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Anxiety Disorders

Anxiety
Fear is an emotional and physiological response to a recognized external threat (e.g. A speeding car or the steep descent in an airplane). Anxiety is a state of apprehension, uncertainty, and fear resulting from the anticipation of a realistic or fantasized threatening event or situation, often impairing physical and psychological functioning. Anxiety is the subjective experience of fear and its physical manifestations. Because fear of recognized threats causes similar unpleasant mental and physical changes, the two terms are usually used interchangeably.

Anxiety is a common and normal response to a perceived threat. Need to distinguish normal from pathological. Pathological Anxiety Inappropriate Either no real source of fear or the source is not sufficient to account for the severity of symptoms. Symptoms interfere with daily functioning and interpersonal relationships/work.

Anxiety
Intensity varies from minor qualms to noticeable trembling to its most extreme form panic. Course also varies with a peak severity being reached within a few seconds or more gradually over minutes, hours or days. Duration also varies from a few seconds to hours or even days or months, although episodes of panic usually abate within ten minutes and seldom last more than thirty minutes.

Anxiety
Anxiety may arise: Unexpectedly ( out of the blue) called spontaneous anxiety or spontaneous panic if intense. Predictably in specific situations called phobic or situational panic. Anticipatory anxiety or panic anxiety triggered by the mere thought of particular situations.

Anxiety and Depression


At least three-fourths of patients with primary depression complain of feeling anxious, worried, or fearful. Extreme anxiety may occur in agitated depression in the form of anguished facial expression, lip biting, picking at fingers, nails or clothing, hand wringing, constant pacing and inability to sit quietly. Primary anxiety can be depressing. If it persists, and particularly if it interferes with functioning secondary depression is the rule rather the exception.

Pathophysiology of anxiety
The neurocircuitry of anxiety has been postulated to arise from the amygdala, the brain area that registers the emotional significance of environmental stimuli and stores emotional memories. The efferent pathways from the central nucleus of the amygdala travel to a multiplicity of critical brain structures, including the parabrachial nucleus (resulting in dyspnea and hyperventilation), the dorsomedial nucleus of the vagus nerve and nucleus ambiguous (activating the parasympathetic nervous system), and the lateral hypothalamus (resulting in SNS activation).

Through reciprocal neuronal pathways connecting the amygdala to the medial prefrontal cortex, cognitive experience of the specific anxiety disorder differs, although fear symptoms may overlap. Panic attacks the fear is of imminent death; Social phobia, the fear is of embarassment; Postraumatic stress disorder, the traumatic memory is remembered or reexperienced; Obsessive-compulsive disorder, obsessional ideas recur and intrude; Generalized anxiety disorder, anxiety is freefloating (i.e., not conditioned to specific situations or triggers).

Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interact with situations, stress, or trauma to produce clinically significant syndromes. Hyperresponsiveness of the amygdala may relate to reduced activation thresholds when responding to perceived social threat. Prefrontal-limbic activation abnormalities have been shown to reverse with clinical response to psychologic or pharmacologic interventions.

In the central nervous system (CNS), the major mediators of the symptoms of anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Positron emission tomography (PET) scanning has demonstrated increased flow in the right parahippocampal region and reduced serotonin type 1A receptor binding in the anterior and posterior cingulate and raphe of patients with panic disorder.

Research and treatment trials suggest that abnormalities in serotonin neurotransmission in the brain are meaningfully involved in obsessivecompulsive disorder (OCD). This is strongly supported by the efficacy of serotonin reuptake inhibitors in the treatment of OCD. Evidence also suggests abnormalities in dopaminergic transmission in at least some cases of OCD.

