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Anxiety disorders

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Show Notes

Slide 1 :

Anxiety Disorders Sharon Romm, MD Associate Professor, Psychiatry University of Washington

Slide 2 :

Overview Anxiety Disorders Normal Due to Medical Condition Substance-Induced Panic and Agoraphobia Specific Phobia and Social Phobia Obsessive-Compulsive Disorder PTSD and ATSD Generalized Anxiety Disorder

Slide 3 :

Normal Anxiety

Slide 4 :

Normal Anxiety Distinguish between normal and pathological Based on patient report of internal state Assessment of clinician, family, friends Pathological: inappropriate response by intensity or duration

Slide 5 :

FREUD Freud: “angst” means fear, not anxiety Distinction arose by accident Fear acute; anxiety chronic Example: boy afraid of barking dogs because he’s actually afraid of his father and associates father with barking dogs

Slide 6 :

Ego Perceived stress depends on defenses and coping mechanisms Ego: collective abstraction for the process by which a person perceives, thinks and acts on external events or internal drives Healthy ego = adaptive balance Balance between impulses and conscience Chronic imbalance = chronic anxiety

Slide 7 :

Problems of Being Anxious Heightened awareness of physical sensations Awareness of feeling anxiety Shame of being found out by others Not being appreciated Altered thinking, cognition

Slide 8 :

Theories of Pathological Anxiety Psychoanalytic: id, separation, castration, superego. Long-term tx Behavioral: conditioned response. Shellfish example. Overestimate danger and underestimate ability to cope Existential: Aware of profound nothingness

Slide 9 :

Which comes first? Biological Psychological

Slide 10 :

Biological Theories Autonomic nervous system. PANIC has sympathetic tone, slow adaptation to stimuli, excessive response Neurotransmitters: Norepinephrine locus ceruleus stimulation produces fear a2 agonists reduce anxiety Serotonin GABA Benzos enhance activity GABAa receptor Low potency treats GAD High potency treats panic Genetic: 50% panic patients have one affected relative

Slide 11 :

Anxiety due to General Medical Condition

Slide 12 :

Anxiety due to General Medical Condition Common. Incidence varies for each condition Etiology: thyroid, Vitamin B12, arrhythmia, post-encephalitis, tumors Panic: COPD, Parkinson’s GAD: Sjögren’s, Grave’s Diagnosis: heightened vigilance

Slide 13 :

Substance-induced Anxiety

Slide 14 :

Substance-Induced Anxiety Common: recreational and prescription Sympathomimetics: cocaine, caffeine Serotinergics: LSD, MDMA DX: symptoms develop within a month Think about malingering and personality disorders, particularly in urban ER’s

Slide 15 :

PANIC

Slide 16 :

Slide 17 :

Panic and Agoraphobia PANIC DISORDER characterized by spontaneous, unexpected PANIC ATTACKS

Slide 18 :

Panic and Agoraphobia Easy to misdiagnose as serious medical condition Easy to miss serious medical condition Frequency of panic attacks vary from many each day to a few a year Agoraphobia: fear of being in a place from which rapid exit difficult

Slide 19 :

Panic and Agoraphobia: Epidemiology Panic disorder: lifetime prevalence 3% Panic attacks: 4% Agoraphobia: 0.6% to 6%

Slide 20 :

Panic and Agoraphobia: Etiology Peripheral and central dysregulation Focus on locus ceruleus, median raphe, limbic system, pre-frontal cortex Panic-inducing substances: no clinical indication CO2, Isuprel, Caffeine, Pondimin, Yohimbine MRI: hippocampus abnormality

Slide 21 :

Panic and Agoraphobia: Etiology Genetic component Cognitive behavioral: can’t explain first attack Psychoanalytic theories: panic results from unsuccessful defense against anxiety. Previously mild signal becomes overwhelming Cause involves unconscious meaning of stressful event

Slide 22 :

Panic Attack Occurs in mental disorder other than panic Can be expected or unexpected 10 minutes rapidly increasing symptoms Extreme fear and sense of impending death Lasts 30 minutes, rarely more than an hour Anticipatory anxiety between attacks

Slide 23 :

Panic Disorder With or without agoraphobia DSM-IV: one attack followed by a month’s concern about having another Young, some faint, healthy Depression common Late-onset needs work-up

Slide 24 :

Panic Disorder: Course 40% resolve long-term 50% have mild symptoms 10% impaired

Slide 25 :

Panic Disorder: Treatment Good Meds: TCA,s SSRI’s, MAOI’s, Benzos Useless Meds: Buspar, Inderal Start low, go slow Benzos: Klonopin, Xanax up to 10mg/d Treat for a year! Combine with CBT

Slide 26 :

PHOBIA

Slide 27 :

Phobias Patients try to avoid stimulus Specific phobia: Most common Familial especially blood-injection-injury Onset as child Social anxiety disorder: 2.5 per 100 Onset as teen

Slide 28 :

Phobias: Treatment Difficult to treat Therapist must be active Insight-oriented therapy, hypnosis, CBT Meds: Benzos, MAOI’s, Inderal

Slide 29 :

OCD

Slide 30 :

OCD Obsession: recurrent, intrusive thought. Not simply worry. anxiety Compulsion: Action. anxiety Person realizes irrationality. Ego-dystonic experience. Attempt at thought supression Lifetime prevalence: 2.5% in all cultures

Slide 31 :

OCD: Course 75% have both obsessions and compulsions Sudden onset after stress 1/3 worsen; 1/3 improve; 1/3 stay ill 1/3 have Major Depression Suicide risk

Slide 32 :

OCD: Treatment Refractory to therapy Meds: Start with SSRI’s If necessary, add Li, try MAOI

Slide 33 :

Seattle earthquake, 2001 PTSD

Slide 34 :

PTDS and ATSD Must experience extreme trauma Re-experience trauma Avoid reminders Numbing Persistent hyper-arousal

Slide 35 :

PTDS and ATSD PTSD: Can develop in a week or a few decades. Duration of symptoms more than one month ATSD: Disturbance lasts at least 2 days, not more than a month and occurs within a month of trauma

Slide 36 :

PTDS and ATSD: Treatment VERY Difficult Treat symptoms: depression, anxiety, mood instability, symptoms resembling psychosis

Slide 37 :

Edvard Munch GENERALIZED ANXIETY DISORDER

Slide 38 :

Generalized Anxiety Disorder Excessive and pervasive worry Significant somatic symptoms: fatigue, irritability, muscle tension, sleep, restless Co-exists with other mental disorders Twice as many women than men One-year prevalence: 3 to 8%

Slide 39 :

Generalized Anxiety Disorder Combine meds and therapy Benzos, Buspar, TCA’s, Inderal Start low go slow

Slide 40 :

ANXIETY DISORDER NOS

Slide 41 :

Anxiety Disorder NOS Some have symptoms that don’t meet DSM-IV criteria for anxiety disorder or adjustment disorder Example: mixed anxiety-depressive disorder

Slide 42 :

Relieve anxiety…Try a cat!Personal communication: Sharon’s Norwegian Forest Cat, 2004

	sromm@u.washington.edu 1 Years ago. Category: Psychiatry

Tags:	Psychiatry

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