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Introduction

A personality disorder is defined, in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition (DSM-IV), as an enduring pattern of inner experience and behaviour that differs markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances.

The International Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organization 1992), defines a personality disorder as: a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerable personal and social disruption.

The aetiology of personality disorders remains obscure. Traditional belief is that these behaviours result from a dysfunctional early environment that prevents the evolution of adaptive patterns of perception, response and defence.

Factors in childhood which are postulated to be linked to personality disorder include:[1]
•Sexual abuse
•Physical abuse
•Emotional abuse
•Neglect
•Being bullied

Emotional or behavioural factors that might play a part include:
•Truanting
•Bullying others
•Being expelled/suspended
•Running away from home
•Deliberate self-harm
•Prolonged periods of misery

The evidence base supporting a link between personality disorder and genetic factors is growing.[2]

People with personality disorders are at increased risk for many psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. Patients with depression and personality disorder have a more persistent condition than those who have depression alone.[3] Some types of mental illnesses are more specific to particular personality disorders.

It is unsurprising from the above that many people with personality disorders offend against the law.[1]

Classification[4]

The ICD-10 gives nine categories of personality disorder. In DSM-IV there are ten personality disorders that are divided into three clusters, designated A, B, C. They will be used here.

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Cluster A

Paranoid personality disorder may present as a prodrome to delusional disorder or frank schizophrenia. There is risk of agoraphobia, major depression, obsessive-compulsive personality disorder and substance abuse. Schizoid personality disorder may precede major depression. Patients with schizotypal personality disorder may develop a brief psychotic disorder, schizophreniform disorder, or delusional disorder. When diagnosed, between 30 and 50% already have major depression and most have a history of at least one major depressive episode.

Schizoid personality disorder has a slight male preponderance.

Cluster B

Antisocial personality disorder increases the risk for anxiety disorders, substance abuse, somatisation disorder and pathological gambling. Borderline personality disorder is associated with substance abuse, eating disorders (particularly bulimia) and post-traumatic stress disorder (PTSD). Suicide is a high risk in borderline patients. Histrionic personality disorder is often associated with somatoform disorders. Narcissistic personality disorder increases risk for anorexia nervosa and substance abuse as well as depression.

Antisocial personality disorder is three times more frequent in men than in women. Borderline personality disorder is three times as common in women as in men. Men account for 50% to 75% of people with narcissistic personality disorder.

Cluster C

Avoidant personality disorder is associated with anxiety disorders, especially social phobia. Dependent personality disorder increases risk for anxiety disorders and adjustment disorder. People with obsessive-compulsive personality disorder may be more liable to myocardial infarction because of their type A lifestyles. They may also be at risk for anxiety disorders. Obsessive-compulsive personality disorder occurs twice as often in men as in women.

The DSM-IV classification has been criticised for having too many personality disorders and there being a considerable overlap between them. DSM-V, due for publication before the end of 2013, is likely to reduce the number from ten to five.[1]

Epidemiology[4]

Studies estimate that personality disorder affects 4-11% of the UK population and between 60-70% of the prison population. This is so common as to be almost a variation of normal rather than pathological. Many of the features we can possibly recognise in ourselves or others but, often, several features are required to make a diagnosis. In the prison population there are probably comparatively few who do not have at least one of personality disorder, mental illness, learning difficulties and substance abuse. International figures must be viewed with caution as the diagnosis is highly dependent upon culture. Figures for prevalence in American society are as follows:[4]
•Paranoid personality disorder – 0.5%-2.5%.
•Schizotypal personality disorder – 3%.
•Antisocial personality disorder – 3% of men, 1% of women.
•Borderline personality disorder – 2%.
•Histrionic personality disorder – 2%-3%.
•Narcissistic personality disorder – less than 1%.
•Avoidant personality disorder – 0.5%-1%.
•Obsessive-compulsive personality disorder – 1%.

There is no genetic difference in incidence.[2]

Personality disorders should not normally be diagnosed in children and adolescents because the development of personality is incomplete and symptomatic traits may not persist into adulthood. The general guideline is that the diagnosis is unsafe until the person is at least 18 years old. The criteria for diagnosis under DSM-IV are closely related to behaviours of young and middle adulthood. Hence, they are unreliable in the elderly.[4]

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Presentation[4]

Personality disorders present with a wide range of problems in social relationships and regulation of mood. Such individuals have usually been like it throughout their adult lives. The patterns of perception, thought and response are fixed and inflexible, although their behaviour is often unpredictable. These patterns do not adhere to their own culture’s expectations. To meet the DSM-IV criteria for clinical diagnosis, the pattern must produce clinically significant distress or impairment in social, occupational or other important areas of functioning. The disorder occurs in all settings, social as well as work, and it is not limited to one sphere of activity.

Cluster A

They tend to be odd or eccentric:
Paranoid personality disorder They display pervasive distrust and suspicion. Common beliefs include:
•Others are exploiting or deceiving them.
•Friends and associates are untrustworthy.
•Information confided to others will be used maliciously.
•There is hidden meaning in remarks or events others perceive as benign.
•The spouse or partner is unfaithful. Pathological jealousy is sometimes called the Othello syndrome.

Schizoid personality disorder This type of personality disorder is less common in clinical settings:
•They are detached from others and have little desire for close relationships.
•There is little pleasure in activities.
•They appear indifferent to praise or criticism and often seem cold or aloof.

Schizotypal personality disorder They show marked eccentricities of thought, perception and behaviour. Typical examples include:
•Ideas of reference (believing that public messages are directed personally at them).
•Odd beliefs or magical thinking.
•Vague, circumstantial, or stereotyped speech.
•Excessive social anxiety that does not diminish with familiarity.
•Idiosyncratic perceptual experiences or bodily illusions.

Cluster B

They tend to be dramatic and emotional:

Antisocial personality disorder See separate article Antisocial Personality Disorder and National Institute for Health and Clinical Excellence (NICE) guidance.[5] People with antisocial personality disorder have a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Onset must occur by age 15 years.

Borderline personality disorder See separate article Borderline Personality Disorder and NICE guidance.[6] The important feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception and moods. Impulses are poorly controlled. At times they may appear psychotic because of the intensity of their distortions. It is a commonly overused diagnosis in DSM-IV.

Histrionic personality disorder
•They also display excessive emotion and attention-seeking behaviour.
•They are quite dramatic and often sexually provocative or seductive.
•Their emotions are labile.
•In clinical settings, their tendency to vague and impressionistic speech is often apparent.

Narcissistic personality disorder Narcissistic patients are grandiose and require admiration from others.[7] Features include:
•Exaggeration of their own abilities or achievements.
•Sense of entitlement.
•Exploitation of others.
•Lack of empathy.
•Envy of others.
•An arrogant, haughty attitude.

Cluster C

They tend to be anxious and fearful:

Avoidant personality disorder
•They are generally very shy.
•There is a pattern of social inhibition, feelings of inadequacy and hypersensitivity to rejection.
•Unlike patients with schizoid personality disorder, they do desire relationships but are paralysed, by their fear and sensitivity, into social isolation.

