Anxiety Disorders

CPG and Update

Dr Jon Lane
 Anxiety Disorders are the most common
psychiatric disorders.
 3.8% Australian adults met criteria for a
DSM IV anxiety disorder in the past
month
 Anxiety disorders account for 25% of the
burden of disease attributed to
psychiatric disorders
 Social Phobia
 Panic Disorder
 Post Traumatic Stress Disorder
 Generalized Anxiety Disorder
 Obsessive Compulsive Disorder
 Anxiety associated with mood disorders
Definitions
 Anxiety- “apprehensive anticipation of future
danger or misfortune accompanied by a
feeling of dysphoria or somatic symptoms of
tension.” APA, 2000
 Anxiety is anticipatory, focused on upcoming
events seen as uncontrollable, unpredictable
and potentially dangerous. Leads to worry
and negative affect.
 Fear- a basic emotion representing an alarm
response to danger perceived in the
immediate environment.
Response Components in Anxiety
and Fear
 COGNITIVE- anticipation of negative
outcome, biases in information processing,
anxious beliefs
 BEHAVIOURAL- avoidance, distractions,
compulsive rituals and other behaviors
that function to improve perceived safety
 PHYSIOLOGICAL- a variety of symptoms
consistent with increased autonomic
arousal
Assessment
 The 3 response domains are not always
highly correlated so each requires separate
consideration.
 Assessment should incorporate
 Diagnostic features
 Severity of symptoms and functional
limitations
 Psychiatric co morbidities
 Medical conditions exacerbating symptoms
 Family History
 Treatment history and preferences
Panic disorder
 Panic attack- a sudden experience of
extreme fear accompanied by symptoms of
increased autonomic arousal. Occurs within
the context of a wide range of anxiety,
depressive and substance use disorders
 Four or more of-
palpitations, sweating, trembling, sensation of
SOB, feeling of choking, chest discomfort,
nausea,, dizziness, derealization, fear of losing
control, fear of dying, paraesthesias, chills or
hot flushes
 Attacks that meet all other criteria but have
fewer than 4 somatic or cognitive symptoms
are called Limited Symptom Attacks.
 Typical panic attacks build to a crescendo
over a period of minutes and attenuate
 The key feature of Panic Disorder is the fear
of the attacks and their consequences
 Lifetime rates for panic attacks are 28.3%
but for panic disorder 3.7%
 Panic disorder with agoraphobia 1.1%
 Agoraphobia with no history of panic 0.8%
Agoraphobia
 Anxiety about being in places or situations
from which escape may be difficult or help
unavailable in the event of a panic attack.
 Fears typically involve clusters of situations
 Situations are avoided or else endured with
distress or with anxiety about having a panic
attack. May require presence of a companion
 May exist without a history of panic attacks
in which case the avoidance is fear of
situations in which anxiety symptoms
experienced
Assessment
 Panic attacks may occur in a number of Axis
I disorders
 Social phobia- panic attacks occur only in
social circumstances with fear of shame
 Specific phobias- panic is situationally bound
 OCD- panic relates directly to obsessional
fears
 Depression- panic attacks frequently occur
on waking and may be nocturnal
 In panic disorder the fear relates to the
consequences of panic
 Details of panic- situations, frequency,
symptom
 Substance use history
 Medical history
 Suicidal ideation- common in PD
 Consequences of panic- avoidance behaviors,
distraction behaviors, safety behaviors
 Presenting “complaint” often unrelated to
panic, and specific enquiry as to the
presence of panic symptoms should be made
if suspected
Management of panic disorder
 Both CBT and pharmacotherapy have
established efficacy in PD with large scale
comparative trials and meta analyses
indicating comparative efficacies for the two
 Both may serve as first line treatments
 Combination of these treatments offers only
limited benefit to monotherapy
 CBT has been shown to be more cost
effective and durable that pharmacotherapy
 Many patients who receive combination
therapy tend to attribute gains to medication
and relapse when medication discontinued
Cognitive behavior therapy
 3 components
 PSYCHOEDUCATION- the nature of panic
symptoms
 COGNITIVE RESTRUCTURING- assistance to
identify and restructure panic related threat
appraisals eg “I will have a heart attack”.
