Anxiety Flashcards
Anxiety disorders overview
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
Development/ neuroscience
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.
Neurobiology of anxiety
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
Stressor
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
Adjustment disorder
Within 3 months of stressor: development of emotional or behavioral symptoms in response
Marked distress out of proportion
Impairment in functioning
Trauma
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
Post Traumatic Stress Disorder
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
Anxiety Precipitants
Social Situation Trauma- PTSD Obsessions- OCD Unprecipitated- panic
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
PTSD
Because of the trauma that he has seen
Has to last for more than one month!
Specific phobia
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.
Types of anxiety
Generalized worries- kind of always worried. Chewing on ideas.
Panic- happens all at once.
Obsessional- recurrent intrusive, same thing
OCD
Presence if obsessions, compulsions, or both
Time consuming or causes distress or dysfunction
Obsessions
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”
Compulsions
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
Generalized anxiety disorder
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
Common reactions
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.
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
GAD
Panic Disorder
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.
Pharmacology
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
Pharmacology
NRIs
NE is important input and output neurotransmitter in the amygdala
Excessive nE
Psychotherapy
Cognitive Behavioral Therapy
Most evidence based therapy
Focuses on exposure and response prevention
Social Anxiety
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
