ÖVERSIKT ÅNGESTSYNDROM

ÖVERSIKT ÅNGESTSYNDROM K L A S S I S K A Å N G E S T S T Ö R N I N G A R O C D P T S D T O R D I V A R S S O N D O C E N T, Ö V E R L Ä K A R E ÅNGESTSYNDROM I Ångestsyndrom Affekter/känslor Kognition/tankar/föreställningar Beteende Rädsla Ångestens fenomenologi Rädslans neurobiologi Bara rädsla? Samsjuklighet Kort om etiologi DSM V 1

MÄNNISKANS AFFEKTER klassiska" omgivningsrelaterade stimuli Glädje/kärlek Vrede/ilska Rädsla Avsky/äckel Förvåning? "Homeostatiska inre miljön Ledsenhet/sorg hunger, törst och trötthet VAD ÄR RÄDSLA? Rädsla - en emotion inducerad av Upfattat hot inbyggda respons orkestreras av Amygdala Fly/gömma sig Fight Freeze/paralys vid extrem skräck (se ex. D-anknytning) Vad är ängslan/ångest? Induceras utan klart eller omedelbart yttre hot Kan induceras av egna tankar, sensationer 2

MEDFÖDDA EMOTIONER ÄR SOCIALA SIGNALER Emotion Rädsla/fruktan Glädje Ledsenhet /sorg Vrede Äckel/avsky förvåning Signal till gruppen Uppmärksamma faran! Delad glädje och delad sorg ökar sammanhållningen i en grupp Signal till motståndaren Signal till andra om otjänlig föda, signal om oacceptabelt beteende Varje emotion kan igenkännas genom egna ansiktsuttryck - evolutionen Okänt fenomen RÄDSLANS OLIKA MOTIV Risk för allt möjligt, inkl. vad man kan göra. Alla + eget beteende OCD Farliga SpF situationer Risk för potentiellt farliga situationer/djur Separation SAD Rädsla/ Oro Dö, sjukdomar PD Risk för livet om barnet kommer från föräldrarna Sociala SoP situationer Social tillhörighet GAD Risk göra bort sig, Skämmas ut visavi gruppen Risk om barnet gjort något så att man riskerar Uteslutas ur gruppen Risk för potentiellt livsfarliga situationer omedelbart begripligt! 3

RÄDSLOR FINNS I TVÅ VARIANTER Alarm rädsla vid akut hotfull situation finns hos flertalet djur Människans system liknar däggdjurens Bekymmer/farhågor om potentiella hot Unikt för människan? En följd av vår förmåga till planering, användning av språkliga och abstrakta begrepp Dessa uttrycks via olika neurobiologiska system RÄDD BEKYMRAD/OROLIG då man konfronteras med en potentiellt farlig situation (S) Alarm i kroppen Höjd vaksamhet Beredskap att Fly Slåss för sitt liv Freeze (d-klass Ankn.) Uthärda utan Amygdala systemet att man i framtiden kommer att konfronteras av ett S att man tidigare gjort något som i framtiden innebär konfrontation med ett S. Svagare version av alarm Älta/grubbla.. undvika Cortico-Striato-Talamo- Corticala loopar 4

ETT SYNDROM INNEFATTAR BÅDA KOMPONENTERNA Två huvudkomponenter vid Ångestsyndrom Affekt Rädsla/ (falskt) alarm Amygdalasyst* Kognition Bekymmer/farhågor Antecipatorisk oro CSTC-loopar Kognition Baciller (ex.) Social missl. Separationer Social skam Typ av Utlösande Situationer Andra Symptom Toa-knopp Handtag Handtvätt tvivel, överdrivet ansvar Prestera vard. interaktion m kamr. Magont Sömn, spänd, Irritabel, LF Skoldags Barnvakt HV, Utbrott, vädja, HV, magont Sömn, ensam Tala i klassen Tala m främling Undvika, HV, magont, utbrott SDR OCD* GAD Fritt fr. Stahl (2008), *lägre Amygdalarespons Britton (2010) SAD Klassiska å-sdr SocAnx BARA RÄDSLA/ORO-BEKYMMER? Symmetri Kännas rätt Äckel/ Avsky Förlora/ Behöva OCD Specifik Fobi Separation Rädsla/ Oro Panik/ PTSD Social Fobi GAD Vid OCD kan alla motiv/känslor man finner vid andra ångeststörningar likväl som egna dito finnas, både sida vid sida med klassiska OCDmotiv och som enda symptom ex. hoarding*, arrangerare mm. * Egen störning i DSM 5 5

