Anxiety Disorders PowerPoint Presentation

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Anxiety disorders, Obsessive-Compulsive and Related disorders, and Trauma and Stressor-related Disorders Heidi Combs, MD Assistant Professor University of Washington/HMC Paul Zarkowski Assistant Professor

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Faculty Disclosure I have no financial relationships to disclose relating to the subject matter of this presentation

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What we will review Epidemiology of anxiety and related disorders Comorbid psychiatric diagnoses Diagnostic criteria for anxiety and related disorders Neuroimaging findings of anxiety disorders Quick questions to screen for anxiety disorders Treatment including psychotherapy and psychopharmacology

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Objectives List the prevalence of anxiety and related disorders Identify comorbid psychiatric diagnoses Perform a quick screen for anxiety and related disorders Apply general pharmacologic approaches to the treatment of anxiety disorders

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General considerations for anxiety disorders Often have an early onset- teens or early twenties Show 2:1 female predominance Have a waxing and waning course over lifetime Similar to major depression and chronic diseases such as diabetes in functional impairment and decreased quality of life

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Normal versus Pathologic Anxiety Normal anxiety is adaptive. It is an inborn response to threat or to the absence of people or objects that signify safety can result in cognitive (worry) and somatic (racing heart, sweating, shaking, freezing, etc.) symptoms. Pathologic anxiety is anxiety that is excessive, impairs function.

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Focused Neuroanatomy Review Amygdala- involved with processing of emotionally salient stimuli Medial prefrontal cortex (includes the anterior cingulate cortex, the subcallosal cortex and the medial frontal gyrus)- involved in modulation of affect Hippocampus- involved in memory encoding and retrieval

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The differential diagnosis of anxiety. Psychiatric and Medical disorders. Psychiatr Clin North Am 1985 Mar;8(1):3-23 Primary versus Secondary Anxiety Anxiety may be due to one of the primary anxiety disorders OR secondary to substance abuse (Substance-Induced Anxiety Disorder), a medical condition (Anxiety Disorder Due to a General Medical Condition), another psychiatric condition, or psychosocial stressors (Adjustment Disorder with Anxiety)

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Anxiety disorders Specific phobia Social anxiety disorder (SAD) Panic disorder (PD) Agoraphobia Generalized anxiety disorder (GAD) Anxiety Disorder due to a General Medical Condition Substance-Induced Anxiety Disorder Anxiety Disorder NOS

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What characteristics of primary anxiety disorders predict subsequent major depressive disorder. J Clin Psychiatry 2004 May;65(5):618-25 Comorbid diagnoses Once an anxiety disorder is diagnoses it is critical to screen for other psychiatric diagnoses since it is very common for other diagnoses to be present and this can impact both treatment and prognosis.

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Epidemiology of anxiety disorders Damsa C. et al. Current status of brain imaging in anxiety disorders. Curr Opin Psychiatry 2009;22:96-110

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Genetic Epidemiology of Anxiety Disorders There is significant familial aggregation for PD, GAD, OCD and phobias Twin studies found heritability of 0.43 for panic disorder and 0.32 for GAD. Hetteman J. et al. A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety disorders. Am J Psychiatry 2001;158:1568-1575

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Specific Phobia

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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 Systematic desensitization

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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 Anxiety is out of proportion to the actual threat posed by the situation 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

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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):221-232 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

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What is going on in their brains?? Study of 16 SAD patients and 16 matched controls undergoing fMRI scans while reading stories that involved neutral social events , unintentional social transgressions (choking on food then spitting it out in public) or intentional social transgressions (disliking food and spitting it out) Blair K. Et al. Social Norm Processing in Adult Social Phobia: Atypical Increased Ventromedial Frontal cortex Responsiveness to Unintentional (Embarassing) Transgressions. Am J Psychiatry 2010;167:1526-1532

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What is going on in their brains?? Both groups ↑ medial prefrontal cortex activity in response to intentional relative to unintentional transgression. SAD patients however showed a significant response to the unintentional transgression. SAD subjects also had significant increase activity in the amygdala and insula bilaterally. Blair K. Et al. Social Norm Processing in Adult Soical Phobia: Atypical Increased Ventromedial Frontal cortex Responsiveness to Unintentional (Embarrasing) Trasgressions. Am J Psychiatry 2010;167:1526-1532

