6. Anxiety Disorders Flashcards
1
Q
Define: Anxiety Disorders (3)
A
- anxiety is a universal human experience which can serve as an adaptive mechanism to facilitate appropriate reactions to external threat
- can be pathological
- manifestations of anxiety are a result of the activation of the sympathetic nervous system
2
Q
Anxiety becomes pathological when? (4)
A
- fear is greatly out of proportion to risk/severity of threat
- response continues beyond existence of threat or becomes generalized to other similar or dissimilar situations
- social or occupational functioning is impaired
- often comorbid with substance use and depression
3
Q
Manifestations of anxiety are a result of the activation of the sympathetic nervous system and can be described how? (3)
A
- physiology: main brain structure involved is the amygdala ; neurotransmitters involved include 5-HT, cholecystokinin, epinephrine, norepinephrine, and DA
- psychology: one’s thoughts about a given situation or stimulus contribute to the feeling of fear and perception of threat
- behaviour: anxiety can lead to avoidance which can result in disruption to daily functioning.
4
Q
Name Differential Diagnosis of Anxiety Disorders (8)
A
-
Cardiovascular
- Post-MI, arrhythmia, congestive heart failure, pulmonary embolus, mitral valve prolapse
- Respiratory: Asthma, COPD, pneumonia
-
Endocrine:
- Hyperthyroidism, pheochromocytoma, hypoglycemia, hyperadrenalism, hyperparathyroidism
-
Metabolic
- Vitamin B12 deficiency, folate deficiency, porphyria, hypoxemia, hypercalcemia
-
Neurologic
- Neoplasm, vestibular dysfunction, encephalitis, trauma (contusion or hematoma), MS, temporal lobe epilepsy
- Infectious: Cerebral (meningitis, HIV, syphilis) or systemic
- GI: Gastritis, esophageal spasm
-
Substance-Induced
- Intoxication (caffeine, amphetamines, cocaine, thyroid replacement, OTC for colds/decongestants), withdrawal (benzodiazepines, alcohol)
5
Q
Describe: Medical Workup of Anxiety Disorder (2)
A
- routine screening: physical exam, CBC, electrolytes, thyroid function test, ECG
- additional screening: extended electrolytes, vitaminB12, folate, chest x-ray, head imaging, neurological consultation, any other tests as per DDx in Table 2
6
Q
Name Risk Factors for the Development of Anxiety Disorders (5)
A
- biological
- endocrine disorders (i.e. hyperthyroidism), respiratory conditions (i.e. asthma), CNS conditions (i.e. temporal lobe epilepsy), substances/medications (i.e. excessive stimulant use), chronic medical illness
- family history
- personal history of anxiety or mood disorder
- XX>XY chromosomes
- psychological
- current stress early childhood trauma, early parental loss
7
Q
Name DSM-5 diagnostic criteria: Panic Disorder (4)
A
- recurrent unexpected panic attacks – a panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur
- palpitations, pounding heart, or accelerated heart rate
- sweating
- trembling or shaking
- sensations of shortness of breath or smothering
- feelings of choking
- chest pain or discomfort
- nausea or abdominal distress
- feeling dizzy, unsteady, light-headed, or faint
- chills or heat sensations
- paresthesias (numbness or tingling sensations)
- derealization (feelings of unreality) or depersonalization (being detached from oneself)
- fear of losing control or “going crazy
- fear of dying
- 1 mo (or more) of “anxiety about panic attacks” - at least one of the attacks has been followed by one or both of the following:
- persistent concern or worry about additional panic attacks or their consequences
- a significant maladaptive change in behaviour related to the attacks
- the disturbance is not attributable to the physiological effects of a substance or another medical condition
- the disturbance is not better explained by another mental disorder
8
Q
Describe mechanisms of panic attacks (Figure)
A
9
Q
Describe epidemiology: Panic Disorder (2)
A
- lifetime prevalence: 5% (one of the top five most common reasons to see a family doctor); M:F = 1:2-3
- onset: average early-mid 20s, familial pattern
10
Q
Describe tx: Panic Disorder (2)
A
- psychological
- Cognitive behavioral therapy CBT: interoceptive exposure (deliberate exposure to unpleasant sensations of arousal associated with a panic attack for experiential disconfirmation of their fears); cognitive restructuring (addressing underlying beliefs regarding the panic attacks), relaxation techniques (visualization, box-breathing), psychoeducation
- pharmacological (first line agents)
11
Q
Describe pharmacological tx: Panic Disorder (8)
A
- SSRIs: fluoxetine, citalopram, escitalopram, paroxetine, sertraline, fluvoxamine
- SNRI: venlafaxine XR
- with SSRI/SNRIs, start with low doses, titrate up as tolerated
- anxiety disorders often require treatment at higher doses for a longer period of time than depression (i.e. full response may take up to 12 wk)
- treat for up to 1 year after symptoms resolve to avoid relapse
- explain expected adverse effects prior to initiation of therapy to prevent non-adherence
- other antidepressants (mirtazapine, MAOIs)
- benzodiazepines considered 2nd line (short-term, lowest effective dose, helpful while titrating antidepressant)
12
Q
Name Criteria for Panic Disorder (acronym)
A
Criteria for Panic Disorder (≥4)
STUDENTS FEAR the 3 Cs
- Sweating
- Trembling
- Unsteadiness, dizziness
- Depersonalization, Derealization
- Excessive heart rate, palpitations
- Nausea
- Tingling
- Shortness of breath
- Fear of dying, losing control, going crazy
- 3 Cs: Chest pain, Chills, Choking
13
Q
What’s the difference between Panic Attack vs. Panic Disorder (2)
A
- Panic disorder consists of panic attacks + other criteria
- Panic attacks can occur in the context of many different disorders
14
Q
Describe prognosis: Panic Disorder (2)
A
- 6-10 yr post-treatment: 30% well, 40-50% improved, 20-30% no change or worse
- clinical course: chronic, but episodic with psychosocial stressors
15
Q
Name DSM-5 diagnostic criteria: Agoraphobia (10)
A
- marked fear or anxiety about two (or more) of the following five situations:
- using public transportation
- being in open spaces
- being in enclosed places
- standing in line or being in a crowd
- being outside of the home alone
- the individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms
- the agoraphobic situations almost always provoke fear or anxiety
- the agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety
- the fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context
- the fear, anxiety, or avoidance is persistent, typically lasting ≥6 mo
- the fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- if another medical condition is present, the fear, anxiety, or avoidance is clearly excessive
- the fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder and are not related exclusively to obsessions, perceived defects or flaws in physical appearance, reminders of traumatic events, or fear of separation
Note: agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned
