Anxiety disorders

·        Introduction.

·        Etiology.

·        General anxiety disorder.

·        Panic disorder.

·        Phobic disorder.

Introduction

1.       Anxiety is an unpleasant emotional state in response to stress and is often accompanied by physiologic and behavioral changes.

2.       Anxiety can arise suddenly, as in panic, or gradually over minutes, hours, or days. The anxiety itself can last for any length of time, from a few seconds to years.

3.       Anxiety disorders are the most common type of psychiatric disorder. The diagnosis of an anxiety disorder is based largely on its symptoms.

4.       Types of anxiety disorders:

a.       Generalized anxiety disorder (GAD).

b.       Panic disorder.

c.       Phobic disorder.

5.       These are disorders characterized by underlying anxiety either directly experienced or controlled automatically by defense mechanisms:

a.    The disorder is experienced as uncomfortable symptoms which the patient feels are foolish and fights against.

b.       Usually abrupt development; in adulthood.

c.    No gross misinterpretation of reality or personality disorganization.

6.       There are two concepts which are important in these conditions:

a.       Primary gain: what the symptom does for the patient’s internal psyche, e.g. prevents overwhelming of the ego.

b.       Secondary gain: what the symptom gets the patient, e.g. sympathy, attention, avoidance of personality.

Etiology

1.       Genetic:

a.       Anxiety neurosis occurs in 15% of relatives of affected patients.

b.       Higher concordance rate for monozygotic twins compared to dizygotic twins.

2.       Psychodynamic theory:

a.       Anxiety disorders reflects overwhelming stress, anxiety and difficulties in the child-parent relationship in early childhood.

b.       Psychoanalysts interpret phobic neurosis as an unconscious avoidance of unacknowledged feelings of temptation, the phobia representing a displacement of the real fear.

3.       Learning theory: regards anxiety as a fear response that has been attached to another stimulus through conditioning.

Generalized anxiety disorder

1.       Generalized anxiety disorder consists of excessive, almost daily anxiety and worry (lasting 6 months or longer) about a variety of activities or events.

2.    The anxiety and worry of generalized anxiety disorder are so extreme that they are difficult to control; the patient does not have awareness of what is triggering the anxious condition.

3.    The person experiences three or more of the following symptoms:

a.       Restlessness.

b.    Easy fatigue.

c.       Difficulty concentrating.

d.       Irritability.

e.       Muscle tension.

f.       Disturbed sleep.

4.       Onset:

a.       Generalized anxiety disorder is common; about 3 to 5 percent of adults have it at some time during a given year.

b.       Women are twice as likely as men to have the disorder.

c.    It often begins in childhood or adolescence but may start at any age.

d.    For most people, the condition fluctuates, worsening at times (especially during times of stress), and persists over many years.

5.       Physiologic symptoms:

a.       Gastrointestinal:

i.     dry mouth.

ii.       difficulty in swallowing.

iii.       epigastric discomfort.

iv.       flatulence.

v.       diarrhoea.

b.       Respiratory:

i.       feeling of chest constriction.

ii.       difficulty in inhaling.

c.       Cardiovascular:

i.       palpitations.

ii.       awareness of missed beats.

iii.       feeling of pain over heart.

d.       Genitourinary:

i.       increased frequency.

ii.       failure of erection.

iii.   lack of libido.

e.       Nervous system:

i.       tinnitus.

ii.       blurred vision.

iii.       dizziness.

iv.       headache.

v.       sleep disturbance.

f.       Psychological symptoms:

i.       apprehension and fear.

ii.       irritability.

iii.       difficulty in concentrating.

iv.       distractibility.

v.       restlessness.

vi.       sensitivity to noise.

vii.       depression.

viii.       obsessional symptoms.

ix.       depersonalization.

6.       Differential medical problems:

a.       Hyperthyroidism.

b.       Hypoglycaemia.

c.       Phaechromocytoma.

7.       Psychiatric disorders:

a.       Depressive illness.

b.       Schizophrenia.

c.       Presenile dementia.

d.       Alcohol dependence.

e.    Drug dependence.

f.       Benzodiazepine withdrawal.

