anxiety disorders

Question 1

how would you explain what anxiety disorders is

Answer 1

anxiety disorders are when one has severe, excessive and persistent anxiety and irrational fears that impairs functioning with everyday living

when anxiety is out of proportion to the actual danger or threat of the situation an persists long after the original trigger has disappeared

Question 2

what are the types of anxiety disorders

Answer 2

GAD
- excessive anxiety and worrying for >6m

PD
SAD
OCD
PTSD

phobias (less amenable to medication therapy)

Question 3

what is the pathophysiology of anxiety disorders

Answer 3

fear and worry circuits
- fear circuit regulated by amygdala
- worry circuit regulated by cortico-striatal-thalamic-cortical (CSTC) loop
- produces physical symptoms (sweating, palpitations, HA, butterflies, trembling, tensing of muscles) and worry symptoms
- physical symptoms can be managed with BZP but worry will require a serotonergic antidepressant

neurochemical dysregulation
- the defense system (originates in the amygdala in the limbic system, responsible for fear, fight or flight responses in response to learned and unlearned threats)
- behavioral inhibition (in hippocampus and septum, responsible for avoidance behavior)
- neurotransmitters (5HT, NE, GABA)

Question 4

what are the etiology of anxiety disorders

Answer 4

• genetic
• perinatal trauma
• medical conditions associated with anxiety
  (CVD: angina, arrhythmia, IHD, CHF, MI; endocrine/ metabolic: hyperT, hyperPTH, hyperK, hypoG, hypoNa, vitB12 and folic acid deficiencies; neurologic: stroke, dementia, delirium, PD, seizures, migraines, inadequate pain control, neoplasm; pulmonary: asthma, COPD, pneumonia, PE; others: anemia, SLE, vestibular dysfunction
• drugs-induced anxiety (xanthines: caffeine, theophylline; corticosteroids; thyroid hormone; stimulants: amphetamines, cocaine; sympathomimetics: pseudoephedrine; antidepressants esp during initiation or rapid dose escalation: TCA, SSRI; DA agonist: levodopa; drug intoxication: digoxin, antihistamine, anticholinergic; drug withdrawal: alcohol, caffeine, BZP, antidepressants, nicotine, sedatives)

Question 5

how is GAD presented

Answer 5

excessive anxiety and worrying for >6m with at least 3 of the following with significant functional impairment
- restlessness, feeling on edge
- easily fatigue
- muscle tension
- difficulty concentrating/ mind going blank
- sleep disturbances

Question 6

how is PD presented

Answer 6

recurrent unexpected panic attacks with at least 1 attack followed by at least 1m of worry about anticipated future panic attacks and/or worry about consequences

panic attacks are a discrete period of intense fear or discomfort with any 4 of the following that develop abruptly and peak in 10mins but usually last up to 20-30mins
- palpitations
- sweating
- trembling/ shaking
- chest pain or discomfort
- abdominal distress or nausea
- feeling dizzy or unsteady
- fear of losing control
- fear of death
- derealization or depersonalization
- chills or hot flushes
- sensations of SOB
- paresthesia

PD can be with or without agorophobia
- which is the anxiety about being in situations that exit is humiliating or help is not readily available

Question 7

how is SAD presented

Answer 7

marked and persistent fear of 1 or more social situations for >6m leading to avoidance and significant functional impairment

Question 8

how is OCD presented

Answer 8

obsessions
- recurrent and persistent thoughts that are intrusive and inappropriate, and a product of one’s own mind

compulsions
- repetitive behavior or mental acts in response to an obsession while aimed at preventing or reducing the distress related to the obsession but are not realistically connected, or are clearly excessive

both together causing marked distress and are time consuming of 1hr or longer or significantly impairs functioning

Question 9

what are the key features of PTSD presentation

Answer 9

• stressor
• intrusive symptoms (persistent reexperiencing)
• avoidance
• negative alterations in mood and cognition
• alterations in arousal and reactivity (aggressive, self-destructive or reckless behavior, hypervigilance, exaggerated startled response, concentration problems, sleep disturbances)

Question 10

what are the rating scales to assess anxiety disorders and the relevant scorings

Answer 10

clinician-rated
*gold standard
- hamilton anxiety scale (HAM-A)
(significant anxiety if 18-20 score, response indicated by 40-50% reduction in score, recovery if score <7)

self-rated
- beck’s anxiety inventory (BAI)
(minimal if 0-7, mild if 8-15, moderate if 16-25, severe if 26-63)
- zung self-rated anxiety scale
*not for use in children