Anxiety disorder

台北榮總精神部社區復健精神科

李鶯喬

DSMIV-TR-2000 classification of anxiety disorders

• Panic disorder without agoraphobia• Panic disorder with agoraphobia• Agoraphobia without panic disorder• Specific phobia• Social phobia• Obsessive compulsive disorder• Posttraumatic stress disorder• Acute stress disorder• Generalized anxiety disorder• Anxiety disorder due to medical condition• Anxiety disorder NOS

Anxiety disorders

• *Sigmund Freud---anxiety neurosis• Normal anxiety:*fear vs. anxiety, psychological

and cognitive sx• Pathological anxiety:

*Psychological theory: Id,superego anxiety, separation anxiety, castration anxiety *Behavioral theory: conditioned response *Biological theory: NE(panic disorder), serotonin (OCD), GABA(general anxiety disorder)

Anxiety disorders

• Brain imaging studies*increase size of ventricles*abnormal in right hemisphere*functional abnormality in frontal cortex, occipital & temporal areas

• Genetic studies*1/2 of panic p’ts—1 affected relatives*higher frequency of lst. Degree relative

• Neuroanatomical: locus ceruleus & raphe nuclei project to limbic system & cerebral cortex

Panic disorder & agoraphobia

• Clinical sx of panic attacks: spontaneous first attack rapidly increasing sx in 10 minutes

fear and sense of impending death or fainting last 20 to 30 minutes

rarely more than l hr intense anxiety or fear with somatic sx of palpitation or tachycardia with anticipatory anxiety

• Clinical sx of agoraphobia: avoid situations in which it would be difficult to obtain help, depression,marital discord,loss work,financial problem

• Life time prevalence rate of panic disorder—1.5-5% (Taiwan 0.2/0.3%), panic attack—3-5.6%, agoraphobia 0.6-6% (Taiwan 1.1/1.5%)

• Women:Men=2-3/1• Mean age of onset 25 y/o• Etiologies:

*Panic-inducing substances: adrenergic antagonist,serotonin releasing agents, GABA receptor antagonist*Brain imaging studies—pathology in temporal, lobes, hippocampus *mitral valve prolapse? *Genetic—4 to 8x increase in lst. Degree rela, higher concordant in monozygotic twin

Course & prognosis of panic disorder

• Onset during late adolescence or early adult

• Chronic, 30-40% symptom free, 50% sx mild, 10-20% significant sx

• 40-80% with depression, 20-40% substance abuse

• Good prognosis: good premorbid function, brief duration

Course & prognosis of agoraphobia

• Panic disorder with agoraphobia—sx (-) while panic disorder (-)

• Agoraphobia without panic---incapacitating, chronic

• Depression & alcohol dependence often complicated

Treatment of panic disorder, agoraphobia

• Drugs: TCA, MAOI, SSRI, BZD, B-blocker

• Cognitive & behavior tx

• Family tx

• Insight-oriented psychotx

Specific phobia & social phobia

• Phobia—irrational fear---conscious avoidance of feared objects, activity,situation

• Social phobia---excessive fear of humiliation or embarrassment in various social settings (public speaking,urinating in public rest room—shy bladder--)

• Specific phobia: animal, storm,height, illness, injury, death, narrow closed space (claustrophobia), blood (erythrophobia)

• Specific phobia *6 month prevalence—5-10% (Taiwan 3.6-4.8%)

*Female:male=2/1*peak age of onset for natural

environment type & blood—5-9 y/o,for situational type-mid 20s

• Social phobia*6 month prevalence---2-3% (Taiwan

0.6/0.5%)*Female>male

*peak age of onset---teens

Etiologies of specific phobia

• Behavioral factors—*conditional emotional reactions (John B. Watson, 1920), stimulus-response model of conditioned reflex (Pavlov), *learning theory

• Psychoanalytic factors--*forbidden unconscious drive, *unressolved childhood oedipal,*castration anxiety, *interaction between genetic factors & environment (temperament of behavior inhibition to the unfamiliar)

• Genetic factors---specific phobia run in families, 2/3 to 3/4 of p’ts with l lst. Degree

Etiologies of social phobia

• Genetic factors---specific phobia run in families, 2/3 to 3/4 of p’ts with l lst. Degree

• Social phobia---trait of behavioral inhibition, parents of persons with social phobia—less caring, more rejecting, more overprotective

• Neurochemical factors—adrenergic, dopaminergic dysfunction

• Genetic factors—3x affected in lst. Degree relative higher concordance in monozygotic twin

Clinical features

• Arousal of severe anxiety

• Panic attacks

• Anticipatory anxiety

• Avoidance behavior

• Substance related disorders

• 1/3 of social phobia with major depression

Course & prognosis

• Financial dependence

• Impairment of social life, occupational performance, school performance

• Substance related disorders---adversely affect the course & prognosis

Treatment

• Insight-oriented psychotx• Hypnosis• Supportive tx• Family tx• Exposure tx (Joseph Wolpe) for specific phobia• Behavioral & cognitive tx for social phobia• Pharmacotx---B antagonist, MOAI,xanax,SSRI

Generalized anxiety disorder (GAD)

• Excessive & pervasive worry, with a variety of somatic sx—sig. Impairment in social or occupational function, marked distress in p’t

• 1 year prevalence---3-8% (Taiwan 3.7-10.5%)• 50-90% of GAD p’ts-comorbid with another

mental disorder• Women/men=2/1

Etiologies of GAD

• Biological factors*GABA or serotonergic or NA dysregulation*lower metabolic rate in basal ganglia & white matter