8.       Treatment:

a.       Antianxiety drugs such as benzodiazepines are usually prescribed, because long-term use of benzodiazepines can lead to physical dependence, the drug must be slowly tapered off slowly rather than stopped abruptly if discontinued.

b.       Buspirone:

i.       another effective drug for many people with generalized anxiety disorder.

ii.    its use apparently doesn't lead to physical dependence.

iii.       however, buspirone may take 2 weeks or longer to start working, in contrast to benzodiazepines, which begin to work within minutes.

c.       Other drugs:

i.       diazepam.

ii.       chlordiazepoxide.

iii.       lorazepam.

d       Generalized anxiety disorder may be associated with underlying psychologic conflicts – psychotherapy may be effective in helping to understand and resolve internal conflicts.

Panic disorder

1.       Introduction:

a.       Panic attacks are discrete periods of intense fear or discomfort, usually for a few minutes, rarely, a few hours.

b.       Panic attacks may occur in any anxiety disorder, usually in response to a specific situation tied to the main characteristics of the disorder.

c.    Is classified as a disorder when the episodes occur more than once and are unpredictable in their appearance.

2.       Characteristics:

a.    Has dramatic, acute symptoms lasting minutes to hours.

b.    Is self limiting.

c.       Occurs in patients with or without chronic anxiety.

d.       Symptoms peak in 10 minutes.

e.    The occurrence of panic attack is unexpected or spontaneous.

f.     The patient is generally well between attacks, although there may be persistent fear of having another attack.

g.       Besides panic disorder, panic attacks may also occur in phobic disorders and post-traumatic stress disorder.

3.       Prevalence:

a.    The life-time prevalence of panic disorder is between 3 and 5%, with women (5%) more commonly affected than men (2%).

b.       Onset is often in late adolescence and early 20s.

4.       Symptoms:

a.    A panic attack involves the sudden appearance of at least 4 of the following symptoms:

i.       shortness of breath or sense of being smothered.

ii.       dizziness, unsteadiness, or faintness.

iii.       palpitations or accelerated heart rate.

iv.       trembling or shaking.

v.       sweating.

vi.       choking.

vii.       nausea, stomachache or diarrhoea.

viii.       feelings of unreality, strangeness, or detachment from the environment.

ix.       numbness or tingling sensations.

x.       flushing or chills.

xi.       chest pain or discomfort.

xii.   fear of dying.

xiii.  fear of ‘going crazy’ or losing control.

b.       Since panic attacks are often unexpected or occur for no apparent reason, people who have them frequently anticipate and worry about another attack--a condition called anticipatory anxiety--and avoid places where they have previously panicked.

c.    This avoidance of places is called agoraphobia. If agoraphobia is severe enough, a person may become housebound.

d.       Because symptoms of a panic attack involve many vital organs, people often worry that they have a dangerous medical problem involving the heart, lungs, or brain and seek help from a doctor or hospital emergency department.

e.    Most also develop agoraphobia – the patient reports that he is afraid of embarrassing self in public. (agoraphobia can occur without panic disorder).

5.       Treatment:

a.    Most people recover from panic attacks without treatment; a few develop panic disorder.

b.       Pharmacotherapy:

i.       drugs used to treat panic disorders include tricyclic antidepressants and antianxiety drugs such as benzodiazepines.

ii.       benzodiazepines work faster than antidepressants but can cause physical dependence and more likely to cause adverse effects such as sleepiness, impaired coordination and slowed reaction time.

iii.       SSRIs are preferred because they are effective and they have fewer side effects and cause less physical dependency than benzodiazepines.

c.       Drugs used:

i.       alprazolam.

ii.       imipramine.

iii.       clomipramine.

iv.       fluoxetine.

v.       paroxetine.

d.       Exposure therapy:

i.     a type of behavior therapy in which the person is exposed repeatedly to whatever triggers a panic attack, often helps to diminish the fear.

ii.       exposure therapy is practiced until the person develops a high level of comfort with the anxiety-provoking situation.

e.       Psychotherapy with a view to gaining insight and better understanding of any underlying psychologic conflicts may also be useful.

Phobic disorders

1.       Phobias involve persistent, unrealistic, intense anxiety in response to external situations.

2.       Characteristics:

a.       Intense fear of an object or situation.

b.       Usually the object or situation of which the person is fearful is not the true feared object; the object feared is being displaced upon.

c.       Encounter with the object or situation produces intense fear.

d.       Person avoids phobic object or situation.

e.       Recognizes the fear is excessive or unreasonable.

f.     The person fears he will experience humiliation or embarrassment.

3.       Categories:

a.       Simple.

b.       Specific.

c.       Social.

d.       Agoraphobia.

