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Anxiety Disorders. Dr Sheila Tighe. Lecture content. Psychology of normal anxiety Anxiety disorders - general features Specific disorders Panic disorder Generalised anxiety disorder Phobias OCD PTSD. Stress.

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anxiety disorders

Anxiety Disorders

Dr Sheila Tighe

lecture content
Lecture content
  • Psychology of normal anxiety
  • Anxiety disorders - general features
  • Specific disorders
    • Panic disorder
    • Generalised anxiety disorder
    • Phobias
    • OCD
    • PTSD
stress
Stress
  • Definition: Experiencing events that are perceived as endangering one’s physical or psychological well-being. The events are known as stressors and the result as the stress response
  • The response to stressors is influenced by
    • Controllability, predictability and challenge to our limits.
    • Holmes Life Events Scale
  • Different psychological responses to stress include
    • Anxiety
    • Anger and aggression
    • Apathy and depression
    • Cognitive impairment
definition of anxiety
Definition of anxiety
  • A vague unpleasant emotion that is experienced in anticipation of some future misfortune
  • A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation
  • May have emotional, behavioural, cognitive and physical components
structures and neurotransmitters involved in anxiety
Structures and neurotransmitters involved in anxiety
  • Structures involved
    • Cerebral cortex
    • Limbic system- hypothalamus, hippocampus, amygdala, cingulum
    • Thalamus, locus ceruleus, raphe nucleus
  • Neurotransmitters
    • NA, 5HT, GABA
fight or flight response
Fight or flight response
  • Physiological response to a stressor
  • Mediated through the hypothalamus and LC
  • Initial activation of the sympathetic nervous system
  • Subsequent activation of the pituitary adrenal axis
  • Terminated by negative feedback and para sympathetic system
effects of sympathetic stimulation
Effects of sympathetic stimulation
  • Mediated through noradrenaline and adrenaline
  • Increased heart rate and contractility
  • Increased respiratory rate
  • Sweating
  • Increased glucose availability
  • Shunting of blood to muscles
  • Increased muscle tension
  • Enhanced blood clotting
effects of hpa axis stimulation
Effects of HPA axis stimulation
  • Mediated through CRH, ACTH and cortisol
  • Promotes breakdown of glycogen to glucose in liver
  • Promotes glucose uptake into cells
  • CRH also activates locus ceruleus
anxiety as a normal adaptive function
Anxiety as a normal adaptive function
  • Evolutionary viewpoint
    • Looks at traits in the context of natural selection and promotion of the species
    • Primitive environment with many physical dangers – anxiety had a protective function as a warning system and in helping escape
    • Anxiety - response to cues of potential danger
    • Protection general or specific depending on nature of threats c.f.. Immune system
    • Avoidance, aggression, freezing or appeasement
anxiety as a normal adaptive function continued
Anxiety as a normal adaptive function continued
  • Preparedness - We are more likely to become anxious in response to cues that represent ancient dangers e.g.,snakes, strangers, storms, blood.
  • Not flowers, leaves, shallow water
  • Not in response to more evolutionary recent dangers - guns, cars
slide14

