ELM 8- Anxiety, PTSD and OCD

What is anxiety

• Anticipation of a potential threat of stressful event.

• Normal and important human response that prepares the body and mind to deal with challenges

Advantages of anxiety:

• Alertness increases and attention becomes focused on the possible threat

• Helps an individual respond more effectively.

• This is normal anxiety.

• Has a clear physiological purpose and can be beneficial

• Sharpening concentration

• Improving performance when facing demanding situations

Disadvantages of anxiety:

• Anxiety can become pathological

• It interferes with day to day activities in this case

• Can become severely disabling

• The boundary between normal and pathological is not clear

• Consider the relationship between the response and the threat

• Pathological anxiety= the response is disproportionate to the level of the threat.

• It can occur in the absence of any threat.

• Physiological anxiety also means normal adaptive anxiety

• Anxiety can produce both psychological and physiological symptoms

Psychological symptoms

• Fearful anticipation of potential threats

• Cognitive disturbances such as difficulty concentrating or persistent worry

• Mild depressive symptoms

• Irritability

Physical symptoms

• Sympathetic arousal-increased heart rate for example

• Increased muscle tension

• Hyperventilation

• Sleep disturbances

• Changes in appetite

7 distinct conditions outline by DSM5 :

• Generalised anxiety disorder (GAD)

• separation anxiety disorder

• selective mutism

• specific phobia

• social anxiety disorder

• panic disorder

• agoraphobia

OCD involves 2 key components

• obsessions are intrusive and distressing thoughts, images or impulses. eg fear of harming someone

• compulsions are repetitive behaviours or mental acts performed in attempt to reduce anxiety produced by the obsessions - eg hand washing

PTSD is characterised by :

• traumatic event

• re experiencing the trauma eg intrusive memories and flashbacks

• avoidance of reminders and heightened arousal

epidemiology of anxiety, PTSD and OCD.

• GAD - 5.7%

• SOCIAL ANXIETY DISORDER - 12.1%

• SPECIFIC PHOBIA - 12.5%

• PANIC DISORDER - 4.7%

• OCD - 2.3%

• PTSD - 6.8%

DSM 5 criteria for generalised anxiety disorder GAD

• excessive anxiety and worrying occuring more days than not

• anxiety about everyday matters

• individual finds it difficult to control

• at least 3 of following are present: one required in children

• fatigue

• difficulty concentrating

• irritability

• restlessness

• sleep disturbance

DSM 5 for panic attack (must have at least 4)

• palpitations/pounding heart

• sweating

• termbling / shaking

• feelings of choking

• chest pain/discomfort

• nausea

• dizziness

• chills/heat sensations

• tingling

• derealisation

• fear of dying

DSM 5 for panic disorder

• panic attacks without an identifiable trigger

• attacks are recurrent and not associated with another mental heath disorder

• at least a month is required of one or both of these symptoms:

• persistent concern of panic attacks

• maladaptive behavioural changes related to attacks

DSM 5 criteria for PTSD

• exposure to a traumatic event

• presence of intrusive symptoms like:

• recurrent involuntary memories

• distressing dreams

• dissociative flashbacks

• intense psychological or physical reactions to reminders of the trauma

• presence of one or both of the following :

• avoidance of trauma related thoughts

• negative alterations in cognition or mood

• examples of alterations in arousal and reactivity such as :

• irritability, hypervigilance, sleep disturbance, difficulty concentrating.

complex PSTD - diagnosed in ICD-11 but not DSM 5

• prolonged, repeated and often inescapable trauma

• childhood abuse

• domestic violence

• captivity

Obsessions vs compulsions

obsessions are:

• recurrent intrusive thoughts

• images or urges that are experienced as distressing and hard to control

• causing harm to oneself/others

• need for order

• compulsions are things such as checking, counting, washing, arranging. this reduces anxiety or prevent a feared outcome.

• can provide temporary relief from the distress associated with obsessions

DSM 5 for OCD

• presence of obsessions, compulsions or both

• symptoms must be time consuming or cause clinically significant distress/functioning impairment

• symptoms must not be attributable to effects of a substance or other condition.

Neurobiology of anxiety

Exaggerated threat response

• amygdalae

• a pair of almond shaped structures located in the medial temporal lobe adjacent to the hippocampus

• hyperactivity of the amygdalae has been reported in studies of these disorders

what is the role of the hippocampus in these disorders

• PTSD - reduced hippocampus volume

• altered connectivity with other brain regions

• hippocampus is central in memory processing and importance of traumatic memories in pathology of PTSD

• OCD - strongly associated with hyperactivity in the corticosteroids-striato-thalamo-cortical loops.

genetic risk factors of the conditions

• all 4 conditions are highly polygenic

• substantial genetic overlap among GAD, panic disorder and PTSD.

• strong shared genetic component between GAD and MDD

• Implicated genes often influence monoaminergic signalling, regulation of the HPA axis

• synaptic plasticity

Animal tests for anxiolytic drugs

• Elevated plus maze

• elevated zero maze

• Vogel water conflict test

• morris water maze

• the rotarod

• marble burying

Non pharmacological therapies

• NICE recommends a stepped approach to treating anxiety disorders, PTSD and OCD.

• CBT if symptoms persist . CBT for GAB follows similar principles to that are used in depression.

• for panic disorder:

• CBT combined with exposure based approaches

• patient exposed to feared situations while learning strategies to manage physical and cognitive responses

• induce dizziness or breathlessness

• for OCD:

• NICE recommends CBT incorporating exposure and response prevention ERP

• gradual controlled exposure to situation that trigger obsessions

• resisting the urge to perform compulsions

• for PSTD:

• there is a window before the onset of symptoms

• attempts to treat trauma survivors to reduce risk

• EMDR for non combat related