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After drug and alcohol abuse, anxiety disorders as a group are actually the most common type of psychiatric disorders. About 25% of the population with anxiety. Among them panic disorder is about 3%. Agoraphobia often complicating panic is at 5%. The third most common disorder in the U.S. overall is social phobia which has recently been renamed social anxiety disorder. 13% of the population. We’ll talk more about it in some detail, something we’re going to be hearing about increasingly since the recent approval of DSS ridroxatene.
Just looking briefly at the menu of the DSM-IV, main disorders are panic disorder, agoraphobia, social phobia GAD, PTS, the obsessive-compulsive disorder which will be covered in a separate unit and then some other disorders. There’s acute stress disorder which is related to PTSD we’ll talk more about. Specific phobia and sort of the residual categories but the main ones are
Looking at the specific disorders, panic disorder up to 3% of the population. Like most anxiety disorders these are more common in women than in men with a prevalence roughly of 3:1 ratio. Why this is the case is not clear. Whether this is a real difference or whether there’s biologic or hormonal factors or genetic factors or whether it represents some sort of ascertainment bias isn’t clear but this is a reliable estimate and true for other anxiety disorders as well.
Typically the onset for panic disorder is in the late teens through the 20s and most drug studies are advocating just about 28. Relatively rare for patients to first show up with panic disorder in the 40s or 50s. If they do that should decrease your suspicion for major depression or some organic etiology that is driving
This is the DSM-IV criteria. Another just sort of issue in terms of the boards. It is worth reading the DSM-IV. For those of you who have trouble sleeping the night before, useful in that regard but a lot of the questions, for different disorders not just anxiety, actually come directly from the text of the DSM-IV. The explanation for the different disorders, prevalence, associated features, demographic issues, right out of the text. Worth not just looking at the criteria but also the text that accompanies it.
This is the DSM-IV criteria for panic disorder. There was a shift from the DSM-III to DSM-IV. In earlier DSM versions, panic attacks were defined by how many panic attacks did the patient have. They had to have at least four to meet the criteria for a disorder. Well, over time, people became aware and experts and clinicians became aware that after awhile some people don’t have as many panic attacks because they’re avoiding different situations. They can still be quite disabled because of panic disorder but the number of panic attacks they have may actually go down. There were episodes where people no longer met criteria for panic disorder because they were having only rare panic attacks because they were so disabled by their phobia.
So the DSM-IV criteria don’t count anymore how many attacks you have. You just have to have had recurrent attacks historically and at least one of them had to be unexpected. It increases the attention to the complications of panic so you have to have concern about additional attacks, anticipatory anxiety, worry about the implications of the attack (Does this mean I have something wrong with my heart?) or a change in behavior – a phobic avoidance. Avoiding situations because of panic. So a deemphasis on attack frequency and an increased emphasis on complications, anticipatory anxiety and phobic avoidance associated with the panic attacks.
Panic disorder can occur either with or without agoraphobia. In epidemiologic studies, there are actually a relatively large proportion of individuals who report panic attacks without accompanied agoraphobia. But in most clinical populations 80% of patients who show up to our offices with panic disorder do so because of at least some agoraphobia.
What’s agoraphobia? It refers to concern about being in places or situations in which attacks have occurred or any situation from which easy escape might be difficult or help unavailable. Traffic, crowds, standing in line. It would be embarrassing or physically difficult for somebody to escape during traffic, escape a movie theater although I have had one patient who on the way to the airport in the tunnel there had a panic attack, stopped their
So escape difficult, help not available. The patient either needs to avoid the situation or endure a lot of distress. They get through it but it’s difficult. They worry about it ahead of time. Or they may need a companion to enter the situation. Some patients say, "Well, I don’t have any problems going places as long as my mom/dad/husband/wife/children are with me.
When we talk about the development of panic and probably other anxiety disorders as well there is likely a genetic predisposition and vulnerability towards anxiety in general that make it variably expressed over time depending on the specific genetic loading, depending on developmental factors – whether the patient was abused, traumatized, exposed to fearful situations and learned to be afraid.
Oftentimes, the anxiety manifests in childhood as behavioral inhibition or fearfulness. As they start getting into school age, problems with separation anxieties, school phobias. Oftentimes the first manifestation of the predisposition to anxiety is in adolescence manifested specifically in social anxiety. Then as I mentioned before onto panic at the age of 18, 20s and early 30s.
