-3% 5 8 OCD Co-morbidity • Major depressive episode: ~67% lifetime prevalence • ↑ lifetime risk for: • • • • • • • alcohol disorders social phobia specific phobia panic disorder eating disorders Schizophrenia tic disorders (~ 40% in juvenile OCD) • ↑ prevalence of Tourette’s syndrome in relatives • Unclear relationship between OCD & obsessive–compulsive personality disorder (OCPD), but it appears that OCPD is not a prominent risk factor for OCD 5 9 Aetiology of OCD Genetics • Monozygotic >> dizygotic • First-degree relatives of patients with childhoodonset OCD have a higher than expected incidence of OCD 6 0 Summary • Anxiety disorders are common • They represent an exaggeration of a normal response which conferred an evolutionary advantage • There is a vast overlap between the categories • They represent a biological failure, not a psychological weakness