Dependent personality disorder Many people exhibit dependent behaviours and traits but people with dependent personality disorder have an excessive need to be cared for and that results in submissive and clinging behaviour, regardless of consequences. Diagnosis requires at least five of the following features:
•Difficulty making decisions without guidance and reassurance.
•Need for others to assume responsibility for most major areas of the person’s life.
•Difficulty expressing disagreement with others.
•Difficulty initiating activities because of lack of confidence.
•Excessive measures to obtain nurture and support.
•Discomfort or helplessness when alone.
•Urgent seeking for another relationship when one has ended.
•Unrealistic preoccupation with fears of being left to self-fend.

Obsessive-compulsive personality disorder
•People with obsessive-compulsive personality disorder are markedly preoccupied with orderliness, perfectionism and control.
•They lack flexibility or openness.
•Their preoccupations interfere with efficient function despite their focus on tasks.
•They are often scrupulous and inflexible about matters of morality, ethics and values, to a point beyond cultural norms.
•They are often ‘stingy’ as well as stubborn.

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Associated features[4]

Physical findings

There are no physical abnormalities to help diagnose personality disorders but there may be findings related to the consequences of various personality disorders.
•Those especially with cluster B disorders, may show signs of intentional self-harm or stigmata of substance abuse. There may be scars from self-inflicted wounds.
•Substance abuse is common and may present the physical stigmata of alcoholism or drug abuse.

Mental status
•Patients with histrionic personality disorder may display ‘la belle indifférence’, a seemingly indifferent detachment, while describing dramatic physical symptoms.
•A hostile attitude is typical of patients with antisocial personality disorder.
•Patients with cluster B personality disorders, particularly borderline personality disorder, frequently display affective lability.
•Patients with paranoid personality disorder voice persecutory ideation without the formal thought disorder observed in schizophrenia.
•Patients with schizotypal personality disorder speak with odd or idiosyncratic use of language.

Investigations[4]

Psychological testing may support or direct the clinical diagnosis.
•The Minnesota Multiphasic Personality Inventory (MMPI) is the best-known psychological test.
•The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are also used.
•The Structured Clinical Interview for DSM-IV for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.

None of these has been reliably validated against DSM-IV diagnoses.

Management[5][6]

General approach

NICE has published guidance on the treatment, management and prevention of antisocial personality disorder and borderline personality disorder. It is clear from this guidance that improvements in the care of such patients are expected and that better collaboration, communication and training are required to achieve this improved care. Such an approach can be applied to management of all the personality disorders. A key element in this guidance is the call for better inter-agency communication and collaboration. The treatment of people with antisocial personality disorder must involve a wide range of services, including particularly:
•Mental health services
•Substance misuse services
•Social care
•The criminal justice system

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Psychotherapy

It used to be taught that psychopaths and personality disorders were untreatable. Psychotherapy is the basis of care for personality disorders. Personality disorders produce symptoms as a result of poor or limited coping skills. Therefore, psychotherapy aims to improve perceptions of and responses to social and environmental triggers.[6][8]
•Psychodynamic psychotherapy examines the ways that events are perceived. It states that perceptions are shaped by experiences in early life and therapy aims to identify perceptual distortions and their origin and to facilitate the development of more adaptive modes of perception and response. Treatment is usually prolonged over a course of several years at intervals from several times a week to once a month. It uses transference.
•Cognitive and behavioural therapy (CBT) suggests that cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events. It explores how people think about their world and their perception of it. It is a very active form of therapy that identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviours. This therapy is usually limited to episodes of 6 to 20 weeks at intervals of once a week. For personality disorders, therapy is repeated often over the course of years.
•Interpersonal therapy (IPT) assumes that difficulties result from a limited range of interpersonal problems, including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6 to 20 sessions. It is used mostly for anxiety and depression and is not widely practised.
•Group psychotherapy allows interpersonal problems to be displayed among a peer group, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication and behaviour. Sessions are usually once weekly over a course that may range from several months to years. The technique enables several people to be treated simultaneously, reducing cost per patient.
•Dialectical behavioural therapy (DBT) is a skills-based therapy that can be used in both individual and group formats. It has been applied to borderline personality disorder. The emphasis is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behaviour. This treatment is also being used with other cluster B personality disorders, to reduce impulsive behaviour.

Pharmacotherapy

Drugs do not cure personality disorders but they may be useful as an adjunct so that the patient may productively engage in psychotherapy. The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation and impulsive-behavioural dyscontrol. Such symptoms may complicate almost all personality disorders to some degree but all of them have been noted in borderline personality disorder.
•A Cochrane systematic review found that mood stabilisers and second-generation antipsychotics may be helpful for specific symptoms in borderline personality disorder but that pharmacotherapy did not affect the overall severity of the condition.[9]
•As the depression of most patients with personality disorders stems from their limited range of ability to cope, antidepressants are usually less effective than in patients with uncomplicated major depression.
•Anticonvulsants help to stabilise the affective extremes in patients with bipolar disorder but are less effective for that purpose in patients with personality disorders. They have some benefit in suppressing impulsive and particularly aggressive behaviour in patients with personality disorder.
•Some personality disorders, especially borderline personality disorder, produce transient psychotic periods, while others such as schizotypal personality disorder show chronic idiosyncratic ideation bordering on psychosis. Response to antipsychotics is less dramatic than in true psychotic disorders but symptoms such as anxiety, hostility and sensitivity to rejection may be reduced. Antipsychotics are normally used for a short period while the symptoms are active. The atypical antipsychotics have almost completely replaced the older neuroleptics because of their margin of safety but neurological side-effects including tardive dyskinesia and neuroleptic malignant syndrome do sometimes occur. Risperidone and olanzapine are often used and sometimes quetiapine and ziprasidone. There is no evidence of superior efficacy of any product and each one may have advantages and disadvantages of adverse effects.
•Benzodiazepines, opiates and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders show impaired impulse control and consequent risk of addiction.

Crisis management

Crisis management: consult the patient’s crisis plan (a plan devised to identify trigger factors, advise on self-help strategies and identify when the individual should seek professional help). •Assess problem and risk: •Maintain a calm and non-threatening attitude.
•Try to understand the crisis from the person’s point of view.
•Explore the person’s reasons for distress.
•Use empathetic open questioning, including validating statements, to identify the onset and the course of the current problems.
•Seek to stimulate reflection about solutions.
•Avoid minimising the person’s stated reasons for the crisis.
•Wait for full clarification of the problems before offering solutions.
•Explore other options before considering admission to a crisis unit or inpatient admission.
•Offer appropriate follow-up within a timeframe agreed with the person.
•Assess risk to self or to others.
•Ask about previous episodes and effective management strategies used in the past.
•Help to manage their anxiety by enhancing coping skills and helping them to focus on the current problems.
•Encourage them to identify manageable changes that will enable them to deal with the current problems.
•Offer a follow-up appointment at an agreed time.

