Welcome to the Oxford Psychiatry Podcast series, you're here with Charlotte Allen and Daniel Maun,
and today we're going to be talking about anxiety disorders. Daniel, can you start off by telling me what the main anxiety disorders are?
Thank you, Charlotte. I'm glad you said Maine, as there are actually many different types of anxiety disorders.
The main ones include the phobias, panic disorder, generalised anxiety disorder and obsessive compulsive disorder.
There are also reactions to stress or trauma, such as post-traumatic stress disorder, acute stress reactions and adjustment disorders.
Thank you for that. It sounds like there are a huge number of different types of anxiety disorders.
Let's take them one by one. And perhaps you could start by telling me about the phobias, right?
The phobias all have in common three symptoms, anxiety restricted to the phobia, significant autonomic symptoms.
By that I mean things like increased breathing, changes in heart rate, sweating and other symptoms like that.
And the last one is avoidance.
Okay, so anxiety, autonomic symptoms and avoidance, how how do those present in agoraphobia or agoraphobia is an interesting one.
Lots of people think it's fear of open spaces, but it's actually fear of the marketplace.
So agoraphobia is actually a fairly well defined cluster of phobias, embracing fears of leaving the home, entering shops, crowds or public places.
Often, actually, the phobia is most severe in public transport.
Panic attacks are frequent feature of episodes, and avoidance of the phobic situation is prominent.
Some people with agoraphobia experience little anxiety, actually,
because they are able to avoid their phobic situations really well and the way that they manage their days.
How is agoraphobia different to social phobia?
Well, social phobia is more fear of scrutiny by other people, and that leads with avoidance of social situations.
More pervasive social phobias are associated with low self-esteem and fear of criticism.
So that's really quite different from fear of particular places that are maybe highly populated by people.
It's about being up the front and being scrutinised by others, which is the key here.
The person might present by complaining about blushing or a tremor or feeling sick or an urgency to urinate.
The patient is sometimes convinced that one of the secondary manifestations of these anxiety, which I mentioned, is actually the primary problem.
So they think actually that the nausea is the main problem. And again, symptoms might progress to panic attacks like they do in agoraphobia.
And then how about specific phobias? Well,
specific phobias are maybe the ones that we're more used to hearing about in in our
friends or family and constitute things like blood phobias or faux phobias about,
well, anything really from an animal to a medical situation.
And these phobias tend to arise in childhood and continue into adulthood.
And again, what we're looking for here is anxiety that is restricted to being around the stimulus,
the autonomic symptoms and the avoidance hangs next.
If we move on to panic disorder, can you tell me what panic disorder is?
Yes. Well, I've mentioned that you can get panic and agoraphobia. A panic disorder is slightly different and can be a diagnosis in itself.
We can take sort of the essential feature is recurrent attacks of severe anxiety,
which are not restricted to any particular situation or set of circumstances.
And therefore, quite unlike specific phobias, where the anxiety is very much related to a particular situation,
the dominant symptoms are the autonomic symptoms.
We probably all have felt panic at different times in our life and we probably could describe what it feels like.
But we make a list of autonomic symptoms that include heart palpitations, chest pain, choking sensations,
dizziness, feelings of unreality can sometimes be there as well, which we call depersonalisation or derealization.
This is where the person sometimes feels as though either the situation has become an.
Real or certainly they don't feel part of the situation.
And then following on from that, so you've got this real crescendo of autonomic symptoms and this can lead into a fear of dying,
losing control, fainting or going mad. And actually, that's what can lead into avoidance of any situation in which the panic attack happened.
A classic story of this might be a panic attack happening just random in a
supermarket leading to a fear of supermarkets or an avoidance of supermarkets.
I think maybe if we just go over that a little bit more,
because it's quite easy to get confused between that panic disorder and agoraphobia, for example, or a specific phobia.
So with panic disorder, there are panic attacks which come out of the blue and then there's a secondary worry about having the panic attack.
And that leads to the to the phobia and the avoidance behaviour. Is that right?
That's right. So actually, panic attacks can arise independent of any circumstance,
but they can be the fact that panic disorder can lead to a specific type of phobia or agoraphobia,
and that can't be the case with panic disorder can lead into agoraphobia at times.
OK, so we've talked about different parts of life that might be affected by anxiety, specific parts of life.
