Anxiety Disorders.pdf

Anxiety Disorders Dr Mitchell Osei-Junior MBBS BSc (Hons) PCBT (foundation) Clinical Educator Youth Mental Health First Aider & Neurodiversity Advocate Activity: Close your eyes and imagine this… Image sourced from: https://images.wsj.net/im-68829/social  Imagine task Think about the l...

Anxiety Disorders Dr Mitchell Osei-Junior MBBS BSc (Hons) PCBT (foundation) Clinical Educator Youth Mental Health First Aider & Neurodiversity Advocate Activity: Close your eyes and imagine this… Image sourced from: https://images.wsj.net/im-68829/social  Imagine task Think about the last time you were really worried/stressed about something… o How was the sensation in your throat? o How was your breathing? o How was your heart? o How did your mind feel? What thoughts were going through your mind? o How was your stomach feeling? Intended Learning Outcomes By the end of this lecture, you should be able to: (i) Recall the DSM-5 diagnostic criteria for the following anxiety disorders: (a) Generalised Anxiety Disorder, (b) Panic Disorder, (c) Social Anxiety Disorder, (d) OCD, & (e) PTSD vs Acute Stress Disorder. (ii) Describe biopsychosocial explanations of anxiety disorders. (iii)Describe biological and psychological methods of treating anxiety disorders. (iv)Apply the NICE CKS guidelines to treat: (a) generalised anxiety disorder, social anxiety and panic disorders, (b) OCD, & (c) PTSD  Why are anxiety disorders important? Did you know that…. (most statistics deliberately pre-pandemic) (1) Pre-pandemic, Mental Health Foundation (2014) findings suggests that 6.6% of the UK population have an anxiety disorder at any one point. (2) Prevalence of Anxiety Disorders in Foundation Year 1 doctors has increased from 22.8% in 2010 to 29.6% in 2017. (McCullough & Van Hamel, 2019) (3) Medical students have higher rates of anxiety (47.1%) in comparison to non-medical students (39%) according to a national study by Medisauskaite et al. (2022) (4) Within the neurodiverse group (Autism, ADHD, Dyslexia, Dyspraxia), Anxiety prevalence ranges between 42-79% (Kent & Simonoff, 2017; Tannock 2009; Ibhour et al. 2021) Diagnostic Criteria of Anxiety Disorders LO1  Top 5 Anxiety Disorders DSM-V (Diagnostic & Statistical Manual of Mental Disorders, 5th Edition, Text Revision)-September 2023 1. Generalised Anxiety Disorder 2. Panic Disorder & agoraphobia 3. Social Anxiety Disorder 4. Obsessive Compulsive Disorder (OCD) 5. Reaction to trauma (PTSD/Acute Stress disorder) Image sourced from: https://www.psychiatry.org/getmedia/25e23297-981d-40d7-9409- 030e9fb2ab20/hero-DSM-5-TR.png?width=1266&height=720&ext=.png  Generalised Anxiety Disorder UK prevalence: 7.2% (Archer, 2022) Core Symptom Plus at least 3 of the following symptoms: Persistent worry that is (i) Restlessness/nervousness disproportionate to any inherent risk. (ii) Low fatigue threshold (iii) Poor concentration Worries often difficult to pinpoint. (iv) Irritability (v) Muscle tension (vi) Sleep disturbance Symptoms present for at least 6 months  Panic Disorder Core Symptoms Plus at least 4 of the following symptoms: (i) Airway symptoms: choking feeling Repeated panic attacks which cause (ii) Breathing symptoms: breathlessness, intense fear and discomfort. chest pain Avoidance behaviours. (iii) Circulation symptoms: palpitations, sweating, dizziness, trembling (iv) Cognitive symptoms: Depersonalisation (feeling detached from oneself), Derealisation (feeling detached from reality), Fear of dying/losing control Symptoms present for at least 1 month (v) Abdominal symptoms: nausea, abdo pain  Social Anxiety Disorder Previously known as “Social Phobia” Core Symptoms A persistent fear of one/more social/performance situations which individual is exposed to unfamiliar people/possible scrutiny by others. Individual fears they will act in way/show biological anxiety symptoms that will be embarrassing and humiliating. This may induce situational panic attacks. Avoidance behaviours Insight that fear is unreasonable/excessive. Symptoms present for at least 6 months  Obsessive Compulsive Disorder (OCD) UK prevalence: 2% (Royal College of Psychiatrist, 2019) Obsession Compulsion Recurrent, persistent, intrusive Repetitive behaviours/cognitive thoughts/impulses/images. act the person feels they must do to neutralise the obsessive thought These create marked