Introduction

The dear disorders, are generally considered as types of anxiety. In this article we consider Panic Disorder, PTSD, Phobia, OCD and others. For a general overview of anxiety, and information about generalised anxiety disorder (GAD), see the article on anxiety.

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 depression – in 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
    • 40% of the population will have a panic attack at some point, and a single panic attack is not diagnostic
  • A panic attack is defined as 4 or more of the following, which have an acute onset, reach a peak within 10 minutes, and typically resolve abruptly:
    • Shortness of breath
    • Dizziness or light-headedness
    • Palpitations
    • Shaking  / tremor
    • Sweating
    • Numbness or tingling int he hands and feet (parasthesia)
    • Hot flushes or chills
    • Chest pain
    • Fear of dying
    • Fear of impulsive uncontrolled behaviour
  • Associated with agoraphobia – >90% of patients will develop agoraphobia as a result of recurrent panic attacks
  • The main danger with a panic attack is fleeing into a situation that is dangerous!

Management

Basic principles

  • Very similar to those used in generalised anxiety disorder
  • Reassure and explain the episodes (psychoeducation)
    • In particular explain that they do not signify an underlying physical medical problem
  • Teach breathing techniques (see anxiety article)
  • Relaxation techniques – e..g yoga
  • Cognitive behavioural therapy – CBT
  • Pharmacological management
    • Often not useful in acute attacks, but occasionally benzodiazepines (or sometime quetiapine) are prescribed for this purpose
    • Long term anti-depressants – typically SSRIs will reduce the frequency and severity of attacks in 60-90% of patients
    • Evidence for which SSRI is better is lacking, although citalopram and escitalopram are often cited SSRIs that is more effective for anxiety disorders
      • In reality, most SSRIs can be used for this purpose, and it often comes down to individual patient response

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), unfamiliar spaces / crowded space (agoraphobia).
  • Other examples include:
    • Aerophobia – fear of drafts
    • Iatrophobia – fear of doctors!
    • Astraphobia – fear of lightning
Phobias are usually treated with graded introduction to the avoided situations, gradually increasing the level of exposure.
Agarophobia is one particularly common phobia
  • Typically 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
    • Public transport
  • 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 traumatic event, e.g. war, assault, rape.

Features include:

  • Intrusive recollections, nightmares and flashbacks
  • Avoidance behaviour of places or events that remind the person of the event
  • Hyperarousal – e.g. exaggerated startle response, irritability, anger, insomnia, hypervigilance
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.

Can be acute (symptoms <3 months), chronic (>3 months) and delayed onset (symptoms onset >6 months after event).

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, and sometimes EMDR
  • EMDR – eye movement desensitisation and reprocessing – is a technique used specifically in PTSD. It is an unusual treatment, and involves recalling traumatic memories whilst moving the eyes in specific patterns of movements
    • 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.
    • The theory is that there is some association between eye movements any memory storage – as seen in REM (rapid-eye-movement) sleep – which is believed to be important for processing the days memories
  • 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.

Obsessive Compulsive Disorder – OCD

OCD causes anxiety which is associated with obsessive thought, and compulsive ritualistic behaviour.

Obsessions

  • Unwanted, intrusive thoughts
    • Sometimes intrusive images in the mind
  • Patient attempts to resist the thoughts

Compulsions

  • Behaviours that result from the obsessive thoughts, believed by the patient to prevent a bad outcome, and may partially and temporarily relieve the anxiety caused by the thoughts
  • E.g. – unwanted intrusive thoughts that germs are present on the hands, received by frequent and recurrent hand washing

Management

  • Typically a combination of psychotherapy (usually CBT) and medication – usually SSRI
  • CBT helps to relieve th obsessions
  • Exposure and response prevention therapy may relieve compulsions – e.g. not washing the hands after touching an object to show that negative consequences do not result

Adjustment Disorder

  • Anxiety symptoms within 3 months of an acute life stressor
  • Usually responds to psychotherapy, and in some cases drug treatment may be considered
  • If symptoms persists >6 months then an alternative diagnosis (e.g. anxiety disorder or depression) should be considered

Somatic Symptom Disorder

Previously somatisation disorder, and previously to that, hysteria.

This diagnosis refers to the tendency to report psychological stress as somatic symptoms or pain.

  • Usually onset before age 30
  • More common in women
  • Often associated with ongoing refusal of reassurance that there is no worrying underlying physical cause for symptoms
  • Common symptoms include:
    • GI – nausea, vomiting, abdominal pain
    • Gynaecological – pelvic pain, dysmenorrhoea
    • Cardiac – palpitations, SOB, chest pain
    • Neurological – amnesia, voice changes, dizziness, difficulty walking or co-ordinating limbs, speech difficulties, swallowing difficulties
    • Pain – all over body pain, headaches, pain in a joint or limb
  • Be wary to exclude an underlying physical cause for symptoms – in particular with cardiac symptoms consider investigation of TFTs, ECG and Holter monitor.
  • Look for another underlying psychological cause – such as depression or anxiety.
  • Careful counselling is the most effective treatment

Differentiating types of anxiety disorder

A good history can help to differentiate the type of anxiety disorder present. Often there is overlap and multiple disorders may be present

SymptomsIndicates
  • Obvious triggers – leading to panic attacks or avoidance behaviours
Simple phobia
  • Panic attacks
  • Catastrophising
  • Often associated with agoraphobia
Panic disorder
  • Avoidance of open air
  • Avoidance of crowded spaces
Agoraphobia
  • Chronic worrying
  • Worries about multiple or most topics
  • Maybe some catastrophising
Generalised anxiety disorder
  • Unwanted intrusive thoughts
  • Ritualised behaviours
Obsessive compulsive disorder
  • Preoccupied about being judged negatively by others
Social phobia
  • Recurrent re-experiencing of a traumatic event
  • Hyperarousal
  • Avoidance of triggers
PTSD

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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