The Phenomneology, Biology, and Treatment of Anxiety Disorders Emil F. Coccaro, M.D.

Transcription

1 The Phenomneology, Biology, and Treatment of Anxiety Disorders Emil F. Coccaro, M.D. MSIII Psychiatry Clerkship University of Chicago

2 What is Anxiety? Anxiety is a normal unpleasant, anticipatory affective state with cognitive, autonomic, neuroendocrine, behavioral, and experiential components. Fear behavior is the response response to specific environmental stimuli that are perceived as potentially dangerous. (Davis 1998)

3 Anxiety and Fear Normal Emotions Purpose Three Components

4 Three Components of Anxiety Physical Feelings Cognition (Thoughts, Interpretations, Images) Behaviours

5 The Physical Component»Increased Heart Rate»Breathlessness»Dizziness»Shaking»Sweating»Unreality/Detachment»Blurred Vision»Blushing»Numbness/Tingling

6 The Cognitive Component»Anxious Thoughts»Anxious Predictions»Anxious Beliefs and Interpretations»Biases in Attention and Memory»Mental Images

7 The Behavioural Component Avoidance of Situations and Activities Subtle Avoidance Strategies, Safety Signals, and Overprotective Behaviours Alcohol, Drug, and Medication Use

8 DSM-IV Spectrum Of Anxiety Disorders Panic Disorder Social / Simple Phobias OCD PTSD GAD

9 Prevalence Of Anxiety Disorders Lifetime Prevalence (%) Any Anxiety Disorder Social Anxiety Disorder PTSD GAD Panic Disorder OCD Kessler et al. Arch Gen Psychiatry. 1995;52:1048. Kessler et al. Arch Gen Psychiatry. 1994;51:8.

10 Comorbidity Of Depression And Anxiety Disorders 70% of social anxiety disorder patients have depression** Depression 50% to 65% of panic disorder patients have depression Panic Disorder HIGHLY COMMON HIGHLY COMORBID Social Anxiety Disorder 49% of social anxiety disorder patients have panic disorder** 67% of OCD patients have depression* OCD 11% of social anxiety disorder patients have OCD** * Rasmussen and Eisen. J Clin Psychiatry. 1992;53(suppl):4. ** Van Ameringen et al. J Affect Disord. 1991;21:93. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed

11 Lifetime Rates Of Anxiety Disorders In Alcohol-Dependent Patients Rates * Panic Disorder Agoraphobia ** Social Anxiety Disorder OCD ** Any Anxiety Disorder Control Alcohol-Dependent * P<.001; ** P<.01. Schuckit et al. Addiction. 1997;92:1289.

12 Economic Burden Of Anxiety Disorders Total Costs = $42.3 Billion Per Year Total Mortality Workplace Costs Pharmaceutical Costs 3% Costs 10% 2% Total Direct Psychiatric Treatment Costs 31% Direct Nonpsychiatric Medical Treatment Costs 54% Greenberg et al. J Clin Psychiatry. 1999;60:427.

13 What is a Panic / Anxiety Attack? An episode of intense fear or discomfort that peaks rapidly (within 10 minutes) and in which at least 4 of the following symptoms were experienced: palpitations, pounding or racing heart sweating trembling or shaking shortness of breath or smothering sensations feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, faint or lightheaded feeling unreal or detached fear of losing control or going crazy fear of dying numbness or tingling sensations chills or hot flushes

14 Diagnostic Criteria For Panic Disorder Criterion A: Criterion B: Criterion C: Criterion D: Recurrent, unexpected panic attacks followed by 1 month(s) of persistent concern about another panic attack, worry about possible implications or consequences of panic attacks, or significant behavioral changes related to panic attacks Diagnosis of panic disorder +/- agoraphobia* Panic attacks not due to physiologic effects of a substance or medical condition Panic attacks not better accounted for by another mental disorder * Agoraphobia is an intense fear of being alone in a place where help might not be available or escape might be difficult. Adapted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed

15 Prevalence Of Panic Phenomenology All Respondents Fearful Spells** 15.6% Panic Attacks 7.3% Recurrent Panic Attacks 4.2% Panic Disorder 3.5% Without Agoraphobia 2% With Agoraphobia 1.5% * Prevalence of DSM-III-R Panic Disorder and related experiences in the US population based on data from respondents in the National Comorbidity Survey. ** Fearful spells corresponds to the concept of simple panic attack. Eaton et al. Am J Psychiatry. 1994;151:413.

