The anxious patient

Royal Free & UCL Medical School Psychiatry Lectures 2010-2011 Dr Theodore Bargiotas ST5 in General Adult Psychiatry-Oxford 21.2.2011

Learning Objectives
1. Symptoms anxious patients may present with 2. From symptoms to diagnosis 3. Anxiety disorders 4. Treatments

Outline
Lecture ~1 hour Cases and case discussion 25 minutes Questions End

Anxiety and Anxiety disorders

What is anxiety?
Anxiety is a normal response to a threat or danger Abnormal when severity is out of proportion to the threat or danger, or when it outlasts them

Performance

anxiety levels

Components of anxiety response (normal and abnormal)

Components of anxiety response (normal and abnormal)

Psychological: restlessness, narrowing of attention, worrying thoughts, increased alertness Somatic: muscle tension, increased respiration Autonomic: heart rate, sweating, dry mouth, urge to urinate or defecate Behaviours: Avoidance of danger, safety behaviours

What are the anxiety disorders?

Abnormal states in which the most striking features are physical and mental symptoms of anxiety In the absence of organic brain disease or another psychiatric disorder

Anxiety disorders as a group

Very common Used to call them neuroses Link with stress apparent in most of them Mixtures of symptoms of anxiety Frequent co-morbidities with other mental disorders

Overview

Historic info
In the past: together with other mood disorders-depression Freud first suggested separate entity of anxiety =>anxiety neurosis (psychological symptoms of anxiety) and =>anxiety hysteria (conversion and phobias) Panic disorder only introduced in the 1980s Conversion now separate, with somatoform disorders

Aetiology of anxiety disorders

Evolutionary basis of fears of animals etc All share a modest genetic predisposition Monozygotic>Dizygotic, more present in first degree relatives

Aetiology of GAD
Stressors+personality predisposed by genetic factors and environmental influences in early life Life events: >4 in the year before Finlay - Jones and Brown 1981 Genetic studies: monozygotic>dizygotic Family studies: > in 1st degree relatives Early experiences: Brown and Harris 1993 Cognitive-Behavioural: conditioning theoriescognitive schemas

Possible Neurobiological mechanisms

The noradrenergic nervous system The HPA axis The amygdala and the bed nucleus of the stria terminalis The septohippocampal system (behavioural inhibition system) The serotonergic system The benzodiazepine--aminobutyric system

Aetiology of anxiety disorders (cont)

Psychoanalytic theories: realistic anxiety, neurotic anxiety, moral anxiety (stemming from ego, id, superego respectively) Freud: Castration anxiety: failure to overcome rivalry with father Experience of unmodified anxiety due to failure of defence mechanisms. Importance of Separation and loss early in life: normally overcome by secure attachment (Bowlby 1969). If this is not the case the individual predisposed to experience anxiety later in life whenever

*learning theory conditioned response (2 stage) * Evolutionary response that is now out of place

Clinical presentation
What symptoms do you expect an anxious patient to have?

Anxiety symptoms-clusters
From Stahls essential psychopharmacology 2008

GAD

Panic disorder

Social Anxiety Disorder

PTSD

OCD

Groups of anxiety symptoms

a) b) c) d) e) f) Psychological arousal Autonomic overactivity Muscle tension Hyperventilation Sleep disturbances Other features

a. Psychological arousal
Fearful anticipation Irritability Sensitivity to noise Restlessness Poor concentration Worrying thoughts =>Fear of losing control, going crazy or passing out =>Fear of dying

b. Autonomic arousal
GI: Dry mouth Difficulty swallowing Epigastric discomfort Excessive wind Frequent or loose motions

b. Autonomic arousal (cont)

Respiratory Sense of constriction in the chest Difficulty inhaling CV Palpitations Discomfort in the chest Awareness of missed heartbeats

b. Autonomic arousal (cont)

Genitourinary Frequent urge to pass urine Failure of erection Menstrual discomfort Amenorrhoea Other Sweating Cold extremities

c. Muscle tension Tremor Headache Aching muscles (usually shoulders and back) Inability to relax d. Hyperventilation Dizziness Tingling sensation Feeling of breathlessness