•Refer in crisis to the community mental health services, especially when: •Levels of distress and/or the risk of harm to self or to others are increasing.
•Levels of distress and/or the risk of harm to self or to others have not subsided despite attempts to reduce anxiety and improve coping skills.
•Patients request further help from specialist services.

Complications

The following may occur more often than expected:
•Suicide.
•Substance abuse (including alcoholism).
•Accidents and injuries.
•Depression.
•Homicide.

Frequent enquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject.[10] There is no risk of implanting the idea of suicide in a patient who is not already considering it. Enquiry about drugs and other available means of suicide may help prevention.

Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalisation of blame for psychological distress and impaired impulse control put the children of these patients at risk of neglect or abuse.

Prevention

The NICE guidance puts some emphasis on identification of individuals at risk of developing personality disorders.[5] A variety of interventions are suggested to try to prevent some of the consequences of the personality disorders covered by this guidance. For example, NICE suggests that services should establish robust methods to identify children at risk of developing conduct problems and that vulnerable parents could be identified antenatally – for example, in antisocial personality, by identifying:
•Parents with other mental health problems, or with significant drug or alcohol problems.
•Mothers younger than 18 years, particularly those with a history of maltreatment in childhood.
•Parents with a history of residential care.
•Parents with significant previous or current contact with the criminal justice system.

A wide variety of different interventions is then suggested, ranging from anger management to parenting classes.

Prognosis

It is not uncommon for people with personality disorders to offend against the law and come into contact with the criminal justice system.[1] They are often held to be untreatable. Treatment is prolonged, difficult and far from universally successful. When society is preoccupied with a punitive approach to offenders rather than the rehabilitation of offenders, the result is overcrowded prisons and recidivism amongst offenders. Jack Straw, when he was Home Secretary, wrote that one of the most important steps for the prevention of re-offending was that the person should secure a job. However, most employers enquire about criminal records and hold it against potential employees. The management of those with personality disorders, including those who have run foul of the law, is not easy and success is limited but the stakes are such that it is essential that society make the effort. The guidance from NICE poses challenges to the different agencies involved in the management and care of individuals with personality disorders.[5][6]

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Definition[1]

This is a chronic condition in which there are numerous physical complaints. These complaints can last for years and result in substantial impairment. In the DSM-5 the condition has been renamed somatic symptom disorder (SSD). There are significant departures from the DSM-IV categorisation which identified somatisation disorder, hypochondriasis, pain disorder,and undifferentiated somatoform disorder . All these are now included under the heading of SSD. Another innovation is that the symptoms need no longer to be medically unexplained but may or may not be associated with another medical condition. Thus, patients who had organic comorbidities such as heart disease, osteoarthritis or cancer – who were previously excluded under DSM-IV – can now be included in the diagnosis of SSD and be considered for appropriate treatment.

In the ICD-10, somatisation is defined as multiple, recurrent and frequently changing physical symptoms usually present for several years, (at least two years) before the patient is referred to a psychiatrist. More latterly, the term ‘unexplained somatic complaints’ was introduced ito describe patients presenting with any physical symptom and frequent medical visits in spite of negative investigations. This term is thought to be more acceptable to patients and has fewer aetiological implications.

The DSM-IV diagnosis of somatisation disorder requiring a specific number of complaints from four symptom groups is no longer a requirement in the DSM-5 diagnosis of SSD. Recent literature has used the terms somatisation disorder, somatic symptom disorder, functional somatic syndromes and somatisation syndromes more or less interchangeably. Much of the evidence base relating to somatisation disorder is, however, also relevant to SSD and has been quoted where appropriate.[2]

SSD.can be associated with a great deal of stigma; there is a risk that patients may be dismissed by their physicians as having problems that are ‘all in their head’.

However, as researchers study the connections between the brain, the digestive system and the immune system, SSD is becoming better understood. It should not be seen as a ‘malingering’ condition that the patient can control.

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Aetiology
•Recent research has shown higher percentages of this disorder in people with irritable bowel syndrome and in chronic pain patients.[3][4]
•A high proportion of patients with post-traumatic stress disorder also suffer from somatisation.[5]
•Antisocial personality disorder is associated with a risk for SSD.[6]
•The somatising patient seems to seek the sick role, which affords relief from stressful or impossible interpersonal expectations (‘primary gain’):[7] •In most societies this provides attention, caring and sometimes even monetary reward (‘secondary gain’).
•This is not malingering, because the patient is not aware of the process through which the symptoms arise, cannot will them away and genuinely suffers from the symptoms.

•Several studies have suggested an association between somatisation and a history of sexual or physical abuse in a significant proportion of patients.[8]
•One study reported that patients with somatisation syndromes were often associated with the interpersonal representation of the unmet need for closeness with others.[9]
•Another study suggested that neuroendocrine genes may be implicated.[10] .

Epidemiology
•Information concerning the epidemiology of SSD as strictly defined by DSM-5 is hard to come by, as the umbrella term encompasses several different disorders. Such information as does exist in the literature chiefly relates to the individual disorders identified in DSM-IV.
•Epidemiological studies generally quote a prevalence of 0.1-0.2% for the general population and a figure of 5% has been quoted for general practice.[11] One general practice study reported a prevalence rate of somatoform disorders of 16.1% increasing to 21.9% when disorders with mild impairment were included.[12]
•The disorder usually begins before the age of 30 and occurs more often in women than in men.[13][14]

Presenting features

DSM-5 has reformulated the criteria to rely less on strict patterns of somatic symptoms and more on the degree to which a patient’s thoughts, feelings and behaviours about their symptoms are disproportionate or excessive.[1] The symptoms are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication. A lifelong history of ‘sickliness’ is often present:
•DSM-5 acknowledges that patients may have a combination of symptoms for which an organic cause can be found and symptoms for which there is no underlying physical explanation.
•Stress often worsens the symptoms.

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Symptoms

Some of the numerous symptoms that can occur with somatisation disorder include:
•Cardiac: •Shortness of breath
•Palpitations
•Chest pain

•Gastrointestinal: •Vomiting
•Abdominal pain
•Difficulty swallowing
•Nausea
•Bloating
•Diarrhoea

•Musculoskeletal: •Pain in the legs or arms
•Back pain
•Joint pain

•Neurological: •Headaches
•Dizziness
•Amnesia
•Vision changes
•Paralysis or muscle weakness

•Urogenital: •Pain during urination
•Low libido
•Dyspareunia
•Impotence
•Dysmenorrhoea, irregular menstruation and menorrhagia

Making a diagnosis
•A thorough physical examination and diagnostic tests are performed to rule out physical causes – which tests are done are determined by the symptoms present.
•A psychological evaluation should also be performed to rule out related disorders: •However, finding evidence of a psychiatric condition does not rule somatisation in or out.
•It can be a clue to the diagnosis.
•There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.

Somatisation is often a diagnosis of exclusion; however, it is much more effective to pursue a positive diagnosis of somatisation when the patient presents with typical features:
•There may be multiple symptoms, often occurring in different organ systems.
•Symptoms that are vague or that exceed objective findings.
•Chronic course.
•Presence of a psychiatric disorder.
•History of extensive diagnostic testing.
•Rejection of previous physicians.

The general practitioner’s emotional response to a patient can serve as an early cue to pursue a somatisation diagnosis:
•A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person.
•A sense of being overwhelmed by a patient who has had numerous evaluations by other physicians.

These can be a signal to the clinician to consider somatisation in the differential diagnosis early in the patient’s evaluation.

Management

Doctors’ explanations of their symptoms are often at odds with these patients’ own thinking and clinicians should take time to ensure their explanations are ‘tangible, exculpating and involving’. Empowering explanations have been shown to improve these patients’ well-being.[13]

The first occasion that the diagnosis is discussed (after the initial investigations have failed to show any organic pathology) is a key moment in the physician-patient relationship. The challenge is to describe the condition to the patient in a manner that avoids any implication of a psychosomatic illness. One journal suggests the following:

‘The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far.'[15]

Once other causes have been ruled out and a diagnosis of somatisation disorder secured, the goal of treatment is to help the person learn to control the symptoms:
•There is often an underlying mood disorder which can respond to antidepressants.
•Unfortunately, those with this disorder rarely admit that it can be caused, at least in part, by mental health problems and may refuse psychiatric treatment.

It is important to ask open-ended questions. The BATHE technique provides a framework for exploration of psychosocial stressors in less than five minutes:[16]

•Background: ‘What is going on in your life?’
•Affect: ‘How do you feel about it?’
•Trouble: ‘What troubles you the most about that situation?’
•Handle: ‘What helps you handle that?’
•Empathy: ‘This is a tough situation to be in. Your reaction makes sense to me.’

It is sensible to avoid setting unrealistic goals:
•In severe cases of somatoform disorder, symptoms are unlikely to resolve completely. Therefore, avoid making the goal of the treatment plan to relieve the patient’s illness. The physician and patient will soon become frustrated and tempted to engage in a new flurry of diagnostic tests and invasive procedures.
•Attempts to ‘take away the symptom’ may cause the patient to substitute another symptom as a result of the need-to-be-sick phenomenon.

A better goal is to help the patient succeed in coping with the symptoms. Treatment is successful if it keeps the patient out of the hospital.

General advice
•The whole primary care health team should be aware of the diagnosis and management plan. This will make the approach to management consistent across the practice.
•Interventions directed at reducing specific sources of stress are most helpful; these may include advice about dealing with marital conflict.
•Some physical exercise is important, as it prevents loss of fitness, enhances self-esteem and provides an opportunity for patients to take a break from oppressive duties or unpleasant situations. One study reported a reduction in symptoms with low-grade short bouts of exercise.[16]
•The importance of pleasurable private time should be emphasised. This may include yoga classes or meditation, bowling or nature walks, which, under the general title of ‘stress management’, can be presented as necessary medical treatments.[17]

Some patients may request tests repeatedly but they should be reminded that they will be followed with frequent and regular visits so that any problems will be identified early. Sometimes requesting investigations becomes a ‘negotiating’ process designed to give the patient some control over what test is performed and to enhance the trust level between the physician and patient.

NB: somatising patients also develop organic diseases, especially common disorders such as osteoarthritis, coronary artery disease and cancer. Thus, preventative health measures and regular screenings must be integrated into the overall treatment plan.

Psychotherapy

Approaches derived from cognitive behavioural therapy have been shown to reduce the intensity and frequency of somatic complaints and to improve functioning in many somatising patients:[18]
•This type of treatment starts with the mutual agreement that whatever the patient has been thinking and doing about the condition has not been successful.
•It then begins to challenge the patient’s beliefs and maladaptive behaviours in a caring manner.
•Short course intervention therapy (eight to 16 sessions) specifically for treatment of somatising patients has been shown to be remarkably effective in improving function and reducing distress.[19]
•The sessions combine general advice such as stress management, problem solving and training in social skills, with specific interventions targeted at the amplification and need-to-be-sick features of somatisation.

Mindfulness therapy is a feasible and acceptable treatment.[20]

Pharmacological

There are psychiatric disorders associated with somatisation, specifically anxiety and depression. These respond well to treatment but, especially with antidepressants,[21] it is important to start with low doses and to increase them progressively to avoid side-effects that may be present at the beginning of treatment and which might discourage the patient from continuing. One study reported the successful use of duloxetine.[22]

A supportive relationship with a sympathetic healthcare provider is the most important aspect of treatment. Regular appointments should be maintained to review symptoms and the person’s coping mechanisms.

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Complications
•Complications may result from invasive testing and from multiple evaluations that are performed while looking for the cause of the symptoms.
•A dependency on pain relievers or sedatives may develop.
•A poor relationship with the healthcare provider seems to worsen the condition, as does evaluation by many providers.

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Antisocial personality disorder is one of nine personality disorders defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition (DSM-IV). For more information, see separate article Personality Disorders and Psychopathy.

People with antisocial personality disorder exhibit traits of impulsivity, high negative emotionality, low conscientiousness and associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness.[1][2]

People with antisocial personality disorder have often grown up with parental conflict and harsh inconsistent parenting. Their childhoods have typically featured parental inadequacies and often transfer of care to outside agencies. Associated with this is a high incidence of truancy, delinquency and substance misuse.[3] This in turn results in increased rates of unemployment, problems with housing and difficulties with relationships. Many people with antisocial personality disorder have a criminal conviction and are imprisoned or die prematurely as a result of reckless behaviour.[1][2]

Criminal behaviour is central to the definition of antisocial personality disorder but there is much more to the disorder than just criminal behaviour. It is often preceded by other long-standing difficulties (socio-economic, educational, family, relationship). Psychopathy is considered to be a considerably severe form of antisocial personality disorder.[2]

The National Institute for Health and Clinical Excellence (NICE) guidance[1] exemplifies a progression from recognition and definition towards more effective management. The challenge posed by this guidance to the mental health services, substance misuse services, social care and criminal justice system is considerable.

Epidemiology[4]
•The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women.
•The prevalence of antisocial personality disorder among prisoners is less than 50%.
•However, only 47% of people with antisocial personality disorder have significant arrest records.

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Presentation[4]

Features include:
•Unstable interpersonal relationships.
•Disregard for the consequences of their behaviour.
•A failure to learn from experience.
•Egocentricity.
•A disregard for the feelings of others.
•A wide range of interpersonal and social disturbance.
•Comorbid depression and anxiety.
•Comorbid alcohol and drug misuse.

It is important to note that antisocial personality disorder is not formally diagnosed before the age of 18 but there may be a history of conduct disorders before this age.

Conduct disorders may be manifested as antisocial, aggressive or defiant behaviour, which is persistent and repetitive. This includes aggressive behaviour (to people or animals), destruction of property, deceitfulness, theft and serious rule-breaking.

Diagnostic criteria[4][5]

People with antisocial personality disorder have a pervasive pattern of disregard for and violation of the rights of others and the rules of society. A history of conduct disorder before the age of 15 is a requirement for a diagnosis of antisocial personality disorder (in the DSM-IV criteria) and includes the following features:
•Repeated breaches of the law. They may well have recurrent criminal convictions.
•Frequent lying and deception, even when there is no obvious gain.
•Physical aggression.
•Reckless disregard for safety of self or others.
•Utter irresponsibility in work and family environments.
•Lack of remorse.

The impending DSM-V classification may well see a re-assessment of the diagnostic criteria in due course.[6]

Differential diagnosis[4]

Diagnosis can be very difficult because of overlapping features and the high frequency of comorbid conditions and problems. Premorbid and developmental history from third parties can be helpful when making a diagnosis:
•Alcoholism.
•Mental disorders secondary to medical conditions (head injuries, seizure disorders).
•Anxiety disorders.
•Other personality disorders.
•Mental retardation.
•Brief psychotic disorder.
•Post-traumatic stress disorder.
•Depression.
•Schizoaffective disorder.
•Schizophrenia.
•Ganser’s syndrome.

Investigations[4]
•Toxicology screen because substance abuse is common (as with many personality disorders). Intoxication can lead patients to present with some features of personality disorders.
•Screening for HIV and other sexually transmitted diseases may be appropriate because of the poor impulse control and disregard of risk associated with antisocial personality disorder.
•Psychological testing may support or direct the clinical diagnosis. For example: •The Minnesota Multiphasic Personality Inventory (MMPI)[7]
•The Eysenck Personality Inventory (EPI)[8]
•The Personality Diagnostic Questionnaire (PDQ)[9]
These have not been reliably validated against DSM-IV Text Revision (DSM-IV-TR) diagnoses.

The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.[2]

Associated diseases[2][4]
•Anxiety.
•Alcohol misuse.
•Drug misuse.
•Depression.
•Attention deficit hyperactivity disorder (ADHD) in childhood.

Management[4][10]

Antisocial personality disorder poses a big challenge to the different agencies which frequently and almost inevitably, have to manage individuals with this disorder. Management by any single agency is not usually possible or recommended. Management in general practice alone is not recommended and referral to psychiatric services is essential.

Practice tips
•Such patients can create very difficult and frightening problems for staff in primary healthcare.
•It is important to identify patients who have antisocial personality disorders and enlist help with appropriate referral.
•It is also important to identify patients at risk of violent behaviour. Assessing risk of violence is not routine in primary care but, if such assessment is required, consider:[1] •Current or previous violence, including severity, circumstances, precipitants and victims.
•The presence of comorbid mental disorders and/or substance misuse.
•Current life stressors, relationships and life events.
•Additional information from written records or families and carers (subject to the person’s consent and right to confidentiality), because the person with antisocial personality disorder might not always be reliable.

•Once identified, a tailored management plan can be used to avoid crises and violent episodes. This will involve staff training and collaboration with other agencies. Use of ‘panic buttons’, chaperones and other measures should be considered.

The treatment of people with antisocial personality disorder must involve a wide range of services including particularly:
•Mental health services.
•Substance misuse services.
•Social care.
•The criminal justice system and associated forensic mental health services.[2]

Drug treatment

No drug has UK marketing authorisation specifically for the treatment of antisocial personality disorder. However, antidepressants and antipsychotics are often used to treat some of the associated problems and symptoms.

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Psychological treatments

Psychotherapy is at the core of care for personality disorders generally. In theory, psychotherapy aims to help patients cope with the disorder by, for example:
•Improving perceptions of social and environmental stressors.
•Improving responses to social and environmental stressors.

Different types of psychotherapy have been used to try to achieve such aims. Cognitive behavioural therapy and group therapy are perhaps the most widely used and available forms of psychotherapy. These should target reduction in offending and antisocial behaviour.[1]

Other considerations
•Good communication is essential between all concerned but especially between healthcare professionals and people with antisocial personality disorder.
•NICE recommends that services should consider establishing antisocial personality disorder networks, where possible linked to other personality disorder networks. They may be organised at the level of primary care trusts, local authorities, strategic health authorities or government offices.[1] These networks should be multi-agency.
•Treatment and care should take into account people’s needs and preferences. People with antisocial personality disorder should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.[1] If the person is under 16, healthcare professionals should follow the guidelines in ‘Seeking consent: working with children’.[11]
•If the person agrees, carers (who may include family and friends) should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need.[1]

Complications[4]
•Suicide
•Substance abuse
•Accidental injury
•Depression
•Homicide

Prognosis[2]

The disorder used to be thought of as lifelong. However, a growing body of research suggests that positive changes can be seen over time. Many patients no longer meet the diagnostic criteria for the condition after a decade. It is acknowledged that the condition is difficult to diagnose and that misdiagnosis may be partly to blame for this ‘improvement’ but it is also considered that many patients do respond to therapeutic interventions. Core characteristics such as lack of empathy do not lessen but evidence suggests that patients develop more control over their impulsivity and cultivate a sense of responsibility.[2]

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Prevention[4]

The incidence of antisocial personality disorder is reduced during times of war and in many Asian cultures. This suggests that social cohesion and an emphasis on communities rather than individuals are significant preventative factors.[2] Families or carers are thus important in prevention and treatment of antisocial personality disorder.[1] NICE suggests that services should establish robust methods to identify children at risk of developing conduct problems and that vulnerable parents could be identified antenatally. For example, identifying:
•Parents with other mental health problems, or with significant drug or alcohol problems.
•Mothers aged younger than 18 years, particularly those with a history of maltreatment in childhood.
•Parents with a history of residential care.
•Parents with significant previous or current contact with the criminal justice system.

The interventions employed after identification of at-risk parents are many and varied according to the problems identified and the age. Examples include:
•Parenting courses
•Anger management
•Cognitive problem solving
•Family therapy
•Multi-systemic therapy
•Multidimensional treatment
•Foster care

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Most people feel anxious from time to time. However, anxiety can become abnormal if it interferes with your day-to-day activities. Anxiety is a symptom of various anxiety disorders which are discussed below. They can often be treated. Treatments include various talking treatments, and medication.

This leaflet is part of our series on anxiety and phobias

Agoraphobia
Generalised Anxiety Disorder
Obsessive-compulsive Disorder
Panic Disorder
Social Anxiety Disorder

What is anxiety?

When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. For example, you might have a fast heart rate, a thumping heart (palpitations), feeling sick, shaking (tremor), sweating, dry mouth, chest pain, headaches, fast breathing.

The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. The nerve messages tend to make the heart, lungs, and other parts of the body work faster. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

Anxiety is normal in stressful situations, and can even be helpful. For example, most people will be anxious when threatened by an aggressive person, or before an important race. The burst of adrenaline and nerve impulses which we have in response to stressful situations can encourage a ‘fight or flight’ response.

Anxiety is abnormal if it:
•Is out of proportion to the stressful situation; or
•Persists when a stressful situation has gone, or the stress is minor; or
•Appears for no apparent reason when there is no stressful situation.

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What are anxiety disorders?

There are various conditions (disorders) where anxiety is a main symptom. You may have an anxiety disorder if anxiety symptoms interfere with your normal day-to-day activities, or if worry about developing anxiety symptoms affects your life. About 1 in 20 people have an anxiety disorder at any one time. The following is a brief overview of the main anxiety disorders. Some people have features of more than one type of disorder.

