Anxiety

Question 1

Describe the anxiety circuitry

(hint: 2 reaction types)

Answer 1

• Fast reaction: thalamus → amygdala → response
• Slow reaction: thalamus → prefrontal cortex determines level of threat → decide if you’re in danger

Question 2

What is normal anxiety?

Answer 2

• fear resulting from the perception of danger
• May arise from internal impulses that threaten a person’s well-being (cramming for a test)

(anxiety is a learning problem→ you must unlearn the process to remove anxiety)

Question 3

What is pathological anxiety?

Answer 3

• Ineffective adaptation to normally occurring threat
• Pathological when functioning is disrupted

Question 4

What are the two types of symptoms that caused disruption in adaptation leading to pathological anxiety?

Answer 4

1. Psychological: worried, demoralization
2. Physical symptoms: cardiac, respiratory, GI or neurological

Question 5

Patients w/ panic or phobias have greater cardiac and respiratory reactivity during _____. Sodium lactate infusions and breathing CO2 may induce ______, which elicit panic attacks.

Answer 5

• sleep
• respiratory alkalosis and exaggerated elevations of brain lactate

Question 6

Anatomic relations to anxiety (3)

Answer 6

1. ​​ Locus coeruleus: relay center for bodies alarm system
2. Dopamine receptors in the prefrontal cortex: avoidance conditioning
3. Dysegulation of serotonin system (panic disorder)
   4.

Question 7

PET studies: look at which structures in anxiety?

Answer 7

1. Amygdala
2. Hypothalamus
3. Prefrontal cortex
4. Fear network

Question 8

Describe the hypothalamic-pituitary-adrenal axis reaction to anxiety

Answer 8

Acute stress → CRF from the paraventricular nucleus (hypothalamus) ⇒ ACTH + cortisol levels → activation of the sympathetic and parasympathetic nervous systems

Question 9

Endocrine disorders that can cause anxiety (4)

Answer 9

1. Pheochromocytoma
2. Thyroid dysfunction
3. Pituitary dysfunction
4. Adrenal disorder

Question 10

Neurological causes of anxiety (4)

Answer 10

1. Head trauma
2. Neurosyphilis
3. Seizure disorder
4. CNS neoplasm

Question 11

Toxic and metabolic causes of anxiety (8)

Answer 11

1. Alcohol or sedative withdrawal
2. Stimulant intoxication
3. Sympathomimetic agents
4. Cannabis
5. B12 deficiency
6. Hypoxia
7. Ischemia
8. Anemia

Question 12

Autoimmune disorders that may cause anxiety (3)

Answer 12

1. Systemic lupus erythematosis
2. Temporal arteritis
3. Polyarteritis nodosa

Question 13

Men with panic disorder have twice the risk of _____

Answer 13

death (cardio & suicide)

Question 14

Anxiety disorders increase the overall rate of _______

Answer 14

Alcoholism

Question 15

Social phobias decrease educational attainment and increase the rate of _______ (2).

Answer 15

1. Teenage pregnancy
2. Marital violence

Question 16

Define classical conditioning

Answer 16

Person learns to associate a neutral object or situation with something that naturally results in a fear response.

(Ex: Watson taught a child to be afraid of a rat by presenting it immediately before a loud and startling noise)

Question 17

Define operant conditioning

Answer 17

Reward vs. punishment influences the response

Question 18

Define negative reinforcement

Answer 18

Person is influenced to escape a situation→ tendency to avoid situation rainforest

(this is not the same thing as punishment!!)

Question 19

Define positive reinforcement

Answer 19

Positive stimulus influences → increases desired behavior

(giving children at Goldstar)

Question 20

Define repression

Answer 20

Unacceptable thoughts, impulses or desires kept out of conscious reach

(trauma: did or didn’t do something → reppress → can’t remember)

Question 21

Interviewing guidelines for anxiety (5)

Answer 21

1. Anxiety symptoms
2. Associated symptoms
3. Life history
4. Medical history
5. Cultural understanding

(and of course, be calm and reassuring, avoid irritation or impatience with them)

Question 22

What is included in a history of anxiety symptoms (6)?