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What is going on in their brains?? Blair K. Et al. Social Norm Processing in Adult Soical Phobia: Atypical Increased Ventromedial Frontal cortex Responsiveness to Unintentional (Embarrasing) Trasgressions. Am J Psychiatry 2010;167:1526-1532

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Functional imaging studies in SAD Several studies have found hyperactivity of the amygdala even with a weak form of symptom provocation namely presentation of human faces. Successful treatment with either CBT or citalopram showed reduction in activation of amygdala and hippocampus Furmark T et al. Common changes in cerebral blood flow in patients with social phobia treated with citalpram or cognitive behavior therapy. Arch Gen Psychiatry 2002; 59:425-433

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Social Anxiety Disorder treatment Social skills training, behavior therapy, cognitive therapy Medication – SSRIs, SNRIs, MAOIs, benzodiazepines, gabapentin

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Panic Disorder

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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 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 A discrete period of intense fear in which 4 of the following Symptoms abruptly develop and peak within 10 minutes:

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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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Panic Disorder Etiology Drug/Alcohol Genetics Social learning Cognitive theories Neurobiology/condi-tioned fear Psychosocial stessors Prior separation anxiety

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Treatment See 70% or better treatment response Education, reassurance, elimination of caffeine, alcohol, drugs, OTC stimulants Cognitive-behavioral therapy Medications – SSRIs, venlafaxine, tricyclics, MAOIs, benzodiazepines, valproate, gabapentin

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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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Prevalence 2% of the population Females to males:2:1 Mean onset is 17 years 30% of persons with agoraphobia have panic attacks or panic disorder Confers higher risk of other anxiety disorders, depressive and substance-use disorders

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Generalized Anxiety Disorder

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Generalized Anxiety Disorder Excessive worry more days than not for at least 6 months about a number of events and they find it difficult to control the worry. 3 or more of the following symptoms: Restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance Causes significant distress or impairment

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Generalized Anxiety Disorder Epidemiology 4-7% of general population Median onset=30 years but large range Female:Male 2:1

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GAD Comorbidity 90% have at least one other lifetime Axis I Disorder 66% have another current Axis I disorder Worse prognosis over 5 years than panic disorder

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GAD Treatment Medications including buspirone, benzodiazepines, antidepressants (SSRIs, venlafaxine, imipramine) Cognitive-behavioral therapy

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Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania Excoriation Disorder

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Prevalence of Obsessive-Compulsive Related Disorders Body Dysmorphic Disorder-2.4% 9-15% of dermatologic pts 7% of cosmetic surgery pts 10% of pts presenting for oral or maxillofacial surgery! Hoarding Disorder- est. 2-6% FM

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Obsessive-Compulsive Disorder

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Obsessive-Compulsive Disorder (OCD) Obsessions defined by: recurrent and persistent thoughts, impulses or images that are intrusive and unwanted that cause marked anxiety or distress The person attempts to ignore or suppress such thoughts, urges or images, or to neutralize them with some other thought or action (i.e. compulsion) Obsessions or compulsions or both defined by:

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OCD continued Compulsions as defined by: Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rigidly applied rules. The behaviors or acts are aimed at reducing distress or preventing some dreaded situation however these acts or behaviors are not connected in a realistic way with what they are designed to neutralize or prevent.

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OCD continued The obsessions or compulsions cause marked distress, take > 1 hour/day or cause clinically significant distress or impairment in function Specify if: With good or fair insight- recognizes beliefs are definitely or most likely not true With poor insight- thinks are probably true With absent insight- is completely convinced the COCD beliefs are true Tic- related

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OCD Epidemiology 2% of general population Mean onset 19.5 years, 25% start by age 14! Males have earlier onset than females Female: Male 1:1

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OCD Comorbidities >70% have lifetime dx of an anxiety disorder such as PD, SAD, GAD, phobia >60% have lifetime dx of a mood disorder MDD being the most common Up to 30% have a lifetime Tic disorder 12% of persons with schizophrenia/ schizoaffective disorder

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OCD Etiology Genetics Serotonergic dysfunction Cortico-striato-thalamo-cortical loop Autoimmune- PANDAS

