Anxiety Disorders

By Salina Chan, R32013

Anxiety & Related Disorders

Generalized anxiety disorderSocial Anxiety disorderPanic attacksPanic disorderAgoraphobiaSpecific PhobiasAcute stress reactionPTSDOCD

Anxiety Disorders

Some terms and general applications…“Marked” = intense or severeAvoid triggers or endure them with intense fear

or anxietyAnxiety in children = crying, tantrums, freezing,

clinging or shrinkingRemember, it’s only a disorder when causes sig

adverse impact on important areas of functioningr/o secondary to substances or medical condition

Generalized Anxiety Disorder

WATCHERSWorry, and Anxiety excessive about a number of activities

6 months 3/6 symptoms below (1 only for children)

TensionConcentrationHyperarousalEnergy (fatigue)RestlessnessSleep problems

Generalized Anxiety Disorder

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for > 6 months, about a number of events or activities (e.g. work, school performance)

Difficult to control, i.e. can’t put off and focus on task at hand

3 of the 6 possible associated symptoms Restlessness/keyed up/on edge Easily fatigued Difficulty concentration/mind going blank Irritability Muscle tension Sleep disturbance

Generalized Anxiety Disorder

More worries = more likely GADWorries about everyday, routine life

circumstances, e.g. job responsibilities health finances health of family members misfortune to their children minor matters, e.g. chores

Generalized Anxiety Disorder

Generalized Anxiety Disorder

MSE: Appearance variable Speech can be rapid Thought form can be trailing, blocking, tangential,

overinclusive “What if” phrases

d/t inability to tolerate uncertainty of future events

Social Anxiety Disorder (Social Phobia)

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others Having a conversation Meeting unfamiliar people Being observed Performing in front of others

Social Anxiety Disorder (Social Phobia)

Fears will act in a way or show anxiety that will be negatively evaluated, e.g.: Humiliating Embarrassing Lead to rejection Offend others

Judged as: Anxious Weak Crazy Stupid Boring Intimidating Dirty unlikable

Social Anxiety Disorder (Social Phobia)

MSEAppearance may show

poor eye contact, rigid body posture, agitation (e.g. rubbing hands, tense), blushing Blushing = hallmark

physical response of SAD

Affect may be shy & withdrawn

Speech may be overly soft voice

Thought content Concerns about being

judged: How they look What they say being embarrassed embarrassing others

Public speaking Grocery lines Talking on phone Poverty/blocking: b/c

stress of interview causes thought blocking

Social Anxiety Video

http://www.youtube.com/watch?v=gmEJEfy5f50 (37:08 – 39:39)

Panic Attack

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time > 4 of the following symptoms occur…

Panic Attack

STUDENTS FEAR Cs Sweating Trembling or shaking Unsteadiness/dizziness/faint/lightheaded Depersonalization/derealization Excessive heart rate, palpitations, or pounding heart Nausea/Abdominal distress Tingling/Numbness Shortness of breath or smothering FEAR of dying, losing control, going crazy Chest Pain, Chills, Choking

Panic Attack

4 Head Dizzy/unsteady/

lightheaded/faint Derealization/

depersonalization Fear losing

control/crazy Fear dying

4 Chest SOB Heart Chest pain

4 Hands Trembling/shaking Chills/heat sweating Paresthesias

1 GI Nausea/abdominal

distress

Panic Attack Differential

Generalized anxiety d/o

Social anxiety d/oPanic disorderSpecific phobiaOCD

Depressive d/oBipolar d/oPersonality d/oPsychotic d/oMedical causes

Hyperthyroidism, cardiac, resp, gastro

Substance-induced

Panic Disorder

Recurrent, unexpected panic attacks

> 1 month of: Persistent

concern/worry about more attacks or their consequences

OR Change in behaviour

related to the attacks

Panic Disorder Video

http://www.youtube.com/watch?v=Ii2FHbtVJzc

Agoraphobia

Marked fear or anxiety about > 2 of following situations Using public transportation Being in open spaces Being in enclosed spaces Standing in line or being in a crowd Being outside of the home alone

Fears or avoids these b/c of thoughts that escape might be difficult or help might not be available in event of developing panic-like symptoms or other incapacitating or embarrassing symptoms

