Introduction

It is often hard to distinguish what is ‘normal’ fear, and what classifies as a psychiatric diagnosis. In practice, often these patients have symptoms of anxiety and fear, and diagnosis from GAD may be difficult.

Epidemiology

  • Affect 3% of men and 6% of women
  • Long duration

Aetiology

  • Genetic component:
    • Risk for general population – 3-6%
    • Risk when first degree relative also has panic disorder – 15%
  • Related to GAD and to a lesser extent, depression

Panic Disorder

  • Periods of uncontrollable anxiety; panic attacks.
  • Usually sudden onset
    • Somatic symptoms
    • Cognitive deficits
  • The patient believes some large misfortune is about to happen to them, e.g. typically heart attack, or some other medical complaint.
  • Often lots of sympathetic stimulatory events – e.g. sweating, tachycardia, palpitations, tremor. May also include parasthesia as a result of rapid overbreathing.
  • May last from a few minutes to a few hours
  • Often present at A&E
  • May occur as part of depressionin which case, they will resolve with treatment of the depression.
  • Usually associated with other fear and anxiety disorders, most notably, agoraphobia.
  • Panic disorder is said to exist if the patient has had >4 panic attacks in a one month period.

Phobia

Phobia is a particular type of anxiety disorder, which is only provoked in certain situations. The patient has no symptoms provided they avoid the stimulus. This often leads to obsessive avoidance behaviours.
Typical phobias include:
  • Of animals – e.g. spiders, snakes, rats, moths
  • Of Situations – e.g. air travel (air phobia), closed spaces (claustrophobia), social situations (social phobia).
Phobias are usually treated with graded introduction to the avoided situations, gradually increasing the level of exposure.
Agarophobia is one particularly common phobia
  • Usually women aged 18-35
  • Not, as often suggested, fear of open spaces, but more the fear of unfamiliar surroundings, with no easy way to ‘escape’ or hide. Typical situations include:
    • Being a long way from home
    • Shops – particularly having to pay before leaving
    • In large shops/shopping malls/cinemas
  • often symptoms are greatly reduced if there is a friend or relative with the affected individual. In some instances, this may even be just a small child.
  • Symptoms tend to get worse over time. The individual may have panic attacks at the thought of going out, or even when there is no obvious stimulus.

PTSD – Post traumatic stress disorder

Occurs after a particularly stressful event, e.g. war, assault, rape. Usually begins within a few months of the incident, and the patient will experience flashbacks – in which the patient feels as though they are ‘re-experiencing ‘ the event – it is much more vivid than just recalling a memory. Other features include nightmares and sleeping problems. The patient may become hypervigilant – where they become very watchful of danger, overly alert, ‘jumpy’ and anxious. There are also usually features of generalised anxiety.
Flashbacks are seen as intrusive, and they can occur at any time. They often have triggers. For example, for an assault that occurred in a park, the patient may experience flashbacks when visiting a park. This can lead to avoidance behaviour – e.g. avoiding visiting parks.
Patient may also turn to drink and drugs to relieve their anxiety.
There is often a history of previous mental health problems.
Research conducted on soldiers after battle have found that ‘de-brieifng’ after the battle, had no effect on reducing PTSD, and may infact have increased the risk of developing the disorder.

Treatment

  • Often involves psychological interventions, again including CBT.
  • EMDR – eye movement desensitisation and reprocessing – this is a technique used specifically in PTSD. It is an unusual treatment, and essentially involves . in recent studies its efficacy has been comparable to CBT.
  • In PTSD it is thught that the heightened emotions experienced with the traumatic event mean that the memory of the event is not stored correctly. This means when the memory is recalled, it is ‘re-experienced’ rather than, remembered. In EMDR, the patient moves their eyes in various eye movement patterns, in 15-30 second bursts, whilst attempting to recall the memory. Sometimes, hand-tapping or another small motor movement is used rather than eye movement. This is known as dual-processing – as the patient moves part of their body, and also tries to recall the memory.
  • The idea is that this dual processing helps to re-process the memory.  And in doing so, the memory becomes stored correctly.
  • Drug treatment – some drug treatments have been shown to improve symptoms, namely SSRI’s and TCA’s. They tend to be good for treating positive symptoms (flashbacks, increased arousal, other symptoms of anxiety), but not very good at treating negative symptoms (avoidance).
  • Most patients are treated with combination therapies of both psychological interventions and drug treatments.

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