Anxiety Flashcards
What percentage of Americans have an anxiety disorder?
25%
What is most common mental disorder in women? Men?
Specific phobia is most common mental disorder in women (2nd in men).
Substance abuse is most common mental disorder in men.
More common in men / women:
Panic, GAD, OCD
Panic and GAD more common in women.
OCD is equal.
2 components of anxiety
1) awareness of physiological sensations (palpitations / sweating)
2) awareness of feeling nervous / frightened
Prognosis of panic disorder, GAD, and OCD
1/4 do well, 1/2 do OK, 1/4 do poorly
What 2 parts of brain have receptors for cortisol?
Hypothalamus and hippocampus
Regulation of amygdala
Amygdala is modulated / regulated via PFC, especially orbitofrontal cortex. PFC involved in extinction or “unlearning” of fear associations. PFC also learns from scary experiences. PFC can activate the amygdala and produce fear as well, such as occurs w/ ruminating.
Systemic effects of chronic stress
Excessive stress / cortisol may lead to HTN, obesity, diabetes, osteoporosis, suppressed immune system, memory problems, changes in brain structure, and depression.
What decreases neurogenesis?
What increases neurogenesis?
Chronic stress such as PTSD may lead to neuronal atrophy in hippocampus. Decreased neurogenesis in subgranular zone. Antidepressants, learning, and exercise help promote neurogenesis.
Anxious temperament
Extreme behavioral inhibition to novel situations or strangers. May involve freezing. Identified early in life. Parents may pass this down via genes and behaviors. Predicts development of anxiety disorders, depression, and drug use later in life.
Biological disturbances seen in panic disorder
Increased catecholamines, increased activity of locus ceruleus, CO2 hypersensitivity, disturbance in lactate metabolism, and abnormality in GABA
Brain abnormalities seen in panic disorder
May have abnormalities in temporal lobe, specifically hypothalamus
DSM criteria for panic disorder (2 main things)
A) recurrent unexpected panic attacks
B) attack is followed by 1+ month of persistent concerns about future panic attacks or maladaptive change in behavior related to attacks (avoidance)
Agoraphobia
May be comorbid w/ panic disorder.
Involves anxiety about 2+ of the following: using public transportation, being in open spaces, being in enclosed spaces, standing in line or in a crowd, or being outside the home alone.
Tx for panic disorder
- Tx w/ meds and psychotherapy.
- SSRI’s are 1st line. SNRI’s are also good.
- Benzos are good during panic attacks but should be limited to short periods of use. Benzos are also good for as needed until the SSRI kicks in.
- CBT used to education pxs to make more appropriate attributions for distressing somatic sxs (not actually having a heart attack or dying). Involves distraction and deep breathing. Exposure therapy may also be helpful.
Biological changes seen w/ GAD.
What parts of brain?
NE, GABA, and 5HT disturbances in frontal lobe and limbic system
Does environment or genetics play a stronger role for GAD?
Environment
DSM criteria for GAD (3 main things)
A) Excessive anxiety and worry (apprehensive expectation) about multiple events or activities for at least 6 months.
B) Difficult to control the worry
C) Anxiety causes significant distress or impairment in social, occupational, or other functioning.
Tx for GAD
- Tx w/ meds and psychotherapy.
- SSRI’s are 1st line. SNRI’s are also good.
- Benzos may be used but are not great due to risk of addiction.
- CBT involves restructuring distortions about anxiety-provoking aspects of their environment. Utilizes deep breathing, muscle relaxation, and imagery.
DSM criteria for OCD (2 main things)
A) Obsessions, compulsions, or both (most pxs have both). Person tries to ignore or suppress thoughts, urges, or images, or relieves them via their compulsion.
B) Obsessions / compulsions are time consuming (takes >1 hr / day) or cause significant distress / impairment.
Pathogenesis of OCD
Caused by serotonin dysfunction. Often have increased activity in PFC (obsessions) and in caudate (compulsions). Strong genetic component. In a different category than anxiety disorders in DSM.
Common co-morbidities in OCD
Pxs w/ OCD also have depression 75% of the time. 20% of having a tic.
PANDAS
Pediatric Autoimmune Neuropsychiatric Disorders Associated w/ Streptococcal Infections. Occurs in pxs following GAS.
May cause OCD.
OCD associated w/ which neurologic disorders?
TBI, epilepsy, or Huntington’s.
Genetically linked to Tourette’s.
Most common obsessions
Contamination, pathological doubt, somatic (fear of having an illness, concern w/ appearance, or preoccupation w/ body parts), need for symmetry / orderliness, aggressive impulses, and sexual impulses
Most common compulsions
Checking, washing, counting, need to ask / confess, symmetry / precision, hoarding.
Indicators of poor prognosis for OCD
Yielding to compulsions, childhood onset, bizarre compulsions, need for hospitalization, and coexisting depression or personality disorder.
Indicators of good prognosis for OCD
Good social / occupational adjustment, presence of a precipitating event (such as pregnancy), and an episodic symptom course.
Treatment for OCD
- Tx w/ meds and psychotherapy.
- SSRI’s are first line, but require higher dose and longer duration than what is needed for depression or anxiety.
- May augment w/ antipsychotic meds and psychosurgery (cingulotomy).
- CBT in this case involves exposure / response prevention. Family therapy is helpful to prevent family members from helping px fulfill their compulsions.
OC personality disorder
Not distressing to the person. Lack insight into obsessions. Inflexible. Anal-retentive. Don’t realize your thoughts / actions are abnormal.
Somatic symptom disorder
Description
Population
Co-morbidities
- Distressing / impairing somatic sxs that cannot be explained by physical / lab exam. May include pain (most common), GI sxs, sexual sxs, and neurological sxs. May cause high levels of anxiety about health and excessive time / energy is related to these matters.
- More common in women.
- Co-morbid anxiety / depression are common.
- Diagnosis of exclusion.
Conversion disorder
Px presents w/ one or more neurological sxs such as blindness, seizures, or paralysis, w/o an identifiable neurological cause. Psychological factors may be causative. Pxs do not intentionally fake these sxs and may not be conscious of any link b/w psychological stress and their sxs.
Anxiety disorder due to a medical condition
Hyperthyroidism, hyperparathyroidism, pheochromocytoma, hypoglycemia, cardiac arrhythmia, mitral vavle prolapse, pulmonary embolus, and MI.
Anxiety disorder due to a substance / medication
Caffeine intoxication, stimulants (such as methylphenidate), alcohol / sedative / hypnotic withdrawal, albuterol, prednisone, thyroid medication, bupropion (antidepressant), pseudoephedrine (decongestant).
