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The following is derived from a
lecture I gave in October 2003 intended for the teaching of
general practitioners and pharmacists. This information is intended for education purposes by health professionals and
should not be used as a substitute for any health professionals' individual
advice and treatment. Every patient needs to be treated as an individual
and individual requirements may differ from general guidelines or principles
like those suggested below.
Contents
What is
anxiety?
What
causes anxiety?
In
which disorders does anxiety occur?
Differences
between the anxiety disorders
Management
of anxiety disorders
Medication
misuse, compliance & self dosing
The Fight or Flight Survival Program
 | Adrenalin acts on end organs to produce the following effects: |
| Shortness of breath, choking, parasthesia (Increased RR : more O2
in blood) |
| Palps, chest pain, flushes (Increased HR so more blood pumped) |
| Trembling, m tension, sweating (prepare for action) |
| Dry mouth, butterflies, nausea, belching (decreased blood flow to
gut) |
| Feeling dizzy, faint, lightheaded (decreased blood flow to brain?) |
| Catastrophic cognitions & fear (brain effects) |
Atavistic fears
| Large carnivores |
| Small poisonous animals |
| Heights |
| Strangers |
| Extreme sensory phenomena (dark, bright light, loud noise, rapid
movement) |
| Unfamiliar water or land |
Adaptive anxiety
Yerkes-Dodson Curve : anxiety is usually facilitating
Maladaptive anxiety …
Excessive anxiety causes:
| decreased capacity for skilled motor movements |
| decreased complex intellectual tasks |
| decreased perception of new information |
Symptoms of maladaptive anxiety
| Panic attacks characterised by:
 | Ongoing hyperventilation (? O2:CO2) causes… |
| Light-headedness |
| Dizziness |
| Headache |
| Myoclonus |
| Carpo-pedal spasm |
| Parasthesiae |
| Confusion |
| Agitation |
|
| Freely-floating low-grade anxiety |
| Avoidance behaviour / dissociation |
What determines the anxiety-performance peak ?
An individual's genetics interacting with their lifetime experiences
| Massive dose of inherited trait anxiety |
OR
| {Moderate dose of inherited trait anxiety (genetic vulnerability) OR Past
environmental triggers sensitising the CNS} |
PLUS
| Recent high-grade environmental trigger |
| Current low-grade environmental triggers |
Trait anxiety
| Trait anxiety is a stable characteristic of biologically based high
emotionality |
| Trait anxiety is probably the single most important determinant of
symptoms |
| Trait anxiety is strongly associated with OCD & GAD, less so with PTSD
& specific phobia |
| People with high trait anxiety have more life events |
Past environmental trauma
Repeated traumatic stimuli occurring
during relevant developmental stages can
recalibrate the level of arousal that the individual ends up with, adapting them
to their particular environment
Endocrine abnormalities occur following early /severe/ repeated trauma:
| [CRF]CSF |
| HPA dysfunction |
| Hippocampal shrinkage |
What traumatic stimuli?
| Early life trauma enhances risk of stress related disorders |
| History of child abuse increases risk of panic disorder, social phobia,
GAD & PTSD (& MDD & Personality Disorder) |
| Esp. pre-pubertal abuse |
| Loss of parent at early age |
| Lack of perceived parental warmth (neglect/ maternal deprivation) |
(Kendler, Nemeroff & others)
Which developmental stages?
