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Anxiety Disorders workshop

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Richard Duffy

on 15 April 2014

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Transcript of Anxiety Disorders workshop

Anxiety Disorders
Obsessive Compulsive Disorder
Generalized Anxiety Disorder
Lifetime prevalence 2-3%

Male = Female

Bimodal peaks 12-14 y and 20-22 y

Mean age of on-set is 20yrs though men have an earlier mean age [19yrs]
Obsessive Compulsive Disorder
Old literal meaning “fear of the market place”
Fear of being in a situation that are difficult or embarrassing to escape from
Extreme anxiety in open spaces, in crowds and on public transport and marked avoidance
75% patients are female
Age at onset ranges from 15-35 years
Patients experience dizziness, depersonalization, and depression
Secondary alcohol and substance misuse may also occur
Rx: CBT(graded exposure), anxiety mx, SSRI, TCA
SSRIs Lower starting dose required
TCA Imipramine, clomipramine
Benzodiazepines Short term use ONLY
Buspirone 5HT-1A partial agonist
Beta Blockers Symptomatic Mx

Less responsive to CBT than other anxiety disorders
Non specific treatments e.g. relaxation training and reassurance
Patients with GAD experience excessive anxiety and worry which are not caused by another anxiety disorder on most days for a period of at least 6 months- free-floating anxiety
Uncontrolled anxiety and worry impair social and occupational performance because restlessness, fatigue, poor concentration, irritability,muscle tension and sleep disturbance commonly occur
Good prognosis
Phobic, ruminative ideas predominate
Absence of compulsions
No childhood symptoms or abnormal personality

Poor prognosis
Males, early onset
Symmetry, exactness symptoms
Family history
Continuous, episodic or deteriorating course
Obsessive Compulsive Disorder
Characterized by obsessional thoughts that repeatedly enter consciousness against the patient’s will
Recognised as the patient’s own thoughts
The thoughts are unpleasant, abhorrent or out of keeping with the patient’s character (ego-dystonic)
Obsessive Compulsive Disorder
Most Common
Enclosed spaces- claustrophobia
Heights- acrophobia
Darkness- achluophobia
Storms- brontophobia
Animals- zoophobia
Blood- haematophobia
Tend to begin in childhood
Rx: CBT (systematic desensitization with relaxation and graded exposure), anxiety mx, flooding, modelling
Specific Phobias
Characterised by a persistent irrational fear that is usually recognised as such and that produces anticipatory anxiety for and avoidance of that feared object, activity or situation
Phobic anxiety differs from normal fear in that it is unreasonable and disproportionate to the stimulus
The commonest phobic anxieties in community samples are specific fears relating to illness, injury, storms or animals, and agoraphobia
The aetiology Genetic, evolutionary, learning theory, unconscious conflict
Phobic disorders
Pharmacological: SSRI’s, TCA’s, BDZ (1-2/52 ONLY),
Psychological: Behavioural, cognitive, psychodynamic
Tx of co-morbidity
A minimum of three attacks within three weeks in the absence of objective danger and without anxiety between attacks (other than anxiety related to anticipation of panic)
DSM-IV criteria
Episodic crescendo anxiety that is recurrent and unpredictable and which occurs in the absence of a stimulus
The heart rate may rise by 40 beats/min
Panic attacks last for 20-30 mins
Panic disorder

Genetic factors: Family studies have shown an increased risk for panic disorder / agoraphobia in ♀ relatives of anxiety d/o probands. Association between hypermobility and anxiety

An increased risk of anxiety d/o in ♀+♂ relatives of panic disorder probands, with prevalence ranging from 10% to 25%

May manifest as ‘neurotic’ or cluster C personality traits
Behavioural theories: Anxiety is a conditioned response to specific environmental stimuli eg.traumatic event

Psychological theories: Patients with anxiety disorders overestimate the probability of harm/threat in a given situation- cognitive element

