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Anxiety Disorders And Obsessive-Compulsive Disorders
Med 2017
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Objectives: Appreciating the prevalence and the burden of various of anxiety disorders Describing the key features of various anxiety disorders Understanding how to differentiate between different anxiety disorders. Recognizing comorbidities of different anxiety disorders Planning psychopharmacologic and psychotherapeutic approaches to different anxiety disorders
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ANXIETY AND FEAR ARE NORMAL
ANXIETY AND FEAR ARE NORMAL!! SERVES IMPORTANT ROLES: ADAPTATION, INITIATION, MOTIVATION ANXIETY PREPARES US TO TAKE ACTION AND IS NORMAL IN MODERATE AMOUNTS
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Benefits of anxiety Yerkes-Dodson law:
Performance improves as a function of anxiety up to a threshold beyond which there is a fall off in performance
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The Continuum Between Normal and Abnormal Anxiety
Anxiety is an expectable part of everyday life Pathological anxiety is on the extreme end of the continuum for Trait anxiety: how anxious a person feels in general (as in generalized anxiety disorder) and/or State anxiety: how anxious a person feels in response to specific events (as in phobias)
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WHAT ARE ANXIETY DISORDERS?
A group of 7 diagnosable disorders some shared features some distinct The most prevalent group of psychiatric conditions
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DIAGNOSING ANXIETY DISORDERS
DSM 5 PANIC DISORDER AGORAPHOBIA GENERALIZED ANXIETY DISORDER SOCIAL PHOBIA SPECIFIC PHOBIA SEPERATION ANXIETY SELECTIVE MUTISM
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SHARED CLINICAL FEATURES
Triggered by innocuous stimuli Maladaptive thinking patterns: tend to catastrophize, misjudge probability Prominent physical symptoms: autonomic arousal Typical behavioral responses: escape, avoidance, help-seeking
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WHY ARE ANXIETY DISORDERS IMPORTANT?
THE MOST PREVALENT PSYCHIATRIC DISORDERS IN ADULTS NATIONAL COMORBIDITY STUDY Kessler et al Arch Gen Psychiatry Jan 1994
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ANXIETY DISORDERS CAUSE IMPAIRMENT
Daily life effects Physical functioning Social functioning Pain Fatigue General health Sense of well being Increased risk of Less Income Fewer than 16 years of education
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INCREASED RISK OF SUICIDE
Overall Anxiety Disorders associated with 3 fold risk for suicide attempts PTSD: 6 fold risk Panic Disorder and GAD: 5.6 fold risk Social Phobia: 2.1 fold risk Kessler et al. Arch Gen Psychiatry. 1999;56:617.
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Other Anxiety Disorders Substance Use Disorders
COMORBIDITY Anxiety Disorders co-occur with many mental and physical disorders, esp. Major Depression Bipolar Disorder Other Anxiety Disorders Substance Use Disorders
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Comer, Ronald J., Fundamentals of Abnormal Psychology, Seventh Edition Copyright © 2014 by Worth Publishers
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ANXIETY DISORDERS ARE ASSOCIATED WITH BIOLOGICAL CHANGES
Brain Imaging Abnormalities Autonomic Activation Neuroendocrine Changes Early Bio-behavioral Changes
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Amygdala Lateral Nucleus
Creates link between conditioned and unconditioned stimulus Exposure to subsequent relevant stimulus, activates Central Nucleus: (coordinates fear response) periaqueductal gray region - freezing or immobility lateral hypothalamus - autonomic responses paraventricular hypothalamus – neuroendocrine
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Shift From Passive Fear to Active Coping in the Brain
LeDoux J and Gorman J Am J Psychiatry 158: , December 2001
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Generalized Anxiety Disorder (GAD)
Characterized by excessive “free floating” anxiety under most circumstances and worry about practically anything Symptoms: feeling restless, keyed up, or on edge; fatigue; difficulty concentrating; muscle tension, and/or sleep problems Must last at least 6 months
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Specific Phobia Marked or persistent fear (>6 months) that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation Anxiety must be out of proportion to the actual danger or situation It interferes significantly with the persons routine or function
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Specific Phobia Epidemiology Up to 15% of general population
Onset early in life Female: Male 2:1 Etiology Learning, contextual conditioning Treatment Behavioural,Systematic desensitization
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How Are Specific Phobias Treated?