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Treatment 40-60% treatment response Serotonergic antidepressants Behavior therapy Adjunctive antipsychotics, psychosurgery PANDAS – penicillin, plasmapharesis, IV immunoglobulin

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Functional imaging studies Increased activity in the right caudate is found in pts with OCD and Cognitive behavior therapy reduces resting state glucose metabolism or blood flow in the right caudate in treatment responders. Similar results have been obtained with pharmacotherapy Baxter L. et al. Caudate glucose metabolic rate changes with both drug and behavioral therapy for obessive-compulsive disorder. Arch Gen Psych 1992;49:681-689

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Trauma- and Stressor-Related Disorders Acute Stress Disorder Adjustment Disorders Posttraumatic Stress Disorder

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Post Traumatic Stress Disorder

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Posttraumatic Stress Disorder Exposure to actual or threatened death, serious or sexual violence in one or more of the following ways: Direct experiencing of traumatic event(s) Witnessed in person the events as it occurred to others Learning that the traumatic events occurred to person close to them Experiencing repeated or extreme exposure to aversive details of trauma

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PTSD continued Presence of 1 or more intrusive sx after the event Recurrent, involuntary and intrusive memories of event Recurrent trauma-related nightmares Dissociative reactions Intense physiologic distress at cue exposure Marked physiological reactivity at cue exposure Persistent avoidance by 1 or both: Avoidance of distressing memories, thoughts or feelings of the event(s) Avoidance of external reminders of that arouse memories of event(s) e.g. people, places, activities

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Negative alterations in cognitions and mood associated with the traumatic event(s) as evidenced by 2 or more of the following: Inability to remember an important aspect of the traumatic event(s) Persistent distorted cognitions about cause or consequence of event that lead to blame of self or others Persistent negative emotional state Marked diminished interest Feeling detached from others Persistent inability to experience positive emotions

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Marked alterations in arousal and reactivity with 2 or more of: Irritable behavior and and angry outbursts Reckless or self-destructive behavior Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance

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Duration of disturbance is more than one month AND causes significant impairment in function Specifiers: With dissociative sx (derealization or depersonalization) With delayed expression (don’t meet criteria until >6 months after event)

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PTSD Epidemiology 7-9% of general population 60-80% of trauma victims 30% of combat veterans 50-80% of sexual assault victims Increased risk in women, younger people Risk increases with “dose” of trauma, lack of social support, pre-existing psychiatric disorder

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Comorbidities Depression Other anxiety disorders Substance use disorders Somatization Dissociative disorders

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Post Traumatic Stress Disorder Etiology Conditioned fear Genetic/familial vulnerability Stress-induced release Norepinephrine, CRF, Cortisol Autonomic arousal immediately after trauma predicts PTSD

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Pharmacotherapy for post traumatic stress disorder. Cochrane Database Sys Rev 2006 Jan 25(1):CD002795 PTSD Treatment Debriefing immediately following trauma is NOT necessarily effective Cognitive-behavioral therapy, exposure Group therapy Medications – antidepressants, mood stabilizers, beta-blockers, clonidine, prazosin, gabapentin

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Prazosin Start at 1mg qhs X 3 nights then increased by 1mg q 3 nights until nightmares improve or patient develops postural hypotension. Some patients can gain benefit a 1mg and some need >10mgs!

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Functional neuroimaging in PTSD Increased amygdalar activation is seen in PTSD pts compared to controls Hypoactivation of the medial prefrontal cortex including the orbitofrontal cortex and anterior cingulate cortex (area implicated in affect regulation) Francati V. et al. Functional Neuroimaging Studies in Posttraumatic Stress Disorder:Review of Current methods and Findings. Depression and Anxiety 2007;24:202-218

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Study found treatment of PTSD with paroxetine resulted in increased anterior cingulate cortex function Fani N. et al. Increased neural response to trauma scripts in posttraumatic stress disorder following paroxetine treatment: A pilot study. Neurosci Letters 2011;491:196-201

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Acute Stress Disorder Similar exposure as in PTSD Presence of >9 of 5 categories of intrusion, negative mood, dissociation, avoidance, and arousal related to the trauma. Duration of disturbance is 3 days to 1 month after trauma Causes significant impairment