Anxiety Disorders
Panic Disorder Agoraphobia Specific Phobia Social Phobia Obsessive Compulsive Disorder Generalized Anxiety Disorder Post-Traumatic Stress Disorder Acute Stress Disorder

Anxiety disorder due to general medical condition Substance Induced anxiety disorder Anxiety Disorder not otherwise specified

Anxiety Disorder due to general medical condition


Causes:

Hyperthyroidism Vitamin B12 deficiency Hypoxia Neurological disorders (epilepsy, brain tumors, multiple sclerosis) Cardiovascular disease Anemia Pheochromocytoma Hypoglycemia

DSM 1V Criteria
Prominent anxiety, panic attacks, or obsessions or compulsions predominate the clinical picture. There is evidence from the history, PE or lab findings that the disturbance is the direct physiological consequence of a general medical condition. The disturbance is not better accounted for by another mental disorder. The disturbance does not occur exclusively during the course of a delirium. The disturbance causes clinically significant distress or impairment in social, occupational or other areas of functioning.

Substance-induced Anxiety Disorder


Caffeine intake and withdrawal Amphetamines Alcohol and sedative withdrawal Other illicit drug withdrawal Mercury and arsenic toxicity Organophosphate or benzene toxicity Penicillin Sulphonamides Sympathomimetics Antidepressants

Panic Disorder
Panic attacks are discrete periods of heightened anxiety that classically occur in people with panic disorder but can also occur in other conditions, especially, phobic disorder and posttraumatic stress disorder. Panic attacks peak and abate within ten minutes. Rarely they last more than one hour.

Panic attack, DSM 1V criteria


A discrete period of intense fear and discomfort that is accompanied by at least four of the following:
Palpitations Sweating Shaking Shortness of breath Choking sensation Chest pain Nausea Light headedness

Depersonalization Fear of losing control or going crazy Fear of dying Numbness or tingling Chills or hot flashes

Panic Disorder
Characterized by experience of panic attacks accompanied by persistent fear of having additional attacks.

DSM IV Criteria for Panic Disorder A) Both (1) and (2) (1) recurrent unexpected Panic Attacks (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy") (c) a significant change in behavior related to the attacks B) The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). C) The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), ObsessiveCompulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Presentation
First attack- usually unexpected, but may follow a period of stress. Subsequent attacks occur spontaneously but may be associated with specific situations. On average they occur 2x per week but may range from several times per day to a few times per year. Anticipatory anxiety between periods is common.

Panic inducing Substances


Induce panic in patients with panic disorder and in some people without panic disorder. Includes: Intravenous sodium lactate Hyperventilation decreases blood CO2, ionized calcium and phosphorus produces paresthesias, lightheadedness, visual changes, and feelings of unreality that contribute to the fear of fainting.

Epidemiology
Lifetime prevalence : 2 5% 2 to 3 times more common in females than males Strong genetic component: four to eight times greater risk of panic disorder if first degree relative is affected. Onset usually from late teens to early thirties (average 25)

Associated conditions
Following conditions are both associated with panic disorder and agoraphobia: 1. Major depression (40-80%) 2. Substance dependence (20-40%) 3. Social and specific phobias 4. Obsessive compulsive disorder

Course and Prognosis


Variable course, often chronic. Relapses common with discontinuation of medical therapy: 10-20% continue to have significant symptoms that interfere with daily life. 50% continue to have mild symptoms 30-40% remain symptom free after treatment.

Treatment
Psychological Behavior therapy Drug therapy

Drug therapy
Acute initial treatment of anxiety Benzodiazepines (only short course, dependence). Dose may be tapered as SSRI are added (anxiolytic). SSRI- are drugs of choice Take 2-4 weeks to become effective. Other antidepressants may be used. treatment should continue for 8-12 months.

Agoraphobia
Always specify panic disorder with agoraphobia or without agoraphobia. Agoraphobia is the fear of being alone in public places. It often develops secondary to panic attacks due to apprehension about having subsequent attacks in public places where escape or needed help may be difficult. Can be diagnosed alone or with panic disorder. 50-75% of patients have coexisting panic disorder.

DSM-IV Diagnostic Criteria for Agoraphobia A) anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or paniclike symptoms, or require the presence of a companion. C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), ObsessiveCompulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Relationship bet. Panic attacks and agoraphobia


Clinical scenario: a person who has a panic attack while shopping in a large supermarket subsequently develops a fear of entering that supermarket. As the person experiences more panic attacks in different settings, they develops a progressive and more general fear of public spaces (agoraphobia).