ÄCKEL/AVSKY Skydd mot fara förknippad med dåliga livsmedel/föda, kroppsvätskor indikerande sjukdom, Djur som spindlar m.fl Affekt även i sociala situationer SocAnx och skam - andra reagera med avsky (attention bias test) Habituering trögare/långsammare? ETT DISTINKT NEUROBIOLOGISKT SYSTEM FÖR ÄCKEL/AVSKY Insula är involverad i emotionen äckel/avsky (disgust) Hos människor och macaquer Insula aktiveras av obehagliga lukter, smaker och av att man ser äckel/avsky avspeglas hos andra personer/ macaquer Främre insula är centrum för lukter och smaker som också kontrollerar viscerala sensationer med till dem relaterade autonoma respons får syninformation från främre delen av ventrala/superiora temporalbarken celler som reagerar på åsynen av ansikten Insula ingår i en krets med putamen ochthalamus (Förväntansångest via Amygdala vid befarad kontakt) Wikepedia, 2013-08-08, (Husted m.fl. (2006) 6

PATOGENES UTVECKLINGSVÄGAR Miljö/anknytning; skola mm Genetik Coping och neurobiologi Amygdala Färdigheter CSTCkretsar* Syndrom GAD OCD Sep Anx Soc Anx Minnesotastudien Warren (1997) Carlson (1998) Shamir-Essakow (2004, 2005) Genetik Sakolsky (2012) Endofenotyp Pine (2007) Pittenger (2011) m. fl. Vad avgör vilket sdr som utvecklas? * OFC-S-T-OFC (målinriktade beteenden); DLPFC-S-T-DLPFC (exekutiva fkt); Insula-S-T-Insula (äckel/avsky) PREVALENS ÅNGESTSTÖRNINGAR I B&U ÅREN 12-Mån Prevalens hos barn: 3.7% - 8.9% (Costello, 1988, 1996.; Ford, 2003.) 6-Mån Prevalens hos tonåringar: 8.7% - 17% (Kashani & Orvaschel, 1988.) Livstidsprevalens hos vuxna: 15% - 25% (Epidemiologic Catchment Area (ECA) and National Comorbidity Study) 14 7

PREVALENS AV ÅNGESTSTÖRNINGAR HOS BARN OCH UNGDOMAR Ångeststörning Barn Tonår Separationsångeststörning 3.5-4.7% 0.7-2.0% Överängslig (GAD) 2.9-4.6% 5.9-7.3% Social Fobi / Undvikande 0.9-1.6% 1.1%+ Specifik Fobi 2.4-9.2% 3.6-4.6% Panikstörning <1% 0.6-4.7% OCD (Pojkar>flickor) 0.1 0.25% 0.5 1.0-1.9%* (Bird, 1988. N=777, age 4-11; Costello, 1988. N=789, age 7-11; Anderson, 1987. N=792, age 11; McGee, 1990. N=962, age 15; Kashani, 1988. N=150, age 14-16); Heyman, 2001, Flament, 1088 15 ÅLDER OCH OCD 0.5% Genomsnittlig prevalens Heyman, 2001 8