| Biosocial goals: |
Archetypal systems: |
| 1. Attachment |
1.The affiliation and bonding archetype |
| 2. Reproduction |
2.The courtship & mating archetype |
| 3. Dominance-striving |
3.The hierarchical ranking dominance-submission archetype |
| 4. Defence (flight or withdrawal) |
4.The stranger archetype responsible for the evasion of
enemies or threats (paranoia) |
| (Gardiner, 1988) |
(Stevens & Price, 2000) |
Psychopathology from Loss of Attachment
Stages resulting from frustration of the ‘Affiliation & Bonding’
archetype:
| Protest: Anxious attachment, Separation anxiety, Neurotic anxiety,
Dependent personality, Hysterical personality |
| Despair: Grief, Depression |
| Detachment : Defensive posture, self-absorption, self-reliance, poor
social integration, Schizoid personality, Sociopathic personality |
(Bowlby, Attachment & Loss, 1969)
Summary about anxiety in general
| Anxiety causes distress & suffering |
| Avoidance causes handicap |
| External locus of control |
| Immature defence styles |
| Lack of assertiveness |
| Victim cycle due to learned helplessness |
| Vulnerability to comorbidity |
| Risk of generational transmission |
| Anxiety disorders: Panic
disorder, Social Phobia, PTSD/ Complex PTSD, OCD, GAD |
| Major depression with anxiety features |
| Personality disorders: Neurotic, dependent, obsessive, paranoid,
histrionic, antisocial, schizoid |
| Somatoform disorders: somatisation, hypochondriasis, conversion, chronic
fatigue |
| Dissociative disorders: “psychogenic” fugue, amnesia, DID,
depersonalisation, derealisation |
| Pain disorders |
| Psychotic disorders, overvalued ideas: body dysmorphic disorder |
| Eating disorders: AN, BN, obesity |
| Adjustment disorders with anxious mood / acute stress disorder |
| Sexual disorders |
| GID |
| Sleep disorders |
| Substance use disorders |
| Factitious & culture bound disorders |
Anxiety Disorders are about irrational fear
& worry
| Panic disorder: |
Physical collapse |
| Agoraphobia: |
Panic |
| Social phobia: |
Negative evaluation & shame |
| Specific phobia: |
Improbable harm to self |
| OCD: |
Self-caused harm |
| GAD: |
Harm to self & loved ones |
| PTSD: |
Past personal harm |
Anxiety Disorders are about avoidance of triggering
situations
| Panic disorder: |
Triggers |
| Agoraphobia: |
anxiety being in places/situations from which escape
difficult or embarrassing leading to avoidance of situations |
| Social phobia: |
Social situations |
| Specific phobia: |
Object, animal, place |
| OCD: |
Obsession triggers Compulsion (to neutralise obsession) |
| GAD: |
Everything |
| PTSD: |
Symbols or triggers of past event |
Diagnosing Anxiety Disorders
| Panic disorder: |
Recurrent PAs, ?LOF, ±Ag |
| Social phobia: |
Fear of performance or social sitns, PA or anxiety, insight,
avoidance, ?LOF, 6 mo(<18yo) |
| Specific phobia: |
|
| OCD: |
O or C, >1, distress or ?LOF, some insight |
| GAD: |
XS anx & worry, can’t divert, somatic Sx, unfocused,
distress or ?LOF |
| PTSD: |
Traumatic event (threatened integrity, intense response),
re-experience event (memories, dreams, flashbacks, hallns), high arousal,
avoidance, >1 mo, ?LOF {Chronic >3 mo} {Delayed onset >6
mo} |
| Acute stress disorder: |
As above but duration 2d-4w Exclusions: no D&A, GMC |
OCD
 In
OCD, genetics appears to play a large part in the development of regional
overactivity in the circuits that evolved to assist people in avoiding contact
with or ingestion of harmful agents
| Knockout HoxB8 (homeobox) gene in mice causes a 5x increase in grooming of
self & others, causing bald patches |
| Expressed in caudate & orbitofrontal cortex (OCD circuit) |
(Greer & Capechi, 2003)
OCD VS PTSD
 |
 |
| Obsessions |
