Anxiety Disorders - Treatment and Management

Anxiety Spectrum Disorders -

Treatment & ManagementMs. Jinu Abraham,

M. Phil. PSW Trainee

Anxiety Spectrum Disorders

F- 40, 41, 42 & 43– Agoraphobia– Social Phobia– Specific (isolated) Phobias– Panic Disorder– Generalized Anxiety Disorder– Obsessive Compulsive Disorder– Acute Stress Disorder– Post Traumatic Stress Disorder

» DSM-IV-TR

Ms. Jinu Abraham, IMHANS, Calicut 2

Fear and Anxiety

Fear– acute, immediate response to suddenly appearing,

imminent danger (proximal threats) Anxiety– sustained, insidious response to danger, as might manifest

when degree to which threat is present remains ambiguous (distal threats)

E.g. – Rodent in a cage Impairment– Disruption in normal functioning– Presence of “clinically significant” distress

» CTP, 9th Edition


Psychophysiological Aspects

Anxiety – physiological activity (cardiovascular activity and

electrodermal system)

– subjective reports (feelings of increased muscle tension, heart racing, perspiration, shortness of breath and palpitations)

– overt behaviors (increased reflexes and enhanced muscle tension)

» CTP, 9th Edition


Analyzing the Details

8 primary anxiety disorders, distinguished from one another by– Focus of anxiety– Specific symptoms

Panic Disorder– Recurrent unexpected panic attacks with anxiety about

having another attack or concerns about consequences of such attacks for one's well-being

– Fear of fear Agoraphobia– Individual's attempt to avoid experiencing another panic

attack


Analyzing the Details…contd

Post Traumatic Stress Disorder– Fear of recollections and reminders of previously

experienced life-threatening event Social Phobia– Fear of embarrassment and rejection

Obsessive Compulsive Disorder– Fear of an idiosyncratic concern (contamination, fire, being

an evil or harmful person, etc.) Generalized Anxiety Disorder– Worry about specific future outcomes

Specific (isolated) Phobias– Fear circumscribed to specific situation or object


Global Burden of Disease (GBD)

13% of GBD – Mental Disorders Treatment Gap (Severe Mental Disorders)– 76-85% , low and middle-income countries– 35-50%, high-income countries

» WHO, 2012


Medical Etiologies of Anxiety

Neurological– Delirium

– Dementia

– Huntington's Disease

– Migraines

– Multiple Sclerosis

– Other degenerative neurological diseases (e.g., Creutzfeldt–Jakob disease)

– Seizure Disorders

– Sleep Disorders

– Transient Ischemic Attacks

Endocrine– Addison's Disease

(hypocortisolism)

– Cushing's s Syndrome (hypercortisolism)

– Hypoglycemia

– Hyperparathyroidism

– Hyperthyroidism

– Hypothyroidism

– Pheochromocytoma


Medical Etiologies of Anxiety…contd Toxins/Poisons

– Lead – Mercury – Manganese – Organophosphates

Cardiopulmonary – Angina – Asthma – Cardiac Arrhythmias – Chronic Obstructive Pulmonary

Disease – Mitral Valve Prolapse – Pulmonary Embolus

Infections – Meningitis – Neurosyphilis

Medications and Drugs – Antidepressants – Antihypertensives – Cough/cold medication (may

contain ephedrine or caffeine) – Corticosteroids – Insulin – Monosodium Glutamate – Oral Contraceptive Pill – Sympathomimetics – Thyroid Supplements – Weight Loss Products – Stimulants

(intoxication/withdrawal) – Alcohol intoxication/withdrawal – Benzodiazepine withdrawal – Marijuana


Treatments

Until middle 20th Century – Psychoanalysis

– Barbiturates

Current Trend– Pharmacotherapy

– Psychotherapy

– Combination of both


Pharmacotherapy

Commonly used drugs for recurrent anxiety– Fluoxetine - Buspirone

– Fluvoxamine - Azapirone

– Paroxetine - Lorazepam

– Sertraline - Clonazepam

– Citalopram - Benzodiazepines

– Escitalopram - Phenelzine

– Venlafaxine » CTP, 9th Edition


Duration

Studies show 20-50% chronic anxiety patients experience recurrence of clinically significant symptoms, several months after discontinuing pharmacotherapy

Guidelines specify – Stable treatment for at least 1-2 years before

consideration of dose reduction or discontinuation–When medication discontinuation instituted,

gradually tapering by 10-25% every 1-2 months while observing for relapse or exacerbation


Cognitive Behavior Therapy

CBT endorsed as first-line treatment – UK’s National Institute of Health and Clinical

Excellence

– American Psychiatric Association Treatment Guidelines

Research finds CBT more cost-effective than medication or other treatments in long term


Cognitive Behavior Therapy…contd

Thought challenging/Cognitive restructuring– Challenge negative thinking patterns that

contribute to anxiety, replacing them with positive, realistic thoughts

1.Identifying negative thoughts

2.Challenging negative thoughts

3.Replacing negative thoughts with realistic thoughts


Exposure Therapy

Encourages systematic confrontation of feared stimuli– external (eg, feared objects, activities, situations)– internal (eg, feared thoughts, physical sensations)– Aim: Reduce fearful reaction to stimulus

4 major theories explain its psychological mechanisms – Habituation– Extinction– Emotional Processing– Self-efficacy

» Kaplan and Tolin, 2011


Exposure Therapy…contd

Habituation– Natural reduction in responding with repeated exposure

Extinction– Overwriting previously learned fear associations

Emotional Processing– Developing new interpretations and meanings for feared

stimuli and fearful responses Self-Efficacy– Increased perception that one is capable of tolerating feared

stimuli and responses» Kaplan and Tolin, 2011


Exposure Therapy…contd

Guidelines– Develop an exposure hierarchy

Brainstorm external and internal stimuli that are feared and avoidedRate each item using the Subjective Units of Discomfort (SUDs)

Scale– Conduct exposures in gradual and systematic manner

Begin with moderately fear-provoking stimuliAssess patient’s fear during exposure using SUD scaleAddress each exposure collaboratively, in controlled and prolonged

mannerProgress to a higher item after the patient shows a reduced fear

response to lower item– Eliminate safety behaviors– Challenge cognitive distortions

» Kaplan and Tolin, 2011


Habituation


Desensitization Therapy

Based on Reciprocal Inhibition Theory by Joseph Wolpe (1958)

Masserman’s experiment with cats– Counter-conditioning, using one association to run

counter to another

– Reciprocal inhibition, responses of anxiety and eating inhibited or prevented each other


Desensitization Therapy…contd

Wolpe’s three-part systematic desensitization procedure:1. The client is trained in deep relaxation

2. The client and therapist construct a list of anxiety-eliciting stimuli, the so-called fear hierarchy, ordered from least to most distressing

3. Starting with the least anxiety-arousing image, the feared stimuli are paired with relaxation, until eventually the most feared stimulus is tolerated calmly


THANK YOU

21Ms. Jinu Abraham, IMHANS, Calicut

Anxiety Disorders - Treatment and Management

Healthcare

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