*25% of lst. Degree relative of p’t-GAD*higher(50%) concordance rate of monozygotic twin

• Psychosocial factors: cognitive-behavioral theory, psychoanalytic theory

Clinical features of GAD

• Primary tx—anxiety,motor tension,ANS hyperactivity,cognitive vigilance

• Excessive anxiety, interfere life• Motor tension—shakiness,restless,headache• ANS hyperactivity-

SOB,sweating,palpitation, G-I sx• Cognitive vigilance—irritability, ease to be

startled

Course & prognosis of GAD

• High incidence of comorbid mental disorders: 25% with panic disorder, many with Major depression

• Chronic, may be lifelong

Treatment of GAD

• Psychotx—cognitive-behavior (relaxation & biofeedback), supportive, insight-oriented psychotx

• Pharmacotx—BZD, buspirone, B-antagonist, TCA

Obsessive compulsive disorder(OCD)

• Obsession---recurrent & intrusive thought, feeling, idea or sensation

• Compulsion---conscious, standardized, recurrent thought or behavior (counting, checking, avoiding)

• Obsessive increase anxiety---compulsions• Realize the irrationality—ego-dystonic

(sometimes ego-syntonic)• Disabling & time-consuming

• 2-3% in general population (Taiwan 0.9/0.5%)

• 10% of psychiatric outpatients

• Male=female in adults,boys>girls

• Mean age of onset---20 y/o

• Comorbid with major depression (67%), social phobia (25%), alcohol use disorder, specific phobia, panic disorders, eating disorders

Etiologies of OCD

• Biological—dysregulation of serotonin• Brain imaging---increased activity in frontal

lobe,basal ganglia (caudate nucleus),cingulum• Genetics---35% of lst. Degree relative, higher

concordance for monozygotic twin• Psychosocial---15 to 35% of OCD p’ts—

obsessional trait• Psychodynamic---*defense mechanism---

isolation, undoing, reaction formation

Clinical features of OCD

• 75% with both obsession & compulsion• Feelings of anxious—countermeasures against the idea

of impulse• Recognize it irrational, strong desire to resist• Four major sx patterns:

*obsession of contamination-wash,avoidance *obsession of doubt-checking *obsession without compulsion-sexual,aggressive *need for symmetry or precision-compulsion slowness

Course and prognosis• 50-70%--onset after a stressful event• Delay 5 to 10 years to psychiatric attention• Chronic,variable, fluctuating,or constant• 20-30% sig. improved,40-50%mod.improve, 20-

40% remain same or worse• 1/3 with major depression• Poor px—yielding to compulsion,childhood

onset,bizarre compulsion,need hosp.,with MD, delusional, schizotypal PD

• Good px—good social & occupational adjustment, ppt(+), episodic nature

Treatment of OCD

• Pharmacotx---SSRI or anafranil

• Behavior tx---exposure & response prevention,desensitization,thought stopping,flooding, aversive conditioning

• Psychotx—insight-oriented psychotx,supportive psychotx

• Family tx, group tx, ECT, psychosurgery

Posttraumatic stress disorder (PTSD) & acute stress disorder

• Emotional stress with a magnitude that would be traumatic for anyone---combat, natural catastrophes, assault, rape, serious accidents

• Reexperiencing of trauma—dreams, thoughts• Persistent avoidance of reminders of trauma,

numbing of responsive to such reminders• Persistent hyperarousal• Depression,anxiety & cognitive difficulties• Minimal duration of one month (PTSD)• Sx occur within 4 wks of events, last for 2 days to

4 wks (acute stress disorder)

• Lifetime prevalence of PTSDF---1-3% of general population, 5-15% of subclinical forms

• High risk group experience traumatic events—lifetime prevalence 5-75%

• 30% Vietnam veterans—PTSD, 25% subclinical

• Single, divorced, widowed, economically handicapped, or socially withdrawn—likely to occur

Etiologies of PTSD

• Stressor• Predisposing vulnerability factors:

*childhood trauma*borderline,paranoid,dependent,antisocial PD*inadequate support system*genetic-constitutional vulnerability to psychiatric illness*recent stressful life changes*perception of external locus of control*recent excessive alcohol intake

Etiologies of PTSD

• Psychodynamic factors*unresolved psychological conflict

• Biological factors*noradrenergic,endogenous opiate

system, hypothalamic-pituitory-adrenal-axis hyperactive

*increased activity of ANS*similarity with MD & panic disorder

Clinical features

• Painful reexperiencing of events• Avoidance & emotional numbing• Constant hyperarousal• Feelings of guilty,rejection,humiliation• Dissociative states,panic attacks,illusion &

hallucination• Impairment of memory & attention• Associated sx:aggression,violence,poor impulse

control,depression,substance related disorders

Course and prognosis

• Onset some time after trauma,sometimes delay as 30 yrs

• 30% complete recovery,40% mild sx,20% mod.sx,10% unchanged or worse

• Good-px—rapid onset,short duration of sx (<6m),good premorbid function,strong social support,absence of psychiatric, medical, substance disorder

• Very young & very old more difficulty, preexisting psychiatric disability, PD more serious

Treatment

• Support,encourage to discuss,education coping mechanisms, behavioral tx, cognitive tx, hypnosis, family tx,group tx

• Pharmacotx—TCA, SSRI, anticonvulsant, inderal, propranolol, clonidine