Reactions to stress

Anxiety can be one of a number of symptoms as a reaction to stressful situations. There are three common types of reaction disorders:

Acute reaction to stress (sometimes called acute stress reaction)

Acute means the symptoms develop quickly, over minutes or hours, reacting to the stressful event. Acute reactions to stress typically occur after an unexpected life crisis such as an accident, bereavement, family problem, bad news, etc. Sometimes symptoms occur before a known situation which is difficult. This is called situational anxiety. This may occur, for example, before an examination, an important race, a concert performance, etc.

Symptoms usually settle fairly quickly, but can sometimes last for several days or weeks. Apart from anxiety, other symptoms include low mood, irritability, emotional ups and downs, poor sleep, poor concentration, wanting to be alone.

See separate leaflet called Acute Stress Disorder for more details.

Adjustment reaction

This is similar to the above, but symptoms develop days or weeks after a stressful situation, as a reaction or adjustment to the problem. For example, as a reaction to a divorce or house move. Symptoms are similar to acute reaction to stress but may include depression. The symptoms tend to improve over a few weeks or so.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) may follow a severe trauma such as a serious assault or life-threatening accident. Symptoms last at least one month, often much longer. Anxiety is only one symptom which may come and go. The main symptoms of PTSD are:
•Recurring thoughts, memories, images, dreams, or flashbacks of the trauma, which are distressing.
•You try to avoid thoughts, feelings, conversations, places, people, activities or anything else which may trigger memories or thoughts of the trauma.
•Feeling emotionally numb and detached from others. You may find it difficult to have loving feelings.
•Your outlook for the future is often pessimistic. You may lose interest in activities which you used to enjoy.
•Increased arousal which you did not have before the trauma. This may include difficulty sleeping, being irritable, difficulty concentrating, and increased vigilance.

See separate leaflet called Post-traumatic Stress Disorder for more details.

Phobic anxiety disorders

A phobia is strong fear or dread of a thing or event. The fear is out of proportion to the reality of the situation. Coming near or into contact with the feared situation causes anxiety. Sometimes even thinking of the feared situation causes anxiety. Therefore, you end up avoiding the feared situation, which can restrict your life and may cause suffering.

Social anxiety disorder

Social anxiety disorder (also known as social phobia) is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or ‘performing’ in front of other people, especially strangers. You fear that you will act in an embarrassing way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. If you go to the feared situation you become very anxious and distressed.

See separate leaflet called Social Anxiety Disorder for more details.

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Agoraphobia

Agoraphobia

This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:
•Entering shops, crowds, and public places.
•Travelling in trains, buses, or planes.
•Being on a bridge or in a lift.
•Being in a cinema, restaurant, etc where there is no easy exit.

But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become very anxious and distressed, and have an intense desire to get out. To avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time.

See separate leaflet called Agoraphobia for more details.

Other specific phobias

There are many other phobias of a specific thing or situation. For example:
•Fear of confined spaces or of being trapped (claustrophobia).
•Fear of certain animals.
•Fear of injections.
•Fear of vomiting.
•Fear of being alone.
•Fear of choking.

But there are many more.

Other anxiety disorders

Panic disorder

Panic disorder means that you get recurring panic attacks. A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. The physical symptoms of anxiety during a panic attack can be severe and include a thumping heart (palpitations), trembling, feeling short of breath, chest pains, feeling faint, numbness, or pins and needles. Each panic attack usually lasts 5-10 minutes, but sometimes they come in waves for up to two hours.

See separate leaflet called Panic Disorder for more details.

Generalised anxiety disorder

If you have generalised anxiety disorder (GAD) you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety (detailed above) may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious. In addition, you will usually have three or more of the following symptoms:
•Feeling restless, on edge, or ‘keyed up’ a lot of the time.
•Tiring easily.
•Difficulty concentrating and your mind going blank quite often.
•Being irritable a lot of the time.
•Muscle tension.
•Poor sleep (insomnia). Usually it is difficulty in getting off to sleep, or difficulty in staying asleep.

See separate leaflet called Generalised Anxiety Disorder for more details.

Mixed anxiety and depressive disorder

In some people, anxiety can be a symptom when you have depression. Other symptoms of depression include low mood, feelings of sadness, sleep problems, poor appetite, irritability, poor concentration, decreased sex drive, loss of energy, guilt feelings, headaches, aches, pains, and palpitations. Treatment tends to be aimed mainly at easing depression, and the anxiety symptoms often then ease too.

See separate leaflet called Depression for more details about depression.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) consists of recurring obsessions, compulsions, or both.
•Obsessions are recurring thoughts, images, or urges that cause you anxiety or disgust. Common obsessions are fears about dirt, contamination, germs, disasters, violence, etc.
•Compulsions are thoughts or actions that you feel you must do or repeat. Usually a compulsion is a response to ease the anxiety caused by an obsession. A common example is repeated hand washing in response to the obsessional fear about dirt or germs. Other examples of compulsions include repeated cleaning, checking, counting, touching, and hoarding of objects.

See separate leaflet called Obsessive-compulsive Disorder for more details.

What is the treatment for anxiety disorders and phobias?

The main aim of treatment is to help you to reduce symptoms so that anxiety no longer affects your day-to-day life.

The treatment options depend on what condition you have, and how severely you are affected. They may include one or more of the following:

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NON-MEDICATION TREATMENTS

Understanding

Understanding the cause of symptoms, and talking things over with a friend, family member or health professional may help. In particular, some people worry that the physical symptoms of anxiety, such as a thumping heart (palpitations), are due to a physical illness. This can make anxiety worse. Understanding that you have an anxiety disorder is unlikely to cure it, but it often helps.

Counselling

This may help some people with certain conditions. For example, counselling which focuses on problem-solving skills may help if you have GAD.

Anxiety management courses

These may be an option for some conditions, if courses are available in your area. The courses may include: learning how to relax, problem-solving skills, coping strategies, and group support.

Cognitive and behavioural therapy

These therapies, if available in your area, can work well for persisting anxiety disorders and phobias:
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety and depression. The therapist helps you to understand your current thought patterns – in particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have that can make you anxious (or depressed). The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious or develop physical symptoms of anxiety.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour or response to the feared object is harmful, and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours. (Note: cognitive and behavioural therapies do not look into the events of the past. They deal with, and aim to change, your current thought processes and/or behaviours.) See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.

Self-help

There are various national groups which can help by giving information, advice and support (see below). They, or your doctor or practice nurse, may also be able to put you in touch with a local group for face-to-face support.

You can also get leaflets, books, tapes, videos, etc, on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress, help you to relax, and possibly ease anxiety symptoms. See separate leaflet in this series, called Stress and Tips on How to Avoid It.

MEDICATION

Antidepressant medicines

These are commonly used to treat depression, but also help to reduce the symptoms of anxiety even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and the anxiety symptoms are helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. This is often too soon to know if the medication will work.
•Antidepressants are not tranquillisers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons. They may differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety disorders. Two examples of SSRIs are escitalopram and sertraline.
•Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first few weeks of treatment to see if you have any problems.