Treatment
Psychological Behavioral Drug treatment

Drug treatment
When panic is present : as you treat panic agoraphobia goes away When agoraphobia alone : behavioral therapy. Behavioral therapy and anxiolytics. When agoraphobia occurs alone it is usually chronic and debilitating.

Specific and Social Phobia


A phobia is defined as a persistent irrational fear that leads to avoidance of the feared object or situation. A specific phobia is a strong, exaggerated, persistent, irrational fear of a specific object or situation. A social phobia is a fear of social situations in which embarrassment can occur.

DSM Specific Phobia

DSM Social Phobia

Common Specific Phobia


Fear of : Animals Heights Blood or needles Illness or injury Death

Common Social Phobia


Fear of : Speaking in public Eating in public Using public restrooms

Epidemiology
Most common mental disorders in the US Affects approximately 5-10% of the population Specific phobia more common than social phobia For specific phobias onset may be as young as five years old for phobias such as seeing blood and as old as 35 for situational fears (heights). Average age of onset for social phobias is mid teens.

Course and prognosis


Not clearly defined

Treatment
Specific phobias Pharmacological treatment has not been found effective. Systemic desensitization, with or without hypnosis, and supportive psychotherapy are often useful. If necessary a short course of benzodiazepines or beta blockers may be used during desensitization to help control autonomic symptoms. Systemic desensitization: gradually expose patient to a feared object or situation while teaching relaxation and breathing techniques.

Social phobia
Paroxetine, an SSRI, has been approved by the FDA for treatment of. Beta blockers are frequently used to control symptoms of performance anxiety. Cognitive and behavioral therapy are useful adjuncts.

Movies: The Aviator, As Good As It Gets

OBSESSIVE COMPULSIVE DISORDER

OCD
Diverse group of symptoms that include recurring, intrusive thoughts, rituals, preoccupations and repetitive behaviours that are time consuming and interfere significantly with function

Either or both
Obsessions = mental event
Recurrent and intrusive thoughts, feelings, ideas or sensations

Compulsions = behaviour
Conscious, standardized, recurrent behaviours (e.g. counting, checking, avoiding)

Sequence of events (generally)


Obsessions Anxious dread Compulsions to decrease anxiety

DSM-IV: OCD
A. Either obsessions or compulsions: Obsessions defined by 1, 2, 3 and 4 1) Recurrent and persistent thoughts/impulses/images experienced at times as intrusive and inappropriate anxiety/distress 2) Not just excessive worries about real life problems 3) Attempts to ignore/suppress thoughts, impulse, or images, or to neutralize with other thought/action 4) Recognized as product of own mind (not imposed from without as in thought insertion) Compulsions defined by 1 and 2 1) Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that person feels driven to perform in response to obsession, or according to rigidly applied rules 2) Aims to prevent/reduce distress, or dreaded situation/event. Behaviours/mental acts not connected in realistic way or are excessive to what they are designed to prevent/neutralize Recognition that obsessions/compulsions are unreasonable Marked distress, time consuming (>1 hour/day), or significant interference Obsession or compulsion not restricted to another Axis I d/o E.g. preoccupation with food in presence of eating d/o, hair pulling in trichotillomania, appearance concern in body dysmorphic d/o R/o substances or general medical condition

B. C. D. E.

Epidemiology
Lifetime prevalence
23% Male = female (adults), male > female (adolescents)

Mean age of onset 20 yo


younger onset in men 2/3 patients have onset by 25 yo <15% onset after 35 yo

Comorbidity
Major depressive d/o
Lifetime prevalence 67%

Social phobia
Lifetime prevalence 25%

ADHD Alcohol and other substance d/o Generalized anxiety d/o Specific phobias Panic d/o Eating d/o Personality d/o Tourettes
Incidence 6 7% 20 30% patients with OCD have history of this