 Patients asked to monitor their cognitions and
learn to treat their thoughts as guesses about the
world rather than as facts
 Patients then asked to review evidence for their
thoughts and to learn to generate and use
rational responses eg “heart racing does not
mean I am going to have a heart attack”
 EXPOSURE- therapist and patient design
exposure exercises to build disconfirming
evidence and build tolerance of uncomfortable
sensations without maladaptive behavioral
responses such as avoidance
 Safety behaviors eg carrying “in case” medication
may undermine treatment as the patient may
attribute the improvement to the use of the
coping strategy
 Similarly the use of relaxation and breathing
techniques may be detrimental as they may
attenuate extinction learning
Other psychosocial treatments
 Evidence that breathing retraining has no
additive effect on outcomes despite its
presence in many CBT protocols
 No evidence for psychodynamic therapies
 Growing evidence in support of exercise
programs
Pharmacotherapy
 Patients with PD are hypervigilent to
bodily sensations and changes and often
tolerate the initiation of medication
poorly as side effects may mimic the
symptoms of anxiety
 Education about side effects essential
 Dropout rates higher for medication than
CBT
Mainstay Treatments
 RANZCP Treatment guidelines recommend
SSRIs, with most evidence cited for
fluvoxamine, but also fluoxetine, paroxetine,
sertraline and citalopram
 However RCT evidence also exists for
venlafaxine
 Earlier evidence for TCAs- imiprimine
 BDZs- most studied is alprazolam. Effective
acutely but high relapse rates following
discontinuation, which will ALWAYS happen.
 NOT recommended for use.
Atypicals
 Little evidence for atypical antipsychotics,
but may be useful in refractory patients
 One RCT established benefit for
olanzapine, but small sample size
 Little evidence for B blockers
 Little evidence for anticonvulsants
Social anxiety disorder
 SAD is the most common anxiety disorder
(National Co morbidity Study 2006 Kessler
et al) lifetime prevalence 12%
 Has a chronic and protracted course that
seldom remits without treatment.
 Women>men
 Co morbidity considerable- depression,
other anxiety disorders, personality
disorders
 Symptoms normally emerge during early
adolescence
Social anxiety disorder
 Usual presentation is an intense, persistent
and irrational fear of being scrutinized or
negatively evaluated by others on social
performance or in interactive situations
 Associated with physical symptoms, cognitive
distortions and behavioural avoidance
 Despite the disabling nature of the condition,
most wait many years before seeking
treatment
 Most present initially to primary care with
physical complaints
SAD pathogenesis
 Multidimensional
 Alterations in major neurotransmitter
systems
 Exaggerated activation of NA- eg blushing,
shakiness, palpitations, nausea, diaphoresis
 Exaggerated sensitivity of post synaptic
5HT1A and 5HT2 receptors
 Dysregulation of GABA receptors
 Decreased CSF dopamine
 Neuroimaging studies- PFC, amygdala, hippocampus
 These brain regions mediate and ascribe the cognitive
appraisal and significance of social situations
 PFC-key role in the cognitive processing and
regulation of emotions. Hypo function interferes with
inhibitory influences on the amygdala resulting in
heightened fear response
 Heightened amygdala reactivity in social situations
 Leaned fear responses to social situations ascribed by
the amygdala is subsequently integrated into the
PFC/Hipp/Amyg circuitry as memory and learned
behaviour
 Genetic factors- evidence from twin
studies
 History of overprotective or overcritical
parenting
 Early exposure to significant psychosocial
stressors eg school bullying, parental
attachment problems
 Main DDx- avoidant personality disorder
 Although avoidant PD sufferers are shy
and demonstrate rejection sensitivity, this
differs from SAD in that the core features
of SAD centre on specific or general
social situations rather than personal
relationships as in avoidant PD.
 However- high co morbidity between
these two conditions
SAD Treatment
 Antidepressants have proven efficacy in the short
and long term Rx of SAD in > 20 RCTs
 SSRIs first line
 Dosing similar to MDD guidelines, guided by past
treatment responses, tolerability, patient
preference
 BDZs efficacious, but effectiveness reduces over
time
 Other agents- Dual action ADTs, atypical
antipsychotics- less studied
 Emerging evidence for the efficacy of pregabalin-
GABA analogue- approved for SAD in Europe
 CBT with an emphasis on exposure
therapy-has demonstrated symptom
reduction but results inconclusive
 In practice, combination medication and
CBT is usually the most helpful approach
Generalized Anxiety Disorder
 The core feature of GAD is an
apprehensive state of mind regardless of
the quality of the stimuli
 Presents with a variety of future focused
automatic negative thoughts and worries
about a variety of subjects. This often
evolves to somatic manifestations such as
muscle tension, insomnia and fatigue.