What about generalised anxiety disorder? How does that present and how does that affect people?
Generalised anxiety disorder is quite distinct from panic disorder,
panic disorder that the person generally feels OK and then has sudden onset of severe anxiety and which is only for a
circumscribed period of time with generalised anxiety disorder is where the anxiety when it does exactly what it says on the tin.
Actually, it's generalised and persistent, but not restricted to any particular environmental circumstance.
And the word we use here or the term we use is free-floating anxiety.
It doesn't matter where the person is or what the person's doing, they remain having a significant degree of anxiety and again,
autonomic symptoms of that, although avoidance doesn't tend to be there because it's not restricted to any particular circumstance.
What about obsessive compulsive disorder? Because I think this is slightly different to some of the other anxiety disorders that you talked about.
Yes, obsessive compulsive disorder is something which is actually often misunderstood because it has been portrayed in many Hollywood films.
And for that reason, people might have a misperception of what it is.
The essential feature is recurrent obsessional thoughts and or compulsive acts.
Now, obsessional thoughts or ideas or images that enter the person's mind repeatedly.
And the person finds these thoughts distressing and tries unsuccessfully to resist having the thoughts they keep happening.
They are. These thoughts are recognised as the person's own thoughts, even though they are involuntary and.
The person finds them unpleasant and the term we use for that is ego dystonic, so it's egocentric.
It might be a thought that you're completely happy with and you feel agrees with you.
Ego dystonic is something which you you don't agree with. And it might not be in agreement with your general principles.
For instance, hitting someone, OK,
something like that says something which is quite distressing to the person which they wouldn't usually consider doing and just comes into their mind.
That is is very worrying for. Yeah. Yeah, that's right.
And you can see that obsessional thoughts are quite well defined and characterised types of thought.
They're repetitive, they're unpleasant. You recognise them with your own thoughts and their ego dystonic.
OK, now if that's an obsession, what is what is a compulsion?
Well, the obsessions can quite often lead to quite a significant amount of anxiety in the person and compulsive acts are.
Carried out to try and reduce that level of anxiety brought about by the obsession, so compulsive acts are repetitive,
stereotyped behaviours that are not inherently enjoyable, and they don't result in the completion of the task and they're not useful.
OK, so as I said, their function is to prevent some reduction of anxiety.
And that's often due to the patient having an obsessive thought, for instance, or an obsession or thought that they might get infected and die.
And the compulsion can therefore be made to try and reduce the likelihood of that happening.
For instance, washing their hands. OK, so it's carried out to try and reduce the chance of this thing happening.
And it's it's. Often washing hands, it can be symmetry.
It can be checking, checking the locks, for instance, if they have a thought that they might get burgled,
they might check the locks or they might check plug sockets or gas cookers.
So the compulsions are carried out to reduce the anxiety. What can happen, though,
with people with OCD is that the compulsive compulsive acts can go on for so long they become
ritualised and the person then becomes unaware of why they check all the plug sockets every hour,
for instance, because in a sense, that rational thought has moved on maybe to a different area, but they've stayed ritualised in their behaviour.
So it's almost becomes then an ingrained pattern of behaviour. That's right.
And could have quite profound consequences for somebody is day to day life.
If they're having to repeat these compulsions, they frequently. That's right.
Sometimes it can take somebody with something with OCD an hour or two hours to
actually leave the house because of these ritualised behaviours and compulsions.
OK. And distress, make it make these things worse or I mean, do these patterns of behaviour stay fixed for a long time or do they change with time?
Well, if we're moving on to prognosis and thinking about that,
then actually this varies greatly between the different disorders and each individual within each disorder can vary quite significantly.
There's actually limited data as to what the predictors of outcome for anxiety disorders.
The general rule is that the future course of the illness is best predicted by the past course.
And although it seems like a bit of a get out clause,
it must be said anxiety disorders do have high rates of comorbidity with depression and alcohol and drug abuse.
And a lot of the increased morbidity and mortality associated with anxiety disorders may be related to this high rate of co morbidity,
it must be said in response to a question, though, Charlotte,
disorders such as OCD and generalised anxiety disorders are both chronic illnesses and symptoms can wax and wane during the patient's life.
Post-Traumatic stress disorder. On the other hand, which maybe will go on to talk about generally tends to improve.
