1 00:00:00,270 --> 00:00:07,020 Welcome to the Oxford Psychiatry Podcast series, you're here with Charlotte Allen and Daniel Maun, 2 00:00:07,020 --> 00:00:16,050 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? 3 00:00:16,050 --> 00:00:22,320 Thank you, Charlotte. I'm glad you said Maine, as there are actually many different types of anxiety disorders. 4 00:00:22,320 --> 00:00:29,850 The main ones include the phobias, panic disorder, generalised anxiety disorder and obsessive compulsive disorder. 5 00:00:29,850 --> 00:00:38,130 There are also reactions to stress or trauma, such as post-traumatic stress disorder, acute stress reactions and adjustment disorders. 6 00:00:38,130 --> 00:00:43,440 Thank you for that. It sounds like there are a huge number of different types of anxiety disorders. 7 00:00:43,440 --> 00:00:50,010 Let's take them one by one. And perhaps you could start by telling me about the phobias, right? 8 00:00:50,010 --> 00:00:58,770 The phobias all have in common three symptoms, anxiety restricted to the phobia, significant autonomic symptoms. 9 00:00:58,770 --> 00:01:09,120 By that I mean things like increased breathing, changes in heart rate, sweating and other symptoms like that. 10 00:01:09,120 --> 00:01:11,970 And the last one is avoidance. 11 00:01:11,970 --> 00:01:23,040 Okay, so anxiety, autonomic symptoms and avoidance, how how do those present in agoraphobia or agoraphobia is an interesting one. 12 00:01:23,040 --> 00:01:28,980 Lots of people think it's fear of open spaces, but it's actually fear of the marketplace. 13 00:01:28,980 --> 00:01:39,000 So agoraphobia is actually a fairly well defined cluster of phobias, embracing fears of leaving the home, entering shops, crowds or public places. 14 00:01:39,000 --> 00:01:46,710 Often, actually, the phobia is most severe in public transport. 15 00:01:46,710 --> 00:01:53,670 Panic attacks are frequent feature of episodes, and avoidance of the phobic situation is prominent. 16 00:01:53,670 --> 00:01:58,860 Some people with agoraphobia experience little anxiety, actually, 17 00:01:58,860 --> 00:02:06,010 because they are able to avoid their phobic situations really well and the way that they manage their days. 18 00:02:06,010 --> 00:02:10,530 How is agoraphobia different to social phobia? 19 00:02:10,530 --> 00:02:18,600 Well, social phobia is more fear of scrutiny by other people, and that leads with avoidance of social situations. 20 00:02:18,600 --> 00:02:25,160 More pervasive social phobias are associated with low self-esteem and fear of criticism. 21 00:02:25,160 --> 00:02:33,570 So that's really quite different from fear of particular places that are maybe highly populated by people. 22 00:02:33,570 --> 00:02:39,300 It's about being up the front and being scrutinised by others, which is the key here. 23 00:02:39,300 --> 00:02:47,440 The person might present by complaining about blushing or a tremor or feeling sick or an urgency to urinate. 24 00:02:47,440 --> 00:02:54,870 The patient is sometimes convinced that one of the secondary manifestations of these anxiety, which I mentioned, is actually the primary problem. 25 00:02:54,870 --> 00:03:04,920 So they think actually that the nausea is the main problem. And again, symptoms might progress to panic attacks like they do in agoraphobia. 26 00:03:04,920 --> 00:03:09,660 And then how about specific phobias? Well, 27 00:03:09,660 --> 00:03:16,230 specific phobias are maybe the ones that we're more used to hearing about in in our 28 00:03:16,230 --> 00:03:24,480 friends or family and constitute things like blood phobias or faux phobias about, 29 00:03:24,480 --> 00:03:31,590 well, anything really from an animal to a medical situation. 30 00:03:31,590 --> 00:03:37,830 And these phobias tend to arise in childhood and continue into adulthood. 31 00:03:37,830 --> 00:03:47,100 And again, what we're looking for here is anxiety that is restricted to being around the stimulus, 32 00:03:47,100 --> 00:03:52,890 the autonomic symptoms and the avoidance hangs next. 33 00:03:52,890 --> 00:03:58,290 If we move on to panic disorder, can you tell me what panic disorder is? 34 00:03:58,290 --> 00:04:07,080 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. 