Tics

Etiology
Biological
Neurotransmitters: 5-HT dysfunction Imaging:
Increased activity of corticostriatal pathways
PET: orbitofrontal, basal ganglia (especially caudate), cingulum

Decreased size of caudate bilaterally (MRI)


Reverses with treatment

Genetics
3-5x increased risk OCD if 1st degree relative with OCD Increased risk OCD if 1st degree relative with Tourettes
Linkage b/w Tourettes, chronic motor tics and OCD

Etiology: Psychological
Learning theory:
Obsessions: conditioned response
Neutral stimuli (thoughts) + anxiety/noxious response noxious interpretation of neutral stimuli

Compulsions: reinforced, learned pattern of avoidance


Interruption of this anxiety

Psychodynamic:
Magical thinking: omnipotence of thought
Thinking about event event occurring
E.g. thinking about parent dying parent dying Skips over action needed for event to occur

Overvaluation of thought
Perceive thoughts as powerful wishes = deeds
E.g. violent thoughts = violent acts Im a violent person

Dynamics supporting OCD


Stressful life events can trigger symptoms Interpersonal conflict Maintaining symptoms for 2o gain

Etiology: Psychological
Cognitive theories:
Excessive sense of responsibility
Non-OCD: intrusive thoughts/impulses = trash OCD: intrusive thoughts/impulses = something dangerous
increased anxiety/depression Increased focus on intrusive thoughts attempts to counteract/neutralize thoughts

Fusion

E.g. compulsions, avoidance, reassurance-seeking

Obsessional thought morally equivalent to activity in thought guilt and anxiety


E.g. thinking of hurting small child as immoral as actually hurting child

Other assumptions in OCD


Having thought = performing action Failing to prevent harm to self/others = causing harm in 1st place Not neutralizing thoughts = seeking/wanting harm to happen One can exercise control over own thoughts Belief that thoughts can be completely controlled

Clinical features
Concealment of symptoms
5-10 years untreated illness before presenting to Often present to other specialists first

Reassurance seeking about basic fears


E.g. Did I wash properly? Did I put glass in the food? reassurance transient comfort cycle starts over

Obsessions, compulsions together/alone


75% have both obsessions and compulsions 5 - 25% pure obsessions without compulsions In chronic OCD may have compulsions in absence of provoking thought
Behaviour performed out of habit

Obsessions/compulsions can change over time

Screening Questions
Compulsions:
Do you ever have to perform a behaviour or repeat some action that doesnt make sense to you or that you dont want to do? For example, washing or cleaning excessively, checking things over and over, counting things repeatedly?

Obsessions:
Do you experience disturbing thoughts, images, or urges that keep coming back to you and that you have trouble putting out of your head? For example, being contaminated by something, something terrible happening to you or someone you care about, or of doing something terrible?

1.

Symptom Patterns Contamination (cleaners)


Obsession: contamination Compulsion: hand washing, avoidance Usually of hard to avoid material (bodily secretions, dust, germs)

2.

Pathological doubt (checkers)


Obsession: danger Compulsion: checking Usually some perception of violence/danger
E.g. stove, door

3.

Repetition obsessions/compulsions (counters/repeaters)


Compulsion: continue repeating an action until done correctly

4.

Intrusive thoughts (pure obsessions)


Obsessions: sexual, religious or aggressive acts repulsive to pt Usually without compulsions

5.

Orderliness
Compulsion: symmetry, precision

6.

Hoarding
Obsession: throwing away something valuable Compulsion: holding on to clutter/garbage

7.

Other
Compulsions: trichotillomania (hair pulling), nail biting, masturbating, compulsive slowness

Sounds like an obsessive-compulsive disorder. Normal people dont spend that much time washing their hands.

