Anxiety OCD.ppt
- 1. Anxiety disorders, Obsessive- Compulsive and Related disorders, and Trauma and Stressor- related Disorders 1
- 2. 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 2
- 3. 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 3
- 4. 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. 4
- 5. 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 5
- 6. 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) 6
- 7. Anxiety disorders Specific phobia Social anxiety disorder (SAD) Panic disorder (PD) Agoraphobia Generalized anxiety disorder (GAD) Anxiety Disorder due to a General Medical Condition . (Some of the medical conditions that may be involved in this disorder are hyperthyroidism, hypothyroidism, hypoglycemia, and hyperadrenocorticism . congestive heart failure and arrhythmia. Breathing problems such as COPD, pneumonia, and hyperventilation also can initiate anxiety) Substance-Induced Anxiety Disorder Anxiety Disorder NOS 7
- 8. Epidemiology of anxiety disorders 8
- 9. 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. 9
- 11. 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 11
- 12. Specific Phobia Epidemiology Up to 15% of general population Onset early in life Female:Male 2:1 Etiology Learning, contextual conditioning Treatment Systematic desensitization 12
- 14. 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 14
- 15. SAD epidemiology 7% of general population Age of onset teens; more common in women. Stein found half of SAD patients had onset of symptoms by age 13 and 90% by age 23. Causes significant disability Increased depressive disorders 15
- 16. 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 16
- 17. Social Anxiety Disorder treatment Social skills training, behavior therapy, cognitive therapy Medication – SSRIs,SNRIs,MAOIs(Isocarboxazid (Marplan) ,Nialamide (Niamid), Phenelzine (Nardil,), benzodiazepines, gabapentin 17
- 19. 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 19
- 20. 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: 20
- 21. 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 21
- 22. Things to keep in mind A panic attack ≠ panic disorder Panic disorder often has a waxing and waning course 22
- 23. Panic Disorder Comorbidity 50-60% have lifetime major depression One third have current depression 20-25% have history substance dependence 23
- 24. Panic Disorder Etiology Drug/Alcohol Genetics Social learning Neurobiology/condi- tioned fear Psychosocial stessors Prior separation anxiety 24
- 25. Treatment 70% or better treatment response Education, reassurance, elimination of caffeine, alcohol, drugs, OTC stimulants Cognitive-behavioral therapy Medications – SSRIs, Venlafaxine (serotonin and norepinephrine reuptake inhibitors (SSNRIs), Tricyclics, MAOIs, benzodiazepines, valproate, gabapentin 25
- 26. Agoraphobia 26
- 27. 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 27
- 28. 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 28
- 29. Prevalence 2% of the population Females to males:2:1 Mean onset is 17 years 75% of persons with agoraphobia have panic attacks or panic disorder Increase higher risk of other anxiety disorders, depressive and substance-use disorders 29
- 31. 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 31
- 32. Generalized Anxiety Disorder Epidemiology 4-7% of general population Median onset=30 years but large range Female:Male 2:1 32
- 33. 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 33
- 34. GAD Treatment Medications including buspirone (an agonist of the serotonin 5-HT1A receptor ), benzodiazepines, antidepressants (SSRIs, venlafaxine, imipramine) Cognitive-behavioral therapy 34
- 35. Obsessive-Compulsive and Related Disorders Obsessive- Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair Pulling Disorder) Excoriation (Skin Picking) Disorder 35
- 36. 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% F<M Trichotillomania 1-2% F:M 10:1! Excoriation Disorder 1.4% F>M 36
- 38. 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: 38
- 39. 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. 39
- 40. 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 40
- 41. 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 41
- 42. 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 42
- 43. Treatment 40-60% treatment response Serotonergic antidepressants Behavior therapy Adjunctive antipsychotics , Psychosurgery(Capsulotomy ,Cingulotomy) 43
- 44. 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 44
- 45. General treatment approaches Pharmacotherapy Antidepresssants Anxiolytics Antipsychotics Mood stabilizers Psychotherapy- Cognitive Behavior Therapy 45
- 46. Crank up the serotonin Cornerstone of treatment for anxiety disorders is increasing serotonin Any of the SSRIs or SNRIs can be used 46
- 47. 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 47
- 48. Other options 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 48
- 49. 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 49
- 50. 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 50
- 51. Psychotherapy Please refer to psychotherapy lecture! 51
- 52. 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! 52