Anxiety Flashcards
- *Anxiety:**
- Involves ____ of a future threat
- Is a normal part of life and can be __
- Associated with___ tension and vigilance
- Generally produces cautious and ___ behavior
- *When does Anxiety become a Disorder?**
- When anxiety is excessive or out of proportion for the situation
- When anxiety persists (generally longer than __ months)
- *Fear:**
- A response to a real or perceived imminent threat
- Triggers “Fight or Flight” response
- reflexive ___ ___ arousal
- Generally produces escape behavior longer than ___ months)
- Associated with distress and/or dysfunction
- *Anxiety:**
- Involves anticipation of a future threat
- Is a normal part of life and can be adaptive
- Associated with muscle tension and vigilance
- Generally produces cautious and avoidant behavior
- *When does Anxiety become a Disorder?**
- When anxiety is excessive or out of proportion for the situation
- When anxiety persists (generally longer than 6 months)
- *Fear:**
- A response to a real or perceived imminent threat
- Triggers “Fight or Flight” response
- reflexive autonomic sympathetic arousal
- Generally produces escape behavior longer than 6 months)
- Associated with distress and/or dysfunction
- *Neurobiology of Anxiety**
- *1. Adrenal Medulla**
- Releases ____
- Pts with ___ (benign tumor that develops in adrenal glands) often panic like symptoms (sweating)
- *2. Amygdala**
- Releases ____
- Associated with __ and aggression)
- Part of the ___ system
- Linked to ___ response
- *3. Insular Cortex:
- **Associated with ___ physical status and somatic ___
**4. Sympathetic Autonomic Arousal
- NT’s involved:**
__,__ and __.
NE: is produced in the__ ___
- Electrical stim. of the __ ___ in animals produced panic response
- Panic attacks can be provoked in panic disorder patients by ___ inhalation, ___ ___ infusion (neurostimulant), ____ (presynaptic α-2 blocker which increases norepi)
Serotonin: Serotonin (5-HT activity) is produced in the frontal cortex by the __ __ ___ - It mediates worry, anticipation, “rumination”
Decreased GABA causes an inability to relax
- *Neurobiology of Anxiety**
- *1. Adrenal Medulla**
- Releases epinephrine
- Pts with pheochromocytoma (benign tumor that develops in adrenal glands) often panic like symptoms (sweating)
- *2. Amygdala**
- Releases epinephrine
- Associated with fear and aggression)
- Part of the limbic system
- Linked to autonomic response
- *3. Insular Cortex:
- Associated withmonitoringphysical status and somaticanxiety**
**4. Sympathetic Autonomic Arousal
- NT’s involved:**
NE, Serotonin, GABA
NE: is produced in the locus coruleus
- Electrical stim. of the locus coruleus in animals produced panic response
- Panic attacks can be provoked in panic disorder patients by CO2 inhalation, sodium lactate infusion (neurostimulant), yohimbine (presynaptic α-2 blocker which increases norepi)
- Serotonin: Serotonin (5-HT activity) is produced in the frontal cortex by the dorsal raphe nucleus
- It mediates worry, anticipation, “rumination”
Decreased GABA causes an inability to relax
Specifc Phobia:
Presentation:
1. Marked fear or anxiety about a specific ___ or __.
- Phobic stimulus is avoided or endured with intense fear or anxiety
- Anxiety is out of ____
- The person recognizes/does not recognize that the fear is excessive or unreasonable
- Generally last more than __ months
- Associated with distress of dysfunction
- Rare/common for pts to seek treatment
Background:
___ month prevalence is __ to __ %
Females: males - __:___
Sometimes follows a ___ event
The fear, anxiety, or avoidance causes clinically significant impairment in social, occupational or other important areas of functioning
Onset typically develop in early ____, typically prior to age ___ for animals, natural environment, blood-injury
Onset typically develop in __-__ for situational phobia
May be precipitated by ___ event
Specifc Phobia:
Presentation:
1. Marked fear or anxiety about a specific object or situation
- Phobic stimulus is avoided or endured with intense fear or anxiety
- Anxiety is out of proportion
- The person recognizes/does not recognize that the fear is excessive or unreasonable
- Generally last more than 6 months
- Associated with distress of dysfunction
- Rare/common for pts to seek treatment
- *Background:**
- *12** month prevalence is 7 to 9 %
Females: males - 2:1
Sometimes follows a traumatic event
The fear, anxiety, or avoidance causes clinically significant impairment in social, occupational or other important areas of functioning
Onset typically develop in early childhood, typically prior to age 10 for animals, natural environment, blood-injury
Onset typically develop in mid-20’s for situational phobia
May be precipitated by traumatic event
Social Phobia:
a shorter acting episode but higher level than social anxiety disorder
1. Fear of social situations
- Including performance situations
- Exposure to situation may be accompanied by __ __
- May be confined to ___ situations or may be ___.
