Anxiety Disorders New Insights

1. Anxiety Disorders New Insights Dr.R.V.S.N.Sarma., M.D., M.Sc., Consultant Physician visit : www.drsarma.in

2. ANXIETY

4. What is anxiety ? • 􀂾􀂾It is a mood-state with • 􀂾􀂾Marked Negative effects • 􀂾􀂾Bodily symptoms of tension • 􀂾􀂾Apprehensions about future • Its consequence is ‘worry’

5. What is physiological worry ? • 􀂾 Worry is a normal response to stressful situations limited to particular situations • Should not exceed the duration of event • Should not spread to other topics • 􀂄 Excessive worry should not be seen as a normal response, as part of one’s personality

6. What is pathological worry ? • 􀂾􀂾It is a component of anxiety • 􀂾􀂾Negative emotional thoughts, images • 􀂾􀂾Uncontrollable and they occur in sequence • 􀂾􀂾Concern about future threats and danger • Their frequency and intensity are more

7. What do people worry about ? • 􀂾􀂾Real problems that could be potentially solved, but are not acted on • 􀂄 Real problems that probably cannot be solved (at least not by the individual), but can be coped with • 􀂄 “Imagined problems” that do not yet exist and probably will never exist • 􀂄 Worry about worry and its consequences

8. Pathological v/s normal anxiety • 􀂾􀂾 Autonomous responses • 􀂾􀂾 Greater intensity • 􀂾􀂾 Longer duration • 􀂾􀂾 Behavior significantly affected • Stressor may be minimal or absent

9. Origin of anxiety • 􀂾􀂾Protective response • 􀂾􀂾Normal/protective anxiety • Fear and pathological anxiety • Common underlying neuro-physiology • 􀂾 Two categories of fear/anxiety • Acute and • Chronic

10. Negative effects of worry Unreasonable fear Anxiety Disorder Panic Disorder Substance abuse Depression

12. What cause Anxiety Disorders ? • 􀂾􀂾No single cause • 􀂄 Several possible causes 􀂄 genetics, other biological factors physiology, infection, injury, trauma 􀂄 temperament, life experiences 􀂄 upbringing, family, school, peers, society in general, Doctors in particular stress - chronic or acute

13. What cause Anxiety Disorders ?

14. Importance of Anxiety Disorders • 􀂾􀂾Accurate Dx and Rx of anxiety disorders is essential • Reduction of secondary psychiatric conditions • Depression • Substance abuse problems

15. Anxiety Disorders - DSM-IV Generalized Anxiety Disorder (GAD) 2. Panic Disorder (PD) with Agoraphobia (AG) 3. PD sans Agoraphobia 4. Specific Phobia (SP) 5. Social Phobia (SoP) 6. Obsessive Compulsive Disorder (OCD) 7. Post traumatic Stress Disorder (PTSD) 8. Acute Stress Disorder 9. SAD, CAD (ASD) 10. Substance-Induced Anxiety disorder (SIAD) 11. Anxiety disorder due some medical illness Dual Diagnosis Disorders

16. Prevalence of Anxiety Disorders Kessler et al. Arch Gen Psychiatry. 1995;52:1048. Kessler et al. Arch Gen Psychiatry. 1994;51:8.

17. Sex differences in Anxiety Disorders Are women more ‘Nutty’ ?

18. Spectrum of Anxiety Disorders http://www.nimh.nih.gov/publicat/anxiety.cfm

20. What is Gen. Anxiety Disorder ? • Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long. • The “What if?” disorder • Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress.

21. Domains of anxiety • 􀂾􀂾Physical • 􀂾􀂾Affective • 􀂾􀂾Cognitive • 􀂾􀂾Behavioral

22. Physical domain • 􀂾􀂾 Anorexia • 􀂾􀂾 Butterflies in stomach • 􀂾􀂾 Chest pain/tightness • 􀂾􀂾 Diaphoresis • 􀂾􀂾 Dry mouth • 􀂾􀂾 Dyspnoea • 􀂾􀂾 Faintness • 􀂾􀂾 Flushing • 􀂾􀂾 Hyperventilation • 􀂾􀂾 Light-headedness • 􀂾􀂾 Muscle tension • 􀂾􀂾 Nausea, Vomiting • 􀂾􀂾 Pallor • 􀂾􀂾 Palpitations • 􀂾􀂾 Paresthesias • 􀂾􀂾 Sexual dysfunction

23. Physical domain contd.. • 􀂾􀂾 Headache • 􀂾􀂾 Shortness of breath • 􀂾􀂾 Stomach pain • 􀂾􀂾 Tachycardia • 􀂾􀂾 Tremulousness • 􀂾􀂾 Urinary frequency • 􀂾􀂾 Diarrhea

24. Affective domain • 􀂾􀂾 Edginess • 􀂾􀂾 Uneasiness • 􀂾􀂾 Terror • 􀂾􀂾 Panic

25. Behavioral domain • 􀂾􀂾 Triggers many responses • 􀂾􀂾 Behavioral in nature • 􀂾􀂾 Concerned with diminishing • 􀂾􀂾 And even avoiding the distress

26. Regulation of locus ceruleus • 􀂾􀂾Alpha-noradrenergic auto receptors • 􀂾􀂾Serotonin receptors • 􀂾􀂾GABA-benzodiazepine receptors • 􀂾􀂾Opiate receptors • Dopamine receptors

27. The amygdala and locus ceruleus

28. Generalized Anxiety Disorder -GAD Restlessness or feeling keyed up or on edge, Being easily fatigued, Difficulty concentrating or mind going blank, Irritability, Muscle tension, Sleep disturbance Pathological anxiety, which is • excessive, chronic and • typically interferes with their ability to function in normal daily activities. • GAD is distinguished from Phobic anxiety – as it is not triggered by a specific object Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events. The person finds it difficult to control the anxiety and worry and has associated three (or more) of the above six symptoms

29. Case # 1 • Ms. D has a chief c/o “worrying about everything” for the last year. She also c/o frequent headaches, fatigue and insomnia secondary to the anxiety. • These symptoms have worsened to the point where she has been distracted and making mistakes at work.