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Screening questions How ever experienced a panic attack? (Panic) Do you consider yourself a worrier? (GAD) Have you ever had anything happen that still haunts you? (PTSD) Do you get thoughts stuck in your head that really bother you or need to do things over and over like washing your hands, checking things or count? (OCD) When you are in a situation where people can observe you do you feel nervous and worry that they will judge you? (SAD)

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Treatment

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General treatment approaches Pharmacotherapy Antidepresssants Anxiolytics Antipsychotics Mood stabilizers Psychotherapy- Cognitive Behavior Therapy

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Crank up the serotonin Cornerstone of treatment for anxiety disorders is increasing serotonin Any of the SSRIs or SNRIs can be used

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How to use them Start at ½ the usual dose used for antidepressant benefit i.e citalopram at 10mg rather than the usual 20mg WARN THEM THEIR ANXIETY MAY GET WORSE BEFORE IT GETS BETTER!! May need to use an anxiolytic while initiating and titrating the antidepressant

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Other options Hydroxyzine- usually 50mg prn. Helpful for some patients but has prominent anticholinergic SEs Buspirone-For GAD- 60mg daily Propranolol-Effective for discrete social phobia i.e. performance anxiety Atypical antipsychotics at low doses for augmentation in difficult to treat OCD pts

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Anticonvulsants Valproic acid 500-750 mg bid (ending dose) carbamazepine 200-600 mg bid (ending dose) Gabapentin 900-2700 mg daily in 3 divided doses (ending dose) Atypical antipsychotics at low doses for augmentation in difficult to treat OCD pts

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Mothers little helpers Benzodiazapines are very effective in reducing anxiety sx however due to the risk of dependence must use with caution Depending on the patient may either use on a prn basis or scheduled DO NOT USE ALPRAZOLAM- talk about a reinforcing drug! For patients with a history of addiction or active drug/ETOH abuse or dependence benzodiazepines are not an option

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Psychotherapy Please refer to psychotherapy lecture!

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Case 1 42 cauc male with a 20 year history of heroin addiction admitted due to SI with a plan to overdose. For the past several months he noted depressed mood, anhedonia, irritability, poor concentration, difficulty with sleep, guilt feelings, hopelessness and on the day PTA SI with a plan. He has a recent lapse of one day on heroin and cocaine. What should we do?

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Further history obtained He endorsed worrying “All the time I am awake” and experiences irritability, muscle tension, fatigue and sleep disturbance associated with the worry. He noted it has been worse since he has become depressed but at best he only spends 4 hours worrying a day, cannot control the worry and feels it interferes with his function. Now what should we do?

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List dx: Heroin dependence, MDD, GAD Treatment-Therapy- Chemical dependency and Cognitive Behavior Therapy Meds- Started Citalopram at 10mg daily and titrated to 20mg then 40mg due to prominent depressive and anxiety sx. Tried hydroxyzine at 50-100mg prn anxiety but it was not helpful. Started gabapentin at 100mg q 4 hours prn anxiety and titrated to 600mg q 4 hours prn with some reduction in anxiety. Also had to reduce the citalopram to 30mg with good results.

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Case 2 28 yo Samoan woman referred for depression. Pt had been started 3 weeks ago on Fluoxetine at 20mg and Trazodone at 150mg while in jail. She endorsed depressed mood, anhedonia, guilt feelings, poor sleep, reduced appetite, poor concentration and hopelessness but no SI. When asked if the Trazodone had helped with sleep she stated no.

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Further history obtained When asked if she had ever experienced any trauma she looked down and shook her head yes. When asked how often she had nightmares she stated ‘Every night since I was 13.” At that age a 3 year saga of sexual abuse began. In reviewing her history she endorsed sx consistent with PTSD, chronic.

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Prazosin was started at 1mg qhs X 3 nights then increased by 1mg q 3 nights and she followed up in one week. She was up to 3mg and was now sleeping through the night. Her mood was also significantly better and she was hopeful. No further increase was needed in the fluoxetine.

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Take home points Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-related disorders are common, common, common! There are significant comorbid psychiatric conditions associated with anxiety disorders! Screening questions can help identify or rule out diagnoses There are many effective treatments including psychotherapy and psychopharmacology There is a huge amount of suffering associated with these disorders!