Biological theories: Major neurotransmitters associated with anxiety are noradrenaline (locus coeruleus), serotonin (raphe nuclei), and gamma amino butyric acid (GABA)
Aetiology of anxiety disorders
Specific phobia
Social phobia
Panic disorder +/- agoraphobia
Generalized Anxiety disorder
Acute stress disorder
Adjustment disorder
Post traumatic stress disorder
Anxiety disorder due to medical condition/substances
Yerkes-Dodson Curve
Anxiety becomes abnormal when it is:
Disproportionate to the stimulus
Continues beyond exposure to the danger
Triggered by harmless situations
Occurring without cause

Anxiety becomes a psychiatric illness when it becomes so exaggerated, frequent and chronic that it causes a “significant impairment of function”

A state consisting of psychological and physical symptoms brought about by a sense of apprehension at a perceived threat

It is important to differentiate normal from pathological anxiety
Normal Anxiety
Protective factors:
Viewing body of dead relative after disaster
Psychopathic personality traits
Psychopathic traits
Predisposing factors
Low education/social class
previous psych illness
Poor supports
Neurotic personality traits
Prior traumatic events
Emotional numbing
intrusive memories/flashbacks/nightmares
avoidance of reminders of the trauma,
marked irritability
Insomnia/sleep disturbance
Partial or complete amnesia
autonomic hyperarousal
Include acute stress reactions and post traumatic stress disorder (PTSD)
Acute stress reaction: Patients develop this disorder following exposure to a threatening event such as assault, a major road accident or a natural catastrophe
Present within minutes to hours in a “dazed and disoriented state” with prominent autonomic symptoms of anxiety
Usually have no premorbid psychiatric diagnosis
Complete resolution of symptoms within 4 weeks (DSM-IV)
Stress disorders
6 month prevalence 2.5-6%
♀>♂ esp early age onset with hx childhood fears + relationship difficulties
Genetic - Heritability 30%
Environmental factors NB eg.Loss of parents by death
Pharmacotherapy (serotonergic action)
Success rate 50-80%
Relapse often following discontinuation

Behavioural methods: modelling, exposure and response prevention. 60-85% effective
Psychoanalytic therapy not effective
Psychosurgery (cingulotomy); 65% improve
Obsessive Compulsive Disorder
First degree relatives of OCD patients have increased rates of:
Anxiety, phobia, depression, schizophrenia
Obsessional traits
OCD (esp. early onset in probands)
Increased rate of OCD in MZ twins vs DZ twins
Tourette’s syndrome
Sydenham’s chorea
Obsessive Compulsive Disorder
Fear of being judged, embarrassed and/or humiliated in social situations
Avoid social interactions and seek to avoid the gaze of others
Age of onset ranges from 15-35 years
Marked anticipatory anxiety
Alcohol and drug misuse common- more so than other phobic anxiety d/o
Secondary depression occurs in up to 40% of patients
Rx: CBT, anxiety mx, antidepressants
Social phobia
F40 - Phobic disorders-
.0 - agoraphobia +/- panic d/o
.1 - social phobias
.2 - specific [isolated] phobias
F41 - Other anxiety disorders-
.0 - panic d/o [episodic paroxysmal anxiety]
.1 - GAD
.2 - mixed anxiety/depressive disorders
.3 - Other mixed anxiety d/o
F42 - OCD
F43 - Reaction to severe stress and adjustment d/o-
.0 - Acute stress reaction
.1 - PTSD
.2 - Adjustment d/o
F44 - Dissociative (conversion) disorders
F45 - Somatoform disorders
ICD- 10
Dr. Richard Duffy
Special Lecturer in Psychiatry
Lifetime prevalence 1.2% [1-4%]
Female:Male ratio 2-3:1
Highest risk in women aged 25-44 y, family history of panic disorder, divorced or separated
Phobic Disorders
Post Traumatic stress disorder
Symptoms arise only after an exceptionally threatening event that is outside the normal range of experience e.g., combat, rape, torture or attempted murder
Delayed onset of symptoms with latency of weeks to months (ICD 10- within 6 months)
Always enquire about.
Substance misuse
Somatization symptoms
Co morbidity
MAOI/TCA intrusive symptoms
SSRIs for avoidance symptoms
Clonidine, CBZ and propranolol reduce arousal
Fluoxetine and Li improve mood and reduce explosiveness
Exposure to aversive memories in a supportive setting known as habituation
CBT - cognitive restructuring
Eye Movement desensitization and reprocessing
25% of people exposed to a threatening event develop PTSD
Reduced hippocampal volume
Amygdala dysfunction leads to enhanced fear response
Greater concordance in MZ vs DZ twins
Risk after a trauma atic event is 8-13% for men and 20-30% for women
Life time prevelence 7.8%
Large cultural diferences
50% will still have PTSD in 10 yrs
Shell shock described following WW1
WW2 it was called multiple names traumatic war neurosis, combat fatigue, battle stress, and gross stress reaction
DSM-1 1952 gross stress reaction
Omitted from DSM-2 in 1968
But reappeared in DSM-3 following the Vietnam war
Observed outside of wartime situations
PTSD first used in 1980
Life time prevalence 11.3%
12 months 8.8%
Male:Female 1:3-20
Childhood onset
MZ:DZ 26%:11%
All other phobias increase your heart rate and BP but haematophobia reduces them both
Strongest genetic link
Numbers & Cause
Panic disorder and agarophobia is up to six times more common in women than in men
Heritability 30-40%
intense fear of dying, losing control, collapsing or “going ma