Sleep disturbance Insomnia (initial most common) Nightmares and Night terrors Sweating Cold extremities Derealisation, depersonalisation

Generalised anxiety disorder

GAD

Generalised anxiety disorder

Anxiety is generalized and persistent but not restricted to or even strongly predominant in any particular situation (free floating). Variable but persistent nervousness and sometimes fears that patient will become ill or have an accident NB symptoms different in children: autonomic arousal often less prominent

Generalised anxiety disorder Epidemiology

Variable 2.4-6.6% Risk factors females, people under 30 Genetic basis 41% monozygotic twins vs 4% dizygotic

Generalised anxiety disorder diagnosis

For at least 6 months prominent tension, worry and feelings of apprehension about everyday events and problems at least four symptoms of anxiety - one must be autonomic arousal but the list of others is expanded Disorder does not meet criteria for panic disorder/ phobic anxiety disorder/ OCD/ hypochondriacal disorder

DD
Onset of scz or dementia Substance abuse to self medicate Endocrinological illness: thyrotoxicosis, phaeochromocytoma, hypoglycemia, or secondary to physical illness Major stresses, eg life at risk (drug trade) Physical illness

Generalised anxiety disorder diagnosis

Exclusion clauses: Not due to physical illness organic mental illness substance misuse or withdrawal

Generalised anxiety disorder Helping patients understand

Stress or worry have many physical and mental effects, and may be responsible for many of their symptoms. Symptoms are likely to be at their worst at times of personal stress. Aim to help the patient to reduce his or her symptoms. These problems are not due to weakness or laziness: patients are trying to cope. Regular structured visits can be helpful.

Treatment-relaxation groups

Generalised anxiety disorder Treatment

Explain to patients If tension-related symptoms: relaxation methods to relieve physical symptoms. Reduction in caffeine intake and a balanced diet problem-solving Supportive psychotherapy Encourage self-help books, tapes and/or leaflets Discuss ways to challenge negative thoughts or exaggerated worries => CBT

Generalised anxiety disorder Medication

Second-line treatment Significant anxiety or persistence despite other measures Immediate-short term Benzodiazepines medication may be used for no longer than two-three weeks. Avoid short-acting benzodiazepines except for sleep Beta-blockers:helpful for peripheral autonomic symptoms such as tremor, palpitations.

GAD-medication
Long term Antidepressant drugs: SSRIs, venlafaxine, imipramine, clomipramine, may be helpful. Buspirone Alpha2- ligands-voltage-gated calcium channels: Gabapentine, Pregabaline

Panic disorder

Panic disorder

Panic disorder
Recurrent attacks of severe anxiety not restricted to any particular situation. They are therefore unpredictable Symptoms of anxiety Do not diagnose panic disorder if depression is present when they start.

Panic Disorder Epidemiology

Rates vary 0.13 rural Taiwan - 2.2% new Zealand Higher rates in women lowest rates in older people but patterns differ in different countries

Panic Attack
= all of the following
Discrete episode of intense fear or discomfort starts abruptly reaches a maximum within a few minutes and lasts some minutes at least four symptoms of anxiety - one must be a symptom of autonomic arousal

Panic Disorder Diagnosis

Exclusion clause: Not secondary to physical illness or other mental illness Moderate - four panic attacks in a month Severe - four panic attacks a week for a month

Panic Disorder Differential Diagnosis

Physical illness Prescribed drugs Depression Phobia

Aetiology

Panic Disorder Treatment

Explain to the patient
treatable Catastrophic misinterpretation of normal sensations is the key mental and physical symptoms reinforce each other Safety behaviours consolidate thoughts

Panic Disorder Treatment

CBT: thoughts, experiments, stopping safety behaviours

Panic Disorder Treatment

Do not move out of situation Do not use alcohol Do monitor caffeine intake Do read self help books

Panic Disorder Treatment : Medication

Consider SSRI if initial CBT fails Note that symptoms can become worse before they become better Avoid benzodiazepines