Benzodiazepines

Benzodiazepines such as diazepam used to be the most commonly prescribed medicines for anxiety. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for anxiety which is very severe and short-term, or now and then to help you over a bad spell if you have persistent anxiety symptoms.

Buspirone

Buspirone is sometimes prescribed to treat GAD. It is an anti-anxiety medicine, but different to the benzodiazepines and is not thought to be addictive. It is not clear how it works. It is thought to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms.

Beta-blocker medicines

A beta-blocker, for example propranolol, can ease some of the physical symptoms such as trembling and a thumping heart (palpitations). They do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease ‘the shakes’.

In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.

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Alcohol and anxiety

Although alcohol may ease symptoms in the short term, don’t be fooled that drinking helps to cure anxiety. In the long run, it does not. Drinking alcohol to ‘calm nerves’ can lead to problem drinking and may make problems with anxiety and depression worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease anxiety.

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Panic disorder can be a severe and disabling illness and is common in primary care. It can be difficult to assess when it presents acutely, as many symptoms may also be experienced with physical illness. Sufferers often present repeatedly to their GP or local emergency department with worrying episodes of multiple symptoms that the patient may ascribe to life-threatening illness.

This condition often co-exists with agoraphobia – the avoidance of exposed situations for fear of panic or inability to escape. Agoraphobia is not a stand-alone diagnosis and occurs very rarely without panic disorder. Panic disorder is often classified into panic disorder with, or without, agoraphobia. Social anxiety disorder can often co-exist and is diagnosed where the situations avoided are predominantly social and interactive in nature.

The first panic attack may be associated with a stressful episode but gradually the attacks become dissociated and occur ‘out of the blue’. It is a chronic condition with relapses and leads to much distress and social dysfunction.[1] Gamma-aminobutyric acid (GABA) receptor dysfunction is thought to play an important role in panic disorder pathophysiology.

Definition
Panic attacks must be associated with >1 month’s duration of subsequent, persisting anxiety about recurrence of the attacks, the consequences of the attacks, or significant behavioural changes associated with them.

A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms, listed below, arise rapidly and peak within 10 minutes of the onset of the attack: •Attacks usually last at least 10 minutes but their duration is variable.
•The symptoms must not arise as a result of alcohol or substance misuse, medical conditions or other psychiatric disorders, in order to satisfy the diagnostic criteria.

Characteristic symptoms experienced during panic attacks
Panic disorder manifests as the sudden, spontaneous and unanticipated occurrence of panic attacks, with variable frequency, from several in a day to just a few per year: •Palpitations, pounding heart or accelerated heart rate.
•Sweating.
•Trembling or shaking.
•Dry mouth.
•Feeling short of breath, or a sensation of smothering.
•Feeling of choking.
•Chest pain or discomfort.
•Nausea or abdominal distress.
•Feeling dizzy, unsteady, light-headed or faint.
•Derealisation or depersonalisation (feeling detached from oneself).
•Fear of losing control or ‘going crazy’.
•Fear of dying.
•Numbness or tingling sensations.
•Chills or hot flushes.

Epidemiology and aetiology

Panic disorder is a common problem. The prevalence of panic disorder with or without agoraphobia in one UK study was 1.70%.[2] In the USA, lifetime prevalence is estimated at 3-5.6% for panic attacks and 1.5-5% for panic disorder. Psychiatric case-finding studies of patients presenting with chest pain to emergency departments found that up to 25% satisfied criteria for panic disorder.[3]

There are many aetiological theories, none of which are proven in isolation. Several aetiological factors may contribute to its occurrence in a given individual. The postsynaptic serotonergic/adrenergic hypersensitivity hypotheses are probably the most biologically plausible and relevant to treatment response but there are also important genetic and environmental factors involved.

Panic disorder can also be associated with the use of certain medications: selective serotonin reuptake inhibitors (SSRIs), benzodiazepine withdrawal and withdrawal from zopiclone. These should be considered in assessing any patient who presents with panic disorder.

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Presentation

Symptoms

The condition is commonly unrecognised and untreated. Most patients are seen in general practice, although patients may present to A&E with somatic symptoms such as chest pain. As attention is given to the physical symptoms, the diagnosis of panic attacks may not be made. Therefore, a high index of suspicion is needed. Screening tools are available.[4][5]

As detailed above the patient will describe a history of sudden onset of episodes of panic featuring four or more of the characteristic symptoms. These will usually peak within 10 minutes and can last for 20-30 minutes but they will rarely persist beyond one hour. There is marked individual variation in the length of attacks. It is worth asking about any triggering caused by alcohol or drugs (including legal drugs such as caffeine, nicotine, complementary remedies or over-the-counter (OTC) preparations). Enquiry about other triggers for the attacks helps in constructing the differential diagnosis:
•Those that arise unexpectedly and without any obvious triggering situation or event are characteristic of panic disorder without agoraphobia.
•Those that arise in a predictable way as a follow-on to a given anxiety-provoking situation or event usually reflect a specific phobia-type diagnosis, or panic disorder with social phobia if the precipitant is a social phenomenon.
•Those that arise in an inconsistent or unpredictable way following exposure to a given anxiety-provoking situation or event suggest panic disorder with agoraphobia.

One cross-sectional study of older patients with persistent dizziness found that anxiety and/or a depressive disorder were present in 22% and this could be a presentation for conditions such as panic disorder.[6]

Signs

There are no specific physical signs associated with the condition, unless the patient is seen during a panic attack, when increased sympathetic outflow may manifest as tachycardia, hypertension, tremors, sweating, etc.

During the panic attack the patient may be extremely preoccupied about suffering death or a severe, life-threatening physical illness. Examination of the mental status reveals no specific findings other than a reflection of anxiety and/or urgency in their appearance, speech or mood (this is not necessary to make the diagnosis). The patient’s affect should be congruent with their mental state. Thought processes should be normal and thought content should be essentially normal but may be preoccupied with death or illness. Thought content should be assessed for suicidal or homicidal ideation, or thoughts of self-harm. Judgement and insight are normally preserved. Abnormalities in thought processes or content (other than impulsive thoughts of suicide or self-harm) suggest alternative psychiatric diagnoses. The presence of incongruent affect should raise concerns that panic disorder is the wrong diagnosis.

Associated diseases

Psychiatric disorders

Panic disorder is frequently associated with agoraphobia (affecting about 26% of sufferers) and/or social phobia (affecting about 33% of sufferers). There is a significant association with mood disorders, particularly depression, with lifetime prevalence rates as high as 50-60%. There appears to be a higher risk of suicide attempts than in the general population. One study found that 98% of panic disorder patients had at least one comorbid disorder.[7] Major depressive disorder and other anxiety disorders were the most common. The other anxiety disorders tended to be persistent, although other depressive disorders and alcohol use disorders had high remission rates.[7] Alcohol and substance misuse can complicate the picture and these can be used in some cases to self-medicate.