Differential Diagnosis
Neurological

Substances

Parkinsons disease Amphetamine intoxication Fronto-temporal CVA Levodopa therapy Trauma Psychiatric Neoplasm Anxiety d/o (Phobia, Epilepsy GAD) Dementia Major depression Huntingtons Schizophrenia Sydenhams chorea Delusional d/o Autism Tourettes

Course and Prognosis


Variable course:
Episodic vs. constant symptoms

Prognosis
2/3 improve, 1/3 same or worsen Negative factors
Poor insight, poor resistance of compulsions, bizarre compulsions Childhood onset, hospitalization Comorbid MDD, personality d/o, delusions, overvalued ideas

Positive factors
Good social/occupational adjustment Onset associated with precipitating event Episodic course

Not influenced by obsessional content

Treatment: Pharmacotherapy
Start with low doses and increase gradually 1st line:
SSRI: fluvoxamine, fluoxetine, paroxetine, sertraline

2nd line:
TCA: Clomipramine (gold standard) Other antidepressants: venlefaxine XR, citalopram, mirtazepine Adjunct: Risperidone

Treatment: Pharmacotherapy
If poor response:
Optimize dose first for at least 10 - 12 week trial
Generally higher response rates at upper end of therapeutic range

If no improvement, switch to another 1st line agent before moving to 2nd line Consider adjunctive therapy with 2nd or 3rd line agent early

For treatment-refractory OCD:


Review for comorbid psychiatric/medical conditions Consider 3rd Line:
Antidepressants: IV clomipramine, escitalopram, phenelzine, tranylcypromine Adjunct: mirtazepine, olanzepine, quetiapine, haloperidal, gabapentin, topiramate, tramadol, riluzol, St. Johns Wart, pindolol

Medications not recommended:


Clonazepam, dispramine, bupropion, lithium, naltrexone, adjunctive morphine

Treatment: Pharmacology
Duration:
Initial response at 6 weeks Should continue for 12 24 months, however most require lifelong treatment
But continue for at least 6 months

Discontinuation:
High risk of relapse on d/c of medications
35-40% relapse within 6 months 88% relapse even after 2 years stable on medications

Not generally advised Studies comparing CBT to medications showed decreased risk of relapse in CBT group following d/c

Treatment: Psychotherapy
As effective as pharmacotherapy Longer lasting than pharmacotherapy on discontinuation CBT
Education Exposure
In vivo and imaginary to anxiety provoking situations, compulsions and obsessions Develop tolerance vs.. avoidance to anxious stimuli

Response prevention
Compulsive behaviours, reassurance seeking and excessive safety behaviours

Cognitive interventions
Correct misperceptions around danger, omnipotence of thought, excessive responsibility Learn to tolerate uncertainty and decrease perfectionism

Family involvement Problem solving Relapse prevention

Treatment:
Reserved for severe treatment refractory OCD
ECT
Not as effective as neurosurgery

Deep Brain Stimulation


Brain pacemaker used in epilepsy, Parkinsons, essential tremor Bilateral indwelling electrodes in anterior limb of internal capsule
Improvement in O-C symptoms, mood, anxiety

Psychosurgery
Procedures: anterior cingulotomy, anterior capsulotomy, tractomy, limbic leucotomy 25-30% efficacy of treatment refractory OCD Seizures are most common complication

GENERALIZED ANXIETY DISORDER

GAD
Indiscriminate, uncontrollable, excessive worry about everything accompanied by somatic distress that is disabling and causes significant dysfunction
2 components:
1. Worry about several life circumstances 2. Somatic distress (tension, nervousness, hyperarousal)

Vs. situation crisis


Worry is restricted to one situational problem

DSM-IV: GAD
A.
B. C.
1) 2) 3) 4) 5) 6)

6 months of excessive worry and anxiety about a number of events/activities Difficult to control worry 3/6 symptoms:
Tension in muscles Concentrating difficulties or mind going blank Irritability (Hyperarousal) Energy loss Restlessness, feeling keyed up, or on edge Sleep disturbance

W A T C

H E R S

D. E. F.

Focus of worry not confined to other Axis I d/o Significant distress or impairment R/o substances, GMC, mood d/o, psychotic d/o or pervasive development d/o