35 00:04:07,080 --> 00:04:13,050 We can take sort of the essential feature is recurrent attacks of severe anxiety, 36 00:04:13,050 --> 00:04:18,480 which are not restricted to any particular situation or set of circumstances. 37 00:04:18,480 --> 00:04:27,300 And therefore, quite unlike specific phobias, where the anxiety is very much related to a particular situation, 38 00:04:27,300 --> 00:04:30,750 the dominant symptoms are the autonomic symptoms. 39 00:04:30,750 --> 00:04:37,080 We probably all have felt panic at different times in our life and we probably could describe what it feels like. 40 00:04:37,080 --> 00:04:45,450 But we make a list of autonomic symptoms that include heart palpitations, chest pain, choking sensations, 41 00:04:45,450 --> 00:04:52,680 dizziness, feelings of unreality can sometimes be there as well, which we call depersonalisation or derealization. 42 00:04:52,680 --> 00:04:59,990 This is where the person sometimes feels as though either the situation has become an. 43 00:04:59,990 --> 00:05:05,380 Real or certainly they don't feel part of the situation. 44 00:05:05,380 --> 00:05:13,000 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, 45 00:05:13,000 --> 00:05:27,760 losing control, fainting or going mad. And actually, that's what can lead into avoidance of any situation in which the panic attack happened. 46 00:05:27,760 --> 00:05:32,890 A classic story of this might be a panic attack happening just random in a 47 00:05:32,890 --> 00:05:40,330 supermarket leading to a fear of supermarkets or an avoidance of supermarkets. 48 00:05:40,330 --> 00:05:42,430 I think maybe if we just go over that a little bit more, 49 00:05:42,430 --> 00:05:51,100 because it's quite easy to get confused between that panic disorder and agoraphobia, for example, or a specific phobia. 50 00:05:51,100 --> 00:05:59,620 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. 51 00:05:59,620 --> 00:06:04,420 And that leads to the to the phobia and the avoidance behaviour. Is that right? 52 00:06:04,420 --> 00:06:09,760 That's right. So actually, panic attacks can arise independent of any circumstance, 53 00:06:09,760 --> 00:06:16,690 but they can be the fact that panic disorder can lead to a specific type of phobia or agoraphobia, 54 00:06:16,690 --> 00:06:22,270 and that can't be the case with panic disorder can lead into agoraphobia at times. 55 00:06:22,270 --> 00:06:29,380 OK, so we've talked about different parts of life that might be affected by anxiety, specific parts of life. 56 00:06:29,380 --> 00:06:35,560 What about generalised anxiety disorder? How does that present and how does that affect people? 57 00:06:35,560 --> 00:06:38,830 Generalised anxiety disorder is quite distinct from panic disorder, 58 00:06:38,830 --> 00:06:48,550 panic disorder that the person generally feels OK and then has sudden onset of severe anxiety and which is only for a 59 00:06:48,550 --> 00:06:54,820 circumscribed period of time with generalised anxiety disorder is where the anxiety when it does exactly what it says on the tin. 60 00:06:54,820 --> 00:07:04,240 Actually, it's generalised and persistent, but not restricted to any particular environmental circumstance. 61 00:07:04,240 --> 00:07:09,600 And the word we use here or the term we use is free-floating anxiety. 62 00:07:09,600 --> 00:07:19,570 It doesn't matter where the person is or what the person's doing, they remain having a significant degree of anxiety and again, 63 00:07:19,570 --> 00:07:30,260 autonomic symptoms of that, although avoidance doesn't tend to be there because it's not restricted to any particular circumstance. 64 00:07:30,260 --> 00:07:38,870 What about obsessive compulsive disorder? Because I think this is slightly different to some of the other anxiety disorders that you talked about. 65 00:07:38,870 --> 00:07:48,290 Yes, obsessive compulsive disorder is something which is actually often misunderstood because it has been portrayed in many Hollywood films. 66 00:07:48,290 --> 00:07:54,860 And for that reason, people might have a misperception of what it is. 67 00:07:54,860 --> 00:08:01,550 The essential feature is recurrent obsessional thoughts and or compulsive acts. 68 00:08:01,550 --> 00:08:09,080 Now, obsessional thoughts or ideas or images that enter the person's mind repeatedly. 69 00:08:09,080 --> 00:08:17,960 And the person finds these thoughts distressing and tries unsuccessfully to resist having the thoughts they keep happening. 