16 Agoraphobia Anxiety about being in places or situations from which escape might be difficult or embarrassing in the event of a panic attack Examples Enclosed Places Standing in Lines Driving Public Transportation Being Alone Crowds Shopping Malls and Supermarkets

17 Quality Of Life In Panic Disorder Panic Disorder (N = 254) Major Depression (N = 738) Neither PDN or MD (N = 17,113) % Marital Discord (past 2 weeks) Markowitz et al. Arch Gen Psychiatry. 1989;46:984. Use Of ER (past year) Financial Dependence (welfare or disability)

18 Diagnosis And Treatment Lower Costs Of Panic Disorder Year Before Diagnosis 1 Year After Diagnosis 50 Costs ($K) Nonpsychiatric Medical Visits Hospitalization Laboratory Tests Lost Productivity N = 61. Salvador-Carulla et al. Br J Psychiatry. 1995;166(suppl 27):23.

19 Specific Phobia Excessive fear of a specific object or situation causing significant distress or impairment Common Specific Phobias Animals and Insects Blood and Injections Heights Storms or Water Flying Enclosed Places Driving Choking Vomiting

20 Indiana Jones Syndrome (Fear of Snakes) Snakes. Why did it have to be snakes?

21 Social Anxiety Disorder (Generalized Social Phobia) Intense fear of social or performance situations causing significant distress or impairment Common Feared Situations Parties Meetings Public Speaking Performing Eating, Drinking, or Writing in Public Crowded Places Initiating and/or Maintaining Conversations

22 Social Anxiety Disorder (DSM-IV) Fear/avoidance of social situations Feared situations avoided or endured with intense anxiety or distress Fear recognized as excessive or unreasonable Fear/avoidance interferes with work, social, family activities Adapted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed

23 Comorbidity In Social Anxiety Disorder Lifetime Prevalence (%) Simple Phobia Agoraphobia Alcohol Major Dysthymia AbuseDepression Drug Abuse OCD Panic Disorder Schneier et al. Arch Gen Psychiatry. 1992;49:282.

24 Social Anxiety Disorder: Educational And Occupational Impairment LSAS Score = 74 * Impairment (%) Wages College Graduation Professional Or Management Positions * LSAS score in controls = 25; ** Impairment (%) refers to percentage change in wages and percentage point changes in probabilities of college graduation and having a technical, professional, or managerial job.

25 Missed Opportunity For Treatment: 195 Patients With Generalized Social Anxiety Disorder 99.5% Not Diagnosed In Past Year 0.5% Diagnosed In Past Year Katzelnick et al., 1998

26 Obsessive-Compulsive Disorder Recurrent and persistent Obsessions intrusive thoughts, impulses, images and/or Compulsions repetitive behaviours or mental acts Symptoms cause marked distress or impairment Time consuming (more than 1 hour/day)

27 Obsessions Contamination Obsessions Excessive Doubting Need for Symmetry Accidental Harm to Others Aggressive Obsessions Religious Obsessions Accidental Harm to Others

28 Compulsions Checking Washing and Cleaning Need to Ask or Confess Symmetry and Precision Hoarding Repeating Actions or Words

29 Hoarding Fear of Germs

30 Coexisting Axis I Diagnoses In Primary OCD Major Depression 67 Simple Phobia 22 Social Anxiety Disorder Eating Disorder Alcohol Use Disorder/Dependence Panic Disorder Tourette Syndrome 7 Separation Anxiety Disorder 2 Rasmussen and Eisen. Psychopharmacol Bull. 1988;24: Lifetime Prevalence (%)

31 Diagnosis Of OCD: Interview Questions Do you ever find that certain thoughts or images keep coming into your head even though you try to keep them out? Do these thoughts make sense to you or do they seem silly or absurd? What do you do to try to get rid of or counteract these thoughts? Do you sometimes feel like you have to do certain things over and over even though you don t want to? Does repeating these actions seem reasonable to you or does it seem excessive? Adapted with permission from Eddy and Walbroehl. Am Fam Physician. 1998;57:1623.