ÅNGESTSYNDROM DEBUTERAR TIDIGT Besesdo, 2010 HÄLFTEN AV VUXNA MED ÅNGESTSYNDROM DEBUTERAR I B&U- ÅREN Besesdo, 2010 9

ÅNGESTSTÖRNINGAR Hög grad av samsjuklighet Ångestsyndrom Ångestsyndrom Ångestsyndrom Affektiva syndrom Ångestsyndrom Andra syndrom - ADHD, tics/ts, ASD,. - missbruk, ODD/CD, BP,.. Samma behandlingsprinciper verksamma vid syndromen Psykoterapi: Exponering Psykofarmakologi: Serotoninaktiva LM SAMSJUKLIGHET VID KLASSISKA Å- SYNDROMEN Anx.Dis. % SAD 3.3 SoP 11.3 GAD 6.8 SAD+SoP 6.8 SAD+GAD 8.0 SoP+GAD 28.1 SAD+SoP+GAD 35.9 >1 Anx 78,8 Andra Störn % Annan Internaliserande* 43.6 ADHD 11.9 ODD/CD 9.4 Tic dis. 2,7 *Observera! Andra anx disorder (SpecFobi, OCD, PTSD och dystymi) Så liten andel OCD att ej specats Data från CAMS (2008) 10

MAN LEVER INTE BARA MED ÅNGESTEN Låg självaktning och förtroende kamratproblem, Skolsvårigheter Samsjuklighet med affektiva- och beteendeproblem Mer kroppsliga sjukdomar Mer somatiska symptom correlerar med starkare ångest och nedsatt funktionsförmåga Messer 1994, Lalongo 1994, 1995, Anderson 1087, McGee 1990, Brady 1992 Långtidsprognosen vid ångestsyndrom I B&U-åren Retrospektiva studier visar att obehandlade ångestsyndrom är stabila Keller, 1992.; Biederman, 1997 12 prospektiva studier visade att ångest i barndomsåren ökar risken utveckla ett ångestsyndrom senare under barndomen I adolescensen Eller I vuxenåren Last, 1996.; Costello, 2003.; Kim-Cohen, 2003.; Gregory, 2007 Homotypic liksom heterotypic kontinuitet 11

ÅNGESTSYNDROMENS FÖRLOPP Återfall är vanliga i kliniska samples: 4-5-års follow-up (f/u) (Cantwell, 1989. n=31): 77% hade inte den ursprungliga ångeststörningen 65% ny störning 30% ny ångestdiagnos (dx) 3-4-års f/u (Last, 1996. n=84): 82% hade inte den ursprungliga ångeststörningen 30% ny störning 16% ny ångest dx 12-års f/u (Weissman, 1999. n=44): 45% major depressive disorder 30% anxiety dx GILLE DE LA TOURETTES SYNDROM (TS) 12

KLASSIFIKATION AV TICS Övergående < 12 mån varaktighet (4-16 % av alla barn) Kroniskt > 12 mån varaktighet (ca 1,5 % av befolkningen) kroniska enkla tics kroniska multipla eller vokala tics Tourettes syndrom Ospecificerat ticssyndrom SYMPTOMVARIATION Debutålder (genomsnittlig): 6 år (2-15 år) Symptomen varierar i intensitet: skurar av skurar av skurar av tics ålder med värsta symptom 10-11 år Förbättring under tonår 13

ÅNGEST MM I DSM 5 S N AB B A B I L D E R. ÅNGESTSYNDROM I DSM 5 F93 Separation Anxiety Disorder* F94 Selective mutism F40xx Specific Phobia F40.10 Social Anxiety Disorder (Social Phobia)* F41 Panic Disorder F40.00 Agoraphobia F41.1 Generalized Anxiety Disorder* F10-19 Substance-Induced Anxiety Disorder F06.4 Anxiety Disorder Attributable to Another Medical Condition F41.8 Other Specified Anxiety Disorder F41.9 Anxiety Disorder Not Elsewhere Classified * De klassiska ångestsyndromen i B&U-åren 14