Systematic desensitization Teach relaxation skills Create fear hierarchy Pair relaxation with feared objects or situations Since relaxation is incompatible with fear, relaxation response is thought to substitute for fear response Several types: In vivo desensitization (live) Covert desensitization (imaginal)
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Panic Disorder
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PANIC ATTACK Sudden escalation and rapid crescendo peak of 4 or more symptoms (physical symptoms prominent Panic can be Spontaneous situation predisposed situation bound Can occur with any anxiety disorder and many other physical and mental disorders
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Panic Disorder Recurrent unexpected panic attacks and for a one month period or more of: Persistent worry about having additional attacks Worry about the implications of the attacks Significant change in behavior because of the attacks
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A Panic Attack is: Palpitations or rapid heart rate Sweating
A discrete period of intense fear in which 4 of the following Symptoms abruptly develop and peak within 10 minutes: Palpitations or rapid heart rate Sweating Trembling or shaking Shortness of breath Feeling of choking Chest pain or discomfort Nausea Chills or heat sensations Paresthesias Feeling dizzy or faint Derealization or depersonalization Fear of losing control or going crazy Fear of dying
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Panic disorder epidemiology
2-3% of general population; 5-10% of primary care patients ---Onset in teens or early 20’s Female: male 2-3:1
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Things to keep in mind A panic attack ≠ panic disorder
Panic disorder often has a waxing and waning course
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Panic Disorder Comorbidity
50-60% have lifetime major depression One third have current depression 20-25% have history substance dependence
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Agoraphobia
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Agoraphobia Marked fear or anxiety for more than 6 months about two or more of the following 5 situations: Using public transportation Being in open spaces Being in enclosed spaces Standing in line or being in a crowd Being outside of the home alone
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Agoraphobia The individual fears or avoids these situations because escape might be difficult or help might not be available The agoraphobic situations almost always provoke anxiety Anxiety is out of proportion to the actual threat posed by the situation The agoraphobic situations are avoided or endured with intense anxiety The avoidance, fear or anxiety significantly interferes with their routine or function
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Social Anxiety Disorder
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Social Anxiety Disorder (SAD)
Marked fear of one or more social or performance situations in which the person is exposed to the possible scrutiny of others and fears he will act in a way that will be humiliating Exposure to the feared situation almost invariably provokes anxiety The anxiety lasts more than 6 months The feared situation is avoided or endured with distress The avoidance, fear or distress significantly interferes with their routine or function Initial remembered traumatic event in 58% Genetic/familial (heritability about 30%) Behavioral inhibition in childhood (increased reactivity to novelty, shyness) Cognitive factors
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SAD epidemiology 7% of general population
Age of onset teens; more common in women. Stein found half of SAD patients had onset of sx by age 13 and 90% by age 23. Causes significant disability Increased depressive disorders Incidence of social anxiety disorders and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007 Mar(4):
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Social Anxiety Disorder treatment
Social skills training, CBT Medication – SSRIs, SNRIs, MAOIs, benzodiazepines, gabapentin
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TREATMENT OF ANXIETY DISORDERS
Promote active coping MEDICATION: Provide information, directly moderate neurobiology COGNITIVE BEHAVIORAL TREATMENT: Provide information, Change neural circuitry through exposure, Teach specific coping techniques
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PATIENTS AND FAMILY NEED INFORMATION
About the illness: symptoms and course Biological aspects of anxiety Psychological components of symptoms Simple principles of conditioned responses Role of thoughts and behaviors in affecting emotions Relationship between physiology, psychology and treatment
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PHARMACOLOGIC TREATMENT OF ANXIETY DISORDERS: EARLY GENERATION
Typical Antidepressants, for example, imipramine, clomipramine, nortriptyline, monoamine oxidase Inhibitors (like phenelzine) Benzodiazepines (alprazolam, clonazepam) Most worked for some, but not all of the anxiety disorders
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PHARMACOLOGIC TREATMENT OF ANXIETY DISORDERS: NEWER MEDICATIONS
SSRIs and SNRIs citalopram fluoxetine fluvoxamine paroxetine sertraline Escitalopram Venlafaxine Doluxetine Act as “broad spectrum” antianxiety agents
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Preferred by many patients