30. GAD – Mr. Fisc Worry that is • 􀂄 Excessive, uncontrollable • 􀂄 Frequent, multiple topics (not only onetime) • 􀂄 More than one day out of two 3 out of 6 other associated physical symptoms • 􀂄 Muscle tension, Restlessness • 􀂄 Fatigued easily, Irritability • 􀂄 Sleep disturbance, Concentration difficulty

32. Acute fear state • 􀂾􀂾Response to life-threatening danger • 􀂾􀂾Terror, helplessness, • Sense of impending disaster/doom • 􀂾􀂾Urgency to flee or seek safety • 􀂾􀂾Sympathetic/Nor-adrenergic activation • 􀂾􀂾Located in locus ceruleus • 􀂾 Corresponds to panic attacks

33. Agoraphobia • Anxiety in situations where escape might be difficult (or embarrassing) or help might not be available in the event of having a panic attack or panic-like symptoms • Situations are avoided or endured with marked distress • May not leave home or may need a companion • Can occur with and without panic disorder

34. Agoraphobia

35. Social Phobia • Marked, persistent fear of social or performance situations where a person is exposed to unfamiliar situations or people or possible scrutiny by others. • The individual fears acting in an embarrassing or humiliating way. • The Person recognizes fear as excessive. • Exposure causes anxiety symptoms or panic • Situations are avoided or endured with anxiety

36. Specific Phobias Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a Panic Attack. The person recognizes that his/her fear is excessive or unreasonable. The phobic situation is avoided or else is endured with intense anxiety or distress

37. Specific Phobias - Examples • Acrophobia fear of heights • Agoraphobia fear of open places • Claustrophobia fear of enclosed places • Ailurophobia fear of cats • Cynophobia fear of dogs • Pathophobia fear of disease • Mysophobia fear of dirt and germs • Arachnophobia fear of spiders • Hematophobia fear of blood • Xenophobia fear of strangers Better-halfophobia fear of wife

39. PAN – The Greek God

40. Panic Attack – DSM IV 􀂾 Palpitations Sweating Trembling or shaking Shortness of breath Feeling of choking Chest pain or discomfort Nausea or abd. distress 8. Feeling dizzy, fainty 9. Derealization (feelings of unreality) 10. Fear of going crazy 11. Fear of dying 12. Paresthesias 13. Chills or hot flushes 􀂾􀂾A discrete period of intense fear or discomfort in which 4 (or more) of the above 13 symptoms develop abruptly and reach a peak within 10 minutes

41. Case # 2 Mrs. B c/o a long h/o episodes of anxiety, SOB, racing heart, sweating, CP, and fears that she is having a MI and will die. These last 30 minutes and are unexpected. She c/o anxiety while in malls and traveling alone to new places for fear of having another attack. Despite a negative w/u, she still worries about having a MI during an attack.

42. Panic Disorder with Agoraphobia • Recurrent unexpected panic attacks: anxiety associated with at least four physical and/or cognitive symptoms cognitive symptoms • At least 1 month of worry about having additional attacks or the consequences of an attack (losing control, having a heart attack, “going crazy”). • Agoraphobia

43. Panic Disorder – Chest pain • Chest pain is a common symptom of panic attacks • 22 – 70% of panic attacks are associated with CP • 18 – 25% of all patients with chest pain have PD • Rates of PD higher among cardiology outpatients with chest pain. • Such patients undergo expensive cardiac workups, but their PD remains undiagnosed & untreated.

45. Obsessive Compulsive Disorder - OCD Obsessions • Recurrent and persistent thoughts, impulses, or images that are experienced during the disturbance, as intrusive and inappropriate, and cause marked anxiety or distress. • The thoughts, impulses, or images are not simply excessive worries about real life problems. • The person attempts to ignore or suppress such thoughts impulses or to neutralize them with some other thought or action. • The person recognizes that the obsessive thoughts, impulses, or images are a product of his or her own mind

46. Obsessive Compulsive Disorder -OCD Compulsions • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) • He/she is driven to perform in response to an obsession, • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event • But, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent and are clearly excessive.

47. Obsessive Compulsive Disorder -OCD • Putamen • Globus Pallidus • Caudate Nucleus • Thalamus • Orbital frontal cortex

49. Post traumatic Stress Disorder- PTSD

50. Post traumatic Stress Disorder- PTSD Experiential requirements • The person has experienced a life-threatening event and has responded with intense fear, hopelessness or horror. • The person’s response to the event occurred more than 4 weeks after it was experienced and lasted more than one month. • The traumatic event is persistently re experienced in several ways, e.g., by intrusive recollections, dreams, illusions, hallucinations, or flashbacks.