Anxiety Disorders - Treatment and Management

1. Anxiety Spectrum
Disorders -
Treatment & Management
Ms. Jinu Abraham,
M. Phil. PSW Trainee

2. Anxiety Spectrum Disorders
 F- 40, 41, 42 & 43
– Agoraphobia
– Social Phobia
– Specific (isolated) Phobias
– Panic Disorder
– Generalized Anxiety Disorder
– Obsessive Compulsive Disorder
– Acute Stress Disorder
– Post Traumatic Stress Disorder
» DSM-IV-TR
Ms. Jinu Abraham, IMHANS, Calicut 2

3. Fear and Anxiety
 Fear
– acute, immediate response to suddenly appearing,
imminent danger (proximal threats)
 Anxiety
– sustained, insidious response to danger, as might manifest
when degree to which threat is present remains ambiguous
(distal threats)
 E.g. – Rodent in a cage
 Impairment
– Disruption in normal functioning
– Presence of “clinically significant” distress
» CTP, 9th
Edition
Ms. Jinu Abraham, IMHANS, Calicut 3

4. Psychophysiological Aspects
 Anxiety
– physiological activity (cardiovascular activity and
electrodermal system)
– subjective reports (feelings of increased muscle
tension, heart racing, perspiration, shortness of
breath and palpitations)
– overt behaviors (increased reflexes and enhanced
muscle tension)
» CTP, 9th
Edition
Ms. Jinu Abraham, IMHANS, Calicut 4

5. Analyzing the Details
 8 primary anxiety disorders, distinguished from one
another by
– Focus of anxiety
– Specific symptoms
 Panic Disorder
– Recurrent unexpected panic attacks with anxiety about
having another attack or concerns about consequences of
such attacks for one's well-being
– Fear of fear
 Agoraphobia
– Individual's attempt to avoid experiencing another panic
attack
Ms. Jinu Abraham, IMHANS, Calicut 5

6. Analyzing the Details…contd
 Post Traumatic Stress Disorder
– Fear of recollections and reminders of previously
experienced life-threatening event
 Social Phobia
– Fear of embarrassment and rejection
 Obsessive Compulsive Disorder
– Fear of an idiosyncratic concern (contamination, fire, being
an evil or harmful person, etc.)
 Generalized Anxiety Disorder
– Worry about specific future outcomes
 Specific (isolated) Phobias
– Fear circumscribed to specific situation or object
Ms. Jinu Abraham, IMHANS, Calicut 6

7. Global Burden of Disease (GBD)
 13% of GBD – Mental Disorders
 Treatment Gap (Severe Mental Disorders)
– 76-85% , low and middle-income countries
– 35-50%, high-income countries
» WHO, 2012
Ms. Jinu Abraham, IMHANS, Calicut 7

8. Medical Etiologies of Anxiety
 Neurological
– Delirium
– Dementia
– Huntington's Disease
– Migraines
– Multiple Sclerosis
– Other degenerative
neurological diseases (e.g.,
Creutzfeldt–Jakob disease)
– Seizure Disorders
– Sleep Disorders
– Transient Ischemic Attacks
 Endocrine
– Addison's Disease
(hypocortisolism)
– Cushing's s Syndrome
(hypercortisolism)
– Hypoglycemia
– Hyperparathyroidism
– Hyperthyroidism
– Hypothyroidism
– Pheochromocytoma
Ms. Jinu Abraham, IMHANS, Calicut 8

9. Medical Etiologies of Anxiety…contd
 Toxins/Poisons
– Lead
– Mercury
– Manganese
– Organophosphates
 Cardiopulmonary
– Angina
– Asthma
– Cardiac Arrhythmias
– Chronic Obstructive Pulmonary
Disease
– Mitral Valve Prolapse
– Pulmonary Embolus
 Infections
– Meningitis
– Neurosyphilis
 Medications and Drugs
– Antidepressants
– Antihypertensives
– Cough/cold medication (may
contain ephedrine or caffeine)
– Corticosteroids
– Insulin
– Monosodium Glutamate
– Oral Contraceptive Pill
– Sympathomimetics
– Thyroid Supplements
– Weight Loss Products
– Stimulants
(intoxication/withdrawal)
– Alcohol intoxication/withdrawal
– Benzodiazepine withdrawal
– Marijuana
Ms. Jinu Abraham, IMHANS, Calicut 9

