Anxiety disorders Flashcards
Define anxiety and distinguish between anxiety and fear
Experience of anxiety
Anxiety has two main components:
- Awareness of being nervous/frightened
- Awareness of physiological sensations
Anxiety vs. Fear
- Fear: Emotional response to real or perceived imminent threat.
- Anxiety: Anticipation of future threat. ^[fear of fear]
Describe the components of the fight or flight response that contribute to anxiety
Fight/Flight Response:
- Physical: Involves the autonomic nervous system – adrenaline and noradrenaline, leading to increased heart rate, redistribution of blood to vital areas, increased respiratory rate, sweating, widened pupils, decreased digestion, and muscle tension.
- Cognitive: Shifts attention to surroundings to search for threats. e.g. seen in PTSD
- Behavioral: Fight or flee; if unable to escape - behaviors like foot tapping, pacing, snapping at people may occur. Can sometimes be warning signs to an issue
Explain Yerkes-Dodson Law
Performance on complex tasks is impaired by hyperarousal (excessive anxiety)
Describe physiological systems implicated in stress
- stressor stimulates cerebral cortex, which in turn activates SAM (upregulation of adrenergic and noradrenergic systems), and HPA (upregulation of cortisol)
List and describe the neurotransmitters implicated in anxiety
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Noradrenaline: Produced in the locus coeruleus of the pons; cell bodies of noradrenergic system located here, its stimulation produces fear, while ablation prevents fear.
- projects to cortex, limbic system, brainstem and spinal cord
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Serotonin: Produced in the dorsal raphe nuclei of the brainstem (Cell bodies of system here); SSRIs are efficacious for anxiety reduction, but LSD (a serotonin agonist) is associated with anxiety.
- projects to cortex, limbic system, hypothalamus
- note: probably better understood as a neuromodulator
- Gamma-Aminobutyric Acid (GABA): GABA-A receptors are widely distributed through the CNS. Benzodiazepines increase chloride ion flow into cells, (net) reducing neuronal firing and (inverse agonists) significantly reducing anxiety.
Describe neurobiological components of anxiety and the neurocircuitry of anxiety
- Fear conditioning involves the amygdala and the ventromedial prefrontal cortex (PFC).
- neural stimulus acquires the capacity to evoke fear
- hard to undo
- Extinction of fear is mediated by sections of the frontal cortex.
- subsequent learning allows the organism to no longer treat the conditioned stimulus as dangerous
- Attention orienting to threat involves the amygdala and ventrolateral PFC.
- threat in environment captures attention e.g. snake
- clinical anxiety is a perturbed attention to threat, and is involved with amygdala and ventrolateral PFC
Neurocircuitry of Anxiety:
- Involves mainly the frontal lobes and limbic system.
- Key circuits include the “Fear circuit” (amygdala, orbitofrontal cortex, and anterior cingulate cortex circuits) and the “Worry circuit” (arising from cortico-striato-thalamo-cortical circuit) ^[implicated
Briefly describe anxiety disorders, epidemiology and risk factors
- Disorders share features of excessive fear and anxiety and related behavioural disturbances
- Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviours
- Panic attacks - fear response
- Anxiety can be developmentally normal or situationally appropriate but becomes a disorder if prolonged
- Many develop in childhood, and persist if not treated
Epidemiology:
- Anxiety disorders are very common, especially in mid-life.
- Most common psychiatric disorders in children and adolescents, although prevalence appears highest in mid-life
- They often co-occur with other psychiatric and medical disorders e.g. cardiac, respiratory and neurological conditions
- Lifetime prevalence in the US: 30.5% for women, 19% for men.
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Risk Factors for Children and Adolescents:
- More common in females.
- Stress related to loss
- **Traumatic experiences play a role.
- Underlying vulnerability (stress-diathesis) : diasthesis refers to a predisposition, in this case to developing anxiety in response to a stressor, that someone may not
- Medical conditions - perinatal damage (less than behavioural problems), respiratory conditions including smoking
- parental anxiety e.g. maladaptive role models, depression
- genetic factors are significant. - 40% for anxiety in adults
Reactivity to CO2:
- Respiratory dysregulation and panic disorder
- respiratory stimulants e.g. CO2 are unlearned, fear-inducing stimuli for air-breathing organisms
- sensitivity to respiratory stimulants identifies individials with a diasthesis for anxiety, closely related to spontaneous panic attacks
- sensitivity to CO2 found in children with separation anxiety disorder, but not social anxiety disorder particularly when familial history of panic disorder exists.
- May be related to amygdala
List clinical anxiety disorders
- Generalised Anxiety Disorder: Chronic, persistent excessive worries about a range of issues.
- Social Anxiety Disorder: Intense fear of situations in which the person may feel scrutinised by others.
- Panic Disorder: Recurring, unexpected panic attacks.
- Specific Phobia: Intense fear of – or aversion to – specific objects or situations.
- Agoraphobia: Fear or anxiety about places where help may not be available, or from which escape may be difficult.
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Obsessive-Compulsive Disorder:
- Obsessions: Repeated intrusive, distressing thoughts.