32 Generalized Anxiety Disorder Excessive Worry About Work Family and Children Health Finances Minor Matters Worry occurs most days (for at least 6 months) Difficult to control worry Associated with disturbed sleep, irritability, restlessness, poor concentration, fatigue, muscle tension

33 Diagnostic Criteria for GAD Excessive anxiety and worry, for more days than not for 6 months, about many subjects Worry is difficult to control Anxiety, worry, physical symptoms impair social, occupational, and other functioning American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.

34 Diagnostic Criteria for GAD (cont d) Associated with 3 of the following restlessness/keyed-up easily fatigued difficulty concentrating irritability muscle tension sleep disturbances Cannot be confined to another Axis 1 diagnosis or the effects of a substance or medical condition American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.

35 Symptom Overlap In GAD And Depression Interest Appetite Esteem Suicide Depression Agitation Dysphoria Sleep Fatigue GAD Concentration Restlessness Tension Irritability Worry Roy-Byrne et al. J Clin Psychiatry. 1997;58(suppl 3):34.

36 Generalized Anxiety Disorder May Be Associated With Never Marrying Receiving Public Assistance Depression OCD Alcohol Use Disorder/Dependence Suicide Attempts N = 63; Massion et al. Am J Psychiatry. 1993;150: Rate (%)

37 Lifetime Prevalence of Comorbid Disorders in Patients with GAD Lifetime Prevalence of Comorbid Disorder (% of patients) Any Disorder Major Depression Panic Disorder Social Anxiety Disorder Alcohol Abuse And Dependence Wittchen et al. Arch Gen Psychiatry. 1994;51:355.

38 GAD: Impairment As impairing as major depression* High utilizers of health care** 66% seek professional help 44% take medication for symptoms * Kessler et al. Am J Psychiatry. 1999;156:1915. ** Wittchen et al. Arch Gen Psychiatry. 1994;51:355.

39 Core Features Of PTSD Trauma Intrusive symptoms Avoidance behavior Emotional Numbing Hyperarousal symptoms

40 Non-Combat-Related Trauma Associated With PTSD Incidence (%) Rape Molestation Physical Attack Accident Physical Abuse Males Females Paroxetine is not FDA-approved for treatment of PTSD. Kessler et al. Arch Gen Psychiatry. 1995;52:1048.

41 Diagnosis Of PTSD In Primary Care Must specifically ask about trauma Assess presence of core symptoms Patient self-rated scales (eg, Impact of Event Scale, MINI) Assess comorbidity (depression, substance use disorders, anxiety disorders)

42 Psychological Treatments Cognitive Treatments Exposure-Based Treatments Relaxation-Based Treatments Ritual Prevention Biological Treatments Medications

43 Cognitive Behavioural Therapy COGNITIVE STRATEGIES In anxiety, thoughts revolve around: "probability overestimation "catastrophizing the consequences That is people overestimate that something bad will happen, and that when it happens, they will be unable to cope.

44 Cognitive Behavioural Therapy BEHAVIOURAL STRATEGIES Controlled exposure to the feared situation Anxiety responses are allowed to "habituate" or decrease without interference Teaches the person that the situation is not dangerous, and that anxiety will diminish.

45 Medications: First Line Selective Serotonin Re-Uptake Inhibitors (SSRIs) Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalpram (Lexapro)

46 Medications: 2 nd -3 rd Line Other Antidepressants (5-HT and NE Reuptake Inhibitors - SNRIs) Venlafaxine (Effexor) Imipramine (Tofranil) Clomipramine (Anafranil) Anti-Anxiety Medications (Benzodiazepines) Alprazolam (Xanax) Clonazepam (Rivotril) Lorazepam (Ativan) Diazepam (Valium) Other Antidepressants (Monoamine Oxidase Inhibitors - MAOIs) Selegeline (Eldepryl) antiparkinsonian agent Phenelzine (Nardil) Tranylcypromine (Parnate)

47 Choosing a Medication Research on effectiveness Side effect profile Previous response to medications Previous response of a family member Additional problems present (e.g., depression) Cost