Well, they're saying that more than one third of those with PTSD never fully recover.
So we can see there's quite a range.
And it's quite difficult, really, without looking at a patient, a particular patient, to determine what a prognosis might be.
Thanks. That's helpful to know a little bit more about prognosis. You mentioned that stress can make anxiety disorders worse.
I just wondered whether stress in itself can precipitate anxiety disorders.
And if so, how might what might that look like in terms of clinical presentations?
Yes, we're getting back to talking about the different types of anxiety disorders.
There are a group of disorders that are a result of stress or stressful events.
The I guess maybe the easiest way to categorise these is according to the onset and the duration.
Acute stress reaction is a very transient disorder that develops in an individual without
any other apparent mental disorder in response to an exceptional physical or mental stress.
And it usually subsides within hours or days.
OK, symptoms can include anything, really, but often disorientation, confusion, agitation or overactivity alongside symptoms of anxiety predominate,
it's important to realise that symptoms often appear within minutes of the stressful
event and will usually disappear within about two or three days of the event,
but often hours.
OK, and how about adjustment disorders, because they are also in response to stress, I think, but the time course is a little bit different.
That's right. Adjustment disorders are sort of the next time period on and usually start within a month and don't last longer than six months.
They arise actually following only often only minor changes to people's lives,
such as a change of job or moving house, as opposed to an acute stress reaction,
which is usually something which is very severe, severe event or a significant event or post-traumatic stress disorder.
So adjustment disorders include symptoms such as some emotional disturbance,
such as anxiety or interference with social functioning or disturbance in sleep or any any sort of change
to a person's life that doesn't meet the criteria of a depressive episode or another anxiety disorder.
And that is seem to arise specifically out of the change in life circumstances.
Would it be fair to say that the symptoms of adjustment disorder are less severe than generalised anxiety disorder, for example?
Yes, that's right.
And we need to make sure that they didn't meet the criteria for generalised anxiety disorder before you made the diagnosis of adjustment disorder.
OK. Also, some people get long term problems after there's been a very stressful event and that can manifest as post-traumatic stress disorder.
Could you say a little bit more about how that can present and what the symptoms are?
Yes, post-traumatic stress disorder has a similar sort of time of onset to adjustment disorders between one or six months usually.
And so it's a delayed or protracted response to a very stressful event which is characterised as exceptionally threatening or catastrophic in nature,
perhaps something like a very bad car accident or the tsunami, for instance.
There are lots of people suffering with PTSD who experienced that.
So the typical features are actually a triad of symptoms which include re-experiencing phenomena,
avoidance and a sense of autonomic or state sorry, of autonomic hyperarousal.
So re-experiencing phenomena are things like flashbacks or dreams or nightmares and
avoidances around specifically to do with activities to remind him of the event.
For instance, if it's a car accident, it might be getting into a car again.
If it's to do with a mugging, they might not want to go back to the place where they were marked.
And the autonomic hyperarousal is or is sometimes called hyper vigilance is is that of a state of always being alert.
So sleep can be difficult because of that. They also it can be very easy to startle because they're very alert and aroused.
Anxiety and depression, also commonly associated with PTSD and suicidal ideation is not uncommon.
You've talked about a range of anxiety disorders now and along the way,
you've mentioned a few things that can trigger anxiety disorders, such as stressful events.
I just wondered as a group, are there any aetiological factors which seem to precipitate these types of illnesses?
Good question. Although there is thought to be some degree of genetic contribution, anxiety disorder,
mostly thought to be a psychological origin, there remains a debate about this.
But there have been many theories, including a theory from Freud, who suggested the panic attacks were due to repressed sexuality.
Well, is that something that is commonly thought of at the moment or is that more a historical fact?
There's more historical fact, actually, and according to more recent theories.
Well, we've actually got quite a good understanding of the geological aetiology of anxiety disorders.
For instance,
classical behavioural psychology suggests that all irrational anxiety is a result of conditioning processes such as classical conditioning.
You might remember Pavlov's dogs. Yes, he had direct or indirect conditioning is connected to the onset of the phobia or anxiety disorder.
So you're talking about learnt patterns of behaviour. That's right.
So, for instance, the person might associate, I don't know, spiders with a very awful situation.
And therefore,
the spiders are then associated with the difficult emotions that actually were brought about by the awful situation of the spider in the first place.