 Patients often report they have been
worried as long as they can remember
Pharmacotherapy treatment
guidelines
 World Federation of Society of Biological
Psychiatry Task Force 2008 reviewed
literature and updated guidelines
 Strongest evidence of efficacy was for
escitalopram, paroxetine, sertraline,
venlafaxine, duloxetine, pegabalin and
quetiapine
 Imiprimine second line choice due to
tolerability limitations
 Benzodiazepines alprazolam, diazepam in
treatment resistant cases with no history of
addiction
Obsessive Compulsive Disorder
 Obsessions- recurrent and persistent
thoughts, ideas, impulses or images that
are experienced as intrusive and senseless
 Compulsions– repetitive behaviours that
are performed in a particular manner in
response to an obsession to prevent
discomfort or to neutralize anxiety
 Obsessions or compulsions cause
distress, are time consuming and interfere
with usual daily functioning
 80% sufferers have another psychiatric
comorbidity, most commonly major
depression at around 54%
 The only significant associations with other
anxiety disorders are with PTSD and panic
disorder
 Heterogenous disorder, with many different
strategies having been used to define
clinically meaningful subtypes- age at onset,
symptom profiles, co morbidity patterns,
clinical course
- Higher frequency of schizophrenia
spectrum disorders in first degree
relatives
- Higher comorbidity rate, in particular
major depression
- Schizotypal personality disorder
- Negative predictor of treatment response
Psychological treatments
Evidence base exists for
- Exposure and Response Prevention
- Systematic desensitization
- Flooding
- Thought Stopping
- Aversive therapy
Pharmacotherapy
 Clomiprimine- TCA with potent serotonergic
reuptake inhibition- has unique anti OCD effects
independent of antidepressant effects. Higher
treatment dropout rates than SSRIs due to side
effect profile
 SSRIs- All have demonstrated efficacy similar to
clomiprimine
 Response to treatment slow- at least 8 weeks
required to assess response
 30-40% have residual symptoms at 12 weeks
 Augmentation- olanzapine, risperidone, quetiapine
in addition to SSRI for refractory patients
Graham
 32 year old mechanic
 Sudden onset 3 years ago of intrusive and
persistent thoughts that he may physically
assault his girlfriend or sexually assault a
child. Onset occurred while watching a
violent TV show.
 No history of violence or acting in
inappropriate ways toward children
 Stable employment, in a relationship for 9
years
 No history of developmental trauma
 Girlfriend now pregnant, exacerbation of
Graham’s intrusive thoughts about sexually
abusing children
 Thoughts present daily
 Highly distressed by thoughts, at times
unable to function due to anxiety. Frequent
panic attacks
 No associated compulsive behaviours
 No response to sertraline to 150mg
 Better response to fluvoxamine 200mg,
but signifcant symptoms remained
 Risperidone 0.5mg added
Kerry
 26 year old hairdresser, own business
 OCD and anxiety symptoms onset age 17
 Persistant intrusive ruminations that she has
run over somebody when driving
 Interferes with driving. Stops multiple times
on short trips to check under the car
 Persistent fear that she has given her clients
cancer. Tips expensive bottles of hair
product down the sink several times per day.
Business struggling because of this
 Symptoms distressing, but not entirely
ego dystonic. At times firmly belies she
has hit someone or given someone
cancer
 In recent times has developed some
overvalued ideas on religion, based on
literal interpretations of the bible.
Refusing to go to shops on Sundays as
“Sunday is a day of rest and those who
work on Sundays are sinners”
 Eldest of 4 siblings. History of schizophrenia in 2
brothers. Strong family history of cannabis abuse,
but Kerry does not use
 Lives alone, not in a relationship, quite socially
isolated
 Clomiprimine not tolerated., no response to
fluoxetine or fluvoxamine. Treatment complicated
by poor compliance- “gives up” on treatment
when no result after 2 weeks.
 Poor engagement in CBT
 Trial aripiprazole- severe nausea
 Most recent treatment- ziprasidone 20mg bd,
monotherapy only as refusing further Rx