Anxiety Disorders

Anita S. Kablinger MD

Associate Professor, Departments of Psychiatry and Pharmacology

LSUHSC-Shreveport

DSM-IV Anxiety Disorders

• Specific phobias

• Panic disorder

• Agoraphobia

• Generalized anxiety disorder

• Social phobia

• Obsessive-compulsive disorder

• PTSD

PTSD: Presentation Outline

• Introduction/History

• Clinical Presentation/DSM-IV Criteria

• Differential Diagnosis

• Etiology/Risk Factors

• Treatment Issues

• Prevention

Introduction/History

• First appeared in DSM-III (1980)

• Recognized by Shakespeare in Henry IV

• Civil War descriptions

• WWI- shell shock and soldier’s heart

• WWII- operational fatigue and combat neurosis

• Organic origin vs psychogenic derivation

Diagnostic Criteria for PTSD

• A. Exposed to traumatic event– The person experienced, witnessed, or was

confronted with an event involving actual or threatened death, serious injury or a threat to physical integrity of self or others

– The person’s response involved intense fear, helplessness or horror

Diagnostic Criteria for PTSD

• B. The traumatic event is reexperienced in one or more of the following ways– Recurrent images, thoughts or perceptions– Recurrent distressing dreams of the event– Acting or feeling as if the event was recurring– Intense psychological distress OR physiologic

reactivity at exposure to cues that symbolize or resemble an aspect of the event

Diagnostic Criteria for PTSD

• C. Persistent avoidance of stimuli associated with trauma and numbing as indicated by 3 or more:– Avoiding thoughts, feelings, or discussion, activities,

places or people that bring back recollections; sense of foreshortened future

– Inability to recall; restricted affect

– Diminished interest or participation

– Feeling detached or estranged

Diagnostic Criteria for PTSD

• D. Persistent symptoms of increased arousal by 2 or more:– Difficulty falling or staying asleep

– Irritability or outbursts of anger

– Difficulty concentrating

– Hypervigilance

– Exaggerated startle response

• E. Duration for more than 1 month

Diagnostic Criteria for PTSD

• F. Clinically significant impairment in functioning

• Acute: Less than 3 months• Chronic: Greater than or equal to 3 months• With delayed onset: Onset at least 6 months after

the stressor

Diagnostic Criteria for Acute Stress Disorder

• A: Exposed to traumatic event

• B. Experiences three or more of:– Subjective sense of numbing, detachment– Reduction in awareness of surroundings– Derealization– Depersonalization– Dissociative amnesia

• C. Persistent reexperiencing of the event

Diagnostic Criteria for Acute Stress Disorder

• D. Marked avoidance of stimuli that arouse recollections of the trauma

• E. Marked symptoms of anxiety or increased arousal

• F. Causes significant impairment

• G. Lasts 2 days to 4 weeks and occurs within 4 weeks of the trauma

Epidemiology

• Prevalence of PTSD: 1-14% community, 3-58% in at-risk populations

• 25-30% lifetime prevalence in Vietnam veterans

• 85% in concentration camp survivors

• May be modulated by cultural differences

• All ages; individuals or groups; F>M

Differential Diagnosis

• Mental disorder secondary to GMC – (ex. head injury)

• Substance-induced disorder

• Dissociative disorders

• Major depressive episode

• Borderline personality disorder

• Malingering

Etiological Factors

• Magnitude of the stress exposure• Cognitive appraisal factors• Intense fear or helplessness predictive• Sympathetic hyperactivity• Psychological factors

– psychodynamic– cognitive– behavioral

Examples of Traumatic Events

• Violent crime• Sexual trauma• Chronic physical

abuse• Military combat• Natural disasters • Manufactured

disasters

• Complicated or unexpected bereavements

• Accidents• Captivity

Risk Factors

• Lack of social support• Family psychiatric

history, esp. anxiety• Previous psychiatric

history• Certain personality

traits• Early separation of

parents

• Parental poverty• Abuse in childhood• Childhood behavioral

problems• Limited education• Adverse life-events

prior to trauma• Female

Six Strongest Predictors of Trauma Exposure

• Male

• Absence of college education

• Extroversion

• Neuroticism

• Early misconduct

• Family psychiatric illness

Six Strongest Predictors for Risk of PTSD

• Female

• Neuroticism

• Early separation from parents

• Prior anxiety or depression

• Familial anxiety

• Familial antisocial personality disorder

Associated Symptoms Important for Treatment

• Survival and behavioral guilt

• Somatic distress

• Paranoia

• Interpersonal alienation

• Vegetative changes of depression

• Hopelessness

• Impulsivity

Course and Prognosis

• 30% recover completely• 40% continue with mild symptoms• 20% moderate symptoms• 10% unchanged or worsen• Startle, nightmares, irritability and

depression often worsen with age• Comorbidity is high (MDD, OCD, Panic,

substance abuse)

Treatment: ASD

• Talking about the trauma allowing: – confrontation– acceptance– process– integration

• Individual or group therapy, hypnosis

• Followed by support and superficiality

Treatment: PTSD

• Requires multiple modalities

• Initial education, support and referrals important to establish trust

• Pharmacotherapy

• Psychotherapy

• Relaxation Training

Treatment: PTSD-Pharmacotherapy

• Duration of at least 8-12 weeks

• Adequate dosages

• Maintenance treatment for at least 1 year

• Antidepressants

• Mood stabilizers

• Propranolol, clonidine

• Atypical antipsychotics

Drug Treatment of PTSD

• Amitriptyline• Fluoxetine• Sertraline*• Paroxetine*• Propranolol• Clonidine• Valproic Acid• Carbamazepine

• 50-300 mg/day• 20-60• 50-200• 20-50• 40-160• 0.2-0.6• 750-1,750• 200-1,200

Drug Treatment of PTSD

• Lithium• Quetiapine• Risperidone• Olanzapine

• 300-1,500 mg/day• 25-700• 0.5-6• 2.5-20

Treatment: PTSD- Individual Psychotherapy

• Crisis Intervention– establish rapport, promote acceptance– educate, attend to general health

• Trauma-focused psychotherapy

• Implosive therapy

• Systematic desensitization

• Hospitalization may be necessary at times

Points to Remember

• If a patient has multiple complaints, think PTSD or personality disorder up front

• Under-detected because we don’t ask the right questions

• One of the few DSM disorders defined by it’s cause!

DREAMSDREAMSDDetachment

RRe-experiencing the event

EEmotional effects

AAvoidance

MMonth in Duration

SSympathetic hyperactivity or hypervigilance

PTSD Questionnaire

DSM-IV Anxiety Disorders

• Specific phobias

• Panic disorder

• Agoraphobia

• Generalized anxiety disorder

• Social phobia

• Obsessive-compulsive disorder

• PTSD