anxiety/distress and reduce the anxiety/distress The obsessions OR compulsions cause marked distress, take >1 hour/day or cause clinically significant distress or impairment in function. Post-Traumatic Stress disorder (PTSD) UK prevalence: F=5.1%, M=3.7% (Baker, 2023) The Criteria is split into 5 Categories: (i) Exposure to actual/threatened death or serious and/or sexual violence. (ii) Presence of intrusive symptom after the event (1+). (iii) Persistent avoidance (with 1 or both behaviours) (iv) Marked alteration in arousal and reactivity (2+) (v) Negative alterations in cognitions and mood associated with traumatic event. (2+) Symptoms present for at least 1 month AND causes significant impairment in function. (if not then acute stress disorder) PTSD Exposure to actual/threatened death or serious and/or sexual violence. These can be either: Direct experiencing of traumatic event Witnessed in person the events as it occurred to others. Experiencing repeated or extreme exposure to aversive details of trauma.  PTSD Presence of intrusive symptom after Persistent avoidance (with 1 or the event (1+). both behaviours) Recurrent, involuntary & intrusive Avoidance of distressing memories of the event. memories/thoughts/feelings of event(s) Recurrent trauma-related nightmares. Dissociative reactions. Avoidance of external reminders that could arouse memories of Intense psychological distress/Marked event. psychological reactivity/both at cue exposure.  PTSD Marked alteration in arousal and Negative alterations in cognitions and mood associated with traumatic event. (2+) reactivity (2+) Irritability Inability to recall important aspect of traumatic event. Recklessness Persistent distorted cognitions about Hypervigilance causes/consequences of event that leads to blame of self/others. Exaggerated startle response Feelings of detachment from others Concentration difficulties Dysthymia (persistent low mood) Sleep disturbance Anhedonia (diminished interest) Biopsychosocial explanations of Anxiety Disorders LO2 Biopsychosocial model of anxiety These are the main families of thought of explanations of anxiety Psychological Social Biological Biological explanations of anxiety This is how we can divide the biological explanations of anxiety Biological neuroendocrinological Genetic neuroanatomy Genetic explanation of Anxiety Twin studies & Heritability According to a Meta-analysis of twin studies by Hettema et al. (2001), heritability is estimated to be between 30-50%. Image sourced from: https://www.sri.com/wp-content/uploads/2021/12/Twin.jpg Neuroanatomy explanation of Anxiety Brain areas involved in learning Ventral medial prefrontal cortex (vmPFC) – Inhibitory learning & dampens anxiety. Anterior cingulate cortex (ACC)- amplifies the fear signal received by amygdala. Amygdala- excitatory learning and hyper-responsive. Image sourced from: https://cdn.xcode.life/wp- content/uploads/2022/06/how_does_brain_affect_anxiety.png Neuroendocrinology explanation of Anxiety Neurotransmitters involved in anxiety – Part 1 GABA– Inhibitory neurotransmitter (via Cl- ion channels) that induces relaxation. Decreased in Anxiety. Glutamate- Excitatory neurotransmitter (via Ca2+ ion channels) that increases neuron excitation. Increased in anxiety. Image sourced from: https://miro.medium.com/v2/resize:fit:1400/1*3dm4bqBlJrLCWSE2No28xg.jpeg Neuroendocrinology explanation of Anxiety Neurotransmitters involved in anxiety – Part 2 Serotonin– Role in anxiety debated whether too high levels (especially in social anxiety disorder) or too low levels. (in vmPFC and amygdala) Dopamine- High dopamine levels increases alertness, vigilance and motivating and maintenance behaviours of anxiety. Image sourced from: https://miro.medium.com/v2/resize:fit:1400/1*3dm4bqBlJrLCWSE2No28xg.jpeg Neuroendocrinology explanation of Anxiety Neurotransmitters involved in anxiety – Part 3 Noradrenaline– Leads to autonomic nervous system symptoms and is increased in anxiety. Gut hormones (cholecystokinin & substance P)- Has known modulatory effect in anxiety. Image sourced from: https://miro.medium.com/v2/resize:fit:1400/1*3dm4bqBlJrLCWSE2No28xg.jpeg Psychological explanations of anxiety This is how we can divide the psychological explanations of anxiety Psychological cognitive Cognitive explanation of Anxiety Cognitive theory number 1- classical