Phobic anxiety disorders

Phobic anxiety disorders

Agoraphobia Social phobia Specific phobias

Phobic anxiety disorders-general

Patients avoid or restrict activities because of fear of specific objectssituations=>anticipatory anxiety develops If severe, social implications. Sometimes physical symptoms (eg palpitations, shortness of breath or asthma). Questioning will reveal specific fears. Focus moves to individual symptoms/secondary fears (dying, losing control or going mad)

agoraphobia

Agoraphobia
Phobias related to distance from home, crowding and confinement. Anxious thoughts about fainting and losing control Panic frequently present Avoidance is prominent Little anxiety if the patient completely avoids situation

Agoraphobia Epidemiology
Female>male Starts early-middle twenties, another peak in mid thirties-(18-35) Rates vary
2-4% year prevalence 6-10% life prevalence

Agoraphobia Epidemiology
increased life events prior to onset

Agoraphobia Diagnosis
Presentation: after panic attack, or during exploration of symptoms of anxiety Fear in or avoidance of at least 2 of
crowds, / public places, / travelling alone, / travelling away from home

At least two symptoms of anxiety (one must be of autonomic arousal) Most likely starts with a panic attack

 Prognosis course is fluctuating, if lasts 1 yr then unchanged at 5 yrs without treatment

Social phobia

Social Anxiety Disorder

Social Phobia
Fear of scrutiny of others => avoidance of social situations low self esteem and fear of criticism May present as blushing, and tremor, urgency of micturition - patient may present these secondary symptoms as their primary problem. May develop panic attacks

Social Phobia Epidemiology

Low in rural Taiwan 0.4% high in New Zealand 3.9% Risk factors highest rates in those who are 18-29, less educated, single and lower socio-economic class

Social Phobia Epidemiology and DD

* onset usually gradual from late puberty (17-30). * gender males = females * overlap with social dysfunction (social skills deficit, avoidant personality disorder). Social phobia limited to specific situations, whereas in social dysfunction there is a more general social skills deficit

Social Phobia Diagnosis

At least two symptoms of anxiety are present in the feared situation, they must have been present since the onset of the problem and occur with at least one of
blushing or shaking fear of vomiting urgency and fear of micturition or defecation

 Depression Alcoholism Increased distress-may be undetected for decades

Specific phobias

Specific phobias
Phobias restricted to highly specific situations
animal type - insects, dogs natural forces - eg storms and water blood, injections, injury type situational elevators, tunnels other

Specific phobias Epidemiology

Common 7-15% Often start in childhood (aged 2-4)

Specific Phobias Diagnosis

Must be present
marked fear of a specific object or situation not included in agoraphobia or social phobia marked avoidance of the object/ situation

Specific Phobias Diagnosis

1. Symptoms of anxiety in feared situation 2. Significant emotional distress caused by the symptoms or the avoidance 3. Symptoms restricted to feared situations 4. Individual recognizes that these are excessive or unreasonable

Differential diagnoses and treatment

Phobic anxiety disorders Differential diagnoses

Depression Panic disorder Organic illness Secondary to other mental illness such as a psychotic illness

Phobic anxiety disorders Essential information for patient

phobias can be treated avoidance makes fears grow following simple steps can diminish fear TOPs groups and Living with Fear work for most people

Phobic anxiety disorders Treatment

Most people do well with CBT and do not need meds Alcohol=>no good solution Antidepressants: if depression or persistent given if depression present Social phobia may be helped by SSRIs, MAOIs B-blockers decrease physical symptoms in performance anxiety

Obsessive compulsive disorder

OCD

Obsessive compulsive disorder

Recurrent obsessional thoughts and/or compulsive acts. Obsessional thoughts
ideas, images or impulses enter patients mind again and again usually distressing patient often tries to resist them recognized as own thoughts

Obsessive compulsive disorder

Compulsion
stereotyped behaviours repeated again and again not inherently enjoyable or useful function to prevent some objectively unlikely event (harm to or by patient) usually recognized as pointless patient attempts to resist resistance causes anxiety