Epidemiology
Lifetime prevalence
US comorbidity study: 5 %
Female (6.6%) : Males (3.6%) 2:1

WHO: 8%

Typical age of onset: late teens, early adulthood

Comorbidity
50 90% GAD sufferers have comorbidities Major depression/dysthymia (50 75%) Panic d/o (25%) Social phobia (23 30%) OCD Substance use d/o Personality d/o (30 60%)
Especially cluster C

Differential dx 1 (= Panic)
Cardiovascular
Anemia HTN Neurological Angina Stroke/ TIA Mitral valve prolapse Migraine CHF Epilepsy MI Multiple Sclerosis Paradoxical atrial tachycardia Huntingtons Hyperactive b-adrenergic state Infection Menieres disease Pulmonary Tumor Asthma Wilsons disease COPD Pulmonary embolus Hyperventilation

Differential dx 2
Endocrine
Addisons Hypoglycemia Carcinoid syndrome Hyperparathyroidism Cushings syndrome Diabetes Pheochromocytoma Hyperthyroidism Premenopausal syndrome Menopausal disorders Amphetamine Hallucinogens Amyl nitrite Marijuana Nicotine Caffeine Anticholinergics Cocaine Theophylline

Drug Withdrawal
Alcohol Sedative-hypnotics Opiates and opioids Anithypertensives Anaphylaxis B12 deficiency Electrolyte disturbances Heavy metal poisoning Systemic infections SLE Temporal arteritis Uremia

Other

Drug intoxications

Etiology: Biological
Findings somewhat contradictory, however Neurotransmitters
5-HT dysfunction GABA dysfunction
? occipital lobe b/c of high density of BZD receptors

Imaging
? Inverse relationship b/w anxiety and metabolic activity
PET: decreased metabolic rate of basal ganglia/white matter Decreased activity in occipital areas, R prefrontal cortex, R post temporal lobe, cerebellum Inc/Dec activity in cortical/limbic and basal ganglia areas

Genetics
Concordance 50% MZ vs. 15% DZ twins 25% risk if 1st degree relative has GAD

Etiology: Psychosocial
Cognitive models
Negatively biased view of world
Selective attention to negative/threat cues in environment

Overestimate probability of negative event occurring Catastrophic thinking


Extreme conclusions for relatively minor events

Sense of inadequacy to cope/control outcome

Psychodynamic
Anxiety is symptom of unconscious, unresolved

Course and Prognosis


Fluctuating
Different symptoms and severity over time

Impairment
Epidemiological catchment area survey
30% on disability 50% working 3x more likely to be working at lower occupational level

Screening Questions
What kinds of things do you worry about? Do you worry excessively about everyday things such as your family, health, work, or finances? Do friends or loved ones tell you that you worry too much? Do you have difficulty controlling your worry, such that the worry keeps you from sleeping or makes you feel physically ill with headaches, stomach troubles or fatigue?

Treatment: Targets
1. Co-Morbid conditions
Antidepressant, cognitive therapy

2. Worry (negative expectations)


Cognitive therapy, antidepressants, distraction

3. Somatic distress from hyper-arousal


Relaxation training, aerobic exercise, Rx

Treatment: Pharmacotherapy
Start with low doses and increase gradually 1st line:
SSRI: paroxetine, escitalopram, sertraline SNRI: venlefaxine XR

2nd line:
BZD: alprazolam, bromazepam, lorazepam, diazepam
For acute GAD on time-limited basis, not indefinitely

Buspirone, imipramine, bupropion XL, pregabalin

Treatment: Pharmacotherapy
If poor response:
Optimize dose first If no improvement, switch to another 1st line agent before moving to 2nd line

For treatment-refractory GAD:


Review for comorbid psychiatric/medical conditions Consider 3rd Line:
Mirtazapine, citalopram, trazodone, hydroxyzine Adjunctive: olanzapine, risperidone

Medications not recommended:


Propranolol

Treatment: Pharmacology
Duration:
Significant response by 6 12 weeks
Some patients report some improvement at 1 week

Should continue for at least 1 year, however most require lifelong treatment

Discontinuation:
High risk of relapse on d/c of medications
25% relapse within 1 month 60 - 80% relapse within 1 year

Not generally advised Studies comparing CBT to medications showed decreased risk of relapse in CBT group following d/c

Treatment: Psychotherapy
As effective as pharmacotherapy Longer lasting than pharmacotherapy on discontinuation CBT
Education Cognitive interventions
Correct unrealistic beliefs about worry (e.g. that it helps problem solving, shows caring, prepares for misfortune) Develop more realistic thoughts around catastrophic thinking, etc.