4.       Specific phobias:

a.    Most common of anxiety disorders – about 7% of women and 4.3% of men have a specific phobia during any 6-month period.

b.       Some specific phobias, such as the fear of large animals, the dark, or strangers, begin early in life.

c.       Many phobias stop as the person gets older.

d.       Other phobias, such as fear of rodents, insects, storms, water, heights, flying, or enclosed places, typically develop later in life.

e.       Treatment:

i.       Exposure therapy, a type of behavior therapy in which the person is gradually exposed to the feared object or situation, is the best treatment for a specific phobia.

ii.       Drugs aren't very useful in helping people overcome specific phobias. However, benzodiazepines (antianxiety drugs) may give a person short-term control over a phobia, such as the fear of flying.

iii.       Psychotherapy, with a view toward gaining insight and understanding of internal conflicts, may be helpful in identifying and treating the conflicts that may underlie a specific phobia.

5.       Social phobia

a.    A social phobic is inappropriately anxious in situations where he may be subject to possible scrutiny by others, and fears that he may act in any way that will be humiliating or embarrassing.

b.       Situations that commonly trigger anxiety among people with social phobia include public speaking; performing publicly, such as acting in a play or playing a musical instrument; eating in front of others; signing a document before witnesses; and using a public bathroom.

c.       When confronted by such situations, he / she immediately experiences an autonomic hyperarousal state.

d.       Social phobia affects both men and women equally; it is commoner than simple phobia, with onset usually around early adolescence and young adulthood.

e.       Social phobia often persists if left untreated, causing many people to avoid activities in which they would otherwise like to participate.

f.       Treatment:

i.       Exposure therapy, a type of behavior therapy, works well for social phobia, but arranging for exposure to last long enough to permit habituation and comfort may not be easy.

ii.       Antidepressants, such as sertraline and phenelzine, and antianxiety drugs, such as clonazepam, can often help people with social phobia.

iii.       Psychotherapy, which involves talking with a therapist to better understand underlying conflicts, (may be particularly helpful for people who are capable of examining their own behavior and making changes in the way they think about and react to situations.

6.       Agoraphobia:

a.       Although agoraphobia literally means fear of the marketplace or open spaces, the term more specifically describes the fear of being trapped without a graceful and easy way to leave if anxiety should strike.

b.       Typical situations that are difficult for people with agoraphobia include standing in line at a bank or supermarket, sitting in the middle of a long row in a theater or classroom, and riding on a bus or airplane.

c.       Some people develop agoraphobia after experiencing a panic attack in one of these situations.

d.       Other people simply feel uncomfortable in these settings and may never, or only later, develop panic attacks.

e.       Agoraphobia often interferes with daily living, sometimes so drastically that it leaves the person housebound.

f.       Onset:

i.       Agoraphobia is diagnosed in 3.8 percent of women and 1.8 percent of men during any 6-month period.

ii.       About two-thirds to three-quarters of the sufferers are women.

iii.   The disorder most often begins in the early 20s; a first appearance after age 40 is unusual.

g.       Treatment:

i.     The best treatment for agoraphobia is exposure therapy, a type of behavior therapy.

ii.    With the help of a therapist, the person seeks out, confronts, and remains in contact with what he fears until his anxiety is slowly relieved by familiarity with the situation (a process called habituation).

iii.       Exposure therapy helps more than 90 percent of the people who practice it faithfully.

iv.   If agoraphobia isn't treated, it usually waxes and wanes in severity and may even disappear without formal treatment, possibly because the person has conducted some personal form of behavior therapy.

v.       People with agoraphobia who are deeply depressed may need to take an antidepressant.

7.       Drugs used:

a.       Diazepam.

b.       Lorazepam.

c.       Moclobemide & Paroxetine (for social phobia).

Obsessive-Compulsive Disorder

1.       Obsessive-compulsive disorder is characterized by the presence of recurrent, unwanted, intrusive ideas, images, or impulses that seem silly, weird, nasty, or horrible (obsessions) and an urge or compulsion to do something that will relieve the discomfort caused by an obsession.

2.       Obsessions:

a.       Obsessions are recurrent ideas, images or impulses, which enter the individual’s mind in a stereotyped manner and against his will.

b.       Often such thoughts are absurd, obscene or violent in nature, or else senseless.

c.       Though the patient recognizes them as his own, he feels powerless over them.

d.    The commonest obsession involved is fear of contamination by dirt, germs or grease, leading to compulsive cleaning rituals.

e.       Other themes of obsessions include aggression, orderliness, illness, sex, symmetry and religion.

f.       People can become obsessional about anything, and their rituals aren't always logically connected to the discomfort that these rituals relieve.