But there have been critics to these simplistic behavioural theories that have actually stress more the cognitive or thought based mechanisms.
Aaron Back is a well known for identifying specific cognition or thoughts with themes of personal danger,
such as death, disease or social rejection, which are common amongst people with anxiety disorders.
And are there any other theories that might help us to understand why these disorders?
Well, yeah, yes.
Psychosis took this sort this sort of cognitive behavioural model a bit further and created the psycho physiological model for anxiety.
According to this model, anxiety or panic can arise as the result of a combination of physiological anxiety symptoms or autonomic symptoms,
which we've talked about have palpitations and increased breathing,
sweating, etc. And the individuals or the patients interpretation of the symptoms is catastrophic,
therefore, that this leads on then to a vicious circle and a crescendo of anxiety.
So they misinterpret the palpitations as potentially being a heart attack,
which makes them more anxious, which worsens the palpitations and then worsens the anxiety.
And this cycle can be very rapid impact disorder, for instance, or less rapid in something like generalised anxiety disorder.
You've mentioned several times about the autonomic affects of anxiety,
and I guess that makes me wonder about any sort of biological predisposition and whether there
are any stress hormones that might be making people more likely to get these dizzy diseases.
Well, that's right. Actually, anxiety does serve a purpose when we think about being anxious.
There are lots of potential situations that are helpful for us to be that.
So is the normal biological process that potentially is got out of hand.
There is evidence that there are alterations in stress hormones and catecholamines noted.
And there have also been new nearby chemical clues from the pharmacological treatment of anxiety.
What I mean by that is that the serotonergic system is particularly important because
we know that the medications that treat anxiety disorders affect the serotonin system,
that selective serotonin reuptake inhibitors. So somehow serotonin plays a very important part in the origin of anxiety disorders.
Clinic for women is the most potent tricyclic, and we know that that is particularly efficacious in obsessive compulsive disorder.
It sounds like there are many different ideological factors to consider that you could just summarise them for me.
Yes, a potential pathogenesis of an anxiety disorder in a given person might be that they have a genetic vulnerability,
which might then lead to reduced regulation of their neurochemistry, possibly affecting serotonergic functions.
Following this, environmental factors may then trigger an initial episode.
And after this, cognitive and conditioning mechanisms might interact to perpetuate this pathological anxiety state and this
model of multiple aetiological factors explains the success of the different types of treatment that we can use.
Moving on to epidemiology, can you say how common these disorders are?
Prevalence rates vary between the different anxiety disorders. And rates also vary dramatically between different studies as well,
which can make it difficult for us to actually come to a decision about specific prevalence or incidence rates for each condition.
The epidemiologic catchment area study from the United States is one that's often cited.
And this this study found prevalence for any anxiety disorder to be twelve point five percent.
But then they split up according to the different diagnosis and found that the prevalence of a simple phobia was 80 percent agoraphobia,
a six percent social phobia, two percent generalised anxiety disorder, four percent panic,
sort of one percent obsessive compulsive disorder, two percent post-traumatic stress disorder, two percent.
That's a bit of a list. But you could see that actually simple phobia and agoraphobia sort of at the top end of the prevalence rates and OCD,
PTSD panic at the lower end of the prevalence rate.
And that's fairly consistent actually between the studies.
It sounds like as a group, though, these are very common illnesses that doctors might see quite frequently.
Yes, they are prevalent conditions. And importantly, a lot of these are managed at the primary care level and often when they are.
Only when they're severe and the presentation is complex to be progressed to a secondary care level of mental health services,
we've already talked a bit about prognosis.
So I think if we move on now to management and I guess in this podcast, we're not going to talk about individual management of every condition,
but more to think about the general principles of anxiety disorder management.
Can you say anything about how you'd approach management of this group of conditions?
Yes, well, I mean, usually we think about the bio psychosocial model of management,
but with anxiety disorders, actually the first line usually is is a psychological approach.
And in essence, cognitive behavioural therapy is the the main psychological approach to managing anxiety disorders.
And there's actually a variety of different CBT or cultivatable therapy approaches or techniques that are used for the different conditions.
For instance, there's trauma focussed CBT for post-traumatic stress disorder or exposure response prevention for obsessive compulsive disorder.
And the reason that there is a variety of approaches is is basically based upon the different theories of why these disorders have developed.