Benefits of anxiety

  • Yerkes-Dodson law:
    • Performance improves as a function of anxiety up to a threshold beyond which there is a fall off in performance
anxiety disorders terminology
Anxiety disorders - terminology
  • Neurosis – William Cullen
    • General deficiency of nervous system
  • Psychoneurosis – Sigmund Freud 1900
    • Unreleased sexual tension - hypochondriasis
    • Repressed thoughts - phobias
  • ICD10 – Neurotic, stress related and somatoform disorders.
  • DSM IV – Anxiety disorders
anxiety disorders16
Anxiety disorders
  • Anxiety disorders are extremes of normal anxiety
  • Occur when normal anxiety system becomes dysregulated - excessive, inappropriate or deficient
  • Common - ECA lifetime prevalence 15 -20%
shared features of anxiety disorders
Shared features of anxiety disorders
  • Substantial proportion of aetiology is stress related.
  • Reality testing is intact.
  • Symptoms are ego dystonic (distressing)
  • Disorders are enduring or recurrent.
  • Demonstrable organic factors are absent
aetiology of anxiety disorders
Aetiology of anxiety disorders
  • Genetic
    • Family studies
    • Linkage studies
  • Neurotransmitter abnormalities
    • 5HT, NA, GABA
  • HPA axis dysregulation
aetiology of anxiety disorders19
Aetiology of anxiety disorders
  • Psycho-analytic theories - unconscious defence mechanisms
    • Phobia - displacement
    • OCD - reaction formation, undoing
    • PTSD - denial, repression
  • Cognitive theories
    • Selective attention and catastrophic thinking
  • Behaviour - learned behaviour
anxiety disorders aetiology
Anxiety disorders - aetiology
  • Social factors
    • Early life adversity
    • Stressful events especially those involving threat
    • Lack of support network
  • Personality factors
    • Some personality traits predispose to certain anxiety disorders – avoidant, perfectionist
panic disorder
Panic Disorder
  • Recurrent attacks of severe anxiety
  • Physical symptoms
    • Palpitations, chest pain, choking sensation, dizziness, breathlessness, tingling in the hands and feet, sweating, faintness.
  • Emotional and behavioural symptoms
    • Fear of dying, losing control, going mad
    • Feeling of unreality - depersonalisation
    • Need to exit situation
panic disorder continued
Panic Disorder continued
  • Sudden in onset
  • Not predictable or confined to a given situation
  • Concern about future attacks and secondary avoidance
  • Otherwise relatively free of anxiety between attacks
  • ICD10 criteria - several severe attacks within a month
panic disorder differential
Panic disorder - differential
  • Panic attacks as part of a phobic disorder
    • distinction between panic disorder and agoraphobia controversial
  • Depression
  • PTSD
  • Substance abuse
  • Physical disorders e.g., phaeochromocytoma
panic disorder epidemiology
Panic disorder - epidemiology
  • ECA - 1% of population
  • More prevalent in females
  • Ages 25 - 44
  • 20% have another anxiety disorder
  • Positive family history of panic disorder in 25%
panic disorder pharmacological treatment
Panic disorder - pharmacological treatment
  • Assess and tx comorbid problems
  • SSRIs - paroxetine, citalopram - can initially worsen panic attacks
  • Benzodiazepines - good short term relief but high risk of dependency - alprazolam
  • TCAs - imipramine, clomipramine
  • MAOIs - especially in mixed panic depressive states but use limited by ADR
  • High rate of relapse on cessation of tx
slide26

Panic Disorder: The Cognitive Perspective

Tendency to interpret a range of bodily sensations in a catastropic fashion.

Selective attention to internal cues and avoidance compound the problem.