70 00:08:17,960 --> 00:08:29,170 They are. These thoughts are recognised as the person's own thoughts, even though they are involuntary and. 71 00:08:29,170 --> 00:08:35,990 The person finds them unpleasant and the term we use for that is ego dystonic, so it's egocentric. 72 00:08:35,990 --> 00:08:39,490 It might be a thought that you're completely happy with and you feel agrees with you. 73 00:08:39,490 --> 00:08:47,200 Ego dystonic is something which you you don't agree with. And it might not be in agreement with your general principles. 74 00:08:47,200 --> 00:08:49,930 For instance, hitting someone, OK, 75 00:08:49,930 --> 00:08:57,650 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. 76 00:08:57,650 --> 00:09:01,060 That is is very worrying for. Yeah. Yeah, that's right. 77 00:09:01,060 --> 00:09:07,150 And you can see that obsessional thoughts are quite well defined and characterised types of thought. 78 00:09:07,150 --> 00:09:12,700 They're repetitive, they're unpleasant. You recognise them with your own thoughts and their ego dystonic. 79 00:09:12,700 --> 00:09:18,550 OK, now if that's an obsession, what is what is a compulsion? 80 00:09:18,550 --> 00:09:28,410 Well, the obsessions can quite often lead to quite a significant amount of anxiety in the person and compulsive acts are. 81 00:09:28,410 --> 00:09:36,450 Carried out to try and reduce that level of anxiety brought about by the obsession, so compulsive acts are repetitive, 82 00:09:36,450 --> 00:09:44,860 stereotyped behaviours that are not inherently enjoyable, and they don't result in the completion of the task and they're not useful. 83 00:09:44,860 --> 00:09:50,850 OK, so as I said, their function is to prevent some reduction of anxiety. 84 00:09:50,850 --> 00:10:02,910 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. 85 00:10:02,910 --> 00:10:10,770 And the compulsion can therefore be made to try and reduce the likelihood of that happening. 86 00:10:10,770 --> 00:10:21,210 For instance, washing their hands. OK, so it's carried out to try and reduce the chance of this thing happening. 87 00:10:21,210 --> 00:10:26,890 And it's it's. Often washing hands, it can be symmetry. 88 00:10:26,890 --> 00:10:31,970 It can be checking, checking the locks, for instance, if they have a thought that they might get burgled, 89 00:10:31,970 --> 00:10:38,200 they might check the locks or they might check plug sockets or gas cookers. 90 00:10:38,200 --> 00:10:43,210 So the compulsions are carried out to reduce the anxiety. What can happen, though, 91 00:10:43,210 --> 00:10:51,550 with people with OCD is that the compulsive compulsive acts can go on for so long they become 92 00:10:51,550 --> 00:11:00,520 ritualised and the person then becomes unaware of why they check all the plug sockets every hour, 93 00:11:00,520 --> 00:11:08,320 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. 94 00:11:08,320 --> 00:11:12,150 So it's almost becomes then an ingrained pattern of behaviour. That's right. 95 00:11:12,150 --> 00:11:15,790 And could have quite profound consequences for somebody is day to day life. 96 00:11:15,790 --> 00:11:20,050 If they're having to repeat these compulsions, they frequently. That's right. 97 00:11:20,050 --> 00:11:25,870 Sometimes it can take somebody with something with OCD an hour or two hours to 98 00:11:25,870 --> 00:11:30,640 actually leave the house because of these ritualised behaviours and compulsions. 99 00:11:30,640 --> 00:11:42,420 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? 100 00:11:42,420 --> 00:11:46,680 Well, if we're moving on to prognosis and thinking about that, 101 00:11:46,680 --> 00:11:56,770 then actually this varies greatly between the different disorders and each individual within each disorder can vary quite significantly. 102 00:11:56,770 --> 00:12:02,760 There's actually limited data as to what the predictors of outcome for anxiety disorders. 103 00:12:02,760 --> 00:12:07,770 The general rule is that the future course of the illness is best predicted by the past course. 104 00:12:07,770 --> 00:12:12,990 And although it seems like a bit of a get out clause, 105 00:12:12,990 --> 00:12:19,470 it must be said anxiety disorders do have high rates of comorbidity with depression and alcohol and drug abuse. 