Obsessive compulsive disorder

Obsession/ compulsion most days for 2 wks

Obsessive compulsive disorder

Distress or interference with the patients functioning e.g. wasting excessive amount if time Most common exclusion cause is symptoms due to other psychiatric illness eg depression, SCZ

Obsessive compulsive disorder Psychiatric clinic population

Obsessions and compulsions 69% Obsessions only 25% Compulsions only 6%

Obsessive compulsive disorder Types of rituals

Cleaning 51% Repeating 40% Checking 38% Orderliness 9%

Obsessive compulsive disorder

Prevalence Epidemiologic Catchment Area study in USA (sample size 18,500): one month prevalence rate 1.3% m=f

Obsessive compulsive disorder epidemiology

Onset usually insidious in early 20s (males earlier than females but equal incidence), with excess of life events in year prior to onset. Fewer are married, those seeking treatment have slightly raised intelligence and social class 92% 10-40 years. Mean age 22. Mean age at presentation 34.

Obsessive compulsive disorder

OC symptoms also in depression (20%25%), in schizophrenia and dementia. 12% past history of anorexia Gilles de la Tourette syndrome, parkinsonism, encephalitis lethargica, head trauma and basal ganglia lesions.

Treatment
CBT: challenging compulsions, belief in catastrophe, relapse prevention Serotoninergic antidepressants Atypical antipsychotic augmentation Psychosurgery(!) in extreme cases!

Mixed anxiety and depression

Mixed anxiety and depressive disorder

Symptoms of anxiety and depression are both present Neither is clear predominant and neither type of symptoms justifies a separate diagnosis if both depression and anxiety are severe enough to satisfy individual criteria then diagnose both

Mixed anxiety and depression

Patient may present with one or more physical symptoms (eg various pains, poor sleep and fatigue), accompanied by a variety of anxiety and depressive symptoms, present for more than six months. These patients may be well known to their doctors, and have often been treated by a variety of psychotropic agents over the years.

Mixed anxiety and depression

Treatment use methods above for treatment of anxiety Medication
simplify medication use as little as possible only continue or start antidepressant if it is shown to work in individual SSRIs, tricyclics, MAOI

Overview of medication for anxiety symptoms-disorders

Medication
Antidepressants Beta-blockers A- ligands (pragabaline-gabapentin) Benzodiazepines Buspirone Antihistamines Sleeping tablets Antipsychotics (small doses)

 Mainly serotonergic for OCD, panic Both noradrenergic and serotonergic for GAD, anxiety and depression -blockers for peripheral symptoms of autonomic arousal

Diagnostic rubric

Diagnosing anxiety disorders

Anxiety
A. B. Feeling tense or anxious? Worrying a lot about things?

Diagnosing anxiety disorders

1.Symptoms of arousal and anxiety?

Diagnosing anxiety disorders

2. Experienced intense or sudden fear unexpectedly or for no apparent reason? Fear of dying Fear of losing control Pounding heart Sweating Trembling/shaking Nausea Chest pains/ breathing difficulty Feeling dizzy / lightheaded or faint Numbness/ tingling sensations Feelings of unreality

Diagnosing anxiety disorders

3.Experiences fear/anxiety when: leaving familiar places travelling alone, eg train, car, plane crowds confined places/public places

Diagnosing anxiety disorders

4. Experienced fear/anxiety when speaking in front of others social events eating in front of others worry a lot about what others think or selfconscious?