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Medical conditions

These may co-exist but one would not generally use the term panic disorder if the symptoms arise directly from the physical illness. Cardiovascular disease such as mitral valve prolapse, cardiomyopathy and hypertension are associated. Chronic obstructive airways disease and migraine headaches are also present in a larger proportion of sufferers than chance would suggest, as are functional disorders such as irritable bowel syndrome and tension-type headache. A recent link with joint hypermobility disorder has been elucidated, further suggesting a genetic basis for panic disorder.[8]

Differential diagnosis

Although a good description of the episode may suggest a panic attack, it is important to exclude other organic conditions. For example, there is a rare case report of a cingulate ganglioma presenting as panic attacks in a teenager.[9] More typical alternatives include:

Psychiatric conditions
•Agoraphobia (often co-exists).
•Social anxiety disorder (often co-exists).
•Anxiety disorders, including generalised anxiety disorder (may co-exist).
•Adjustment disorders.
•Bipolar disorder.
•Depression.
•Dissociative disorders.
•Factitious illness.
•Somatisation disorder.
•Mental symptoms arising as a result of physical illness.
•Obsessive-compulsive disorder.
•Specific phobic disorders.
•Post-traumatic stress disorder.
•Stimulant-drug misuse (including caffeine-related illness).

Physical conditions
•Hyperthyroidism.
•Phaeochromocytoma.
•Carcinoid syndrome.
•Hypoglycaemic episodes (possibly due to insulinoma in those not using insulin/oral hypoglycaemic agents).
•Paroxysmal cardiac dysrhythmia.
•Mitral valve prolapse.
•Myocardial infarction.
•Recurrent small pulmonary emboli.
•Epileptiform disorders, particularly temporal lobe epilepsy.
•Withdrawal from alcohol/sedatives/opiates.
•Paroxysmal vestibular disorders – eg, Ménière’s disease.

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Investigations

There are no specific investigations to diagnose the condition but clinicians may feel inclined to refer the patient, or carry out tests to exclude underlying physical causes for the symptoms. Whilst it is important not to miss likely physical causes, one should not endlessly or excessively investigate these patients. Such a course of action can leave them with the impression that there actually is a physical problem, which their doctor(s) just can’t find.

After initial exclusion of top-ranking physical causes, with the confirmation of characteristic clinical features of panic disorder, the absence of a physical cause should be clearly explained to the patient. Response to treatment will be better in those patients who accept the absence of physical causes for their symptoms and in those who have an understanding of the nature of panic disorder as a primarily mental phenomenon.

Management

The National Institute for Health and Care Excellence (NICE) recommends a stepped care approach.[1]

Step 1: recognition and diagnosis

This has been dealt with in the ‘Presentation’, ‘Differential diagnosis’ and ‘Investigations’ sections, above.

Step 2: treatment in primary care

General
•Try to involve the patient’s family or carer if the patient allows this. It is important for them to understand how they can best help the patient during an attack.[10]
•Advise avoiding anxiety-producing substances – eg, caffeine.[11]
•It is important to exclude alcohol or drug misuse as a factor and to treat these problems if present. Reassessment after successful management of substance-related issues will reveal if this is true panic disorder. Response to pharmacological/psychological therapies is likely to be poor in the face of alcohol/drug misuse or dependence.

Offer the following interventions (listed as per NICE in the order – according to the evidence base – of duration of efficacy):

Cognitive behavioural therapy (CBT)
•Treatment focused on the recognition of factors which trigger the panic, and behavioural methods to cope with the symptoms, have been found to be very useful.
•Trained and supervised personnel should be involved in the delivery of treatment, working to empirically grounded protocols.
•1-2 hours a week is suitable for most people over a four-month period.
•Briefer CBT of about seven hours may be appropriate for some patients, combined with self-help materials.
•More intensive CBT over a shorter period of time may be suitable for some patients.
•Overall, there is evidence of a moderate treatment effect with psychological treatments in primary care.

Medication

General principles •Before prescribing, consider age, previous treatment, tolerability, other medication, comorbidities, personal preference, cost and risk of self-harm (SSRIs are less dangerous than tricyclics in overdose).
•Inform the patient about possible side-effects (including a temporary increase in anxiety at the start of treatment), delay in onset of effect, possible discontinuation symptoms, the length of treatment and the need to follow dosage instructions.
•Provide written information appropriate to the patient’s needs.
•Start with a low dose to minimise side-effects.
•Some patients may need long-term treatments and a dose at the upper end of the range.
•Do not prescribe benzodiazepines, sedative antihistamines and antipsychotics for panic disorder.
•Antidepressant drugs have been shown to be effective in reducing the amplitude of panic, reducing frequency of, or eliminating, panic attacks and improving quality-of-life measures in this group of patients.
•Offer an SSRI licensed for this indication first-line unless contra-indicated.
•Consider imipramine or clomipramine if there is no improvement after 12 weeks and further medication is indicated (NB: neither is licensed for this indication in the UK, so document informed consent).
•Review the patient after two weeks to check for side-effects and efficacy, and at 4, 6 and 12 weeks.
•If there has been an improvement after 12 weeks, continue for 6 months after the optimum dose has been reached.
•If medication is used for longer than 12 weeks, review at 8- to 12-weekly intervals.
•Follow the summary of product characteristics of the individual drugs for other monitoring requirements.
•Use self-completed questionnaires to monitor outcomes where possible.
•At the end of treatment, withdraw the SSRI gradually, as dictated by patient preference, and monitor monthly for relapse for as long as appropriate to the individual.
•If there is no improvement and a second intervention has not been tried, go to Step 3 (below).
•If there has been no improvement and a second intervention has been tried, go to Step 4 (below).

Self-help
•Give the patient details of books based on CBT principles, and contact details of any available support groups. There is evidence that self-help interventions are an effective option for people with panic disorder.[12]
•Promote exercise as part of good general health. There is some evidence of a reduction in anxiety symptoms following exercise. A systematic review suggested that the effect is not as great as antidepressants but it could be a useful adjunct.[13]
•Patients may benefit from advice on how they can control some of their symptoms by using abdominal/diaphragmatic breathing. Simple advice on this is available in the leaflet Panic Attack and Panic Disorder.
•Monitor the patient on a regular basis, usually every 4-8 weeks, preferably using a self-completed questionnaire.

Step 3

Reassess the condition and consider alternative treatments.

Step 4

If two interventions have been offered without benefit, consider referral to specialist mental health services. Specialist treatment may include management of comorbid conditions, structured problem solving, other types of medication and treatment at tertiary centres.

Prognosis

The literature is contradictory about prognosis. In one study the panic disorder had a long course lasting several years.[7] In another study in primary care only a quarter of the patients with panic disorder and agoraphobia had remission in a three-year follow up. Yet, three quarters of those with just panic disorder improved.[14]

Prevention

Those who suffer can help themselves by recognising triggers to panic and ameliorating them through avoidance or CBT-based strategies. Those who have recovered should be made aware that the condition may relapse and that they should seek early help for further treatment if panic attacks return.