Exposure
Imaginary exposure to worry-related imagery and catastrophic situations Practice eliminating unrealistic safety behaviour (e.g. excessive reassurance seeking, having family members call all the time)

Emotional regulation
Relaxation techniques, mindfulness-based meditation Learn to tolerate anxiety

Problem solving
Sleep hygiene, time management , procrastination, avoidance Deal with interpersonal conflicts Increase pleasurable activities and focus on life goals

Relapse prevention

POSTTRAUMATIC STRESS DISORDER

History (1)
Irritable heart syndrome
US Civil War Soldiers generalized weakness, palpitation, CP and heaviness, SOB, sweating, GI changes Thought to be cardiac origin

Shell Shock
WWI Brain damage from exploding shells

History (2)
Combat Neurosis, Operational fatigue
Emphasized pre-trauma characteristics
Re-activation of early developmental conflicts

15 20 yr follow up study (Archibald, 1962)


Disabling condition involving startle response, sleep changes, dizziness, blackouts, avoidance or activities like combat and internalization of feelings

Post-Traumatic Stress disorder


Vietnam War Renewed interest in war-related psychiatric d/o Political/economic pressure inclusion on DSM-III

PTSD
Development of symptom cluster after exposure to traumatic life event of painful reexperiencing, avoidance and emotional numbing and constant hyperarousal. Basic elements:
A. B. C. D. Traumatic stress Intrusive recollections Avoidance and numbing Increase arousal

DSM-IV (1)
A.
1) 2)

Exposure to traumatic event with both of


Experience, witness or confronted with event that involved actual or threatened death/serious injury, or physical threat to self/others Intense fear, helplessness or horror

B.
1) 2) 3) 4) 5)

Persistent reexperience in 1/5 ways


Intrusive recollections (images, thoughts, perceptions) Recurrent distressing dreams Acting/feeling as if event recurring (sense of reliving, illusions, hallucinations, dissociative flashbacks) Intense psychological distress to internal/external cues Physiological reactivity to internal/external cues

C.
1) 2) 3) 4) 5) 6) 7)

Avoidance of stimuli and numbing of responsiveness with 3/7


Avoid thoughts, feelings, or conversations Avoid activities, places, or people Inability to recall important aspect of trauma Markedly diminished interest in activities Feeling of detachment or estrangement from others Restricted range of affect (e.g. unable to have loving feelings) sense of foreshortened future (e.g. does not expect to have a career, marriage, children, or normal life span)

DSM-IV (2)
D. Persistent increased arousal with 2/5
1) 2) 3) 4) 5) Sleeplessness (falling or staying asleep) Irritability Concentration difficulties Hypervigilance Exaggerated startle response

E. F.

>1 month of B, C, and D Significant distress or functional impairment

Specify if Acute: < 3 months duration Chronic: >3 months duration Specify if Delayed onset: symptom onset >6 months after stressor

Screening Questions
Are you bothered by memories, thoughts, or images of a very upsetting event that happened to you or someone close to you in the past? For example:
Being in a fire or serious accident? Being raped, assaulted, or abused? Seeing someone else badly hurt or killed?