10. Treatments
 Until middle 20th
Century
– Psychoanalysis
– Barbiturates
 Current Trend
– Pharmacotherapy
– Psychotherapy
– Combination of both
Ms. Jinu Abraham, IMHANS, Calicut 10

11. Pharmacotherapy
 Commonly used drugs for recurrent anxiety
– Fluoxetine - Buspirone
– Fluvoxamine - Azapirone
– Paroxetine - Lorazepam
– Sertraline - Clonazepam
– Citalopram - Benzodiazepines
– Escitalopram - Phenelzine
– Venlafaxine
» CTP, 9th
Edition
Ms. Jinu Abraham, IMHANS, Calicut 11

12. Duration
 Studies show 20-50% chronic anxiety patients
experience recurrence of clinically significant
symptoms, several months after discontinuing
pharmacotherapy
 Guidelines specify
– Stable treatment for at least 1-2 years before
consideration of dose reduction or discontinuation
– When medication discontinuation instituted,
gradually tapering by 10-25% every 1-2 months
while observing for relapse or exacerbation
Ms. Jinu Abraham, IMHANS, Calicut 12

13. Cognitive Behavior Therapy
 CBT endorsed as first-line treatment
– UK’s National Institute of Health and Clinical
Excellence
– American Psychiatric Association Treatment
Guidelines
 Research finds CBT more cost-effective than
medication or other treatments in long term
Ms. Jinu Abraham, IMHANS, Calicut 13

14. Cognitive Behavior Therapy…contd
 Thought challenging/Cognitive restructuring
– Challenge negative thinking patterns that
contribute to anxiety, replacing them with positive,
realistic thoughts
1.Identifying negative thoughts
2.Challenging negative thoughts
3.Replacing negative thoughts with realistic thoughts
Ms. Jinu Abraham, IMHANS, Calicut 14

15. Exposure Therapy
 Encourages systematic confrontation of feared stimuli
– external (eg, feared objects, activities, situations)
– internal (eg, feared thoughts, physical sensations)
– Aim: Reduce fearful reaction to stimulus
 4 major theories explain its psychological
mechanisms
– Habituation
– Extinction
– Emotional Processing
– Self-efficacy
» Kaplan and Tolin, 2011
Ms. Jinu Abraham, IMHANS, Calicut 15

16. Exposure Therapy…contd
 Habituation
– Natural reduction in responding with repeated exposure
 Extinction
– Overwriting previously learned fear associations
 Emotional Processing
– Developing new interpretations and meanings for feared
stimuli and fearful responses
 Self-Efficacy
– Increased perception that one is capable of tolerating feared
stimuli and responses
» Kaplan and Tolin, 2011
Ms. Jinu Abraham, IMHANS, Calicut 16

17. Exposure Therapy…contd
 Guidelines
– Develop an exposure hierarchy
Brainstorm external and internal stimuli that are feared and avoided
Rate each item using the Subjective Units of Discomfort (SUDs)
Scale
– Conduct exposures in gradual and systematic manner
Begin with moderately fear-provoking stimuli
Assess patient’s fear during exposure using SUD scale
Address each exposure collaboratively, in controlled and prolonged
manner
Progress to a higher item after the patient shows a reduced fear
response to lower item
– Eliminate safety behaviors
– Challenge cognitive distortions
» Kaplan and Tolin, 2011
Ms. Jinu Abraham, IMHANS, Calicut 17

18. Habituation
Ms. Jinu Abraham, IMHANS, Calicut 18

19. Desensitization Therapy
 Based on Reciprocal Inhibition Theory by Joseph
Wolpe (1958)
 Masserman’s experiment with cats
– Counter-conditioning, using one association to run
counter to another
– Reciprocal inhibition, responses of anxiety and
eating inhibited or prevented each other
Ms. Jinu Abraham, IMHANS, Calicut 19

20. Desensitization Therapy…contd
 Wolpe’s three-part systematic desensitization
procedure:
1. The client is trained in deep relaxation
2. The client and therapist construct a list of
anxiety-eliciting stimuli, the so-called fear
hierarchy, ordered from least to most distressing
3. Starting with the least anxiety-arousing image,
the feared stimuli are paired with relaxation, until
eventually the most feared stimulus is tolerated
calmly
Ms. Jinu Abraham, IMHANS, Calicut 20

21. THANK YOU
21Ms. Jinu Abraham, IMHANS, Calicut