- *Onset and Course:**
- Typical onset in ___-___ (may have been shy as a child)
- Course usually ___ (may attenuate in adulthood, or person just avoids phobic situations)
Dx:
- Becomes a diagnosis when the anxiety prevents an individual from participating in a __ __ or causes marked __
Treatment:
__ __
Social Phobia:
a shorter acting episode but higher level than social anxiety disorder
1. Fear of social situations
- Including performance situations
- Exposure to situation may be accompanied by panic attack
- May be confined to specific situations or may be generalized
- *Onset and Course:**
- Typical onset in mid-teens (may have been shy as a child)
- Course usually continues (may attenuate in adulthood, or person just avoids phobic situations)
Dx:
- Becomes a diagnosis when the anxiety prevents an individual from participating in a desired activity or causes marked distress
- *Treatment:**
- *group therapy**
Social Anxiety Disorder - a similar but higher degree of ____ PD
- *Presentation:**
1. Marked fear/anxiety about one or more ___ situations
2. Focused on scrutiny of others and potential humiliation or embarrassment
3. Social situations almost always produce ___
4. Social situations are endured or avoided
5. Last more than __ months
6. Associated with distress and dysfunction
Background:
___ month prevalence is __% in U.S.
Females: Males – __:___
75% of patients have onset between __ to __ years (median onset __ years)
Can be markedly impairing of work, social, and personal function
Needs to be distinguish from “___ ___”
Social Anxiety Disorder - a similar but higher degree of avoidant PD
- *Presentation:**
1. Marked fear/anxiety about one or more social situations
2. Focused on scrutiny of others and potential humiliation or embarrassment
3. Social situations almost always produce anxiety
4. Social situations are endured or avoided
5. Last more than 6 months
6. Associated with distress and dysfunction
Background:
12 month prevalence is 7% in U.S.
Females: Males – 2:1
75% of patients have onset between 8 to 15 years (median onset 13 years)
Can be markedly impairing of work, social, and personal function
Needs to be distinguish from “normative shyness”
GAD: Presentation:
- Excessive anxiety and worry (__ to __ hrs per day) on more days than not for at least ___ months
- Individual finds it difficult to control the ____
- Associated with restlessness, being easily fatigues, difficulty concentrating, irritability, muscle tension, and sleep disturbance
- Causes distress or dysfunction
- Often accompanied by ____
- A acute/chronic disorder
- Can be relayed to psychosocial stressors
- Much like “pain,” it is subjectively assessed for ____ by the pt.
Background:
___ month prevalence ___% in U.S.
Females: males – __:___
Often lifelong but median onset is age ___
Can wax and wane (worse under stress)
Can be quite disabling (accounts for 110 million disability days per year in US)
Physical Symptoms:
Feelings of ____
Fatigue
____ tension
Insomnia
GAD: Presentation:
- Excessive anxiety and worry (8 to 10 hrs per day) on more days than not for at least 6 months
- Individual finds it difficult to control the worry
- Associated with restlessness, being easily fatigues, difficulty concentrating, irritability, muscle tension, and sleep disturbance
- Causes distress or dysfunction
- Often accompanied by depression
- A chronic disorder
- Can be relayed to psychosocial stressors
- Much like “pain,” it is subjectively assessed for severity by the pt.
Background:
12 month prevalence 2.9% in U.S.
Females: males – 2:1
Often lifelong but median onset is age 30
Can wax and wane (worse under stress)
Can be quite disabling (accounts for 110 million disability days per year in US)
Physical Symptoms:
Feelings of restlessness
Fatigue
muscle tension
Insomnia
Panic Attack:
Background Info:
Introduced in 1980 with the DSM-III
Initially agoraphobia with or without panic attacks
___ times more in women than in men
Prevalence ___% of females ages __ to ___
Presentation:
____ unexpected panic attacks AND __ month or more of persistent concern or worry about additional panic attacks or their consequence (“anticipatory anxiety”) OR ___ behavioral change (“avoidance behavior”)
What is a panic attack?
Sudden intense feelings of severe anxiety with accompanying physical symptoms- a “____”
Anxiety develops ____ and reaches a peak within ___ to ___
Panic attack lasts __ to ___minutes
May be spontaneous
Always precipitated, if panic only occurs in response to a specific stimulus, this suggests ____.
Can occur from ___ (nocturnal panic attacks)
Physical Symptoms
Palpitations, pounding heart, tachycardia, sweating, trembling or shaking (almost feels like heart attack)
Sensations of shortness of breath or smothering - dyspnea
Feeling of choking
Chest pain or discomfort
Nausea or abdominal discomfort
Dizzy, unsteady, lightheaded, or faint feeling (not vertigo and not true L.O.C.)
Chills or hot flashes
Paresthesias (numbness or tingling sensations), generally perioral and finger tips
Cognitive Symptoms:
Intense ____
____ (feeling of unreality)
___ (detached from oneself, own body )
Fear of losing control or going crazy
Fear of dying
Panic Attack Course:
Typically begins in late adolescence (___ to ___) or early adulthood (especially in patients with family history for Panic Disorder)
May begin with “limited symptom attacks”
Patient typically has one or more ED visits
If undiagnosed/untreated patient may develop phobias, avoidance behavior, depression (demoralization) and/or substance use disorder
May culminate in ____ thoughts/actions
Typically demonstrates a ___ course
Panic Attack:
Background Info:
Introduced in 1980 with the DSM-III
Initially agoraphobia with or without panic attacks
2.5 times more in women than in men
Prevalence 2.5% of females ages 15 - 24
Presentation:
Reuccrent unexpected panic attacks AND 1 month or more of persistent concern or worry about additional panic attacks or their consequence (“anticipatory anxiety”) OR maladaptive behavioral change (“avoidance behavior”)
What is a panic attack?
Sudden intense feelings of severe anxiety with accompanying physical symptoms- a “crescendo”
Anxiety develops abruptly and reaches a peak within seconds to minutes
Panic attack lasts 10 to 20 minutes
May be spontaneous
Always precipitated, if panic only occurs in response to a specific stimulus, this suggests phobia.
Can occur from sleep (nocturnal panic attacks)
Physical Symptoms
Palpitations, pounding heart, tachycardia, sweating, trembling or shaking (almost feels like heart attack)
Sensations of shortness of breath or smothering - dyspnea
Feeling of choking
Chest pain or discomfort
Nausea or abdominal discomfort
Dizzy, unsteady, lightheaded, or faint feeling (not vertigo and not true L.O.C.)
Chills or hot flashes
Paresthesias (numbness or tingling sensations), generally perioral and finger tips
Cognitive Symptoms:
Intense anxiety
Derealization (feeling of unreality)
Depersonalization (detached from oneself, own body )
Fear of losing control or going crazy
Fear of dying
Panic Attack Course:
Typically begins in late adolescence (15 to 24) or early adulthood (especially in patients with family history for Panic Disorder)
May begin with “limited symptom attacks”
Patient typically has one or more ED visits
If undiagnosed/untreated patient may develop phobias, avoidance behavior, depression (demoralization) and/or substance use disorder
May culminate in suicidal thoughts/actions
Typically demonstrates a progressive course
Agoraphobia:
- *Background Info:**
- Associated with fear on not being able to escape or not control oneself resulting in embarrassment
- Avoidance of the agoraphobic situations
- ___ months or more in duration
- Fear or anxiety is out of proportion to the situation
- Causes distress and/or dysfunction
Presentation:
- Marked fear or anxiety about 2 or more of the following situations:
- Using public _____
- Being in __ __
- Being in ___ places
- ___ in line or being in a ___
Being outside of the home alone
Agoraphobia:
- *Background Info:**
- Associated with fear on not being able to escape or not control oneself resulting in embarrassment
- Avoidance of the agoraphobic situations
- 6 months or more in duration
- Fear or anxiety is out of proportion to the situation