Epidemiology
Lifetime prevalence in general population 8%
Females (10%) : Males (5%)
Females: assault/rape, Males: combat

Subclinical PTSD 5 15%

Greater prevalence in high-risk groups


Vietnam veterans: 30 % PTSD, 25% subclinical Rape victims: 1 month after >50%, 1 year 25%, several years 5 10%

Generally 25% of those exposed to DSM-IV criterion type events develop PTSD

Etiology: Biological
Neurotransmitters
Hyperactivity of NA, endogenous opiate systems Hypersensitivity of HPA Axis/Decreased cortisol

Structures involved
Amygdala
Integrates sensory information + emotional tone + neuromodulation for memory consolidation

Hippocampus
Organize memory Extreme stress disrupts hippocampal function so that memory is stored as an affective state or as sensory fragments

Etiology: Psychosocial
Psychodynamic
Trauma reactivates prior quiescent, unresolved psychological conflict

Cognitive model
Difficulty processing/rationalizing trauma or coping with effects Experience kept alive as a memory pain reexperienced Attempts to avoid/deny to decrease anxiety

Behavioural model
Trauma + intense fear paired with conditioned stimulus (internal or external - smells, sights, sounds) Conditioned stimulus elicits fear alone Avoidance of both unconditioned and conditioned stimuli

Comorbidity
2/3 develop at least 2 other disorders
Depressive d/o Substance-related d/o Anxiety d/o Bipolar d/o

Comorbid d/o increase risk of PTSD

Differential Diagnosis
Psychiatric
Other anxiety d/o (panic, GAD) Major Depressive d/o Alcohol or substance-use d/o Acute intoxication or withdrawal Phobias Personality d/o (especially borderline PD) Factitious d/o Dissociative d/o Schizophrenia Adjustment disorder

Course and Prognosis


Typically delay in symptom onset
Short as 1 week

Symptoms fluctuate over time


May intensify with acute stress

If untreated:
Full recovery 30%, at 1 year 50% Mild symptoms 40% Moderate symptoms 20% Unchanged or worse symptoms 10%

Good Prognostic Factors


Rapid onset of symptoms Short duration of symptoms Good premorbid functioning Strong social supports Absence of other psychiatric/substance/medical d/o No other risk factors

Treatment: Pharmacotherapy
Start with low doses and increase gradually 1st line:
SSRI: fluoxetine, paroxetine, sertraline SNRI: venlefaxine XR

2nd line:
Antidepressant: fluvoxamine, mirtazapine, moclobemide, phenelzine Adjunctive: risperidone, olanzapine

Treatment: Pharmacotherapy
If poor response:
Check compliance Optimize dose first If no improvement, switch to another 1st line agent before moving to 2nd line

For treatment-refractory PTSD:


Review for comorbid psychiatric/medical conditions Consider 3rd Line:
Amitriptyline, imipramine, escitalopram Adjunctive: carbamazepine, gabapentin, lamotrigine, valproate, tiagabine, topiramate, quetiapine, clonidine, trazodone, buspirone, bupropion, prazosin, citalopram, fluphenazine, naltrexone

Treatment: Pharmacology
Duration:
Some response with SSRIs by 2 4 weeks; trial is 8 weeks Some studies show improvement up to 36/52
Sertraline: non-responders as 12/52, responded by 36/52

Chronic PTSD: continue for at least 1 year

Discontinuation:
High risk of relapse on d/c of medications
25% relapse within 6 months But relapse rate is generally lower than untreated patients

Studies of CBT showed more sustained benefit in CBT group following d/c at 6 18/12

Treatment: Psychotherapy
CBT
Education Emotional regulation
Management skills to help cope and reduce distress Relaxation techniques such as muscle, breathing and imagery Practice acceptance based approaches to reduce avoidance of difficult emotions

Exposure
Confront feared situations, memories, emotions until distress is significantly diminished Imaginal exposure to repeatedly review trauma based on memories of event including emotions In vivo exposure by confronting avoided situations

Cognitive interventions
Identify dysfunctional thinking patterns associated with anxiety, depression, anger, shame Challenge irrational cognitions and replace them with functional, realistic beliefs

Problem solving
Overcome social withdrawal and negative impacts on relationships Address excessive substance use or unhealthy coping methods Encourage positive activities and goals

Relapse prevention