Anxiety disorders

Question 1

Anxiety disorder impact

Answer 1

considerable suffering/impaired functioning
Prevalence: among the most common psychiatric disorders
1 year prevalence: 12-17%
leading cause for seeking mental health services

Question 2

Normal/clinical anxiety

Answer 2

anticipation of future threat
characterized by:
- muscle tension
- vigilance in preparation for danger
- cautious or avoidant behaviours

Question 3

Normal/clinical fear

Answer 3

Emotional response to real or perceived therat
characterized by:
- surges of autonomic arousal
- thoughts of immediate danger
- escape behaviours

Question 4

Clinical fear and anxiety

Answer 4

excessive in relation to degree of threat
persistent
significant distress/impairment in social and occupational functioning

Question 5

Features of anxiety/related disorders

Answer 5

Unwanted emotions: panic attacks, chronic hyperarousal, excessive fear

Unwanted thoughts: obsession, excessive worries, intrusive recollections

Unwanted actions: avoidance, escape, distraction, compulsions

Fear of consequences and maladaptive behaviours

Question 6

Major DSM-5 anxiety disorders and related disorders

Answer 6

Panic disorder
Agoraphobia
Specific phobia
Social anxiety disorder
GAD
PTSD
OCD

Question 7

Panic attacks

Answer 7

occurs in all anxiety disorders
discrete period of intense fear or discomfort
abrupt onset
peaks w/in 10 minutes
peak intensity lasts an average of 20 minutes
can occur during waking hours/during sleep
>=4 symptoms required to define a panic attack
attacks with fewer than four symptoms = limited symptom panic attacks

Question 8

Panic attack symptoms

Answer 8

Need four or more, otherwise a "limited symptom" panic attack
Palpitations
trembling/shaking
choking sensations
nausea/GI distress
chills/hot flushes
derealization/depersonalization
fear of dying
sweating
dyspnea
chest pain or discomfort
paresthesias (numbness, tingling)
dizziness/faintness
fear of losing control/going crazy

Question 9

Unexpected/spontaneous panic

Answer 9

characteristic of panic disorder

Question 10

Expected panic attacks

Answer 10

triggered by a phobic stimulus

Question 11

Cognitive model of panic attacks

Answer 11

Trigger –> perceived threat –> apprehension –> body sensations –> interpretation of sensations as catastrophic –> threat, etc.

Question 12

Panic disorder

Answer 12

Recurrent, unexpected panic attacks
A month or more of:
- persistent concern about further attacks
- worry about implications
- significant change in behaviour

Question 13

Agoraphobia

Answer 13

typically a result of panic disorder
Fear of situations in which escape might be difficult or embarrassing if panic-like symptoms occur
feared situations are avoided/endured with dread

Question 14

Situations commonly feared/avoided in agoraphobia

Answer 14

Travelling
being far from home
enclosed spaces
wide open spaces
supermarket line-ups
high places
being alone

Question 15

Specific phobia

Answer 15

severe, excessive, persistent fear
exposure evokes fear/panic
avoidance
recognizes fear is unreasonable
Not panic disorder
Subtypes:
animal, natural environment stimuli, situations, blood-injection-injury, others

Question 16

Specific phobia of dentistry

Answer 16

80% adults apprehensive, 20-30% only visit when in pain
5% visit only in extreme circumstances
Commonly due to traumatic childhood experiences
50% have blood-injury injection phobia

Tx: BDZ prior to visit, but will relapse; CBT with lasting benefits

Question 17

Social anxiety disorder

Answer 17

Severe, excessive, and persistent fear of:
- social intreactions
- social performance situations
exposure to phobia evokes fear/panic
extreme fear of negative evaluation
person typically avoids
recognizes fear is unreasonable

Question 18

Generalized anxiety disorder

Answer 18

excessive anxiety and worry
difficulty controlling worry
thinks worrying is proactive
associated symptoms: restless, tension, feeling "on edge", concentration difficulties, irritability, insomnia
lasts at least 6 months

Question 19

OCD

Answer 19

either obsessions or compulsions
rule-forming
Obsessions: recurrent, persistent thoughts, impulses, or images
- intrusive, unwanted
- not simply excessive worries

Compulsions:

• repetitive behaviours/mental acts
• aimed at reducing distress or preventing harm

Question 20

PTSD

Answer 20

exposure to a traumatic event
4 groups of symptoms:
1) re-experiencing
2) avoidance
3) negative changes in mood/cognition
4) hyperarousal

> 1 month

Question 21

Trauma exposure and PTSD

Answer 21

PTSD is comparatively rare to trauma!

most people are resilient

Question 22

Trends of anxiety disorders

Answer 22

most: F:M gender ratio range from 2-3:1
OCD: gender ratio 1:1 but earlier onset in males
age of onset:
- varies with disorder
- varies with exposure to stressors
- most arise in adolescence
- phobias often arise in childhood

Question 23

Conditioned fear reactions

Answer 23

Classical conditioning
Operant conditioning (avoidance learning)
Role in PTSD, phobias)

Question 24

Maladaptive fears

Answer 24

prominence role in panic disorder and social anxiety disorder
appear to play a role in other anxiety disorders

Question 25

Genetics factors - anxiety disorder

Answer 25

No big genes associated with anxiety disorders
Polymorphisms?
Suggestive evidence of the role of genes involved in NT function and neuronal development

Question 26

Environmental factors - anxiety disorder

Answer 26

Family environment not as important as previously thought, although likely plays some role
extreme family family environments are likely to contribute to risk of developing anxiety disorders
Expressed emotion of family membranes can exacerbate/perpetuate anxiety disorders
environmental experiences outside of family are important: fear conditioning experiences

Question 27

Neuroanatomy implicated in anxiety disorders

Answer 27

Amygdala
HPA axis
prefrontal cortex
hippocampus
frontal-striatal circuits (OCD)

Question 28

Circuit implicated in anxiety

Answer 28

Sensory thalamus
Amygdala
Cortex
Hippocampus
HPA axis
all interplay (amygdala/cortex in the middle)

Question 29

Frontal-striatal circuits implicated in OCD

Answer 29

Thalamus:
Putamen - anterolateral OFC (motor control, response inhibition)
Dorsal caudate - dorsolateral PFC (working memory, executive function) - ACC/ventromedial PFC 9error monitoring, doubting) - nucleus accumbens

Question 30

Neurotransmitter systems implicated in anxiety disorders

Answer 30

GABA
Glutamate
Serotonin
Noradrenaline
Dopamine

Question 31

Cognitive factors in anxiety disorders

Answer 31

Dysfunctional beliefs
Selective attention to threat
Misinterpretation of threat

Question 32

Anxiety sensitivity

Answer 32

fear of arousal-related body sensations (fear of fear)
Arises from beliefs about consequences of sensations
- somatic: discomfort vs death
- cognitive: mild vs permanent mental incapacitation
- social: none vs social ostracism/ridicule

Question 33

Anxiety treatment

Answer 33

1) CBT (exposure therapy, cognitive restructuring), SRI (fluoxetine, sertraline, paroxetine, clomipramine)

Question 34

Norepinephrine production metabolism

Answer 34

Tyrosine –> L-DOPA –> Dopamine –> DA –> Norepinephrine

Question 35

Circuits involed in anxiety disorders

Answer 35

Amygdala centered circuit

Cortico-striato-thalamic circuit

Question 36

Neurochemistry of anxiety

Answer 36

GABA is the key NT
Benzodiazepine: enhances GABA activity in limbic/cortical circuits
Increased NE: symptoms of anxiety
increased 5HT turnover in limbic regions in acute stress
Less evidence for changes in HPA axis