Anxiety disorders

Presented by : P.Harsha Vardhan Reddy

Anxiety : definition

• Anxiety is an emotional state commonly caused by the perception of real or perceived danger that threatens the security of an individual. It allows a person to prepare for or react to environmental changes. Everyone experiences a certain amount of nervousness and apprehension when faced with a stressful situation.

• This is an adaptive response, and is transient in nature.

• Anxiety can produce uncomfortable and potentially debilitating psychological (e.g., worry or feeling of threat) and physiological arousal (e.g., tachycardia or shortness of breath) if it becomes excessive. Some individuals experience persistent, severe anxiety symptoms and possess irrational fears that significantly impair normal daily functioning. These persons often suffer from an anxiety disorder.

Anxiety disorders Reported more by women than men.

• Anxiety disorders are among the most frequent mental disorders encountered in clinical practice.

• Health care professionals often mistake anxiety disorders for physical illnesses, and only 23% of patients receive appropriate treatment.

• Failure to diagnose and manage anxiety disorders results in negative outcomes including overuse of health care resources, increased morbidity, and mortality.

Fear vs Phobia

• Fear protects you from danger. Phobias have little to do with danger.

• More than 19 million Americans have a phobia -- an intense, irrational fear when they face a certain situation, activity, or object. With a phobia, you may know your anxiety and fear are not warranted, but you can't help the feelings. And they can be so intense they virtually paralyze you.

• The Three Kinds of Phobia

• Hundreds of different phobias have been identified, including phobophobia or fear of phobias. But when talking about phobias, which are a kind of anxiety disorder, experts divide them into three categories -- 

• agoraphobia, an intense anxiety in public places where an escape might be difficult;

•  social phobia, a fear and avoidance of social situations; and

•  specific phobia, an irrational fear of specific objects or situations.

Pathophysiology

• Data from biochemical and neuroimaging studies indicate that the modulation of normal and pathologic anxiety states is associated with multiple regions of the brain and abnormal function in several neurotransmitter systems, including norepinephrine (NE), γ –aminobutyric acid (GABA), and serotonin (5-HT).

• Noradrenergic model : This model suggests that the autonomic nervous system of anxious patients is hypersensitive and overreacts to various stimuli. The locus ceruleus may have a role in regulating anxiety, as it activates norepinephrine release and stimulates the sympathetic and parasympathetic nervous systems.

• γ-Aminobutyric acid (GABA) receptor model : GABA is the major inhibitory neurotransmitter in the CNS. Many antianxiety drugs target the GABAA receptor. Benzodiazepines (BZs) enhance the inhibitory effects of GABA,which has a strong regulatory or inhibitory effect on serotonin (5-HT), norepinephrine, and dopamine systems.

• Anxiety symptoms may be linked to underactivity of GABA systems or downregulated central BZ receptors. In patients with GAD, BZ binding in the left temporal lobe is reduced Abnormal sensitivity to antagonism of the BZ binding site and decreased binding was demonstrated in panic disorder.

• Abnormalities of GABA inhibition may lead to increased response to stress in PTSD patients.

• • 5-HT model : GAD symptoms may reflect excessive 5-HT transmission or overactivity of the stimulatory 5-HT pathways. Patients with SAD have greater prolactin response to buspirone challenge, indicating an enhanced central serotonergic response. The role of 5-HT in panic disorder is unclear, but it may have a role in development of anticipatory anxiety. Preliminary data suggest that the 5-HT and 5-HT2 antagonist metachlorophenylpiperazine causes increased anxiety in PTSD patients.

• In patients with SAD, there may be abnormalities in the amygdala, hippocampus, and various cortical regions.

• Lower hippocampal volumes in patients with PTSD may be a precursor for subsequent development of PTSD.

Clinical presentation :

GENERALIZED ANXIETY DISORDER

• The diagnostic criteria for GAD require persistent symptoms for most days for at least 6 months.

• The essential feature of GAD is unrealistic or excessive anxiety and worry about a number of events or activities. or other important areas of functioning.

• The majority of patients with GAD eventually will develop another mental disorder.

• GAD is usually the primary disorder in patients with comorbid anxious depression.

Presentation of Generalized Anxiety Disorder

Psychological and cognitive symptoms :

• Excessive anxiety

• Worries that are difficult to control

• Feeling keyed up or on edge

• Poor concentration or mind going blank

Physical symptoms :

• Restlessness, Fatigue, Muscle tension, Sleep disturbance, Irritability

Panic disorder :

• Panic disorder begins as a series of unexpected (spontaneous) panic attacks involving an intense, terrifying fear similar to that caused by life-threatening danger.