OCD I DSM 5 F 00 Obsessive-Compulsive Disorder F 01 Body Dysmorphic Disorder F 02 Hoarding Disorder F 03 Hair-Pulling Disorder (Trichotillomania) F 04 Skin Picking Disorder F 05-06 Substance-Induced Obsessive-Compulsive or Related Disorders F 07 Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition F 08 Obsessive-Compulsive or Related Disorder Not Elsewhere Classified SEPARATION ANXIETY DISORDER Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures 2. persistent and excessive worry about losing major attachment figures or possible harm to them, such as illness, injury, disasters, or death. 3. persistent and excessive worry about events that could lead to separation from a major attachment figure (e.g., getting lost, being kidnapped, having an accident, dying) 4. persistent reluctance or refusal to go out, away from home, to school, work, or elsewhere because of fear of separation 5. persistent and excessive fear or reluctance about being alone or without major attachment figures at home or in other settings 15

SEPARATION ANXIETY DISORDER 6. persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure 7. repeated nightmares involving the theme of separation 8. repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, or vomiting) when anticipating or experiencing separation from major attachment figures The fear, anxiety or avoidance is persistent, typically lasting six or more months. Note: A shorter duration is appropriate in cases of acute onset or exacerbation of severe symptoms (e.g. school refusal or complete inability to separate from home or attachment figures). The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. The disturbance is not better accounted for by OBS! punkterna 5-6 = undvikande SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny* by others. Examples include social interactions (e.g., having a conversation), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech). The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (e.g., be humiliated, embarrassed, or rejected) or will offend others. The social situation(s) almost always provoke fear or anxiety. (Note: in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations.) The social situation(s) are actively avoided or endured with marked fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by the social situation. (Note: Out of proportion refers to the sociocultural context.) *avsky i AR 16

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) The fear, anxiety, or avoidance is persistent, typically lasting six or more months The fear, anxiety, and avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The disturbance is not better accounted for by another.. Specify if: Selective Mutism: Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations Kristensen, H.: tör ikke eller kan icke? GENERALIZED ANXIETY DISORDER (GAD) A. Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (e.g., family, health, finances, and school/work difficulties, *). B. The excessive anxiety and worry occurs on more days than not, for 3 months or more C. The anxiety and worry are associated with one or more of the following symptoms: 1. restlessness or feeling keyed up or on edge 2. muscle tension D. The anxiety and worry are associated with one (or more) of the following behaviors: (nästa OH) I B&U åren handlar bekymren ofta om kamratrelationer 17

GENERALIZED ANXIETY DISORDER (GAD) 1. marked avoidance of activities or events with possible negative outcomes 2. marked time and effort preparing for activities or events with possible negative outcomes 3. marked procrastination in behavior or decision-making due to worries 4. repeatedly seeking reassurance due to worries E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). G. The disturbance is not better accounted for by. PANIKSYNDROM A. Recurrent unexpected panic attacks B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional Panic Attacks or their consequences (e.g., losing control, having a heart attack, "going crazy") 2. Significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having Panic Attacks, such as avoidance of exercise or unfamiliar situations) C. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better accounted for by another. 18

OBSESSIVE-COMPULSIVE DISORDER A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety or distress The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion) Compulsions are defined by (1) and (2): Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive OBSESSIVE-COMPULSIVE DISORDER Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts B. The obsessions or compulsions are time-consuming (for example, take more than 1 hour a day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. 19

OBSESSIVE-COMPULSIVE DISORDER D. The content of the obsessions or compulsions is not better accounted for by the symptoms of another DSM-5 disorder. (e.g., excessive worries in Generalized Anxiety Disorder; ritualized eating behavior in an Eating Disorder; hair pulling in Hair Pulling Disorder(Trichotillomania), skin picking in Skin Picking Disorder; stereotypies in Stereotypic Movement Disorder; preoccupation with appearance in Body Dysmorphic Disorder; preoccupations with objects in Hoarding Disorder; preoccupation with substances or gambling in Substance Use and Related Disorders; preoccupation with serious illness in Illness Anxiety Disorder; preoccupation with sexual urges or fantasies in a Paraphilia; preoccupation with impulses in Impulse Control Disorders; guilty ruminations in Major Depressive Disorder; thought insertion or delusional preoccupations in a Psychotic Disorder; or repetitive patterns of behavior in Autism Spectrum Disorder). Bejerot,S.: Psykiatrins kameleont OBSESSIVE-COMPULSIVE DISORDER Indicate whether OCD beliefs are currently characterized by: Good or fair insight: The individual recognizes that OCD beliefs are definitely or probably not true, or that they may or may not be true Poor insight: The individual thinks OCD beliefs are probably true Absent insight: The individual is completely convinced OCD beliefs are true Specify if: Tic-related OCD: The individual has a lifetime history of a chronic tic disorder 20