panic disorder psychological treatments
Panic disorder - psychological treatments
  • Behavioural therapy
    • exposure and response prevention
    • relaxation techniques
  • Cognitive behaviour therapy
    • education
    • recognition and change of negative thoughts
generalised anxiety disorder
Generalised Anxiety Disorder
  • Anxiety is generalised and persistent
  • Free-floating anxiety – not situational.
  • ICD10 - symptoms present most days for weeks
  • Motor tension
    • Muscle tension, twitching and shaking, restlessness, .
  • Apprehension
    • Feeling on edge,unable to cope, poor concentration, insomnia, irritability
  • Autonomic over-activity
    • Lightheadedness, sweating, tachycardia, dry mouth, epigastric discomfort
gad epidemiology
GAD - epidemiology
  • One year prevalence 3 - 8%
  • Females more likely 2:1
  • Age of onset 20 - 35
  • 50% have another psychiatric diagnosis
gad differential
GAD - differential
  • Other anxiety disorders
  • Depression
  • Substance abuse
  • Schizophrenia
  • Physical conditions
    • hyperthyroidism, angina
  • Early dementia
gad management
GAD - Management
  • Biological
    • Benzodiazepines - short-term tx
    • SSRIs -
    • Venlafaxime
    • MAOIs
  • Psychological
    • Anxiety management - based on CBT principle
phobias
Phobias
  • Anxiety evoked by specific circumstances or situations. Fear is out of proportion to the situation and is beyond voluntary control.
  • Agoraphobia
  • Social phobia
  • Specific phobias
  • Plus or minus panic disorder
  • Avoidance is a characteristic feature
  • Strong association with depression
agoraphobia
Agoraphobia
  • Fear of open spaces, crowds or public places.
  • Fear of travelling by public transport
  • Fear that it may be difficult to get to a place of safety (home)
  • Situations where an immediately available exit is lacking are avoided.
agoraphobia symptoms
Agoraphobia - symptoms
  • Autonomic symptoms - faintness, palpitations, SOB, sweating
    • Panic attacks marker of severity
  • Psychological symptoms - fear, dread
  • Behavioural symptoms - avoidance to the extent that the person becomes house bound
  • Cognitive symptoms - “ I might have died”
agoraphobia epidemiology similar to panic disorder
Agoraphobia - epidemiology(similar to panic disorder)
  • Predominantly females – 75%
  • Age of onset – 15 to 35
  • Risk factors
    • Stressful life events
    • Family history – 20% relative with agoraphobia
    • Domestic instability – family or marital difficulties
    • History of childhood fears or enuresis
    • Overprotective family members
  • Differential diagnosis
    • Depression, schizophrenia, dementia
agoraphobia management and prognosis
Agoraphobia - Management and Prognosis
  • Behaviour therapy - graded exposure and systematic desensitisation
  • CBT
  • Family therapy
  • Self help books
  • Pharmacotherapy - as for panic disorder
social phobia
Social Phobia
  • Fear of scrutiny by others in relatively small groups
  • Fear of acting in a way that will be embarrassing or humiliating or appear ridiculous
  • Feared social situation associated with intense anxiety and distress - blushing, tremor,butterflies
  • Leads to avoidance of social situations that involve e.g., eating, public speaking - isolation
  • Differential diagnosis
    • Body dysmorphic disorder, panic disorder, depression, paranoid psychosis
social phobia epidemiology
Social phobia - epidemiology
  • Roughly equal sex incidence
  • Onset in adolescence
  • Prevalence - 1-2 %
  • Often co-morbid depression or alcohol and substance abuse
social phobia management
Social phobia - management
  • Assess and treat co-morbid conditions
  • Pharmacotherapy
  • Behavioural and CBT techniques
specific phobias
Specific phobias
  • Anxiety provoked only in response to a specific stimulus or situation
  • Panic attacks can occur
  • Degree of disability is related to ease or difficulty of avoiding the feared object
  • Feared object usually something that posed a threat at some time in history - animals, storms, heights, darkness, blood
  • Behavioural approach most useful
obsessive compulsive disorder
Obsessive Compulsive Disorder
  • Repetitive unwanted obsessions or compulsive acts
  • Obsession is recurrent and intrusive thought, feeling, idea, image or impulses
    • Usually distressing e.g., contamination, obscene, violent
    • Sometimes futile e.g., quasi-philosophical
    • Indecision between two alternatives
    • Resisted but this causes tension
    • Recognised as the person’s own thoughts
ocd continued
OCD continued
  • Compulsions are stereotyped behaviours repeated again and again
    • Cleaning, checking, tidying, counting,
    • Sometimes marked indecision or slowness
    • Not enjoyable or useful
    • May be thought of as protective in some way and can reduce anxiety
  • Autonomic symptoms present
  • Close links with depression
ocd epidemiology
OCD epidemiology
  • Lifetime prevalence 1 -2%
  • Equal sex incidence
  • Age of onset 20 - usually abrupt
  • Often delay of years in seeking tx
  • Course chronic and fluctuating
  • Often co-morbid anxiety disorders, (social phobia 25%), depression (67%), eating disorders
ocd management
OCD - Management
  • Behaviour therapy
    • Exposure and response prevention
    • Paradoxical injunctions
  • CBT - less useful
  • Pharmacotherapy
    • SSRIs, Clomipramine
    • Augmentation with quetiapine or risperidone
    • Clonazepam
slide45
OCD
  • Psychosurgery - indicated rarely for severe intractable cases
  • Outcome 60% respond to SSRIs but relapse is common on cessation of tx
  • Predictors of poor outcome are male sex, early onset and obsessional slowness
disorders arising as a reaction to stress
Disorders arising as a reaction to stress
  • Acute stress reaction
  • Post traumatic stress disorder
  • Adjustment disorders - mild transient response to stress precipitated by life events within the normal range
  • Clear-cut stressor or trauma without which disorder would not occur
acute stress reaction
Acute stress reaction
  • Overwhelming traumatic experience involving threat to life, physical integrity or social position of individual or a loved one
  • RTA, battle, rape, multiple bereavement
  • Daze, disorientation, mixed picture
  • Withdrawn or agitated
  • Autonomic symptoms
  • Onset within minutes, resolves 48-72 hrs
post traumatic stress disorder ptsd
Post traumatic stress disorder PTSD
  • Delayed or protracted response to trauma ( often involving threat to life)
  • Onset usually within 6 months of event
  • Core symptom is “reliving the event”
    • Flashbacks, nightmares, waking dreams
  • Emotional numbness and detachment
  • Avoidance of activities, situations that remind person of trauma
ptsd continued
PTSD continued
  • Autonomic hyper arousal
  • Hypervigilance, increased startle, insomnia
  • Mood disorder - anxiety or depression
  • Abuse of alcohol or drugs
ptsd mx
PTSD - Mx
  • SSRIs, Serotinergic TCAS
  • Behavioural tx
  • CBT
  • Family tx
  • Debriefing - no clear evidence base
ptsd outcome
PTSD - outcome
  • Symptoms fluctuate over time
  • Most intense at times of stress
  • 30% complete recovery
  • 10 % do badly
  • Predictors of poor outcome - Hx of childhood trauma, borderline or ontisocial personality traits, poor support network, heavy alcohol intake
dissociative and somatoform disorders
Dissociative and somatoform disorders
  • Disorders in which person presents with physical symptoms for which there is no medical explanation
  • Psychological explanation or cause often present
  • Diagnosis of exclusion
  • Liaison psychiatry
summary
Summary
  • Anxiety disorders are common
  • They are distressing and cause loss of function
  • They occur commonly with other co-morbid psychiatric disorders
  • They are amenable to pharmacological and psychological treatment
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