Anxiety

Question 1

Anxiety disorders overview

Answer 1

Anxiety disorders usually begin in childhood (phobias) or adolescents
More common in females (generally)
Rates higher in lower SES and education
Genetics- serotonin transporter gene?
Temperament and personality: behavioral inhibition and anxiety sensitivity/ resiliency

Question 2

Development/ neuroscience

Answer 2

HPA axis and cortisol is the basic “stress response” for infants 0-3 months, attachment related

At 3 months of age the amygdala comes on line (fear)

Fast fear response through the amygdala
Slower processing fear response through prefrontal cortex (becomes fully online about 15 years of age)

Fast fear- fast response when you see something out of the side of your eye and think its a snake you jump and then realize it is a twig.

Slow processing- when you think about it and then realize that it is not a snake. Allows us to further process things.

In anxiety- fast fear response goes out of whack.

Question 3

Neurobiology of anxiety

Answer 3

HPA axis dysregulation (stress response system and NTs)

BDNF necessary for growth and maintenance of neurons; appears to be decreased with high levels of stress

Polymorphisms at the serotonin transport allele with long long genotype conferring more resilience (culturally dependent) to stress related anxiety and depression

Question 4

Stressor

Answer 4

A stimulus or event (positive or negative) that provokes a stress response in an organism
Losing a child 
Divorce
New house 
New job
Getting married

Question 5

Adjustment disorder

Answer 5

Within 3 months of stressor: development of emotional or behavioral symptoms in response

Marked distress out of proportion

Impairment in functioning

Question 6

Trauma

Answer 6

Exposure to actual threatened death, serious injury, or sexual violence in 1 or more ways
Directly experiencing trauma
Witnessing event (in person) as it occurred to others
Learning that trauma happened to close family member or friend (violent or accidental event)
Repeated or extreme exposure to details of trauma

Question 7

Post Traumatic Stress Disorder

Answer 7

Trauma
For greater than one month:
Intrusion: memories, dreams, dissociation distress, marked physiologic reactions
Avoidance
Negative/ flattened alterations in cognitions and mood
Arousal: hypervigilance, reckless, irritability, decreased sleep, anger, concentration, startle (increased startle response)

These people tend to have a bad outlook. Foreshortened future.

Note if these things last for less than a month : acute stress disorder

Question 8

Anxiety Precipitants

Answer 8

Social
Situation
Trauma- PTSD
Obsessions- OCD
Unprecipitated- panic

Question 9

56 year old M from fire department. 3 months ago comes in for physical and mentions that since retiring he can not sleep well, feels irritable, gets angry and cannot stop thinking about the suicide scenes he viewed on calls. Most likely suffering from

Answer 9

PTSD
Because of the trauma that he has seen

Has to last for more than one month!

Question 10

Specific phobia

Answer 10

Marked fear or anxiety about object/situation
Common- flying, enclosed spaces, heights, storms, animals, injection, blood
Provoked immediate anxiety or fear
Avoided
6 months of more/happen each time/ out of proportion to actual threat

Note this is more than just being afraid. Has to be extra.

Question 11

Types of anxiety

Answer 11

Generalized worries- kind of always worried. Chewing on ideas.

Panic- happens all at once.

Obsessional- recurrent intrusive, same thing

Question 12

OCD

Answer 12

Presence if obsessions, compulsions, or both

Time consuming or causes distress or dysfunction

Question 13

Obsessions

Answer 13

recurrent and persistent thoughts/ images/ urges which are intrusive and cause anxiety/distress or preventing dreaded event or situation
Common- contamination, pathological doubt, impulses, sexual images
“Filth, harm, lust, blasphemy”

Question 14

Compulsions

Answer 14

repetitive behaviors or mental acts person feels driven to perform and with goal of decreasing anxiety/distress or preventing dreaded actis or situation
Common- washing, ordering, checking, praying, counting, repeating words

Question 15

Generalized anxiety disorder

Answer 15

Excessive worry/ anxiety about events/activities for more than 6 months

Cannot control worry

Worry associated with 3 of 
restlessness/ keyed up/ on edge
Easily fatigued 
Concentration problems 
Irritability 
Muscle tension
Sleep disturbance

Question 16

Common reactions

Answer 16

Avoidance 
Hypervigilance 
compulsions / obsessiveness 
Muscle tension 
Irritability
Poor concentration 
Fatigue 
Sleep problems 

Note: people want to avoid the thing that makes them anxious but DON’T. can make worse. Try going to a smaller grocery if afraid of going to them.

Question 17

Woman presents with frequent headaches. She feels worried most of the time for the last few years. She feels all keyed up and cannot relax. HAs are like a band around her head. Cause of HAs is

Answer 17

GAD

Question 18

Panic Disorder

Answer 18

Recurrent and unexpected panic attacks with 4 of the following 
Palpitations 
Sweating 
trembling/shaking 
SOB
Choking 
Chest pain
Nausea/ GI distress 
Dizzy, lightheaded/ faint 
Chills or heat 
numbness/ tingling 
derealization/ depersonalization 
Fear of losing control
Fear of dying 

And 1 or more both for 1 month
Worry about more attacks or their consequences
Change in behavior due to attacks

Note: panic attacks at works about 15 minutes in. Generally goes away in 20 minutes. Does not quite go back to baseline.

Question 19

Pharmacology

Answer 19

SRIs
Serotonin is a key neurotransmitter of innervations of the amygdala
Serotonergic inputs to the amygdala may lead to inhibition of output
SRIs increase BDNF
Start low, go SLOW, aim HIGH
SSRIs cause anxiety transiently after initiation of treatment
Consider benzo bridge
Aim very HIGH in dosage range to treat OCD or panic disorder

Question 20

Pharmacology

Answer 20

NRIs
NE is important input and output neurotransmitter in the amygdala
Excessive nE

Question 21

Psychotherapy

Answer 21

Cognitive Behavioral Therapy
Most evidence based therapy
Focuses on exposure and response prevention

Question 22

Social Anxiety

Answer 22

Marked fear or anxiety of 1 or more social/performance situations exposed to scrutiny by others

Common- public speaking, eating, drinking, initiating/maintaining conversations
Fears humiliation by manifesting anxiety- such as blushing/sweating.shaking

Avoid these situations or endured with significant anxiety

6 months or more/ happen each time/ out of proportion to actual threat