106 00:12:19,470 --> 00:12:28,140 And a lot of the increased morbidity and mortality associated with anxiety disorders may be related to this high rate of co morbidity, 107 00:12:28,140 --> 00:12:31,080 it must be said in response to a question, though, Charlotte, 108 00:12:31,080 --> 00:12:43,470 disorders such as OCD and generalised anxiety disorders are both chronic illnesses and symptoms can wax and wane during the patient's life. 109 00:12:43,470 --> 00:12:50,890 Post-Traumatic stress disorder. On the other hand, which maybe will go on to talk about generally tends to improve. 110 00:12:50,890 --> 00:12:55,410 Well, they're saying that more than one third of those with PTSD never fully recover. 111 00:12:55,410 --> 00:12:56,850 So we can see there's quite a range. 112 00:12:56,850 --> 00:13:07,140 And it's quite difficult, really, without looking at a patient, a particular patient, to determine what a prognosis might be. 113 00:13:07,140 --> 00:13:15,060 Thanks. That's helpful to know a little bit more about prognosis. You mentioned that stress can make anxiety disorders worse. 114 00:13:15,060 --> 00:13:19,770 I just wondered whether stress in itself can precipitate anxiety disorders. 115 00:13:19,770 --> 00:13:24,900 And if so, how might what might that look like in terms of clinical presentations? 116 00:13:24,900 --> 00:13:29,220 Yes, we're getting back to talking about the different types of anxiety disorders. 117 00:13:29,220 --> 00:13:36,720 There are a group of disorders that are a result of stress or stressful events. 118 00:13:36,720 --> 00:13:45,150 The I guess maybe the easiest way to categorise these is according to the onset and the duration. 119 00:13:45,150 --> 00:13:51,750 Acute stress reaction is a very transient disorder that develops in an individual without 120 00:13:51,750 --> 00:13:57,690 any other apparent mental disorder in response to an exceptional physical or mental stress. 121 00:13:57,690 --> 00:14:01,520 And it usually subsides within hours or days. 122 00:14:01,520 --> 00:14:16,760 OK, symptoms can include anything, really, but often disorientation, confusion, agitation or overactivity alongside symptoms of anxiety predominate, 123 00:14:16,760 --> 00:14:21,590 it's important to realise that symptoms often appear within minutes of the stressful 124 00:14:21,590 --> 00:14:27,740 event and will usually disappear within about two or three days of the event, 125 00:14:27,740 --> 00:14:31,000 but often hours. 126 00:14:31,000 --> 00:14:38,920 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. 127 00:14:38,920 --> 00:14:49,690 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. 128 00:14:49,690 --> 00:14:54,460 They arise actually following only often only minor changes to people's lives, 129 00:14:54,460 --> 00:14:59,920 such as a change of job or moving house, as opposed to an acute stress reaction, 130 00:14:59,920 --> 00:15:09,130 which is usually something which is very severe, severe event or a significant event or post-traumatic stress disorder. 131 00:15:09,130 --> 00:15:15,880 So adjustment disorders include symptoms such as some emotional disturbance, 132 00:15:15,880 --> 00:15:23,590 such as anxiety or interference with social functioning or disturbance in sleep or any any sort of change 133 00:15:23,590 --> 00:15:31,300 to a person's life that doesn't meet the criteria of a depressive episode or another anxiety disorder. 134 00:15:31,300 --> 00:15:38,890 And that is seem to arise specifically out of the change in life circumstances. 135 00:15:38,890 --> 00:15:46,660 Would it be fair to say that the symptoms of adjustment disorder are less severe than generalised anxiety disorder, for example? 136 00:15:46,660 --> 00:15:48,280 Yes, that's right. 137 00:15:48,280 --> 00:15:56,090 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. 138 00:15:56,090 --> 00:16:06,070 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. 139 00:16:06,070 --> 00:16:10,390 Could you say a little bit more about how that can present and what the symptoms are? 140 00:16:10,390 --> 00:16:19,000 Yes, post-traumatic stress disorder has a similar sort of time of onset to adjustment disorders between one or six months usually. 141 00:16:19,000 --> 00:16:28,690 And so it's a delayed or protracted response to a very stressful event which is characterised as exceptionally threatening or catastrophic in nature, 142 00:16:28,690 --> 00:16:33,820 perhaps something like a very bad car accident or the tsunami, for instance. 143 00:16:33,820 --> 00:16:39,580 There are lots of people suffering with PTSD who experienced that. 144 00:16:39,580 --> 00:16:47,200 So the typical features are actually a triad of symptoms which include re-experiencing phenomena, 145 00:16:47,200 --> 00:16:55,210 avoidance and a sense of autonomic or state sorry, of autonomic hyperarousal. 146 00:16:55,210 --> 00:17:03,340 So re-experiencing phenomena are things like flashbacks or dreams or nightmares and 147 00:17:03,340 --> 00:17:07,990 avoidances around specifically to do with activities to remind him of the event. 148 00:17:07,990 --> 00:17:12,250 For instance, if it's a car accident, it might be getting into a car again. 149 00:17:12,250 --> 00:17:16,960 If it's to do with a mugging, they might not want to go back to the place where they were marked. 150 00:17:16,960 --> 00:17:26,440 And the autonomic hyperarousal is or is sometimes called hyper vigilance is is that of a state of always being alert. 151 00:17:26,440 --> 00:17:37,030 So sleep can be difficult because of that. They also it can be very easy to startle because they're very alert and aroused. 152 00:17:37,030 --> 00:17:47,430 Anxiety and depression, also commonly associated with PTSD and suicidal ideation is not uncommon. 153 00:17:47,430 --> 00:17:51,690 You've talked about a range of anxiety disorders now and along the way, 154 00:17:51,690 --> 00:17:57,060 you've mentioned a few things that can trigger anxiety disorders, such as stressful events. 155 00:17:57,060 --> 00:18:04,700 I just wondered as a group, are there any aetiological factors which seem to precipitate these types of illnesses? 156 00:18:04,700 --> 00:18:10,550 Good question. Although there is thought to be some degree of genetic contribution, anxiety disorder, 157 00:18:10,550 --> 00:18:16,250 mostly thought to be a psychological origin, there remains a debate about this. 158 00:18:16,250 --> 00:18:27,860 But there have been many theories, including a theory from Freud, who suggested the panic attacks were due to repressed sexuality. 159 00:18:27,860 --> 00:18:32,120 Well, is that something that is commonly thought of at the moment or is that more a historical fact? 160 00:18:32,120 --> 00:18:37,940 There's more historical fact, actually, and according to more recent theories. 161 00:18:37,940 --> 00:18:44,420 Well, we've actually got quite a good understanding of the geological aetiology of anxiety disorders. 162 00:18:44,420 --> 00:18:44,990 For instance, 163 00:18:44,990 --> 00:18:54,710 classical behavioural psychology suggests that all irrational anxiety is a result of conditioning processes such as classical conditioning. 164 00:18:54,710 --> 00:19:06,180 You might remember Pavlov's dogs. Yes, he had direct or indirect conditioning is connected to the onset of the phobia or anxiety disorder. 165 00:19:06,180 --> 00:19:10,020 So you're talking about learnt patterns of behaviour. That's right. 166 00:19:10,020 --> 00:19:24,570 So, for instance, the person might associate, I don't know, spiders with a very awful situation. 167 00:19:24,570 --> 00:19:25,380 And therefore, 168 00:19:25,380 --> 00:19:35,430 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. 169 00:19:35,430 --> 00:19:46,140 But there have been critics to these simplistic behavioural theories that have actually stress more the cognitive or thought based mechanisms. 170 00:19:46,140 --> 00:19:53,520 Aaron Back is a well known for identifying specific cognition or thoughts with themes of personal danger, 171 00:19:53,520 --> 00:20:00,720 such as death, disease or social rejection, which are common amongst people with anxiety disorders. 172 00:20:00,720 --> 00:20:05,310 And are there any other theories that might help us to understand why these disorders? 173 00:20:05,310 --> 00:20:06,690 Well, yeah, yes. 174 00:20:06,690 --> 00:20:18,330 Psychosis took this sort this sort of cognitive behavioural model a bit further and created the psycho physiological model for anxiety. 175 00:20:18,330 --> 00:20:27,000 According to this model, anxiety or panic can arise as the result of a combination of physiological anxiety symptoms or autonomic symptoms, 176 00:20:27,000 --> 00:20:32,430 which we've talked about have palpitations and increased breathing, 177 00:20:32,430 --> 00:20:41,550 sweating, etc. And the individuals or the patients interpretation of the symptoms is catastrophic, 178 00:20:41,550 --> 00:20:46,680 therefore, that this leads on then to a vicious circle and a crescendo of anxiety. 179 00:20:46,680 --> 00:20:51,270 So they misinterpret the palpitations as potentially being a heart attack, 180 00:20:51,270 --> 00:20:57,360 which makes them more anxious, which worsens the palpitations and then worsens the anxiety. 181 00:20:57,360 --> 00:21:08,230 And this cycle can be very rapid impact disorder, for instance, or less rapid in something like generalised anxiety disorder. 182 00:21:08,230 --> 00:21:12,850 You've mentioned several times about the autonomic affects of anxiety, 183 00:21:12,850 --> 00:21:17,770 and I guess that makes me wonder about any sort of biological predisposition and whether there 184 00:21:17,770 --> 00:21:24,340 are any stress hormones that might be making people more likely to get these dizzy diseases. 185 00:21:24,340 --> 00:21:32,560 Well, that's right. Actually, anxiety does serve a purpose when we think about being anxious. 186 00:21:32,560 --> 00:21:37,760 There are lots of potential situations that are helpful for us to be that. 187 00:21:37,760 --> 00:21:43,030 So is the normal biological process that potentially is got out of hand. 188 00:21:43,030 --> 00:21:49,750 There is evidence that there are alterations in stress hormones and catecholamines noted. 189 00:21:49,750 --> 00:21:57,610 And there have also been new nearby chemical clues from the pharmacological treatment of anxiety. 190 00:21:57,610 --> 00:22:04,030 What I mean by that is that the serotonergic system is particularly important because 191 00:22:04,030 --> 00:22:10,120 we know that the medications that treat anxiety disorders affect the serotonin system, 192 00:22:10,120 --> 00:22:22,440 that selective serotonin reuptake inhibitors. So somehow serotonin plays a very important part in the origin of anxiety disorders. 193 00:22:22,440 --> 00:22:34,030 Clinic for women is the most potent tricyclic, and we know that that is particularly efficacious in obsessive compulsive disorder. 194 00:22:34,030 --> 00:22:41,170 It sounds like there are many different ideological factors to consider that you could just summarise them for me. 195 00:22:41,170 --> 00:22:50,770 Yes, a potential pathogenesis of an anxiety disorder in a given person might be that they have a genetic vulnerability, 196 00:22:50,770 --> 00:22:59,350 which might then lead to reduced regulation of their neurochemistry, possibly affecting serotonergic functions. 197 00:22:59,350 --> 00:23:04,120 Following this, environmental factors may then trigger an initial episode. 198 00:23:04,120 --> 00:23:14,290 And after this, cognitive and conditioning mechanisms might interact to perpetuate this pathological anxiety state and this 199 00:23:14,290 --> 00:23:23,760 model of multiple aetiological factors explains the success of the different types of treatment that we can use. 200 00:23:23,760 --> 00:23:32,180 Moving on to epidemiology, can you say how common these disorders are? 201 00:23:32,180 --> 00:23:40,720 Prevalence rates vary between the different anxiety disorders. And rates also vary dramatically between different studies as well, 202 00:23:40,720 --> 00:23:53,560 which can make it difficult for us to actually come to a decision about specific prevalence or incidence rates for each condition. 203 00:23:53,560 --> 00:24:00,710 The epidemiologic catchment area study from the United States is one that's often cited. 204 00:24:00,710 --> 00:24:10,630 And this this study found prevalence for any anxiety disorder to be twelve point five percent. 205 00:24:10,630 --> 00:24:21,070 But then they split up according to the different diagnosis and found that the prevalence of a simple phobia was 80 percent agoraphobia, 206 00:24:21,070 --> 00:24:29,690 a six percent social phobia, two percent generalised anxiety disorder, four percent panic, 207 00:24:29,690 --> 00:24:37,180 sort of one percent obsessive compulsive disorder, two percent post-traumatic stress disorder, two percent. 