5. Anxiety Disorders

Question 1

Describe: Anxiety (4)

Answer 1

• Anxiety is part of the human adaptive reactions to external threats by activating the sympathetic nervous system–fight or flight. It is an alerting signal that warns of impending danger and is characterized by an unpleasant, vague feeling of apprehension and often accompanied by autonomic arousal symptoms.
• Fear is an alerting signal to something known, external or definite while anxiety is often unknown, internal and vague.
• Anxiety becomes pathological if:
  
  • Fear is out of proportion to severity of threat.
  • When social and/or occupational functioning is/are impaired.
• An exaggerated fear response has been postulated in the etiology of AD.

Question 2

Research studies have focused on the specific regions of the brain that coordinate fear and store memory for future exposure to the same stimuli, namely what? (2)

Answer 2

the amygdala and hippocampus.

Question 3

Research studies have focused on the specific regions of the brain that coordinate fear and store memory for future exposure to the same stimuli, namely, the amygdala and hippocampus.

Neurotransmitters that connect these brain regions have also been studied extensively including what? (4)

Answer 3

• the dopaminergic
• serotonergic
• glutaminergic
• GABAergic systems.

Question 4

Name categories of DDX of anxiety disorders (3)

Answer 4

• Psychiatric
• Substance-induced
• Medical

Question 5

Name PSYCHIATRIC DDX of ADs (6)

Answer 5

• Anxiety disorders
  
  • Specific Phobia
  • Panic disorder
  • Agoraphobia
  • Generalized Anxiety
• Depression
• Somatization disorder
• Depersonalization disorder
• Obsessive-compulsive and related disorders
• Trauma and stressor related disorders
  
  • Acute stress disorder
  • Posttraumatic stress disorder

Question 6

Name SUBSTANCE-INDUCED DDX of ADs (8)

Answer 6

• Alcohol
• Caffeine
• Cannabis
• Phencyclidine
• Inhalants
• Withdrawal from sedatives, hypnotics or anxiolytics
• Opioid
• Cocaine, amphetamine, other stimulants

Question 7

Name MEDICAL DDX of ADs (5)

Answer 7

• Hyperthyroidism and hypothyroidism
• Cardiac disease
  
  • Mitralvalve prolapse
  • Ischemic heart disease
  • Arrhythmias
• Diabetes
• Vestibular nerve disease
• Pheochromocytoma (rare)

Question 8

Describe HX of anxiety (15)

Answer 8

• Patient identifiers: name, age, occupation
• Social and contextual information: relationship status, living arrangement, work or source of income, children, caregivers of children besides the patient
• Ask about symptoms and features in Figure 19.7
• Recent and current stressors: personal losses that have occurred or anticipated (e.g., death in family, loss of work, property), role transitions, financial difficulties, interpersonal conflict, isolation, exposure to trauma
• Social supports available
• Suicide risk assessment
• Substance use
• Psychiatry review of systems: screen for symptoms of depression, mania/hypomania, anxiety, or psychosis
• Psychiatric history
• Forensic history
• Family psychiatric history
• Medical history
• Medications
• Allergies
• Personal history: childhood relationships, performance in school at different stages, highest level of education, occupations held, relationships in adolescence and adulthood, history of abuse at any stage in life

Question 9

Describe diagnostic process of anxiety disorders (7)

Answer 9

• There is/are cue(s) that brings on anxiety such as an object or situation that is avoided or endured, and has lasted for 6 months or more and impairs functioning
  
  • Cue is an object -> Specific phobia
  • Cue is a situation
    
    • Patient fears anxiety symptoms will be negatively evaluated by others in social situations -> Social anxiety disorder (Social phobia)
    • Anxiety about situations where escape may be difficult (two or more of: public transport, open spaces, closed spaces, crowd or lineup, outside of home alone) -> Agoraphobia
• There are symptoms of panic: tachycardia, sweating, trembling, shortness of breath, feeling of choking, chest pain, nausea, dizziness, chills, numbness, derealization, fear of losing control, fear of dying
  
  • The patient has one month or more of worry about having more panic attacks and/or behaviours to avoid having panic attacks
    
    • Panic disorder
• There is excess worry and anxiety about a number of topics for most days for at least 6 months and there are three or more of the following: feeling keyed up, fatigue, concentration problems, irritability, muscle tension, sleep disturbance
  
  • Generalized anxiety disorder
• Substance/medication induced anxiety disorder
• Anxiety disorder due to another medical condition
• Trauma related
  
  • Acute stress disorder
  • Post-traumatic stress disorder
• There are recurrent and unwanted thoughts or repetitive behaviours or mental acts that are time-consuming and impairing
  
  • Obsessive-compulsive disorder

Question 10

Describe general observations and physical exam: ADs (6)

Answer 10

• Mental status exam: body language, psychomotor retardation/agitation (fidget- ing, moving about, hand-wringing, nail biting, hair pulling, lip biting, tremor), decreased eye contact, decreased range of affect (primarily anxious), suicidal/ homicidal ideation/plan/intent
• Examine vital signs
• Pupils, and skin for diaphoresis
• Stigmata of drug and/or alcohol use
• Thyroid gland
• Weight loss

Question 11

Describe investigations for ADs and finding/interpretation associated (6)

Answer 11

• CBC: To rule out anemia and/or infection
• Electrolytes: To rule out electrolyte imbalance
• BUN, creatinine: To rule out renal failure
• Fasting blood glucose: To rule out hyper- or hypoglycemia
• Thyroid (TSH): To rule out hyper- or hypothyroidism
• Urinalysis: Street drugs

Question 12

Describe: BIOLOGICAL treatment for anxiety disorders (7)

Answer 12

• SSRIs – first-line treatment
  
  • May initially exacerbate anxiety: start low and go slow
• SNRIs – first-line treatment
• Mirtazapine
• Benzodiazepines
  
  • Often used for emergency management of generalized anxiety and panic disorders
  • Caution with benzodiazepines for sedation, cognitive effects, and dependence
  • Abrupt withdrawal of benzodiazepines may be dangerous (i.e., risk of seizures, delirium tremens)
• TCAs
• MAOIs
• Buspirone
  
  • Buspirone has demonstrated efficacy for generalized anxiety but not panic

Question 13

Describe: PSYCHOSOCIAL treatment for anxiety disorders (2)

Answer 13

• CBT
• Behavioural (exposure) therapy

Question 14

Describe: SOCIAL treatment for anxiety disorders (4)

Answer 14

• Family involvement
• Education and support
• Support group
• Community resources