Anxiety Disorders Flashcards
1
Q
why learn about anxiety disorders?
A
- Most common psychiatric problem that presents to primary care physicians often presenting as a medical complaint (GI, cardiac)
- 40 million adults, 18% of US pop
- lifetime prevalence of 30% in females, 19% in males (2:1)
- These patients are 3-5 x’s more likely to go to the doctor; 60% of anxiety disorder patients go to their PCP
- During primary care setting first interview 80% of anxiety diagnoses are missed
2
Q
when is anxiety pathological
A
consider the anxiety’s BAID:
- behavior
- autonomy
- intensity
- duration
3
Q
what are the domains of anxiety
A
- physical
- affective
- cognitive
- behavioral
4
Q
fear vs. anxiety
A
- Aspects of fear and anxiety overlap, but in general:
- Fear-emotional response to real or perceived imminent threat; autonomic behavior surges for fight or flight, thoughts of immediate danger and/or escape for future danger and cautious or avoidant behavior
- Anxiety-anticipation of future threat; Muscle tension and vigilance in preparation
- Different anxiety disorders often have both, but may have more of one than the other
5
Q
pathological anxiety
A
Anxiety can be a normal reaction to identifiable stressors that society considers understandable. Anxiety becomes pathological when any of the following happens:
- Autonomy- anxiety without obvious reason
- Intensity- out of proportion response, causes dysfunction and/or is not bearable
- Duration- lasts longer than expected
- Behavior- coping mechanisms are not enough and/or patient displays other dysfunctional (usually avoidance) behaviors
6
Q
physical domains of anxiety
A
- constitutional
- skin
- HEENT
- cardiac
- pulm
- GI
- GU
- musculoskeletal
- neurologic
7
Q
other domains (ABC)
A
- Affective: ranges from edginess to terror & panic; often viewed as irritability or restlessness
- Cognitive: Worry, apprehension, poor concentration, feeling your mind has gone blank, feeling tense/jumpy, anticipating the worst
- Behavioral: Changes made in an effort to diminish or avoid the distress; responses can be checking behaviors, rituals, avoidance
8
Q
What is the origin of anxiety
A
- protective response
- common underlying neurophysiology
- integrated with memory
- genetic and experiential factors
- biological and neuroanatomical structures involved:
- autonomic system, mostly sympathetic
- locus ceruleus
- limbic system-governs emotion/behavior
- amygdala-fear processing center
- hippocampus-memory formation/recollection
- hypothalamus-homeostasis
- autonomic system, mostly sympathetic
9
Q
common underlying neurophysiology
A
- biological and neuroanatomical structures involved
- anxiety circuits
- two core symptoms-fear and worry
- fear (amygdala-centered circuit): panic and phobia-often sudden, known threat
- worry (cortico-striatal-thalamic-cortical circuit): unknown, vague threat
- anxious misery
- apprehension
- expectation
- obsessions
- NT and anxiety
-
Serotonin (5-HT)-produced predominantly by raphe nuclei and modulates many homeostatic responses (mood, sleep, anxiety, appetite, sex drive)
- Low 5-HT has been linked with aggression, impulsivity, depression, suicide attempts, self-injury, intrusive thoughts and repetitive behavior
- Norepinephrine (NE)-made in Locus Cereleus; associated with orienting, selective attn, hypervigilance, mood, and autonomic arousal
- GABA-brain’s primary inhibitory NT; Medications that increase GABAergic tone, such as benzodiazepines, alleviate anxiety
- Glutamate-excitatory NT made in presynaptic neuron terminals; most abundant messenger in brain; involved in learning & memory
-
Serotonin (5-HT)-produced predominantly by raphe nuclei and modulates many homeostatic responses (mood, sleep, anxiety, appetite, sex drive)
10
Q
epidemiology of anxiety disorders
A
- panic disorder
- agoraphobia
- generalized anxiety disorder (GAD)
- specific phobia
- social phobia/social anxiety disorder
- anxiety disorder due to another medical condition
- substance/medication-induced anxiety disorder (SIAD)
- peds:
- separation anxiety disorder
- selective mutism
- ***PTSD and OCD are no longer under anxiety disorder
11
Q
Panic attack
A
- an abrupt surge of intense fear or discomfor that peaks within 10 mins and has FOUR OR MORE of the following symptoms:
- PANICS (p3,a,n2,i2,c4,s4)
12
Q
Panic disorder
A
- recurrent, unexpected panic attacks without and identifiable trigger
- at least one attack has been followed by A MONTH OR MORE of the following:
-
**anticipatory anxiety
- persistent concern/worry about additional panic attacks or the consequences of the panic attack
- “Im going crazy” or “Im going to have a heart attack”
- significant, maladaptive change in behavior related to the attacks
-
**anticipatory anxiety
- attacks are not better accounted for by another mental disorder or general medical condition
- age of onset-usually late teens to early 20s, median age 24
- course-untreated, waxes and wanes over time
- moderate genetic component
- usually co-morbid with another psychiatric comorbidity
- 1st-agoraphobia, 2nd-GAD (generalized anxiety disorder)
- MDD=most non-anxiety disorder
13
Q
Panic disorder course
A. Age of Onset
B. Frequency and Severity
C. Sans tx
A
-
A. Age of Onset
- Median age of onset 20-24 years old;
- Rare to start in childhood& starting after age 45 y/o is unusual
- In older adults low prevalence is due to age related “dampening” of the autonomic nervous system response. Disorder often appears to recede later in life
-
B. Frequency & severity of panic attacks very widely
- Frequency: may be consistent for a time (1/week), have bursts (daily attacks), separated by months with no attacks
- Severity: may have full symptom attacks (4 or more symptoms) or limited symptom attacks (<4 symptoms); the number and type of panic attack symptoms frequently differ from one attack to the next
- C. Without tx: waxing & waning course of illness
- < 20% ongoing major impairment
- ~50% mild impairment
- ~ 33% recover
14
Q
Panic disorder-other numbers
A
- Panic attacks & panic disorder diagnosis in the prior 12 mo= suicide RF
- Highest number of medical visits among the anxiety disorders
- Each yr in U.S. : ~200k nml coronary angiograms-33% of these pts have panic disorder.
- When symptoms are less typical of CAD & pts are referred for non-invasive testing: > 50% of patients with negative tests have panic disorder.
- Patients investigated for vestibular disorders due to complaint of dizziness: 33% have panic disorder
15
Q
Panic disorder Etiology (2)
A
- Neurocircuitry model theory: abnormally sensitive fear network, centered in amygdala
- GABA, serotonin, NE, implicated
17
Q
Agoraphobia
A
- marked fear/anxiety about at least 2 of the following situations (5 total)
- tx: systemic desensitization!
18
Q
GAD
A
- Excessive anxiety + worry a/b a number of events and activities
- occurring most days for at least 6 mo.
- Despite having insight into the unrealistic and excessive nature of the worrying, the pt finds it difficult to control the worry and the thoughts interferes with focus
- Intensity, duration or frequency of the anxiety and worry is out of proportion to likelihood or the anticipated event.
- This worry is accompanied by three or more somatic symptoms:
20
Q
Specific phobia
A
- ***pt tend to have >1, avg. 3
- ***blood/injction/injury: M=F
21
Q
Social Anxiety Disorder (Social Phobia)
A
- Clinically significant fear or anxiety about one or more social situations in which pt is exposed to the scrutiny of others.
- May include:
- social interactions (having a conversation, meeting new ppl)
- being observed (eating in a public place)
- performance (public speaking, oral exam)
- Pt is concerned about behaving (showing their anxiety) in a manner that will be humiliating/embarrassing.
- These social situations almost always provoke fear + anxiety
- Blushing=hallmark symptom of this disorder.
23
Q
SAD
A
- fairly common
- course: majority of kids with SAD do not have anxiety disorders over thir lifetime
- can be seen in adults
24
Q
Selective Mutism
A
25
Q
Approach to diagnosing anxiety disorders-Step 1
A
rule out substance inuced causes
26
Q
approach to diagnosing anxiety disorders-Step 2
A
rule out medical conditions
*work up screen: blood glucose, UA, CBC, CMP, ammonia, TSH, B12/folate, RPR, ECG
30
Q
Acute Stress Disorder
A
linked to PTSD, one usually leads to the other
big diff: PTSD, negative alteration in mood AND cognition; diff duration
31
Q
PTSD
A
derealization and depersonalization as well, also exaggerated startle response
**NO BZ!!!
32
Q
OCD
A
- recurrent o and/or c that are severe enough to be time consuming (>1hr/day)
- persona understands o/c unreasonable or excessive, but they “just have to do it”
- obsessions: persistent ideas, thoughts, images, or urges
- experienced as intrusice and inappropriate, cause marked anxiety or distress
- “ego-dystonic” (not enjoyable)
- dirt/contamination=most common, followed by doubts
- compulsions: behaviors or mental acts
- co morbidity: tic disorder (especially if OCD childhood onset)
- Tx: 1st line SSRIs (***high dose)
34
Q
Different pacing of exposure therapy (3)
A
- graded
- flooding
- systemic desensitization
35
Q
How helpful is exposure therapy?
A
- habituation
- extinction
- self-efficacy
- emotional processing