208 00:24:37,180 --> 00:24:49,150 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, 209 00:24:49,150 --> 00:24:52,610 PTSD panic at the lower end of the prevalence rate. 210 00:24:52,610 --> 00:24:56,800 And that's fairly consistent actually between the studies. 211 00:24:56,800 --> 00:25:03,400 It sounds like as a group, though, these are very common illnesses that doctors might see quite frequently. 212 00:25:03,400 --> 00:25:13,530 Yes, they are prevalent conditions. And importantly, a lot of these are managed at the primary care level and often when they are. 213 00:25:13,530 --> 00:25:25,380 Only when they're severe and the presentation is complex to be progressed to a secondary care level of mental health services, 214 00:25:25,380 --> 00:25:27,840 we've already talked a bit about prognosis. 215 00:25:27,840 --> 00:25:38,520 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, 216 00:25:38,520 --> 00:25:43,170 but more to think about the general principles of anxiety disorder management. 217 00:25:43,170 --> 00:25:49,640 Can you say anything about how you'd approach management of this group of conditions? 218 00:25:49,640 --> 00:25:54,080 Yes, well, I mean, usually we think about the bio psychosocial model of management, 219 00:25:54,080 --> 00:26:01,520 but with anxiety disorders, actually the first line usually is is a psychological approach. 220 00:26:01,520 --> 00:26:10,040 And in essence, cognitive behavioural therapy is the the main psychological approach to managing anxiety disorders. 221 00:26:10,040 --> 00:26:17,990 And there's actually a variety of different CBT or cultivatable therapy approaches or techniques that are used for the different conditions. 222 00:26:17,990 --> 00:26:28,280 For instance, there's trauma focussed CBT for post-traumatic stress disorder or exposure response prevention for obsessive compulsive disorder. 223 00:26:28,280 --> 00:26:39,920 And the reason that there is a variety of approaches is is basically based upon the different theories of why these disorders have developed. 224 00:26:39,920 --> 00:26:53,570 So, for instance, exposure, response, prevention tries to help the patient unlearn these conditioned responses to their anxiety. 225 00:26:53,570 --> 00:27:03,080 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, 226 00:27:03,080 --> 00:27:06,680 that would help some of the obsessive symptoms? That's right. 227 00:27:06,680 --> 00:27:15,090 So we use generic cognitive behavioural principles and adapt them for each different model. 228 00:27:15,090 --> 00:27:16,710 So that's that's the first line. 229 00:27:16,710 --> 00:27:28,700 And the second low and move on to a pharmacological approach is and I guess there are a number of different pharmacological approaches, 230 00:27:28,700 --> 00:27:39,430 the first of which is selective serotonin reuptake inhibitors, or SSRI, which are effective against most anxiety disorders. 231 00:27:39,430 --> 00:27:45,760 For severe OCD, you can think about using KLEMET for Maine, which is a tricyclic, which I've mentioned, 232 00:27:45,760 --> 00:27:52,210 or potentially an antipsychotic in third line for severe cases, 233 00:27:52,210 --> 00:27:58,270 there are quite a number of other pharmacological strategies which are all second or third line. 234 00:27:58,270 --> 00:28:01,810 Can I say a little bit more about some of those? 235 00:28:01,810 --> 00:28:10,690 Well, yeah, one of them is Buspar Own, which is a five to one, a partial agonist, which might be golddigger for some people, 236 00:28:10,690 --> 00:28:18,880 but actually quite an important receptor when thinking about the mediation of anxiety 237 00:28:18,880 --> 00:28:24,640 neurologically Buspar and is used in the treatment of generalised anxiety disorder. 238 00:28:24,640 --> 00:28:31,810 It's not used for treating acute anxiety, though, as the anxiolytic effect can take up to two weeks to develop. 239 00:28:31,810 --> 00:28:35,950 And what about benzodiazepines? Because you haven't mentioned those yet. 240 00:28:35,950 --> 00:28:39,830 And I just wonder whether they have a role in the treatment of anxiety disorder. 241 00:28:39,830 --> 00:28:51,110 Yes, benzodiazepines have a controversial role, Ashley, and anxiety disorders mainly due to their potential for producing dependence. 242 00:28:51,110 --> 00:28:56,960 They are highly effective in reducing acute anxiety. 