1. Anxiety disorders IV year teaching Christopher Gale Department of Psychological Medicine Dunedin School of Medicine

2. Anxiety is…. … a subjective experience of unpleasant anticipation, accompanied by characteristic behavioural and physiological responses (e.g. avoidance, vigilance and arousal) Evolutionary value: to protect individuals from danger. Present in most/?all higher animals – ? universal mechanism by which organisms adapt to adverse conditions. Symptoms:  Cognitive (feelings of apprehension, fear)  Physical symptoms (shortness of breath, trembling, palpitations etc);  Endocrine and physiological changes Spectrum Normal Emotion Pathological State severe symptoms & functional impairment

3. Panic. Overwhelming sense of impending doom or disaster. Physical symptoms.  Tachycardia.  Shortness of Breath.  Chest pain.  Tingling lips and extremities.  Nausea, vomiting, diarrhoea  Weakness. Collapse. If specific → Phobia. If random → Panic disorder

4. Anxiety Sense of fear around an event or stimulus → distress, or panic. May be specific May be generalized (multiple topics of anxiety, most of the day, nearly every day) Can lead to:  Avoidance  Self medication with substances.  Ritualisation of behaviour.

5. DSM and anxiety Clustering based on phenomenology; divorcing of depressive vs anxiety components

6. Obsessions, compulsions. Obsession is an unwanted, repeated distressing thought that is seen as:  From one's own mind.  Distressing.  Not controlled. Compulsions are a ritualised repeated behaviour that is seen by the patient as preventing or minimising risk of feared event occuring eg hand washing, checking doors locked.

7. Traumatic event. Out of ordinary life events. Risk of death or severe injury (including fear of) or witnessing same. Would be seen as distressing by most people. Examples  Living in war zone.  Physical or sexual assault  Car crashes Although panics are not traumatic as such can have similar post event sequelae.

8. Following trauma Nightmares: of event. Flashbacks. Like nightmares, full re experience of event including all senses and the sense of fear. Can be stimulated by certain triggers of the trauma (including therapy) or may occur randomly. Foreshortened future. Lack of confidence in planning years, weeks or days at work or relationships. Emotional numbness.

9. Where does anxiety arise in the brain? Multiple components Amygdala (A) and insular cortex (B) activation– key structures in emotional processing/integration (Etkin Am J Psych 2007)

10. Prevalence of anxiety & substance disorders

11. Rate of disorders: WHO surveys, selected countries. 1.81.71.03.15.3Japan 4.70.80.00.83.3Nigeria 8.20.10.33.85.8Italy 9.11.10.33.66.2Germany 18.40.71.48.512.0France 26.43.86.89.618.2United States 12.22.51.34.86.8Mexico anySubst.Impulse control MoodAnxiety Country

12. Severity of disorders, Te Rau Hinengaro

13. Factor Analysis of CIDI data from 10,641 participants in the Australian National Survey of Mental Health and Well-Being, a large-scale community epidemiological survey of mental disorders

14. General   Think of diagnoses, not diagnosis.   Consider priority of treatment. Timing for treatment. Use of others – practice nurse, primary mental health. Consider referral   Opinion   Management   Positive approach: can minimize disability.

15. Treatment General techniques. Talking therapies Medication

16. Behaviour therapies   Applied relaxation. Education about anxiety. Activity Scheduling. Befriending. Exercise Relaxation technique & practice.   Bibliotherapy “Anxiety and Neurosis handbook” etc. Internet therapy – via CrufAD (in Australia) and now integrated in most GP practices (in New Zealand)

17. Graded exposure. Phobias.  List of stimuli and programmed increase in anxiety provoking triggers.  Can expose symptoms panic (exercise, antihistamines). OCD  add response prevention (expose and no ritual).

18. Cognitive therapy. More effective in GAD Very useful in depression, which is quite co-morbid. Common distortions.  Over responsible  Perfectionism (“All or nothing”)  Catastrophization (“Mountains out of molehills”). USE MANUAL.

19. Comments medications. Generally do not control all symptoms. Take six to ten weeks to work. Need higher doses SSRI than in depression: 20 – 60 for GAD, 40 – 100 for OCD.

20. Medications. Antidepressants.  SSRI, TCA, MAOI Anticonvulsants  Gabapentin, Pregabalin, Tigiabatine Aziopirones.  Buspirone, Gepirone. Benzodiazepines. (dependancy) Hyoscine & Kava (side effects) Low dose antipsychotics esp Quetiapine (side effects ++)