COGNITIVE BEHAVIORAL TREATMENTS ARE EQUALLY EFFICACIOUS AS MEDICATION FOR ANXIETY DISORDERS Preferred by many patients Associated with improvement in biological as well as psychological abnormalities
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CBT MODEL OF PANIC DISORDER
Catastrophic misinterpretation Conditioned response Bodily Sensation Fear Physiological arousal 14
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Behavioral Anxiety Management
Decrease Physiological Arousal Slow Abdominal Breathing Progressive Muscle Relaxation Re-Instate Normal Activities Exposure to Anxiety Provoking Situations
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Target Negative Thinking and Logical Errors
Cognitive Therapy Target Negative Thinking and Logical Errors Overestimation of Probability of Negative Consequences Catastrophizing Techniques Identify and Challenge Negative Thoughts Provide Alternative Explanations
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WHAT TO REMEMBER ABOUT ANXIETY DISORDERS
Common and debilitating conditions Often co-occur with other medical and psychiatric conditions Characterized by prominent somatic symptoms catastrophic misinterpretations escape and avoidance behaviors
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WHAT TO REMEMBER ABOUT ANXIETY DISORDERS
Avoidance Can prevent help-seeking Inhibits reporting of symptoms Highly treatable Medication, especially serotonin active antidepressants Cognitive behavioral treatment
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Obsessive-Compulsive Disorders
body dysmorphic disorder, hoarding disorder, Trichotillomania excoriation disorder
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OCD OBSESSIONS: Recurrent and persistent thoughts COMPULSIONS:
Repetitive behaviors or mental acts Distress/Dysfunction
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OCD Contamination concerns hand-washing
Possible harm concerns checking Symmetry concerns symmetry behaviours
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Obsessive-Compulsive Disorder
Diagnosis is called for when symptoms: Feel excessive or unreasonable Cause great distress Take up much time Interfere with daily functions
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NOT OCD Obsessive-compulsive personality disorder
Pathological or problem gambling, compulsive sexual disorder, problematic internet use Hoarding concerns hoarding behaviors Being a meticulous professional or student
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OCD 4th most common psychiatric disorder in one USA study
10th most disabling of all medical disorders in WHO BoD study Subclinical washing, checking, symmetry, symptoms are common (Ruscio et al, 2008)
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OCD Spectrum Range of disorders with intrusive thoughts and repetitive behaviors - Tourette’s syndrome - Body Dysmorphic Disorder - Hypochondriasis - Hoarding Disorder - Trichotillomania - Skin Picking Disorder
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Epidemiology The lifetime prevalence of OCD is between 2 and 3%. Child/adolescent prevalence is 1-2.3%. There is similar epidemiology among diverse cultures (studies in Europe, Asia and Africa have confirmed rates). In adults, male and female prevalence is the same. In children and adolescents, males are more likely than females to be affected.
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Epidemiology II Mean age of onset is approximately 20 years old (males with mean around 19 and females around 22). Two-thirds of affected people have onset before age 25. Less than 15% have onset after age 35.
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Biological Serotonin Hypothesis Clomipramine, SSRI’s, mCPP
Neuroimmunology PANDAS, autoimmune Genetics 1st degree relatives 35%, Monozygotes 80-87% Neuroimaging Orbital Frontal Cortex, Basal Ganglia, Anterior Cingulate Gyrus
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Screening Questions Why Screen?
Lag time from onset to diagnosis, shame Do you have repetitive thoughts that make you anxious and that you can’t get rid of no matter how hard you try? Do you keep things extremely clean or wash your hands frequently? Do you check things to excess? Check for comorbidity Lifetime MDD in adults is 2/3. OCD often precedes MDD in kids and adults
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Treatment Pharmacotherapy Cognitive-Behavioral Therapy Psychosurgery
Deep Brain Stimulation
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OCD: Biological Perspective
Serotonin-based antidepressants (sertraline; Paroxetine,clomipraine) Bring improvement to 50–80% of those with OCD Relapse occurs if medication is stopped Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective
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OCD: Behavioral Perspective
In fearful situation, perform a particular act (washing hands) When threat lifts, associate improvement with random act After repeated associations, believe compulsion is changing situation Act becomes method to avoiding or reducing anxiety
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OCD: Behavioral Perspective
Behavioral therapy Exposure and response prevention (ERP) Clients are repeatedly exposed to anxiety-provoking stimuli and told to resist performing compulsions Therapists often model behavior while client watches
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BE HAPPY DON’T WORRY BE HAPPY BE HAPPY BE HAPPY BE HAPPY BE HAPPY
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