243 00:28:56,960 --> 00:29:08,690 Unfortunately, due to tolerance, their efficacy reduces significantly within two to three weeks of using them. 244 00:29:08,690 --> 00:29:20,000 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. 245 00:29:20,000 --> 00:29:27,440 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, 246 00:29:27,440 --> 00:29:33,560 you are going to be needing to use increased doses. The patient will come back to you and potentially ask for more. 247 00:29:33,560 --> 00:29:40,460 And you need to be aware of that. Are there any other medications that could be used, that kind of third line? 248 00:29:40,460 --> 00:29:48,810 Yes. Pregabalin is an anticonvulsant drug used for neuropathic pain and as an adjunct therapy for seizures, 249 00:29:48,810 --> 00:29:53,130 but it has a licence for generalised anxiety disorder. 250 00:29:53,130 --> 00:30:01,680 Propranolol is a beta blocker, which you might have heard of before, use it as a antihypertensive. 251 00:30:01,680 --> 00:30:13,080 Now, this is not cardio specific and for that reason actually is very good at reducing the autonomic symptoms. 252 00:30:13,080 --> 00:30:24,660 So whilst it might not help in the sort of the mind state of anxiety, it reduces all the bodily reactions to anxiety. 253 00:30:24,660 --> 00:30:34,910 For instance, snooker players can use it as a performance enhancing drug, so it reduces tremor and reduces the heart rate. 254 00:30:34,910 --> 00:30:41,570 You mentioned earlier that drug misuse, alcohol misuse can be common in anxiety disorders. 255 00:30:41,570 --> 00:30:47,240 So do you need to consider those aspects when treating somebody? 256 00:30:47,240 --> 00:30:51,230 Yes, you're right to mention that because substance misuse, 257 00:30:51,230 --> 00:30:56,900 such such as alcohol or recreational drug use, are more common in those with anxiety disorders. 258 00:30:56,900 --> 00:31:08,270 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, 259 00:31:08,270 --> 00:31:15,740 because these can lead into the vicious cycle of increasing anxiety and these 260 00:31:15,740 --> 00:31:20,510 leard mechanisms that we've learnt talked about of how to reduce anxiety states. 261 00:31:20,510 --> 00:31:24,230 These can just perpetuate the anxiety disorder. 262 00:31:24,230 --> 00:31:32,540 Interestingly as well, though, and we mustn't forget, although we all use this drug potentially as caffeine, 263 00:31:32,540 --> 00:31:46,430 caffeine can be very important to reduce in people with anxiety disorders and actually looking at their caffeine intake, 264 00:31:46,430 --> 00:31:55,890 cans of coke, tea, coffee, and just cutting that out of of day to day use can be very helpful in their management. 265 00:31:55,890 --> 00:32:01,970 Finally, are there any aspects of social support to help in management? 266 00:32:01,970 --> 00:32:11,220 Yes, structured activities providing appropriate support groups alongside employment support is very important. 267 00:32:11,220 --> 00:32:20,460 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. 268 00:32:20,460 --> 00:32:24,360 But again, most anxiety disorders are managed in the community. 269 00:32:24,360 --> 00:32:31,830 So providing a good social support for people and encouraging, particularly someone with agoraphobia, 270 00:32:31,830 --> 00:32:37,590 might need a friend or a member of the family to help them in the early stage of treatment to get them out. 271 00:32:37,590 --> 00:32:42,410 And for instance, people with OCD might need the support and encouragement. 272 00:32:42,410 --> 00:32:53,810 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. 273 00:32:53,810 --> 00:33:00,530 Thank you very much. That was a great introduction to diagnosis and management of anxiety disorders. 274 00:33:00,530 --> 00:33:06,560 If listeners want any further information about these conditions, can you suggest any extra resources? 275 00:33:06,560 --> 00:33:11,180 Well, yes, I was. And as always, we refer back to the Oxford Textbook of psychiatry, 276 00:33:11,180 --> 00:33:22,070 which is an excellent resource for understanding anxiety disorders with more depth and looking into the management of these conditions. 277 00:33:22,070 --> 00:33:30,840 Otherwise, the Royal College of Psychiatry website has some interesting and helpful information leaflets. 278 00:33:30,840 --> 00:33:34,440 Lovely. Thank you very much. Goodbye.