ANXIETY DISORDERS Psychiatrické centrum Praha 3. LF UK Praha Centrum neuropsychiatrických studií.
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Transcript of ANXIETY DISORDERS Psychiatrické centrum Praha 3. LF UK Praha Centrum neuropsychiatrických studií.
Definition of anxiety
Anxiety:
Feelings of fear or dread
Not-concrete content
Inner tension
Autonomic symptoms
Anxiety Disorder = duration-wise and/or intensity-wise out of proportion reactions.
ANXIETY DISORDERS
• Anxiety disorders are the most common mental illnesses: an estimated 13 percent of adults ages 18 – 54 in a given year, or more than 19 million people (USA), are affected by these debilitating disorders. There are several major types of anxiety disorders, each with its characteristics.
AnxietyPrimary human emotion
Adaptation in phylogeny:
Protection against repeated danger
Preparation for fight or flight
Continuum against normal and pathological anxiety
Epidemiology5 % prevalence
SPECIFIC PHOBIA 4.5%
PANIC DISORDER ± AGORAPHOBIA 2%
SOCIAL ANXIETY DISORDER 4%
POST TRAUMATIC STRESS DISORDER 3.5%
OBSESSIVE COMPULSIVE DISORDER 2.5%
GENERALIZED ANXIETY DISORDER 3%
2x higher prevalence in F comp.M (GAD a phobias)
OnsetEarly adulthood
30- 35 y. (GAD)
CourseChronic
Agoraphobia and OCD v 80% chronification
20-25 30-35 y.
intenzity
yearsStress event
MEDICAL CAUSES OF ANXIETY
MEDICAL CONDITIONS (thyreotoxicosis)
BEVERAGES HERBAL TREATMENTS PRESCRIPTION DRUGS STREET DRUGS
Psychology of anxiety
Psychoanalytic and dynamic theories: Unconscious conflicts call for defensive mechanisms
to handle the anxiety. Bringing the unconscious conflicts into awareness
eliminates the need for defensive mechanisms and alleviates the anxiety
Learning and behavioral theories:
Learning of maladaptive behaviors
The cognitive model:
Disordered cognition leads to mental disorders.
The vulnerability-stress model
Abnormal behavior
= Predisposition + Stress
Predisposition due to genetic background.
Stress due to environmental challenge.
Research paradigm: fraternal vs. identical twins.
Neurobiology of anxietyGenetics
Rats: anxiety reactors and non-reactors (fervency of defecation, vocalization during separation)
Offspring (panic disorder): 15-20% (vs. 2-4% in controls)
GAD in monozygotic twins : 20-30% vs. less than 10% in dizygotic (Kendler, 1992)
Neurobiology of anxietyNeuroanatomy
Anxiety: limbic system, amygdala, locus coeruleus, frontal cortex, hyperperfuzion (asymmetric) parahipokampal gyrus in lactate infusion (Panic disord)
(Reiman, 1984)
Ablation of amygdala – anxiety amelioration
(Davis, 1992)
Information processing and anxiaty
Emotional stimulus
Amygdala Hippocampus
mPFC OFC
Thalamus
Autonomic reaction
Behavioral reaction
Endocrinne reaction
Deklarativní paměť
L. Coeruleus (Noradrenaline)
Neurobiology of anxietyNeurotransmittion
GABAA
Noradrenaline (L.coeruleus)
2 antagonists (yohimbin) – induction of anxiety
5-HT agonism acute- anxiogenic effect, chronic (SSRI) anxiolytic effect
Etiology of pathological anxiety
Anxiety
Biological factors
DispositionGABA, NADR, 5-HT, LS and amygdala, somatic disease (thyroid gland, feochromocytoma, mitral valve prolapsus, arytmia, myocardial ischemic disease …Psychogenic factors
Triggers, changes in
disposition
DynamicIntrapsychical conflict Separation, frustrationStrong attachment ProtectivityStress acute or chronic
Behavioral and cognitive Learned (conditioned) behaviourLearned (conditioned) cognition
Versions of anxiety
Anxiety:
Generalized (free floating)
Panic (paroxysmal)
Anxiety is unstable and frequently is transformed into different clinical symptomatic clusters.
Transformation of pathological anxiety
Anxiety:
Generalized (free floating) Panic (paroxysmal)
concretization Phobia
compulsiveness OCD
dissociation Dissociative, conversive disorders
somatization Somatophorm disorders
grief Anxiety depressive disorder
F40-F48 NEUROTIC, STRESS-RELATED AND SOMATOFORM DISORDERS
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive-compulsive disorder
F43 Reaction to severe stress, and adjustment disorder
F44 Dissociative [conversion] disorder
F45 Somatoform disorders
F48 Other neurotic disorders
Anxiety DisordersDSM-IV
• Panic disorder (w/wo agoraphobia)• Agoraphobia (w/o a history of panic
disorder)• Generalized anxiety disorder (GAD)• Obsessive-compulsive disorder (OCD)• Social phobia • Specific phobia• Posttraumatic stress disorder• Acute stress disorder
Panic Disorder
• Discrete, unexpected episodes of intense fear and alarming physical symptoms (panic attack)
• Most frequent presentations:– Neurological…………..44%– Cardiac………………..39%– Gastrointestinal..……...33%
• One year prevalence of 1% - 2% • Twice as common in women than men• 60% - 90% comorbid depression
Panic disorderGenotype: predisposition in twin studies.Biochemical: serotonin deficiency in the
limbic system.Physiological: chronic hyper-activation of
the limbic system.Behavioral: hyper-vigilance to external and
internal cues.Learning: excessive classical acquisition
of fear and operant acquisition of avoidance.
