Panic disorder

Of themselves, panic attacks carry no diagnostic specificity, and many people have them during their lives. Sometimes, they are an indicator of an underlying physical problem, and these need to be investigated where appropriate (see Box 8.1).

If panic attacks occur habitually, with no clear organic cause and no particular predictable precipitant, a diagnosis of panic disorder should be considered. The panics themselves are often associated with interpanic anxiety, mostly relating to the thought of having another attack. Even if there is no clear precipitant, avoidance behaviour might ensue, particularly of situations in which the person considers their risk of another panic to be high. Classically, people find their home environment the most reassuring, and can become essentially housebound. The exception is those individuals who tend to wake from sleep in the throes of a panic attack.

Treatment includes psychoeducation, breathing retraining, and, where indicated, formal cognitive therapy. Medications that are most effective include the selective serotonin reuptake inhibitors (SSRIs), though the initial energising effects can be bothersome and, therefore, starting at a low dose is sensible. Benzodiazepines are sometimes resorted to in order to attenuate an acute attack, and can be very effective, though the message can be a disempowering one for the patient and benzodiazepines can become something of a ‘crutch’ for the individual.

Phobic disorders

Once anxiety becomes linked to a certain situation or thing and results in avoidance thereof to the extent that this impedes everyday life, the individual should be considered to have a phobic disorder. The important thing here is that therapeutically, if avoidance is demonstrated, then the psychological technique of exposure/response prevention (EX/RP) can be employed. Essentially, this involves mapping the behaviours, fears and avoidances, and helping the patient tackle their fears in a structured hierarchical way (i.e. starting with something relatively easy, conquering that, then moving to the next step). An analogy is engaging in a step-wise exercise program, with the clinician as the coach.

Specific phobia is common, but does not usually come to medical attention. There is fear and avoidance of any or a combination of myriad objects or situations: spiders and snakes often feature, probably due to inherent evolutionary preconditioning. Treatment is EX/RP.

Agoraphobia (literally ‘fear of the market place’) is characterised by fear of situations where the individual feels trapped. These include busy supermarkets, heavy traffic and public transport; open spaces are also often feared and avoided, and home is seen as ‘safe’, resulting in the ‘housebound housewife’. DSM–IVTR links agoraphobia specifically among the phobic disorders, with panic disorder, though panic can actually occur with any of the phobic disorders. More often than not, agoraphobia begins with a panic attack in an agoraphobic situation, resulting in withdrawal from the situation and subsequent avoidance. Technically, agoraphobia can occur without panics, but this is usually seen in those patients who habitually avoid the situations in which they might panic. Treatment is psychoeducation, EX/RP, and, if required, SSRIs or serotonergic and noradrenergic reuptake inhibitors (SNRIs). In general, medications should be used in the anxiety disorders if the features in Box 8.3 pertain.

Social anxiety disorder (SAD) is now a well-established disorder, despite initial cynicism that it was merely a pathologising of normal shyness. People with SAD are significantly impaired by their disorder, which often begins in the teens and thus impacts on the normal social developmental trajectory. There are two main forms:

Treatment includes cognitive behaviour therapy (CBT), especially dealing with the core negative cognition of making a fool of oneself in front of others, and an hierarchical approach to the behavioural avoidance: group treatment can be particularly useful. SSRIs and SNRIs are useful adjuncts, with the general guidance shown in Box 8.3.

Blood-injury phobia is unique among the phobic disorders in that the physiological response to the sight of blood is a vaso-vagal one, with profound hypotension and fainting. Of interest too is that it seems to be strongly genetic, with an autosomal dominant pattern having been shown in some families. Treatment is complex, but CBT techniques can be applied with modifications to encompass the vaso-vagal response to the ‘exposure’.

Generalised anxiety disorder (GAD)

Generalised anxiety disorder (GAD) has become something of a residual diagnosis, being effectively ‘trumped’ by panic disorder. There is considerable comorbidity with depression, and some researchers consider it should be subsumed under the affective disorders. However, a clinical syndrome with predominant ‘free floating’ anxiety is certainly seen in practice. Female predominant, GAD usually begins insidiously, even seeming to grow out of an anxious personality structure. Symptoms include anxiety about just about everything, including what might or might not happen. Many patients with GAD also focus on their physical health, with a strong tendency to somatise and present to doctors with physical symptoms (see Ch 11). Muscle tension, headaches and abdominal discomfort are common. Sleep is often restless and unrefreshing.

Treatment includes psychoeducation and in particular teaching relaxation techniques. Problem solving is useful: the patient is taught about prioritising important tasks and tackling them in a paced manner, rather than being so overwhelmed by everything that nothing is achieved. More formal CBT can be usefully employed, with a focus on challenging catastrophic thinking and modifying associated un-useful behaviours, such as doctor-shopping or benzodiazepine abuse. SSRIs and SNRIs are a useful adjunct, particularly in the face of mood disturbance.

Post-traumatic syndromes

Interindividual variation in response to trauma has been noted for centuries, and it is remarkable how some people can deal with what seems to others to be horrific trauma, with equanimity, while others can be severely incapacitated by exposure to what might objectively seem ‘trivial’. Thus, trauma is in part in the eye of the beholder, and the subjective view of it is critical. Specifically, if the trauma is perceived as potentially life-threatening or likely to cause physical harm and injury, then it is more likely to cause post-traumatic stress disorder (PTSD). Apart from the trauma itself, the main risk factor for a pathological post-traumatic syndrome is the make-up of the individual, both in terms of past psychiatric problems and past experience of and response to trauma.

The course of symptoms can be perturbed to some extent by legal issues such as compensation, but the notion of a compensation neurosis, where symptoms resolve once compensation is settled, has been largely scotched.

Acute stress disorder shares many features with PTSD (see below), but by definition occurs from 2 days to 1 month following a traumatic event. Dissociative symptoms (e.g. depersonalisation, detachment, dissociative amnesia) are given particular prominence.

A diagnosis of PTSD is made if symptoms persist (for at least a month in DSM–IVTR). The classic triad is:

hyperarousal, with symptoms akin to GAD, and including an exaggerated startle response

avoidance of places or things associated with the event, and triggering of symptoms in response to reminders of the event; and emotional numbing, or detachment from others and the world around one, and

reliving experiences, including nightmares and flashbacks regarding the event.

Arguably, it is this last set of symptoms that sets PTSD apart from other psychiatric disorders.

Comorbidities are common, and include depression, and benzodiazepine, alcohol and illicit substance abuse. Chronic pain syndromes, following injury sustained during the event, can lead to (prescribed) opiate addiction. Loss of physical integrity, of work capacity and of role can compound matters.

Treatment of PTSD is complex, and needs to encompass all facets of the disorder, and also address, where indicated, comorbid substance use, depression and pain syndromes. Specific approaches include a variety of psychological treatments, including CBT and EX/RP. Group therapy can be particularly useful in terms of mutual support from group members, and the other benefits of the group process, as outlined in Chapter 14. SSRIs and SNRIs are commonly prescribed for anxiety and depressive symptomatology. Hypnotics or low dose atypical antipsychotics (see Ch 13) can assist sleep. Benzodiazepines are best avoided apart from initial short-term use.

A particularly contentious issue is that of debriefing following traumatic events, as a prophylactic measure. The weight of evidence is that this should not be done on a universal basis, but the offer of general support and the opportunity to ventilate feelings about the event are seen as helpful.