Recurrent thoughts & images |
| Compulsions |
Avoidance & dissociation |
| Distress & high arousal |
Distress & high arousal |
| Insight |
Insight |
Obsessions & Compulsions
Examples of thematic associations:-
| Contamination |
Cleaning/grooming |
| Hoarding/saving |
Hoarding/collecting |
| Symmetry/exactness |
Ordering/arranging |
| Repeating |
| Aggressive |
Avoiding |
| Sexual |
Mental rituals |
| Religious/morality |
Compulsive questioning |
| Pathological doubt |
Checking |
| Superstitious |
Counting |
| |
Moving/touching |
A neurobiological model of PTSD
 All
known connections between thalamus and cerebral cortex are reciprocal, two-way
radiations (thalamocortical and corticothalamic), and they contribute
conspicuously to the formation of the internal capsule and corona radiata
Possible sequence of events in PTSD:
| Fear response |
| Causes excessive activation of threat response neural circuitry |
| Inadequate orbital prefrontal feedback |
| Failure to switch off activation of the threat response system |
| Failure of recovery |
Factors affecting diagnosis
| Pt focus on physical symptoms |
| Focus on physical symptoms |
| Time |
| Psychological mindedness |
| Familiarity with pt |
Treatment
| Identify & Diagnose |
| Psychoeducation |
| Psychopharmacology |
| Psychotherapy |
| Relapse prevention |
Building a management plan
| Engage |
| Reassure & instil hope |
| Psychoeducate |
| Discuss therapeutic options |
| Negotiate contract |
| Initiate treatment |
| Triage |
Psychoeducation
Use Metaphors
 Local
overactivity
Chemical
imbalance
 “Stuck in
1st gear” ... Need oil!
Psychoeducation
| Lifestyle measures |
| Breathing exercises |
| Progressive muscle relaxation |
| Pleasant events |
| Regular exercise |
| Dietary |
| Education handouts & videos |
Which treatment modality? (chronic stress symptoms)
| Early life trauma: Psychotherapy > Meds alone (M=F) |
| No early life trauma: Meds > PT alone |
| Combination better in both |
| PT most important variable in those with abuse histories |
(Nemeroff Charles, APA, 2003)
Psychopharmacology
| TCA
| Serotonergic (Clomipramine) |
| noradrenergic / mixed (e.g. Nortriptylline) |
|
| MAOI (Parnate) |
| SSRI
| Mildly sedating (e.g. Luvox, Aropax) |
| Non sedating (e.g. Cipramil, Zoloft) |
| Long acting (Prozac) |
|
| RIMA (Moclobemide) |
| SNRI (Efexor, Avanza, Edronax) |
| SSRI + SNRI |
| Propranolol |
| Adjuncts
| Propranolol |
| Atypical antipsychotics |
| Classical antipsychotics |
| Benzodiazepines |
|
| Complementary/ alternative? |
Treat each brain region
| Cortex:
| Irrational cognitions |
| Psychotherapy |
|
| Limbic:
| GABA receptors /Anticipatory anxiety |
| Benzos |
|
| Reptilian:
| Brainstem nuclei / panic symps |
| Antidepressants |
|
Pharmacology of Anxiety Disorders
| Panic disorder: |
SSRI, mirtazepine, b-blocker |
| Agoraphobia: |
| Social phobia: |
Moclobemide, SSRI |
| Specific phobia: |
SSRI |
| OCD: |
SSRI, clomipramine |
| GAD: |
SSRI |
| PTSD: |
SSRI, mirtazepine, propranolol |
Benzodiazepines
| What are they? |
| When do you consider them? |
| Should you consider them? … What are the risks? |
| How do you weigh the risks vs benefits? |
| How do you minimise the risks? |
| How do you manage benzo abuse & dependency? |
Effects & benefits
| Anxiolytic – for anxiety symptoms |
| Hypnotic – for insomnia |
| Myorelaxant – for muscle relaxation & spasms |
| Anticonvulsant – for fits |
| Amnesia – for premedication |
| Sedation – for procedures |
| Detoxification – for alcohol withdrawal |
| Antipsychotic – for acute psychosis / mania (hyperexcitability &
aggression) in combination with antipsychotics |
Risks
| Iatrogenic
| Abuse : intermittent binge use |