Diagnosing anxiety disorders

Summing up Positive to A, B and 1, recurring regularly, negative to 2, 3 and 4 Indication of Generalized anxiety Positive to 1 and 2: indication of panic disorder Positive to 2 and 3: indication of agoraphobia Positive to 3 and 4: indication of social phobia

Cases

Case 1
CASE VIGNETTE 1 Francis is a M.W.M. and presents with extraordinary concern about the safety of his wife and young daughter. He rarely leaves them alone when away (e.g., at work) he telephones home every hour. He has lost one job because of this, and his wife has threatened to leave him if he does not seek psychiatric help. Six months ago, the symptoms, which have been present for years, became worse after his wife had a serious automobile accident. Francis describes recurrent, unbidden thoughts in which dangerous events befall his family and he is not there to save them. He knows the thoughts are silly and they come from his own mind rather than any real danger, but he cannot resist contacting his wife or daughter in some way to be certain they are safe. His wife has arranged to lift the telephone receiver briefly, then hang up, which is usually sufficient to allay his fears for an hour or so. There is no history of significant medical illness or Substance Abuse. The client completed 2 years of college and has a responsible job. He performs well, and is not particularly perfectionistic, overly conscientious (except with regard to his familys safety), rigid, or preoccupied with details.

 OCD

Case 2
George, 21 yo male. Lives with parents. Self employed as sound and studio specialist. Presents with intense and recurrent worries about the possibility of vomiting. He was last sick more than 7 years ago when ill from a tummy virus, however, he avoids all meat except chicken, and other food like fish, eggs and anything unhealthy, for fear of vomiting. He also avoids getting close to people who have any virus, to avoid a tummy bug. Occasionally he becomes so caught up in his worry and rumination that he has panic attacks. When he was 8 a classmate vomited all over him, which made him feel humiliated in class. At the age of 14 he had a tummy virus and since then his fear of being sick has been with him continually. Its intensity fluctuates. Became much worse since a trip to Spain two years ago. He does not tend to worry about anything else. He doesnt drink alcohol, and smokes 2-3 joints of cannabis a week, which relaxes his thoughts. No other medical history

 Emetophobia

Helen is a 35 year old M.B.F. who for the past 6 months, has had increasing anxiety and occasional panic attacks. Although the anxiety and panic were initially not associated with any particular situation they are now associated with her work as a personnel director for a large corporation. When she goes to work she often (sometimes more than once a week) has sudden attacks of nausea, perspiring, a feeling of unreality and impending doom, and trembling. These symptoms become quite intense within a few minutes and last less than half an hour. Helen dreads the episodes, which are so uncomfortable that she occasionally prevents them by staying home rather than going to the office. She has noticed that the episodes, which initially came randomly and unexpectedly, have recently become more specifically associated with certain responsibilities, such as board meetings and presentations to her superiors. Helen denies any discomfort from the meetings and presentations themselves, saying that she enjoys her position, handles it well, and feels very comfortable as a member of the management team. She is not affected in ordinary social situations or while working with people in other settings. The client has never had other psychiatric symptoms, enjoys a normal family life, and is in good health. She takes no medications, has a low caffeine intake, and denies drug or alcohol abuse. Physical examination, with thyroid tests and echocardiogram, is normal.

 Panic disorder

Case 1
30 yrs male Mother dead - withdrawal from social life Not going out alone Tense in social situations, fears scrutiny Continually on edge panic attacks Drinking Now depressed

Case 2
35 Worried that her sweat smelled terrible Ideas of reference Avoidance of social situations because she thinks she smells Believed neighbours talking about her Baths and changes clothes 4 times a day

Case 3
30 Fear he might abuse or kill his 8 yr old daughter Resists but cannot stop thoughts Reassurance does not help Avoids being left alone with her Depressed quit his job Asks to be in a locked ward

Case 4
30 yr old woman Poor sleep, cant concentrate, restless Changed jobs, separated from husband Raped Poor sleep and nightmares about the event Hyper-vigilant Increased startle, misidentification, suicidal

Case 5
45 years old Intense bouts of anxiety and hyperventilation lasting Avoidance of supermarkets and theatres Carrying mobile phone for help Wanted to be accompanied where she went

References
Gelder, Harrison, Cowen Shorter Oxford Textbook of Psychiatry, 5th edition Gelder, Andreasen, Lopez-Ibor, Geddes New Oxford textbook of Psychiatry 2nd ed 2009 Apu Chakraborty: notes from lecture on anxiety disorders 2006

Thank you

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