3.       Compulsions:

a.       Compulsive acts or rituals are stereotyped behaviors, performed repetitively without the completion of any inherently useful task.

b.       Rituals used to control an obsession include washing or cleaning to be rid of contamination, checking to allay doubt, hoarding to prevent loss, and avoiding the people who might become objects of aggression.

c.    Most rituals, such as excessive hand washing or repeated checking to make sure a door has been locked, can be observed.

d.       Other rituals are mental, such as repetitive counting or making statements intended to diminish danger.

4.       Prevalence:

a.       Obsessive-compulsive disorder affects about 2.3 percent of adults and occurs about equally in men and women.

b.       Because people with this disorder are afraid they'll be embarrassed or stigmatized, they often perform their rituals secretly, even though the rituals may occupy several hours each day.

c.       About one third of the people with obsessive-compulsive disorder are depressed at the time the disorder is diagnosed. Altogether, two thirds become depressed at some point.

5.       Etiology

a.       Psychodynamic theory:

i.       Freud regards obsessions as psychological responses to unconscious impulses of an aggressive or sexual nature.

ii.    He focused on the mother-infant interaction, and considered issues of aggression and autonomy to be paramount around the time of toilet training when the child tries to withhold faecal masses while the mother persuades that he gives that up.

iii.       Obsessive compulsive behaviors then are an expression of hostile impulses by the child against the mother.

iv.   The development of obsessional symptoms in later life is seen as a regression to this earlier anal-sadistic phase in life.

b.       Learning theory:

i.       Views obsessions and compulsions as conditioned responses to reduce anxiety, and become established when the patient experiences some relief by this mechanism, which in turn reinforces the act.

ii.       Compulsive rituals also provide the feeling of order and control, something which most OCD patients are preoccupied with, and afraid of losing.

c.       Organic factors:

i.     OCD is associated with neurological disorders involving dysfunction of the striatum, including Parkinson’s disease, Sydenham’s chorea, and Huntington’s chorea.

ii.       Neuroimaging data suggest that abnormalities exist in the frontal lobe and basal ganglia.

6.       Clinical features:

a.       Obsessions.

b.       Compulsions.

c.       Anxiety symptoms.

d.       Avoidance behavior: the sufferer will simply avoid public toilets, or touching any ‘contaminated’ objects which would lead to restricting one’s social life.

e.       Depression.

7.       Differential diagnoses:

a.       Generalized anxiety disorder: the patient typically experiences ‘free-floating’ anxiety rather than pre-occupation with certain thoughts or fears as in OCD.

b.       Panic disorder: the patient often describes discrete attacks of acute anxiety, and is generally well in between.

c.       Phobic disorder: exhibit avoidance behaviors like OCD, but the anxiety is more situation specific and focal in nature.

d.       Some patients with major depressive disorder experience rumination of negative thoughts; the latter are secondary to the mood state, and would normally diminish once the mood is elevated.

e.       Schizophrenic patients may exhibit stereotyped behaviors, but there are also delusions and hallucinations.

f.     Most people with obsessive-compulsive disorder are aware that their obsessions don't reflect actual risks. They realize that their physical and mental behavior is excessive to the point of being bizarre.

7.       Pharmacotherapy:

a.    The mainstay of pharmacotherapy for OCD are the antidepressants: clomipramine, fluoxetine, fluvoxamine, paroxetine and sertraline.

b.       Mood stabilizers have been used in augmenting the antidepressant treatment especially in patients with concomitant major depression.

c.       Sometimes the very bizarre compulsions or obsessional thoughts in OCD patients almost border on the psychosis and antipsychotic drugs, e.g. haloperidol, trifluoperazine have been prescribed in low dosage in combination with antidepressants.

8.       Cognitive behavior therapy:

a.       Exposure therapy: it involves the deliberate exposure of the OCD patient to some anxiety provoking stimuli.

b.       Modelling: involves a demonstration by the therapist on how to handle a feared situation without resorting to compulsive rituals.

c.       Cognitive therapy: the patient is taught to challenge the validity of his fears, which are often an over-estimation of risk.

9.       Electroconvulsive therapy is generally not useful in OCD patients who are not depressed or suicidal.

10.       Prognosis:

a.    OCD has a chronic and deteriorating course, with waxing and waning of symptoms.

b.       Recent advances in pharmacotherapy and cognitive behavioral therapy have been able to bring about significant relief of OCD symptoms in as many as 70% of patients.