| Dependency syndrome : tolerance, craving, compulsive seeking, WS,
reduced LOF, problems e.g. DUI, occupational / social / interpersonal
impairment, financial stress |
| Oversedation |
| Drug interactions |
| Memory impairment |
| Paradoxical stimulant effects |
| Depression, emotional blunting |
| Adverse effects in elderly & pregnancy |
| Exacerbation of underlying disorder |
|
| Legal consequences e.g. investigation of Dr |
Benzo withdrawal syndrome
| Anxiety |
| Irritability |
| Insomnia |
| Somatic symptoms |
| Hyperarousal |
| Rebound of anxiety disorder symptoms |
| Craving & doctor shopping |
Scenarios / presentations
| Acute stress response? |
| Grief reaction? |
| Acute exacerbation of anxiety / depression / manic / psychotic disorder? |
| Preceding contact with known stressor / trigger / situation? |
| Pain – acute / chronic (migraine / m-skeletal …)? |
| Insomnia – acute / chronic ? |
| Intoxication / withdrawal – alcohol / opiate / THC ? |
| Epilepsy ? |
| Lost script ? |
Prevention of misuse
| Choose the right patient
| Familiarity |
| Personality maturity |
| No history past substance misuse |
|
| Plan at time of first script:
| Time frame of use |
| Next step - if symptoms unabated e.g. referral, discontinuation,
change in med |
|
| Alternatives
| Regular review |
| Other medications e.g. low dose TCA, atypical antipsychotic, low
potency classical antipsychotic |
| Long vs short acting forms/ repeats - PBS |
|
Management of misuse
| Psychoeducation |
| Discontinuation of prescription |
| Slow withdrawal |
| Switch from short to long acting benzo |
| Referral |
| Manage underlying disorder |
| Doctor shopping hotline (1800-631-181) DOH |
| Harm minimisation e.g. high dose dependency, elderly |
Psychotherapy
Treatment should aim to:
| Reduce emotional sensitivity to stress |
| Reduce the worrying thoughts about outcomes |
| Reduce the avoidance behaviours related to situations |
How to tackle anxiety symptoms in context of high
arousal & avoidance?
| Acknowledge patient’s limitations:
| Low frustration tolerance |
| Sensory overload |
| Avoidance |
|
| Work within patient’s current parameters |
| Problem solving: break down problems into steps & master each step
before moving on to the next step |
| Plan for anxiety: BCEs, SUDS, backup meds, referrals |
CBT
| Problems |
| Goals |
| Sequence: easiest to hardest |
| Planning exposure tasks |
| Implementing |
| Review |
| Renegotiation |
Review
| Monitoring |
| Relapse prevention
| lifestyle |
| coping style |
| maintenance |
|
| Referral
| paramedical |
| psychiatry |
| inpatient |
|
Troubleshooting
| Diagnosis |
| Treatment resistance |
| Non-compliance |
| Medication misuse |
| Comorbidity |
| Family |
[ Computers in Psych ] [ Metaphorical models ] [ Doctors' Mental Health ] [ Dissertation - Exercise for Elderly Depression ] [ Publication - Exercise for Elderly Depression ] [ Inpatient Dynamics ] [ Sensory Deprivation ] [ Medication use in first onset psychosis ] [ Surviving Trauma ] [ Teen Exam Stress ] [ Anxiety Disorder Lecture ] [ Noradrenergic antidepressants lecture ] [ PTSD Lecture ] [ DMH Lecture ] [ DMH Lecture ] [ EP lecture 1 ] [ Psychiatric Emergencies ] [ Low self-esteem ] [ Being Perfect ] [ Anger Interview ] [ Living in a wealthy safe city... ] [ Stress Put to the test ] [ War of Words ] [ Over 55s ] [ EP lec ] [ EP radio IV ]
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Citation suggestion: Dr Gary Galambos, Anxiety Disorders Lecture
(http://www.ep.org.au/gg/lecs/anx.htm) [date accessed]
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M.B.B.S. F.R.A.N.Z.C.P.
Page last updated: 23 August 2005
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