OBSESSIONER OCH KOMPULSIONER Kontamination Oro att skada/bli skadad Somatisk sjd/fel på kroppen Sexualitet Skrupulositet/handla rätt/göra fel mot Gud Siffror/magi/skrock Symmetri / Exakthet Förlora/tappa (Hoarding) Rengöra/tvätta Kontrollera Räkna Försäkringsritualer Mentala rit (böner/mottanke) Magiska handlingar Upprepa Ordna / Arrangera Balansera /Utjämna Beröra Samla/Spara (Hoarding) TRAUMA- AND STRESSOR-RELATED DISORDERS I DSM 5 F94.1 Reactive Attachment disorder F94.2 Disinhibited Social Engagement disorder F43.10 Posttraumatic Stress Disorder nu med avsnitt om barn <= 6 år F43.0 Acute Stress disorder F43.20-25 Adjustment Disorders F43.8 Other Specified Trauma and/or Stressor-related disorder F43.9 Unspecified Trauma and/or Stressor-related disorder 21

AKUT STRESSYNDROM Exposure to actual or threatened: a) death, b.) serious injury, c.) sexual violation, in one or more of the following ways: 1. directly experiencing the traumatic event(s) 2. witnessing, in person, the event(s) as they occurred to others 3. learning that the event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental 4. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). (Note: this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related). Presence of nine (or more) of the following symptoms in any of the four categories of intrusion, dissociation, avoidance, and arousal, beginning or worsening after the traumatic events occurred PTSD Note: The following criteria apply to adults, adolescents, and children older than six. A. Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways: 1. directly experiencing the traumatic event(s) 2. witnessing, in person, the traumatic event(s) as they occurred to others 3. learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental 4. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:. 22

PTSD FÖRSKOLEBARN A. In children (less than age 6 years), exposure to one or more of the following events: death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: 1. directly experiencing the event(s) 2. witnessing, in person, the event(s) as they occurred to others, especially primary caregivers (Note: Witnessing does not include events that are witnessed only in electronic media, television, movies or pictures.) 3. learning that the traumatic event(s) occurred to a parent or caregiving figure; B. Presence of one or more intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: PTSD FÖRSKOLEBARN B. Presence of one or more intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. recurrent distressing dreams in which the content and/or affect of the dream is related to the traumatic event(s).. 3. dissociative reactions in which the child feels or acts as if the traumatic event(s) were recurring. 4. intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 5. marked physiological reactions to reminders of the traumatic event(s). 23

PTSD FÖRSKOLEBARN One item from criterion C or D below: C. Persistent avoidance of stimuli associated with the traumatic event 1. activities, places, or physical reminders that arouse recollections of the traumatic event 2. people, conversations, or interpersonal situations that arouse recollections of the traumatic event. D. Negative alterations in cognitions and mood associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by one or more of the following: 1. markedly diminished interest or participation in significant activities, including constriction of play 2. socially withdrawn behavior 3. persistent reduction in expression of positive emotions E. Alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by two or more of the following.. MM ÅNGEST FINNS VID MÅNGA SYNDROM I DSM 5 Somatic Symptom Disorders Somatic Symptom Disorder Illness Anxiety Disorder Egentlig depression Morgonångest ASD/ADHD Livet blir oförutsägbart, mycket intryck 24

TICS/TOURETTE I DSM 5 TACK FÖR UPPMÄRKSAMHETEN! 25