Answer 22

1. Psych & Physical symptoms
2. Onset
3. Duration
4. Distribution
5. Quality
6. Intensity

Question 23

Which associated symptoms are particularly important with anxiety disorder?

Answer 23

1. Depression
2. Suicidal ideation

Question 24

When taking a life history for a patient with anxiety what two things would you want to know?

Answer 24

1. Psychosocial triggers
2. Context of anxiety

Question 25

Anxiety disorders have a tremendous overlap with _____ (disease).

Answer 25

MDD (it is possible to have MDD, GAD & SAD simultaneously)

Question 26

What is the first rule of panic attacks?

Answer 26

A single panic attack does not mean they have panic disorder

Question 27

Criteria for panic attack: A discrete period of intense fear or discomfort, **w/four (or more)** of the following developed abruptly and reached a peak within 10 minutes:

Answer 27

1. ***_Palpitations_*** 2. ***_Sweating_*** 3. ***_Trembling_*** 4. ***_Sensation of SOB_*** 5. ***_Feeling of choking_*** 6. ***_Chest pain_*** 7. Nausea 8. Dizzy, unsteady, lightheaded, or faint 9. Derealization or depersonalization 10. Fear of losing control or going crazy 11. Fear of dying 12. Paresthesias 13. Chills of hot flashes

Question 28

Agoraphobia: anxiety ***_about places_*** (2 or more of the following) for at least ***_6 months_***:

Answer 28

1. Use public transport 2. Being in open spaces 3. Being in closed spaces 4. Standing in line or in a crowd 5. Being outside of home alone

Question 29

Agoraphobia anxiety last \_\_\_\_\_.

Answer 29

at least 6 months (not better accounted for by another psychiatric disorder)

Question 30

Agoraphobia: Situations are avoided or feared because ________ (2).

Answer 30

* Escape might be difficult * Help might not be available in the event of a panic attack (Fear or anxiety is out of proportion to the actual danger posed)

Question 31

Criteria for panic disorder: Recurrent unexpected panic attacks that happen to be followed by ***_at least one month_*** of ***_one of the following_***:

Answer 31

1. Panic about having a panic attack 2. Worry about the implications of another attack 3. Maladaptive change in behavior-related to the attacks (can happen in your sleep)

Question 32

Panic disorder occurrence is highly variable and may occur either _____ or _____ (time frames).

Answer 32

several per day or 2/xs a year

Question 33

Panic disorder are often comorbid with ______ (5).

Answer 33

1. MDD 2. Social phobia 3. GAD 4. OCD 5. PTSD (in order from most to least common)

Question 34

Physical findings of panic disorder (2).

Answer 34

1. Transient tachycardia 2. Moderate elevation of systolic blood pressure

Question 35

General medical conditions comorbid with panic disorder (5)

Answer 35

1. Arrhythmias 2. Asthma 3. Hyperthyroidism 4. COPD 5. IBS

Question 36

Panic disorder: genetics

Answer 36

* Prevalence in first degree relatives 20% * 45% concordance in identical twins; 15% in non-identical twins

Question 37

Prevalence of panic disorder: lifetime? one-year? femal:male

Answer 37

* Lifetime 1-3.5% * One-year: 0.5-1.5% * Female:male 2:1 (Agoraphobia present 1/3 to ½ patients with PD)

Question 38

Panic disorder age of onset & course

Answer 38

* Late adolescence - mid-thirties * Chronic: waxing and waning

Question 39

Panic disorder: primary treatment (4)

Answer 39

1. Relaxation training 2. CBT 3. SSRI 4. SNRI

Question 40

Panic disorder secondary treatment (2)

Answer 40

1. TCA 2. Benzos (tertiary: MAOI's, anticonvulsant. Adjuncts: buspirone, beta blocker)

Question 41

Relaxation exercises for panic disorder

Answer 41

1. Visual Imagery 2. Diaphragmatic Breathing 3. Autogenic training 4. Progressive Muscle Relaxation 5. Yoga 6. Meditation (be familiar)