conditioning Fear conditioning- suggests that a neutral unconditioned stimulus (US) paired with an aversive conditioned stimulus (CS) repeatedly will lead to conditioned response (CR) even without the US eventually. Image sourced from: https://www.verywellmind.com/thmb/F8-ukXB8bZ- 0VKnGIYrJGDxKPNs=/1500x0/filters:no_upscale():max_bytes(150000):strip_icc()/2794859-article-classical- Cognitive explanation of Anxiety Cognitive theory number 2- operant conditioning Escape/Avoidance behaviours- If a situation is aversive and an individual responds by taking themselves away from it this becomes a negative reinforcer. Prevents finding the possibility of finding a non-pleasant experience and creates maintenance of anxiety. Image sourced from: https://opentext.wsu.edu/principles-of-learning-and-behavior/wp- content/uploads/sites/93/2019/04/Figure-6.1-4th-ed..jpg Cognitive explanation of Anxiety Cognitive theory number 3- cognitive biases Attention bias- Bias towards threat. Interpretation bias- Negative interpretation of ambiguous stimuli. Confirmation bias- Selective attention to things which may confirm belief. Above thought to be linked with frontal hypo-responsivity & amygdala hyper- responsivity. Images sourced from: https://www.verywellmind.com/thmb/57T8rZP-0uC_VXZ- jEGBAXise6Q=/1500x0/filters:no_upscale():max_bytes(150000):strip_icc()/what-is-a-confirmation-bias-2795024_SOURCE- fef0b016bc1540038090a12e9a71b460.png & https://www.howtogetyourownway.com/biases/pics/attentional-bias.png Social explanations of anxiety This is how we can divide the social explanations of anxiety Social Social Psychosocial Social explanation of Anxiety Psychosocial theory- Adverse life events It can take one event/series of event to trigger fear/trauma response to similar situations. Psychosocial theory suggests unresolved life crises contribute to acquired anxiety. In turn this life events lead to cognitive behaviours and thus in turn neurological adaptations. Images sourced from: https://www.centerforchildcounseling.org/wp-content/uploads/2018/06/Blog-ACEs-Pyramid.png Social explanation of Anxiety Social learning theory- Vicarious learning Vicarious learning= observational learning. Vicarious learning implicated in phobia acquisition theory of very common phobias. (i.e. arachnophobia, ophidiophobia, acrophobia) Images sourced from: https://www.centerforchildcounseling.org/wp-content/uploads/2018/06/Blog-ACEs-Pyramid.png Biopsychological methods of treating Anxiety Disorders LO3 Biopsychological model of treating anxiety These are the main families of thought of the treatment of anxiety Psychological Biological treatments of anxiety This is how we can divide the biological treatments of anxiety Square breathing Antidepressants Anxiolytics Note: any pharmacological treatment mentioned today will be expanded upon in Term 4 Membranes & Receptors & Term 6 Clinical Pharmacology Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) SSRIs (i.e. sertraline, fluoxetine) – prevent presynaptic reuptake of serotonin (5-HT) therefore increasing acute effect of 5-HT transmission and eventually would lead to normal serotonin levels due to the inhibitory feedback loop. Side Effects: diarrhoea, agitation, bradycardia, postural hypotension, increased suicidal ideations in young people in first 8 weeks. Images sourced from: https://www.researchgate.net/publication/7730046/figure/fig1/AS:280319933599768@1443844888471/Schematic-diagram- showing-mechanism-of-action-of-SSRIs-These-agents-block-the-reuptake.png Antidepressants Selective Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) SNRIs (i.e. Venlafaxine, Duloxetine) – prevent presynaptic reuptake of serotonin (5-HT) & noradrenaline. Therefore, increasing acute effect of both transmission and eventually would lead to normal serotonin levels due to the inhibitory feedback loop. Side Effects: headaches, dry mouth, dizziness, nausea, agitation, postural hypotension (hypertension in higher doses), potential sexual dysfunction Images sourced from: https://www.researchgate.net/publication/363492587/figure/fig3/AS:11431281095931687@1668057808785/SNRIs- mechanism-of-action.png Anxiolytics Benzodiazepines (BZDs) BZDs (i.e. Lorazepam, Diazepam, Chlordiazepoxide) – Bind to γ2 subunit of GABA-A receptors. Therefore, increasing GABA binding which opens the Cl- channels for relaxation. Side effects: sedation effects at inappropriate times, ataxia, impaired concentration. Images sourced from: https://www.researchgate.net/publication/363492587/figure/fig1/AS:11431281095915972@1668057808637/Mechanism-of- action-of-benzodiazepines.png Square breathing Mental Health First Aid/Mindfulness Technique Works as a good short-term measure especially in a “crisis”/Panic state. Acts as a distractor Controlled breathing downregulates sympathetic drive. Images sourced from: https://calmerry.com/wp-content/uploads/2022/11/Square-in-the-air-breathing.png Psychological treatments of anxiety This is how we can divide the psychological treatments of anxiety EMDR Psychological Psychotherapy/counselling Mindfulness CBT Mindfulness Focusses on the present in a holistic way Mindfulness aims to change the relationship between you and your thoughts. Grounds you in the present by being aware of acknowledging and making acceptance with one’s thoughts, feelings, body sensations and surroundings. Examples of techniques: meditation, breathing exercises, heightened attention to daily activities. Images sourced from: https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSw_wYkPpO7iFhRIlkIXYUttRIGg- SbIg_7ddSpUy5pUrLxEtUyV5RoZ5krbetnIIzLK2w&usqp=CAU Cognitive Behavioural Therapy (CBT) Focusses on the present in a cognitive and physical way CBT aims to challenge your thoughts. CBT looks at biases that maintain the thoughts and aims to challenge them. CBT suggests a relationship between thoughts, feelings and both physical and psychosocial behaviours. Images sourced from: https://media.post.rvohealth.io/wp-content/uploads/sites/4/2022/05/264290-basic-principles-of- cognitive-behavioral-therapy_1296x1181-938x1024.jpg Psychotherapy/counselling Addresses the past and priotise the therapist-client relationship (Psychodynamic) Psychotherapy aims to improve wellbeing by exploring emotional, behavioural and psychological concerns whilst addressing past experience which could have contributed to it. Counselling aims to empower clients to develop personal growth and positive change by making healthier decisions and cope with challenges whilst providing a space for more active listening. Images sourced from: https://focus.psychiatryonline.org/cms/10.1176/foc.4.2.167/asset/images/medium/171table2.jpeg  Eye-Movement Desensitisation & Reprocessing (EMDR) Especially for PTSD Structured course which therapist helps patient reprocess distressing memories. During sessions, the patient recalls traumatic memories whilst simultaneously focusing on an external stimuli. The dual attention believed to facilitate processing of traumatic memories and reduce their emotional impact. Images sourced from: https://www.rennetwonggates.com/wp-content/uploads/2021/08/NEW-EMDR.jpg NICE CKS guidelines of treating Anxiety Disorders LO3 Guidelines for treating GAD, Panic Disorders, & Social Anxiety Disorder Step 1: Self-help Step 2: Psychological Step 3: Medications therapies o SSRIs oSelf-help o CBT - 1st line if 1st 2 steps -Square breathing - The usual preferred fail/marked functional first line therapy impairment. -Mood diary/Headspace approach -Mindfulness activities o BZDs o Counselling/Psycho - 2-3 weekly reviews with therapy - Not licenced for long- the GP term use. Only for short- term agitation. Guidelines for treating OCD Step 1: Self-help (in Step 2: Psychological Step 3: Medications CAMHS mild OCD only) therapies oSelf-help o CBT o SSRIs -Square breathing - The usual preferred - 1st line if 2nd step first line therapy fail/marked functional -Mood diary/Headspace approach in adult impairment. -Mindfulness activities OCD (all severities) - Review and follow up and CAMHS OCD with Child Adolescent (moderate-severe) Mental Health Services (CAMHS) Guidelines for treating PTSD Step 1: Psychological Step 2: Medications therapies o EMDR o SSRIs/SNRIs - The most appropriate - 1st line if 2nd step therapy fail/marked functional impairment. o CBT - Suitable alternative o antipsychotics - Can be considered. Summary In today’s lecture we have covered (a) The DSM-5-TR criteria of anxiety disorders (b) The biopsychosocial model explanations of anxiety (c) The biopsychological treatments of anxiety (d) NICE CKS guidelines of treating anxiety disorders. Any questions? 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