- Compulsions: Need to perform certain routines, e.g., washing, checking, counting rituals.
List medical disorders associated with anxiety
- CV: angina, arrhythmia, MI, stroke
- ENdo: hyperthyroidism, DM, hypocalcemia, phaeochromocytoma
- GI/genitourinary: peptic ulcer disease, pancreatic cancer, UTI
- Metabolic: anaemia, hypogly, hyperh, hyponatremia
- pulmonary: COPD, pneumonia, hypoxaemia
- neuro: delirium, demontia, seizure disorders, Parkinson’s
Describe GAD
- Excessive worry and anxiety that is difficult to control.
- ‘Free-floating’ anxiety – worries in multiple domains, e.g., work/social/health, apprehension about everyday events.
- Causes significant anxiety and distress.
- Often comorbid with major depression or other anxiety disorders.
- Onset often in late teens, 20s.
- Twice as common in females.
- Lifetime prevalence of 4-12%.
Describe GAD symptoms and treatment
- Symptoms present most days for >6 months:
- Restlessness / feeling keyed up / on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension.
- Sleep disturbance.
- Somatic symptoms are common presenting complaints – e.g., headache, chronic diarrhoea.
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Treatment:
- CBT and serotonergic antidepressants (e.g., SSRIs and SNRIs) seem to have similar efficacy.
- Choose based on availability and patient preference.
- Watchful waiting may be appropriate for mild cases.
- Also consider sleep, hygiene, diet and exercise
Describe social anxiety disorder
- some shyness is normal: 33% consider themselves far more anxious than others in social situations
- shyness is heightened in certain developmental times
- Fear of social situations, especially involving scrutiny or strangers
- Fear of embarrassing themselves in social situations
- Avoidance of these situations, or enduring them with intense discomfort – can lead to marked reduction in quality of life –> disorder
- Can be associated with substance abuse especially alcohol to manage
- 12mth prevalence of 3-7%, lifetime prevalence 5-12% in USA
- Persistent – present for 6 months or more
- Often present for many years before patients seek treatment
Describe social anxiety disorder treatment
- CBT – probably more durable symptom response than pharmacotherapy.
- Pharmacotherapy – faster symptom response. SSRI/SNRI is first line. - may take a long time to respond to serotonergics ^[may increase response with greater dose]
- Randomised trials haven’t demonstrated superiority of therapy vs. medications.
- Consider combination of CBT + Pharmacotherapy if failure to respond to single modality.
- Watchful waiting may be reasonable – e.g., especially young adults may need psychoeducation and time to decide.
Describe panic disorder and its symptoms and distinguish between panic attacks
- Definition: Abrupt surge of intense fear or discomfort that reaches a peak within minutes.
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Symptoms (4 or more of the following):
- Palpitations, Sweating, Trembling/shaking, Dyspnoea/sensation of smothering, Feeling of choking, Chest pain/discomfort, Nausea or abdominal distress, Dizziness/presyncope/feeling faint, Chills or heat sensations, Paraesthesia (numb/tingling), Derealisation or depersonalisation, Fear of losing control or ‘going crazy’, Fear of dying.
- It is not a mental disorder
- It cannot be diagnostically coded
- it an occur in a variety of disorders: depression, PTSD, substance use, cardiac, respiratory, GI, vestibular conditions etc
Panic Disorder
- Recurrent panic attacks. Some are not triggered or expected.
- Sustained (>1 month) worry about future attacks or consequence, or change in behaviour (e.g., avoiding precipitating circumstances).
- If attacks are only ever triggered in specific situations and are never spontaneous, may be related to the underlying disorder e.g. specific phobia or social phobia
- 12-month prevalence ~2%.
- May present with chest pain and sense of impending doom e.g. fit, in 20s
- Three symptom domains: attack frequency, anticipatory anxiety, phobic avoidance
- Treatment: Should be guided by patient preference. Psychotherapy (CBT) seems to reduce risk of relapse compared to antidepressants, especially exposure and response prevention. Pharmacotherapy may need to treat for at least a year.
- Antidepressants: SSRIs – start low due to sensitivity to overstimulation (anxiety, jitteriness, insomnia)
- Benzodiazepines: Efficacious but high abuse potential. Avoid if history of substance use disorder. Can also induce avoidance behaviours. Choose longer-acting benzodiazepines – less inter-episode anxiety.
Describe agoraphobia
- Fear or anxiety about places where help may not be available, or from which escape may be difficult
- Can occur alone or with panic disorder
- individuals may insist on family member accompanying them in agoraphobic situations
- when severe, patients may simply refuse to leave home
- Diagnostic criteria:
- Intense fear, arising from thoughts that escape might be difficult or help unavailable, of two or more of:
- using public transport
- being in open spaces
- being in enclosed spaces
- being in a crowd, or standing in line
- being outside of home alone
- Intense fear, arising from thoughts that escape might be difficult or help unavailable, of two or more of:
- Agoraphobic situations almost always induce fear or anxiety
- leads to avoidance
- fear is out of proportion with danger proposed
- present for more than 6 months
- Treatment has limited evidence base, treat as per panic disorder (SSRIs, psychotherapy, other medications)