Complications. Once people start to have panic attacks, they worry about having more attacks. They avoid situations that they’re afraid of where they worry about entering feared situations. High rates of comorbidity. 50% or more of panic patients in clinical samples report that multiple anxiety disorders, social anxiety, generalized anxiety, OCD, PTSD, high rates of depression probably the most important comorbidity. At least two_thirds.
What is often not appreciated, panic disorder is associated with premature and excessive mortality in men from cardiovascular causes and both men and women increased rates of suicide particularly in those patients with comorbid depression or common in personality borderline spectrum sorts of disorders.
Treatment in terms of pharmacotherapy. The tricyclics were the gold standard for awhile. They have been supplanted by the use of SSRIs, Paxil and Zoloft have indications for panic disorder. I think Prozac is seeking one.
Social phobia. Patients with social phobia are often crippled by a fear of embarrassment or saying something or acting in a way that would be socially inappropriate and make them the object of ridicule or scorn. This is a disorder that is increasingly being recognized. It is, again, the third most common disorder behind alcohol abuse and major depression in this country.
The first common fear that people report is a fear of public speaking, performance anxiety, social phobia. Interestingly, the second most common fear that is reported is the fear of death and I always thought it was rather interesting that all things being equal most people would rather die than give a talk. Some of us get to do both at the same time.
There’s an interesting gender gap, if you will, in social phobia. In epidemiologic standards, just going door to door, women tend to have social anxiety, social phobia more than men do but up until recently anyway, men presented more for treatment. Here again we don’t fully understand the reasons for this. One reasonable hypothesis is that for men in sort of traditional roles, being shy, withdrawn, unassertive is more likely to hinder them in terms of advancing at work or finding a partner. Now with more women entering the work force in higher levels of jobs, I guess the good news/bad news is more women are presenting for treatment of social phobias. They find it hampering them.
As I mentioned earlier, the age of onset for social phobia is actually earlier and among the major disorders, anxiety and otherwise, social phobia tends to have the earliest age of onset. The mean age of onset is typically in early adolescence – 13 years of age. This is a disorder that strikes early, sometimes even earlier in childhood.
The criteria. Again, a fear of acting in a way or appearing to be anxious as such that the individual is going to be embarrassed or humiliated in situations in which they are being scrutinized by the people.
Other modifiers. The situation almost invariably has to provoke anxiety. Most of us, the first time we walk into a group of people we don’t know get a little bit anxious. Having to give a talk for the first time. Maybe the third time it becomes anxiety provoking. But for most individuals, repeated exposure will dampen the anxiety. For people with social phobia it’s always the first time.
The person needs to recognize that their fear is excessive or unreasonable. This is to distinguish it from psychosis. These patients don’t really believe that other people bear them ill in the same way as a psychotic or paranoid person does.
Avoidant personality. There was concern in the past about whether or not there was a difference between avoidant personality and social phobia. Now most people believe that avoidant personality is just a more severe form of social phobia. To distinguish between panic disorder and social phobia, both can have panic attacks. Panic disorder patients are worried about having other attacks. Social phobics are worried about entering situations in which they are going to be scrutinized by others.
Perhaps the best way I can distinguish it is to tell you about a patient who we saw on our unit – a woman with social phobia who decided she wanted to go sky diving. She took the class, went up and was sitting there in the plane with a group of other people. She became so uncomfortable having to interact with the other students in the plane while they were flying up that she volunteered to be the first one out and as soon as they opened the door she jumped out. If you remember that patient, you know the difference between social phobia and panic.
Panic disorder. High rates of alcohol and drug abuse and significant amounts of comorbid depression. Course tends to be chronic. Pharmacotherapy. Now Paxil has got an indication for it. Social phobia. SSRIs have good data demonstrating efficacy. Beta blockers which I’ll mention briefly are effective for performance anxiety, for public speaking fears or other kinds of performance situations but are not effective for the generalized type of social phobia which is the most common and the most disabling. Benzodiazepines are effective as well but not for the comorbid depression. Tricyclic antidepressants do not work for social phobia. This is one of the few situations in which there is not just a side effect difference but actually an efficacy difference between the tricyclics and some of the other antidepressants and then cognitive behavioral therapy also is effective for social phobia.
Posttraumatic stress disorder another growth area, if you will, in psychiatry with the increasing recognition that this is a condition that affects not just veteran populations but also the general population as well. Estimates are that at least 1% of the general population has PTSD or a current study suggests that now this may even may be higher. Somewhere between 40-80% of the U.S. population is exposed in one way or another to significantly traumatic events and of those, depending on the study you look at, upwards of half of those exposed to trauma may develop PTSD. So the numbers might even be higher. Civilians exposed to trauma estimates up to 15%. Among veteran populations 20%. This is a disorder that is dependent on an external psychosocial event or it can occur at any age in which a patient is exposed to trauma.