- Causes distress and/or dysfunction
Presentation:
- Marked fear or anxiety about 2 or more of the following situations:
- Using public transportation
- Being in closed spaces
- Being in open places
- standing in line or being in a crowd
Being outside of the home alone
Anxiety Induced by: Substances, Medications or Medical Conditions
Common Substances:
- A___ 2. C__ 3. C___ 4. C__ 5. M__ 6. Phencyclidine (PCP) 7. H__ 8. I___ (glue)
Common Medications:
- S___ 2. S____ 3. Sedative/hypnotics 4. Theophylline (induced anxiety attacks) 5. ___ agonists 6. C___ 7. Anticholinergics 8. ___ hormone 9. Insulin 10. Oral contraceptives 11. A___ (especially TCA’s)
Common Medical Conditions:
1. Pulmonary Disorders
- C___
- A___
- P___
- ___ starvation
2. Endocrine Disorders
- Hyper/hypo ____
- ____ (rare, benign tumor that develops in an adrenal gland)
- Episodic___ assoc. w/ insulinomas
- ___parathyroidism
3. Cardiac Disorders
- Cardiac arrhythmia
- Congestive heart failure/MI
- Pulmonary embolism
4. Neurological Disorders
- S____
- V____ dysfunction
- N___
5. Others:
- ___ ___syndrome (very important)
Anxiety Induced by: Substances, Medications or Medical Conditions
Common Substances:
- Alcohol 2. Cocaine 3. Cannabiis 4. Caffeine 5. Meth 6. Phencyclidine (PCP) 7. Hallucinogens 8. Inhalants (glue)
Common Medications:
- Stimulants 2. Sympathomimetics 3. Sedative/hypnotics 4. Theophylline (induced anxiety attacks) 5. Beta agonists 6. C 7. Anticholinergics 8. Thyroid hormone 9. Insulin 10. Oral contraceptives 11. Antidepressants (especially TCA’s)
Common Medical Conditions:
1. Pulmonary Disorders
- COPD
- Asthma
- Pneumonia
- O2 starvation
2. Endocrine Disorders
- Hyper/hypo thyroidism
- Pheochromocytoma (rare, benign tumor that develops in an adrenal gland)
- Episodic hypoglycemia assoc. w/ insulinomas. (your adrenal glands kick in and release adrenaline and cortisol, which causes you to feel more anxious and aroused and also has the specific purpose of causing your liver to release stored sugar in order to bring your blood sugar level back to normal.)So the subjective symptoms of hypoglycemia arise both from a deficit of blood sugar and a secondary stress response mediated by the adrenal glands. Adrenaline, or epinephrine, and cortisol, or hydrocortisone, are stress hormones secreted from the adrenal glands, which sit above the kidneys. … Cortisol binds to receptors on the fat cells, liver and pancreas, which increases glucose levels available for muscles to use.
- Hyperparathyroidism
3. Cardiac Disorders
- Cardiac arrhythmia
- Congestive heart failure/MI
- Pulmonary embolism
4. Neurological Disorders
- Seizures
- Vestibular dysfunction
- Neoplam
5. Others:
- Irritable bowel syndrome (very important)
OCD
Obsession:
- ____ thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety and distress
- Not simply excessive worries about real life problems
Compulsions:
- ____ behaviors or mental acts that the person feels driven to ____ or according to rules that must be rigidly applied that the person recognizes are excessive or unreasonable.
Background Info:
- Typically starts in ___ or early ____. Often first symptoms around age ___.Usually a ___ course
- Waxes and wanes, possibly related to stress
- 15% have progressive deterioration in functioning (still an indication for psychosurgery)
Comorbidities:
- Panic disorder, phobias
- ___ Disorders
- ___ ___ Disorder
- Questionable relationship to ____’s disorder
Medications:
- ____s 2. ___’s (Clomipramine aka Anafranil)
- May require __ doses and longer duration than in depression
- Very minimal placebo response in trials
__ ___ __ - mainstream treatment
Side Effects of TCAs
SO UTerlly SD
OCD
Obsession:
- Recurrent thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety and distress
- Not simply excessive worries about real life problems
Compulsions:
- Repetitive behaviors or mental acts that the person feels driven to perform or according to rules that must be rigidly applied that the person recognizes are excessive or unreasonable.