• During an attack, patients often describe an overwhelming sense of doom, a fear of dying or losing control, and at least four physical symptoms.

• Panic attacks usually last no more than 20 to 30 minutes,

• With the peak intensity of symptoms within the first 10 minutes.

• Secondary to the panic attacks, many patients eventually develop agoraphobia.

Symptoms of a Panic Attack

Psychological symptoms :

• Depersonalization, Derealization, Fear of losing control, Fear of going crazy, Fear of dying.

Physical symptoms :

• Abdominal distress, Chest pain or discomfort, Chills, Dizziness or light-headedness, Feeling of choking, Hot flushes, Palpitations, Nausea, Shortness of breath, Sweating, Tachycardia, Trembling or shaking.

SOCIAL ANXIETY DISORDER :

• SAD is characterized by an intense, irrational, and persistent fear of being negatively evaluated or scrutinized in at least one social or performance situation. Exposure to the feared circumstance usually provokes an immediate situation-related panic attack.

• Blushing is the principal physical indicator and distinguishes SAD from other anxiety disorders.

• Adults with SAD usually recognize their fear is excessive and unreasonable; however, they are unable to overcome it without treatment.

• In individuals under 18 years of age, the duration of symptoms is at least 6 months. The fear or avoidance is not caused by a drug or other substance (e.g., cocaine), or a general medical or psychiatric Disorder.

• The mean age of onset of SAD is during the mid-teens. Rates of SAD are slightly higher among women than men and more frequent in younger cohorts. It is a chronic disorder with a mean duration of 20 years.

Presentation of Social Anxiety Disorder

Fears

• Being scrutinized by others, Being embarrassed, Being humiliated

Some feared situations

• Addressing a group of people, Eating or writing in front of others, Interacting with authority figures, Speaking in public, Talking with strangers, Use of public toilets

Physical symptoms

• Blushing, Butterflies in the stomach, Diarrhea, Sweating, Tachycardia, Trembling

Types

• Generalized type: fear and avoidance extend to a wide range of social situations

• Nongeneralized type: fear is limited to one or two situations.

• SPECIFIC PHOBIA

POSTTRAUMATIC STRESS DISORDER

• In PTSD, exposure to a traumatic event causes immediate intense fear, helplessness, or horror.

• PTSD can occur at any age, and the course is variable.

• One-third of patients with PTSD have a poor prognosis, and about 80% have a concurrent depression or anxiety disorder.

• Over half of men with PTSD have comorbid alcohol abuse or dependence, and about 20% of patients attempt suicide.

Presentation of Posttraumatic Stress Disorder

Re-experiencing symptoms

• Recurrent, intrusive distressing memories of the trauma, Recurrent, disturbing dreams of the event, Feeling that the traumatic event is recurring (e.g., dissociative flashbacks), Physiologic reaction to reminders of the trauma

Avoidance symptoms

• Avoidance of conversations about the trauma, Avoidance of thoughts or feelings about the trauma, Avoidance of activities that are reminders of the event, Avoidance of people or places that arouse recollections of the trauma, Inability to recall an important aspect of the trauma, Anhedonia, Restricted affect, Sense of a foreshortened future (e.g., does not expect to have a career, marriage)

Hyper-arousal symptoms

• Decreased concentration, Easily startled, Hypervigilance, Insomnia, Irritability or angry outbursts

Subtypes

• Acute: duration of symptoms is less than 3 months

• Chronic: symptoms last for longer than 3 months

• With delayed onset: onset of symptoms is at least 6 months posttrauma

Obsessive-compulsive disorder (OCD)

• Obsessive-compulsive disorder (OCD) is one of the ten leading causes of disability.

• Patients with OCD experience significant impairment in their quality of life (QOL), with reductions in social, family, and occupational functioning.

• OCD affects far more individuals than was thought in the past.

• Because of the nature and potential severity of signs and symptoms and the resultant negative effects on QOL, OCD is considered a major medical condition.

• Clinicians should be able to identify OCD and understand the current treatment options.

• There is no exact cause for this condition.

Presentation of Obsessive-Compulsive Disorder

Obsessions

• Repetitive thoughts (e.g., feeling contaminated after touching an object, doubting whether the stove was turned off), Repetitive images (e.g., recurrent sexually explicit pictures), Repetitive impulses (e.g., need for symmetry or putting things in specific order, impulse to shout out obscenities in a church)

• Compulsions

• Repetitive activities (e.g., hand washing, checking, ordering, need to ask, need to confess)

• Repetitive mental acts (e.g., counting, repeating words silently, praying)

DRUG-INDUCED ANXIETY

• Drugs are a common cause of anxiety symptoms. Anxiety occurs during the use of central nervous system (CNS) stimulating drugs in a dose-dependent manner, but ingestion of minimal amounts can result in marked anxiety, including panic attacks, in some individuals.

• The onset of drug-induced anxiety is usually rapid after the initiation of therapy; look for a recent drug or dosage change to rule out drug etiologies for anxiety.

• Anxiety occurs occasionally during the use of cns depressants, especially in children and the elderly; however, anxiety complaints are more common as complications of drug withdrawal after the abrupt discontinuation of these agents.

Drugs Associated with Anxiety Symptoms

• Anticonvulsants: carbamazepine• Antidepressants: selective

serotonin reuptake inhibitors, tricyclic

• antidepressants• Antihypertensives: felodipine• Antibiotics: quinolones, isoniazid• Bronchodilators: albuterol,

theophylline• Corticosteroids: prednisone• Dopa agonists: levodopa

• Herbals: ma huang, ginseng, ephedra

• Nonsteroidal anti-inflammatory drugs: ibuprofen

• Stimulants: amphetamines, methylphenidate, caffeine, cocaine

• Sympathomimetics: pseudoephedrine

• Thyroid hormones: levothyroxine

• Toxicity: anticholinergics, antihistamines, digoxin

• Withdrawal: alcohol, sedatives.

MEDICAL DISEASES ASSOCIATED WITH ANXIETYCommon Medical Illnesses Associated with Anxiety Symptoms :

Cardiovascular :

• Angina, arrhythmias, congestive heart failure, ischemic heart disease, myocardial infarction

Endocrine and metabolic :

• Cushing’s disease, hyperparathyroidism, hyperthyroidism, hypothyroidism, hypoglycemia, hyponatremia, hyperkalemia, pheochromocytoma, vitamin B12 or folate deficiencies

Neurologic :

• Dementia, migraine, Parkinson’s disease, seizures, stroke, neoplasms, poor pain control

Respiratory system :

• Asthma, chronic obstructive pulmonary disease, pulmonary embolus, pneumonia

Others :

• Anemias, systemic lupus erythematosus, vestibular dysfunction

Treatment :

• Treatment for anxiety disorders often requires multiple approaches.

• The patient may need short-term treatment with an anxiolytic, such as a benzodiazepine, to help reduce the immediate symptoms combined with psychological therapies and an antidepressant for longer term treatment and prevention of symptoms returning.

Psychotherapy :

• The specific psychotherapy with the most supporting evidence in anxiety disorders is cognitive behavioural therapy (CBT). Cognitive behaviour therapy focuses on the ‘here and now’ and explores how the individual feels about themselves and others and how behaviour is related to these thoughts.

• Through individual therapy or group work the patient and therapist identify and question maladaptive thoughts and help develop an alternative perspective. Individual goals and strategies are developed and evaluated with patients encouraged to practice what they have learned between sessions.

• Therapy usually lasts for around 60–90 minutes every week for 8–16 weeks, or longer in more resistant cases.

• Specific phobias are also almost exclusively treated using exposure techniques and most patients will respond to this treatment. Only a very few will require additional drug therapy.

Pharmacotherapy :

Benzodiazepines : Benzodiazepines are commonly prescribed to provide immediate relief of the symptoms of severe anxiety. A number of different benzodiazepines are available. These drugs differ considerably in potency (equivalent dosage) and in rate of elimination but only slightly in clinical effects.

All benzodiazepines have sedative/hypnotic, anxiolytic, amnesic, muscular relaxant and anticonvulsant actions with minor differences in the relative potency of these effects.

Mechanism of action :

Anti-depressants :

Selective serotonin reuptake inhibhitors Tricyclic antidepressants Monoamine oxidase inhibhitors

Other medications occasionally used in anxiety :

• Hydroxyzine – sedating anti-histamine – used in GAD

dose- 50-100mg

• Anti-psychotics – has limited evidence and high side effects

• Pregabalin – only for GAD (licenced)

• Buspirone – 5HT1a partial agonist(anxiolytic-psychoactive drug)-GAD

• Propranolol & oxprenolol- licensed to treat anxiety symptoms- used in PTSD

Summary :