The criteria. The patient has to have experienced or witnessed an event that involved the threat of death or bodily harm or that most people would consider to be severely fearful. So being really yelled at by your mother, while that’s traumatic, doesn’t classify as a trauma sufficiently intense enough to meet the criteria for PTSD. So it needs to be something that involves a real threat of harm to self or to somebody else.
So I was just talking to some people over in the burn unit yesterday. They find that in burned children, for instance, rates of PTSD are actually higher in the parents than they are in the children. The exposure needs to involve, on the part of the individual, intense fear or sense of helplessness or horror.
There are three major categories of symptoms associated with PTSD. One is intrusive, reexperiencing. These are kinds of flashbacks. They are the flashback sort of a phenomenon so intrusiveness. Autonomic arousal on exposure to the trauma and then recent trauma or situations that remind one of the trauma. The third is withdrawal. The patients tend to seek to avoid situations that remind them of the trauma or general numbness and withdrawal from family or social interaction. So intrusiveness, withdrawal, arousal are the three major categories of symptoms of PTSD and patients need to meet criteria for a number of them in each category to make the diagnosis.
Duration of symptoms has to be at least one month because after major trauma, most individuals will have at least some symptoms consistent with PTSD – sleeplessness or an anticipatory anxiety. It must make a difference in the patient’s life in terms of stress or impairment.
Clinical issues. Increased rates of antisocial acts or withdrawal of individuals who develop PTSD. High rates of depression, suicide, new onset of alcoholic use or exacerbation of preexisting alcohol abuse. These patients often show up in primary care or general medical settings with a variety of nonspecific physical complaints for which no clear etiology can be determined. Orthopedists will see a lot of these patients. Oftentimes the diagnosis may not be picked up right away but after a major car accident or automobile accident or trauma – being mugged or assaulted – the patients might develop PTSD and will recurrently go to orthopods.
Risk factors. Patients who have prior histories of depression, personality disturbances (borderline narcissistic or otherwise), alcohol/drug abuse, early trauma, chaotic childhood are at increased risk to develop PTSD. Individuals who are better integrated, more social supports actually are in some ways relatively protected from developing PTSD. The nature of the trauma makes a difference. Manmade traumas – that is, being tortured or assaulted – is much more likely to result in PTSD than an act of God like a hurricane or a fire, things like that. Isolated experiences more likely to cause PTSD than one in which the entire community shares in the trauma. Again, high rates of comorbidity, depression, alcohol abuse and so forth.
Typically, PTSD, if it’s going to develop, develops within about three months of onset of the trauma but in some individuals it may occur in months or even years. Later, there’s an ongoing debate about whether or not patients will start recovering memories of childhood or how much of that is real but certainly in many cases there does seem to be a delayed onset of PTSD.
Acute stress disorder you should be at least somewhat familiar with. It looks like PTSD in some ways but occurs within a month of the trauma and persists for only about four weeks. This category is actually relatively common. It’s patients who have been exposed to a trauma but the symptoms that they experience are the sleeplessness, anxiety seem to be rather time limited.
For about 50% of cases, recovery is within three months although a third or more of patients are still symptomatic after a year. And for those individuals it tends to be chronic.
There has been increasing interest in PTSD as a number of companies state indications for their drugs. Paxil and Prozac are in the process of doing the studies to get PTSD indication. So with that sort of common increase in public education campaigns comes the problem with increased prevalence of individuals in general population seeking treatment for PTSD.
Treatments. Psychotherapy. Support helpful but in and of itself probably not particularly effective. More effective kinds of psychotherapy are cognitive behavioral therapies in which patients not only talk about their trauma but are given specific management kinds of tools to deal with the feelings that come up when they do reexperience the trauma. They’re continually exposed to thoughts of the trauma but given breathing, muscle relaxation, cognitive exercises damping down their alarm reaction which is basically PTSD.
There is now some interesting work being done with virtual reality where I’ve sort of lived for years. But Vietnam veterans who are now being put in computer simulated environments in which they feel like they’re flying into the rice paddy in Vietnam, landing, the sounds of the helicopter going off. Wearing goggles with visual input of landing in a rice field for a Vietnam or other veteran, very powerful provocative memories of the trauma and the exposure and the interventions are done right at that point and they prove to be very useful as well as for the treatment of phobias.
Pharmacotherapy is all over the map. Everything has been tried. Everything and nothing works 100%. At this point, the data is probably strongest for SSRIs. For PTSD, as I said, a number of the companies are seeking indications and we’re developing a good database demonstrating reasonable efficacy against the broad spectrum of effects for these disorders.
Generalized anxiety disorder, GAD, 5% of the general population. Here again in women more than men about 2:1. Age of onset typically in childhood or adolescence. In our studies and other studies, patients with depression or adult anxiety disorders often report histories of over anxiousness when they’re in childhood, over anxiousness would likely be the childhood manifestation of generalized anxiety.
Excessive anxiety, worry, difficulty controlling worry for at least six months. Cardinal feature or the single symptom that is most highly associated with GAD is worry and difficulty controlling worry and then they have to have at least three out of six symptoms of arousal – restlessness, fatigue, trouble concentrating, sleep disturbance and so on. But worry is the cardinal feature.
It is worry unrelated to other disorders so it’s not just ruminative kind of worry about being a bad person that might be associated with depression. It needs to be out of proportion in the judgment of the clinician of the patient to the stimulus. So it’s not worry about having a test or about a job interview. It is persistent worry over six months or more. It needs to make a difference in the patient’s life. Either bother them a lot, cause distress or impairment of function. Again, more common in primary care settings. It may be accounting for the observation for 20% of people who walk in the door of their primary care doctor walk out with a prescription for benzodiazepine in one study. So it’s a rather staggering figure. Again, high rates of depression and alcohol abuse.
The course tends to be chronic. Worsened with stress and the patient may have spontaneous or reduced remissions but for the majority of patients it tends to be a rather persistent disorder. Therapy can be helpful. There are now cognitive behavioral therapy programs that are directed towards GAD treatment. At this point, given that 80% of these patients are also depressed, antidepressants are the cornerstone of treatment. Previously tricyclics, now SSRIs being used first line. Buspirone I’ll mention later, may be effective for GAD. There’s been some concerns about its effectiveness in clinical practice. Maybe you’ve got the dose aggressively raised in order to get efficacy and then benzodiazepines effective as well.
Specific phobia or simple phobia. These are patients who are afraid of things like heights, blood, closed places, certain kinds of animals. About 10% of the population, most patients with phobias never seek treatment. They just avoid the situation that they’re afraid of. They may come in for treatment if forced to have to confront their fears. They’re forced to get onto a plane, for instance.
Different subcategories would be to specify, animal fears, dogs and so forth. Usual onset in childhood. Natural environment, storms, lightning also childhood. Heights. Situational factors, elevators and so forth and then blood injection phobias. People are afraid of blood or getting a needle. It has to be a persistent, obsessive unreasonable fear. It always needs to frighten the person. They need to recognize that it’s excessive and it needs to make a
It needs to be not accounted for better by other disorders. So it can’t be agoraphobia or it can’t be fear of social situations which would be consistent with social phobia. We talked about the different subtypes already. You should be aware for the purposes of the boards as well as clinical practice about the four or five major categories of specific phobic subtypes.
Predisposing events. You know, we’re used to thinking about phobias developing just as a result of some sort of traumatic event. Someone becomes afraid of a dog after being bitten. That usually occurs but it’s also worth noting that phobias run in families. There does seem to be a familial and probably genetic underpinning to phobias. For instance, dog phobics tend to beget dog phobics. So there does seem to be a genetic transmission.
Patients can also develop phobias because of information transmission. Some people became afraid of AIDS even if they didn’t have any risk factors because of all this stuff in the paper about it and so forth. It’s interesting from an evolutionary point of a view that a lot of the things that we’re afraid of as phobics may have represented a threat at some point during evolution. So being afraid of snakes and spiders is probably not a bad idea. Being a closed place where you might risk suffocation. Heights you might fall down. It’s interesting that most of the things that we have our phobias about evolutionarily make sense but things that we should be phobic about nowadays like electrical sockets and other kinds of things, we rarely hear people developing phobias about.
Transient phobias during childhood are common and normal, if I can use such a word. If they persist into adulthood, however, only 20% spontaneously remit. The comprehensive treatment for phobia is behavioral therapy. Exposure and response prevention.
Pharmacotherapy. Typically benzodiazepines could be useful acutely getting somebody onto a plane but are not long term therapy. The SSRIs have become first line agents for most of what we treat in outpatients; exceptions – psychosis maybe or substance abuse – with a combination of control trial data. There are now five SSRIs currently on the US market – Prozac, Zoloft, Paxil,