Background Info:
- Typically starts in childhood or early adolescence. Often first symptoms around age 8. Usually a chronic course
- Waxes and wanes, possibly related to stress
- 15% have progressive deterioration in functioning (still an indication for psychosurgery)
Comorbidities:
- Panic disorder, phobias
- Eating Disorders
- Major Depressive Disorder
- Questionable relationship to Tourette’s disorder
Medications:
-
SSRIs 2. TCA’s (Clomipramine aka Anafranil)
- May require higher doses and longer duration than in depression
- Very minimal placebo response in trials
- *Cognitive Behavioral Therapy** - mainstream treatment
Side Effects of TCAs
SO UTerlly SD
Sedation, Orthostatic hypotension, urinary retention, tachycardia, decreased sexuality, dry mouth
Two ways to treat anxiety: pharmacologically and nonpharmacologically
- *Pharmacological:**
1. ___
-
-
-
-
- ___
- ___
- ____
- ____
Nonpharmacologically:
1. ___
- ___
- ___
Two ways to treat anxiety: pharmacologically and nonpharmacologically
- *Pharmacological:**
1. Antidepressants: - **MAOI’s
- TCA’s
- SSRIs**
- *- NSRIs**
2. Benzodiazepines
3. 5-HT1A partial agonists
4. Noradrenergic Suppressors
- Antihistamines
- *Nonpharmacologically:**
1. CBT
- Desensitization
- Psychodynamic Psychotherapy
Antidepressants for Anxiety:
- MAO Inhibitors - ___ (Nardil)
- TCA’s -____ (tofranil), ____ (Anafranil)
- SSRIs - ____ (Paxil), ___ (Zoloft)
- NSRIs
- Dual Mechanism Agents ___ (Effexor), ____ (Cymbalta)
Advantages:
- Can be quite effective
- No risk of __ or ___
- Can be taken __-___ with no obvious detrimental effects
Disadvantages:
- Troubling side-effects
- ____ response (2-3 wks )
- ___ effectiveness
Antidepressants for Anxiety:
- MAO Inhibitors - Phenylzine (Nardil)
- TCA’s - Impramine (tofranil), Clomipramine (Anafranil)
- SSRIs - Peroxetine (Paxil), Sertraline (Zoloft)
- NSRIs
- Dual Mechanism Agents Venlafaxine (Effexor), Duloxetine (Cymbalta)
Advantages:
- Can be quite effective
- No risk of abuse or dependence
- Can be taken long-term with no obvious detrimental effects
Disadvantages:
- Troubling side-effects
- Delayed response (2-3 wks )
- Partial effectiveness
Benzodiazepines
- Particularly indicated for ___ resolution of panic attacks in panic disorders
Drugs:
- ___ (Xanax)
- ____ (Klonopin)
Advantages
- Tolerable
- ____ effective
- Potent _____
- *Disadvantages**
1. S___
- ___motor impairment
- D___
- ____ potential
- __/___ impairment
- Very dangerous to use in____ b/c of fall risks
Benzodiazepines
- Particularly indicated for rapid resolution of panic attacks in panic disorders
Drugs:
- Alprazolam (Xanax)
- Clonazepam (Klonopin)
Advantages
- Tolerable
- Rapidly effective
- Potent anxiolytic
- *Disadvantages**
1. Sedation
- Psychomotor impairment
- Dependence
- Abuse potential
- Memory/cognitive impairment
- Very dangerous to use in elderly b/c of fall risks
5-HT1A Partial Agonists Drugs for Anxiety
Drugs:
____
- *Advantages:**
1. No ___
- No ____
- No __ potential
- Can be helpful for __ or ___.
Disadvantages:
- Not effective for __ ___
- Must be taken steadily for __ to __ wks to have effect
5-HT1A Partial Agonists Drugs for Anxiety
- *Drugs:**
- *Buspiraone**
- *Advantages:**
1. No dependence
- No impairment
- No abuse potential
- Can be helpful for irritability or aggression
Disadvantages:
- Not effective for panic disorders
- Must be taken steadily for 1 to 2 wks to have effect
- *Noradrenergic Suppressors**
1. _____ (Inderal) -b-blocker
- ___ (b-blocker)
- ___ (b-blocker)
- ____ (presynap. alpha2 agonist)
Advantages:
- ____ good for performance anxiety and tremors
- Good for pts with ___ triggers and/or ___
Disadvantages:
- ___ and ___ don’t cross BBB, so less ___ affect on CNS
- Clonidine - not useful in __ __
- *Noradrenergic Suppressors**
1. Propanolol (Inderal) -b-blocker
- Atenolol (b-blocker)
- Nadolol (b-blocker)
- Clonidine (presynap. alpha2 agonist)
Advantages:
- Proponol good for performance anxiety and tremors
- Proponol good for pts with cardiac triggers and/or tremors
Disadvantages:
- Atenolol and Nadolol don’t cross BBB, so less depressant affect on CNS
- Clonidine - not useful in panic disorders