palpitations, sweating, trembling, SOB, choking Chest pain or discomfort, nausea or abd. Discomfort, parasthesias, chills or hot flushes
Co morbidity
Agrophobia 30-50%
Depression Up to 68%
Other anxiety disorders 50%
Alcohol up to 30%
Medical conditions
Mitral valve prolapse
Increased sensitivity to serotonin
Increased adrenergic activity
Decreased GABA sensitivity
Altered metabolic activity from lactate
CO hypothesis
Irregular amygdala or hypothalamus
Psychological factors:
Learning theory: Use of rituals prevents the natural reduction in anxiety that would normally occur
Psychoanalytic: Defence responses to unconscious conflict
Obsessional personality located at anal stage of development
Neurological factors
Caudate size which normalises with Rx
More abnormal births
Neuronal loop: orbito-frontal cortex-caudate-thalamus (supported by MRI+PET studies)
Commonest obsessions are contamination,doubt,orderliness,symmetry
Compulsions are recurrent, stereotyped actions, carried out in response to obsessional thoughts not useful/enjoyable
They relieve the tension produced by obsessional thoughts and may have a symbolic, magical quality
Repeating rituals are seen in 50% of patients with OCD but checking, cleaning and counting are also common
During this workshop there will be a number of questions for discussion. divide into groups of 2-4 for these discussion times

Learning points
To be able to distinguish normal anxiety from an anxiety disorder
To understand the different features of common anxiety disorders
To be able to form a differential diagnosis for a patient presenting with symptoms of anxiety
To understand the treatments of different anxiety disorders
Case Study
You are the psych reg on call. A less than helpful ED reg refers you a lady saying she is anxious and has no medical problems, is not psychotic and not depressed.
What different diagnosis could he mean when he say she is anxious?
What questions is it important to ask?
What causes anxiety disorders?
What is the difference between normal anxiety and pathological anxiety?
What is a phobia?
What are common phobias?
Case study continued
In ED you meet Sarah the "anxious" lady. Sarah is 32 Sarah has been having long standing anxiety for the last two years. It is there most of the time and she finds herself worry about everything. This has greatly impaired her functioning and her quality of life. Prior to this she was a teacher and she has had to stop working. The anxiety is not about anything particular. What is the most likely diagnosis?
What are the potential co-morbidities she may have?
How would you manage her generalised anxiety?
Case study continued
While you are seeing Sarah in the ED she starts to have a panic attack
What symptoms might she experience?
She asks you for some diazepam as her GP has been giving this to her for the last few months
Do you think this has helped her?
Will you give her diazepam now?
If you are interested in understanding more about panic attacks you can watch the video below in your own time
Do you recognise either of the two following clips?
What symptoms of OCD do you notice?
What are the obsessions?
What are the compulsions you notice?
The OPD cart of a patient with OCD
Full transcript