115. Anxiety Disorders Flashcards
What percent of the population has an anxiety disordeR?
What are the psychoanalytic, behavioral, cognitive, and physiologic theories of anxiety?
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
What is the biology of anxiety? What systems are involved?
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
OCD
- sx
- DSM 5 Criteria
- 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)
OCD
- Onset
- Course
- Features
- Biological Factors
- Neurological Factors
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
Panic Attack
- sx
- DSM5 Criteria for Panic Disorder
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
Panic Disorder
- onset
- comorbidity
- epidemiology
- course
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
Agoraphobia
- DSM 5 criteria
- marked fear/anxiety of 2+ of: public transportation, open spaces, enclosed public spaces, crowds, alone outside home
- persistent >6mo and out of proportion
Specific Phobia
- DSM5 Criteria
- Epidemiology
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
Social Anxiety Disorder
- DSM 5 Criteria
- 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
GAD
- DSM 5 Criteria
- Epidemiology
- Comorbidity
- 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)
Treatments of Anxieties
Non-pharm and pharm
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