So, for instance, exposure, response, prevention tries to help the patient unlearn these conditioned responses to their anxiety.
And that is some say in OCD, for example, said, is this right that you would just stop the compulsive acts and by learning to stop those acts,
that would help some of the obsessive symptoms? That's right.
So we use generic cognitive behavioural principles and adapt them for each different model.
So that's that's the first line.
And the second low and move on to a pharmacological approach is and I guess there are a number of different pharmacological approaches,
the first of which is selective serotonin reuptake inhibitors, or SSRI, which are effective against most anxiety disorders.
For severe OCD, you can think about using KLEMET for Maine, which is a tricyclic, which I've mentioned,
or potentially an antipsychotic in third line for severe cases,
there are quite a number of other pharmacological strategies which are all second or third line.
Can I say a little bit more about some of those?
Well, yeah, one of them is Buspar Own, which is a five to one, a partial agonist, which might be golddigger for some people,
but actually quite an important receptor when thinking about the mediation of anxiety
neurologically Buspar and is used in the treatment of generalised anxiety disorder.
It's not used for treating acute anxiety, though, as the anxiolytic effect can take up to two weeks to develop.
And what about benzodiazepines? Because you haven't mentioned those yet.
And I just wonder whether they have a role in the treatment of anxiety disorder.
Yes, benzodiazepines have a controversial role, Ashley, and anxiety disorders mainly due to their potential for producing dependence.
They are highly effective in reducing acute anxiety.
Unfortunately, due to tolerance, their efficacy reduces significantly within two to three weeks of using them.
So whilst I think there's a lot of fear about their use, potentially rightly so, they are highly effective in acute high anxiety states.
We just need to be aware of their capacity for producing dependence and the fact that if you use it for two or three weeks,
you are going to be needing to use increased doses. The patient will come back to you and potentially ask for more.
And you need to be aware of that. Are there any other medications that could be used, that kind of third line?
Yes. Pregabalin is an anticonvulsant drug used for neuropathic pain and as an adjunct therapy for seizures,
but it has a licence for generalised anxiety disorder.
Propranolol is a beta blocker, which you might have heard of before, use it as a antihypertensive.
Now, this is not cardio specific and for that reason actually is very good at reducing the autonomic symptoms.
So whilst it might not help in the sort of the mind state of anxiety, it reduces all the bodily reactions to anxiety.
For instance, snooker players can use it as a performance enhancing drug, so it reduces tremor and reduces the heart rate.
You mentioned earlier that drug misuse, alcohol misuse can be common in anxiety disorders.
So do you need to consider those aspects when treating somebody?
Yes, you're right to mention that because substance misuse,
such such as alcohol or recreational drug use, are more common in those with anxiety disorders.
And it's it's absolutely essential that we tackle these as actually the sort of first thing we do when we manage a patient,
because these can lead into the vicious cycle of increasing anxiety and these
leard mechanisms that we've learnt talked about of how to reduce anxiety states.
These can just perpetuate the anxiety disorder.
Interestingly as well, though, and we mustn't forget, although we all use this drug potentially as caffeine,
caffeine can be very important to reduce in people with anxiety disorders and actually looking at their caffeine intake,
cans of coke, tea, coffee, and just cutting that out of of day to day use can be very helpful in their management.
Finally, are there any aspects of social support to help in management?
Yes, structured activities providing appropriate support groups alongside employment support is very important.
I think you do need to think about the risk that the patient presents and, of course, whether they need to be in a hospital or not.
But again, most anxiety disorders are managed in the community.
So providing a good social support for people and encouraging, particularly someone with agoraphobia,
might need a friend or a member of the family to help them in the early stage of treatment to get them out.
And for instance, people with OCD might need the support and encouragement.
So actually, a social network is really important and I guess we'll be seeing them do is helping them regain their independence and functionality.
Thank you very much. That was a great introduction to diagnosis and management of anxiety disorders.
If listeners want any further information about these conditions, can you suggest any extra resources?
Well, yes, I was. And as always, we refer back to the Oxford Textbook of psychiatry,
which is an excellent resource for understanding anxiety disorders with more depth and looking into the management of these conditions.
Otherwise, the Royal College of Psychiatry website has some interesting and helpful information leaflets.
Lovely. Thank you very much. Goodbye.