Cognitive: over-interpretation of autonomous cues & lack of control.
PANIC ATTACK
Tension
time5 - 25 min
Functional tension
Triggers:excerciseworriessexnonREMpanicogens
COGNITIONBIOLOGICAL CHANGESANXIETYSOMATIC REACTIONSANXIOUS BEHAVIOUR
ADAPTATION REACTION -INHIBITION
Anticipation anxiety and cognitionHigh arousalSafeguarding and avoidance behaviour Interpersonal changes
Case: Panic Disorder
It started 10 years ago. I was sitting in a seminar in a hotel and this thing came out of the clear blue. I felt like I was dying. For me, a panic attack is almost a violent experience. I feel like I'm going insane. It makes me feel like I'm losing control in a very extreme way. My heart pounds really hard, things seem unreal, and there's this very strong feeling of impending doom. In between attacks there is this dread and anxiety that it's going to happen again.
From the National Institute of Mental Health’s Web Site
Panic disorder – a case story"In between attacks there is this anxiety that it's
going to happen again. I'm afraid to go back to places where I've had an attack. Soon won't be anyplace where I can go and feel safe from panic.“
“For me, a panic attack is a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds hard, I feel I can't get my breath, and that things are crashing in on me.”
Find the autonomic, cognitive, behavioral and emotional feeling components.
Agoraphobia
• Anxiety about being in situations from which escape might be difficult or embarrassing– unexpected or situationally predisposed panic
attack – panic-like symptoms
• Situations are avoided or endured with marked distress or anxiety
• Not better accounted for by another mental disorder like social phobia or specific phobia
Generalized Anxiety Disorder
• Chronic, excessive worry, with symptoms of increased motor tension and arousal
• Typically seek help for somatic concerns• Women > men• One year prevalence of 3 - 4%• Prevalence in primary care setting of 8%
General Anxiety Disorder Clinical Example
I always thought I was just a worrier. I'd feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I'd worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn't let something go. There were times I'd wake up wired in the morning or in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. My heart would race or pound. And that would make me worry more.
From the National Institute of Mental Health’s Web Site
Generalized anxiety disorder"I'd have terrible sleeping problems. There were times I'd wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I'd feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomachache, I'd think it was an ulcer.”
Find the autonomic, cognitive, behavioral and emotional feeling components.
Obsessive-Compulsive Disorder(OCD)
• Obsessions: recurrent uncontrollable thoughts that are
intrusive and senseless• Compulsions: repetitive behaviors (rituals)
to neutralize discomfort or prevent a dreaded event
• Women = men• One year prevalence of 2%
Obsessive-Compulsive Disorder Clinical Example
I couldn't do anything without rituals. They transcended every aspect of my life. Counting was big for me. When I set my alarm at night, I had to set it to a number that wouldn't add up to a "bad" number. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. If I was writing a term paper, I couldn't have a certain number of words on a line if it added up to a bad number. I was always worried that if I didn't do something, my parents were going to die. Or I would worry about harming my parents, which was completely irrational.
From the National Institute of Mental Health’s Web Site
Social Phobia
• Fear of being embarrassed in a social setting• Point prevalence of 5-10%• High co-morbidity with alcohol abuse and
depression• Occurs more frequently among biological
relatives• Epidemiologically, women > men however in
clinical samples men women
Social Phobia Clinical Example
I couldn't go on dates or to parties. For a while, I couldn't even go to class. My sophomore year of college I had to come home for a semester. My fear would happen in any social situation. I would be anxious before I even left the house, and it would escalate as I got closer to class, a party, or whatever. I would feel sick to my stomach—it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.
From the National Institute of Mental Health’s Web Site
Specific Phobia
• Persistent, irrational fears of certain objects or situations
• Examples: snakes, closed-in spaces, flying, blood/injury, storms, and bridges
• One year prevalence of 9%• Sex ratio varies
– 75-90% animal/natural type are female; 55-70% blood injection type are female
From the National Institute of Mental Health’s Web Site
Specific Phobia Clinical Example
I'm scared to death of flying, and I never do it anymore. It's an awful feeling when that airplane door closes and I feel trapped. My heart pounds and I sweat bullets. If somebody starts talking to me, I get very stiff and preoccupied. When the airplane starts to ascend, it just reinforces that feeling that I can't get out. I picture myself losing control, freaking out, climbing the walls, but of course I never do. I'm not afraid of crashing or hitting turbulence. It's just that feeling of being trapped.
From the National Institute of Mental Health’s Web Site
Posttraumatic Stress Disorder(PTSD)
• Occurs in response to an event in which grave physical harm was threatened or occurred– Event is re-experienced– Persistent avoidance of reminders– Persistent increased arousal
• Symptoms > 1 month (PTSD)• Symptoms < 1 month (Acute Stress Disorder)• Lifetime prevalence of 1 - 14%
Posttraumatic Stress Disorder (PTSD) Clinical Example
I was raped when I was 25 years old. For a long time, I spoke about the rape on an intellectual level, as though it was something that happened to someone else. I was very aware that it had happened to me, but there just was no feeling. "I started having flashbacks. They kind of came over me like a splash of water. Suddenly I was reliving the rape. I would get very flushed or a very dry mouth and my breathing changed. I was held in suspension. I was in a bubble, just kind of floating.
From the National Institute of Mental Health’s Web Site
TYPES OF TREATMENTS
• COUNSELLING / PSYCHOTHERAPY– Cognitive– Behaviour– Interpersonal
• DRUG THERAPIES– Minor Tranquilizers– Antidepressant / Anti anxiety