115. Anxiety Disorders

Question 1

What percent of the population has an anxiety disordeR?

What are the psychoanalytic, behavioral, cognitive, and physiologic theories of anxiety?

Answer 1

30%
Psycho - anxiety as unconscious signal for danger, incomplete repression
Behavioral: classic conditioning (neutral stim picks up physical sx response), operant conditioning (negative escape reinforcement, increases freq of anxious behavior)
Cognitive: inaccurate thinking of overestimate threat and underestimate control
Physiologic: signs assoc with EPI release, anxiety due to peripheral phenomenon, SNS more difficult to adapt to repeated stim and respond excessively to moderate stim

Question 2

What is the biology of anxiety? What systems are involved?

Answer 2

Anxiety from same circuit as FEAR response
(Amygdala, Hippocampus, Locus Coeruleus, Hypothalamic-Pituitary-Adrenocortical Axis)

GABA: major inhibition of CNS, reduces anxiety
5HT: attenuate activity of locus coeruleus (modulates anxiety)
NE: dysregulation precipitates anxiety with bursts of activity

Question 3

OCD

• sx
• DSM 5 Criteria

Answer 3

• presence of EITHER obsessions OR compulsions (or both)
• individual HAS realized obsessions/compulsions are excessive/unreasonable
• sx are time-consuming (>1hr/day) or cause sig distress/impairment

Obsessions

• recurrent, persistent thoughts as intrusive/unwanted, causing distress
• excessive realistic worries
• pt attempts to suppress obsessions thru compulsions
• pt recognizes obsessions are compulsions of their mind

Compulsions

• repetitive behaviors or mental acts person feels driven to perform due to obsession/rigid rules
• performance aimed at reducing anxiety or preventing dreaded outcome (unrealistically)

Question 4

OCD

• Onset
• Course
• Features
• Biological Factors
• Neurological Factors

Answer 4

Onset in adolescence
Course: improves, recurs in adulthood (progressive deterioration in ~15%)
Features: 50% germaphobe obsessions, “Checking” common, 25% pure obsessionals, primary obsessional slowing is uncommon
Bio: genetic component, +FamHx = 4x risk, link to Tourette’s, Syndenham’s Chorea (assoc to strep), and PANDAS (peds autoimmune disease)
Neuro: Assoc with Epilepsy/BG lesions, more activity in cingulate cortex, caudate, prefrontal cortex

Question 5

Panic Attack

• sx
• DSM5 Criteria for Panic Disorder

Answer 5

Discrete period of intense fear/discomfort w/at least 4sx abruptly developing, peaking w/in 10 min (20-30min)

sx: heart palpitations, sweating, nausea, abd distress, heat/chills, SoB, dissy, unsteady, faint, fear of losing control/dying

Panic Disorder: Recurrent unexpected panic attacks, at least 1 attack followed by a month of either concern about another attack/consequences, maladaptive behavior change due to attack

Question 6

Panic Disorder

• onset
• comorbidity
• epidemiology
• course

Answer 6

Adolescence to 30s (peak 25)
Comorbid with MDD, Other anxiety disorders, Secondary MDD, Somatization Disorder
Dx delayed due to physical sx
Epi: 2% prevalence in 1 year for attack (1.6% prevalence for panic disorder); W>M 2-3x
Course: 1/3 recover w/o tx, 1/2 improve w/ tx, 1/5 unchanged, waxes and wanes

Question 7

Agoraphobia

- DSM 5 criteria

Answer 7

• marked fear/anxiety of 2+ of: public transportation, open spaces, enclosed public spaces, crowds, alone outside home
• persistent >6mo and out of proportion

Question 8

Specific Phobia

• DSM5 Criteria
• Epidemiology

Answer 8

DSM5:

• marked fear/anxiety about specific object/situation
• specific obj always provokes fear/anxiety (causes active avoidance)
• persistent (>6mo) and causes distress/impairment

Epi: 10% lifetime prevalence, 75-90% in women
Bimodal onset: childhood and early adulthood
Familial aggregation: fears similar w/in families

Question 9

Social Anxiety Disorder

- DSM 5 Criteria

Answer 9

• marked fear/anxiety about 1+ social situations where pt exposed to potential scrutiny by others
• pt fears that they will show anxiety and be negatively evaluated
• social situations almost always provoke anxiety
• social situations avoided or endured with intense fear/anxiety
• fear/anxiety out of proportion, persistent (>6mo), causes distress/impairment

Question 10

GAD

• DSM 5 Criteria
• Epidemiology
• Comorbidity

Answer 10

• excessive anxiety/worry more days than not for >6mo, about several events/activities
• difficult to control worry
• 3+ sx: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension (occipital), sleep disturbance (insomnia)
• cause distress/impairment
• not due to substance/general med condition

Epi: 3-5% lifetime prevalence, early onset, fluctuating course, genetics overlap w/ those in MDD

Comorbidity: 90% have another disorder, 62% have MDD (consider other anxiety, PTSD, adult ADHD - untx)

Question 11

Treatments of Anxieties

Non-pharm and pharm

Answer 11

Psychotherapy:

• CBT
• Desensitization therapy (phobias)
• Relaxation Techniques
• Response Prevention/Flooding (OCD)
• Psychodynamic/Interpersonal
• Exercise

Pharm

• Antidepressants: block panic attacks (prophylactic) and tx comorbid MDD (1st line SNRIs!)
• Buspirone: blocks 5HT, DA
• Benzodiazepines: only short term due to tolerance/withdrawal
• Neurosurgery for refractory cases
• TMS

30% remission, 50% improvement, 20% remain ill