Specific Phobias

Marked fear or anxiety about a specific object or situation Persistent (> 6

months) Out of proportion to

the actual danger Nearly every time

Types of Phobia: BEAST Blood/Injection/Injury Environment, natural

(heights, storms) Animal/Insect Situational (airplane,

closed spaces) Things, other (loud

noise, clowns, vomiting)

Trauma-Related Disorders

Acute Stress Reaction

Exposure to actual or threatened death, serious injury, or sexual violation in > 1 of the following ways Directly experiencing the traumatic event Witnessing, in person, the event as it occurred to others Learning that the event occurred to close family/friends

(must be violent/accidental) Experienced repeated or extreme exposure to aversive

details of the traumatic event

> 9 symptoms that last 3 days – 1 monthPrecursor to PTSD

Post-Traumatic Stress Disorder (PTSD)

A. Traumatic event 1. Re-experiencing event (1/5)2. Avoidance and emotional numbing (3/7)3. Arousal increased (2/7)

B. Unable to function C. Month or more

Post-Traumatic Stress Disorder (PTSD)

Traumatic event person experienced, witnessed actual or threatened serious injury, death, or threat to

physical integrity of self or other Person experienced intense helplessness, fear, and horror

Re-experiencing event (1/5) intrusive thoughts, nightmares, flashbacks, or recollection

of traumatic memories and images. Avoidance and emotional numbing (3/7)

detachment from others; flattening of affect; loss of interest; lack of motivation; and persistent avoidance of activity, places, persons, or events associated with the traumatic experience

Unable to function Symptoms are distressing and cause significant

impairment in social, occupational, and interpersonal functioning

Arousal increased (2/7) usually manifested by startle reaction, poor concentration,

irritable mood, insomnia, and hypervigilance

Post-Traumatic Stress Disorder (PTSD)

“Doc, I’ve got Anxiety!”

Anxiety d/oBipolar d/oDepressive d/oPsychotic d/oSleep d/oSubstance use d/o

Social Anxiety Disorder Differential

Normative shynessAgoraphobiaPanic disorderGeneralized anxiety

disorderSeparation anxiety

disorderSpecific phobiasSelective mutism

Major depressive disorder

Body dysmorphic disorderDelusional disorderAutism spectrum disorderPersonality disorderOther mental disorders,

e.g. Scz, eating d/oOther medical conditionsOppositional defiant

disorder

Anxiety Disorders – Treatment

Rule out medical conditions (VINDICATE) TSH, pheochromocytoma, hypoglycemia, arrythmia, asthma

Lifestyle eat well, exercise, socialize, relaxation

Psychotherapy CBT, EMDR

Meds Antidepressants, B-Blockers (must cross BBB) Benzodiazepines & Antipsychotics

Medications

Antidepressants: Use higher doses than for depression, e.g. ~50% more SSRI , e.g.

Cipralex 30mg Setraline 150-200mg

SNRI Venlafaxine: 250-300mg Desvenlafaxine: 100mg

Mirtazapine: 30-45mg Buspirone: 30mg Trazadone: 50 to 400 mg

Medications

Beta-blockers Social Performance anxiety

Benzodiazepines Clonazepam, Ativan Short-term or PRN use Good to use when starting SSRIs to minimize

activating effects

Antipsychotics Seroquel: PRN or regular doses

Medications

Psychotherapy

Details after this lecture

Cognitive Behavioural Therapy

Eye movement desensitization and reprocessing

Obsessive-Compulsive Disorder

Q: What is an Obsession?

A: Recurrent and persistent thoughts, impulse or images

Experienced as intrusive and inappropriate Cause marked anxiety and distress Not just worries about real life problems The person tries to ignore or suppress them Recognized as being part of their own mind

Q: What is a Compulsion?

A: Repetitive behaviours or mental acts that a person feels has to be done: In response to an obsession According to rules that have to be applied rigidly

Aimed at preventing or reducing distress or preventing a dreaded event or situation Excessive or not connected in a realistic way in what

is trying to be prevented

Obsessive – Compulsive Disorder

Obsessions AND/OR Compulsions

Pt recognizes are unreasonable

Cause marked distress, are time consuming (>1hr/day) or interfere with functioning

Treatment

Medications SSRI TCA: Clomipramine

Gold standard Antipsychotics: alone or as adjuvant txn

E.g. Seroquel 400-500mg, Risperidone 1-2mg

Psychotherapy CBT