Anxiety Disorders Flashcards
Normal Anxiety
- an aversive CNS response to real threat or danger
- prepares the organism for immediate action (“flight/fight” response)
- related to the adaptive emotion, fear
- distinct in that anxiety usually is anticipatory, more diffuse (we can reflect, think about things. In the future that might make us anxious)
- it allows us to survive
Fear Circuit
Midbrain and cortical structures involved in processing of fear response
- amygdala is the heart of this response. It’s the central player in processing fear (and other emotional stimuli) and coordinates the cortical and hypothalamic activity in response to emotions. Abnormalities have been implicated in PD, PTSD, and social phobia
- fast part of this response is the autonomic nervous system
- slower part of this response is designed for longer term behavioral responses in HPA axis (etiology of anxiety disorders may involve dysregulation of one or both of these components of the fear/anxiety response)
- hippocampus is normally thought to be a region that restrains the stress response
Pathological Anxiety
Reaction is out of proportion to the actual threat
-4 components:
Autonomic (Heart racing, sweating, shaking)
Behavioral (restlessness, seeking reassurance)
Cognitive (intrusive catastrophic thoughts, worry, and poor concentration)
Physical (muscle tension or fatigue, HA, SOB, chest pain)
Types of Anxiety Disorders
- panic disorder (has components of all 4 categories with intense autonomic and physical symptoms)
- generalized anxiety disorder (cognitive symptoms are more prominent, although physical symptoms are often present)
- phobias
- separation anxiety disorder (more common in kids)
Not technically anxiety disorders anymore:
- PTSD (cognitive, behavioral are strong components)
- OCD (almost entirely cognitive and behavioral components of anxiety)
General Info about Anxiety Disorders
Comorbidity: high rates or comorbid depression and substance abuse
DDx: may mimic cardiac and other conditions with increased autonomic arousal
Pathophysiology:
-all have a genetic component
-PD and GAD linked with dysregulation of brain noradrenergic systems
-OCD: linked to dysregulation of serotonergic transmission
(Some are 40-50% heritable. Panic Disorder is the most heritable)
Course:
- tend to be chronic or recurrent illnesses
- comorbidity with depression relates to high suicide risk
Tx:
-all are treatable
Panic Disorder
Key feature: recurrent unexpected panic attacks.
-associated with persistent concern over having another attack
Prevalence: 1.6%
Gender ratio: 2:1 female to male
Avg. age of onset: most commonly in late 20s
Can lead to agoraphobia due to patients fear of future attacks
Panic Attack Symptoms
- racing heart
- sweating
- trembling or shaking
- shortness of breath
- feeling of choking
- chest pain
- nausea
- feeling dizzy
- derealization
- fear of losing control*****
- fear of dying**
- paresthesias
- chills or hot flashes
- feel like you’re losing your mind**
DSM Dx Criteria for Panic Disorder
recurrent panic attacks (4 of 13 symptoms must be present)
-at least one of the following for one month:
Persistent concern about having more attacks
Worry about implications of attacks
Change in behavior due to the attacks
Treatment of Panic Disorder
Antidepressants
- SSRIs
- TCAs and MAOIs
- —may need to start with lower doses and titrate slowly
-Benzodiazepines:
May be tapered when adequate antidepressant coverage is established
Preferred agents are longer acting/slower onset like clonazepam
May need to use these in the short term. if they don’t have substance abuse history. Tend to like to use ones that are less “addictive”.
Psychotherapy:
-CBT: systematic desensitization used if agoraphobia is present
Generalized Anxiety Disorder (GAD)
Key features: unrealistic or excessive worry about 2 or more life circumstances for at least 6 months
-additional physical and cognitive symptoms of anxiety
Prevalence: 1.7-2.6% of Gen. Pop.
2:1 female to male ratio
-have to do with oversensitivity with noradrenergic fear response
Diagnostic Criteria for GAD
1: excessive anxiety or worry about a number of events for at least 6 month period
2: the anxiety is difficult to control
3: presence of 3 additional symptoms
- restlessness
- fatigue
- poor concentration
- irritability
- muscle tension
- sleep disturbance
Tx: Antidepressants: TCAs, SSRIs, SNRIs Benzodiazepines: better for short-term Buspirone: 5HT-1a agonist (works better than placebo, not as effective as benzos? Also may work better in patients who haven't already been treated with benzos) Psychotherapy: CBT
Phobias
-persistent and irrational fear of something that results in a compelling desire to avoid whatever that particular thing is 3 classes: -agoraphobia -social anxiety disorder -specific phobia
Agoraphobia
- fear of being in at least TWO situations or places where escape might be difficult or help may not be available
- may occur in context of panic disorder or on its own
Tx:
- if present with panic disorder use meds + CBT
- in agoraphobia without a history of panic disorder, behavioral modifications (systematic desensitization) alone may be tried
Social Anxiety Disorder
Key feature: fear of one or more social or performance situations Most common feared situations: 1: Public Speaking 2: Eating in Public 3: using public restrooms 4: writing publicly 5: attending parties, interviews
Age at onset: most often begins in late childhood or early adolescents
Prevalence: 2.7%
Gender ratio: more common in women
Dx Criteria of Social Anxiety Disorder
Persistent fear of social or performance situations that always provokes anxiety:
- Anxiety is out of proportion to the actual threat
- situation is avoided/endured with difficulty
- the fear interferes with the person’s life
Tx:
- behavior modification therapy
- antidepressants: SSRIs and MAOIs
- beta blockers
Specific Phobia (dx criteria)
persistent fear of specific objects or situations that almost always provoke anxiety
-fear is out of proportion to actual threat
-phobic situation interferes significantly with the person’s functioning
E.g.’s: flying, heights, animals, blood, driving
Tx:
Behavior Modification: exposure training and systematic desensitization
Antidepressants: SSRIs and SNRIs
OCD
Key features: recurrent obsessions and/or compulsions that are recognized as person’s own thoughts and as being excessive
-chronic, disability condition in many patients
Dx Criteria:
Recurrent obsessions and/or compulsions that:
-the person tries to suppress
-the person recognizes as being excessive
-cause dysfunction and/or distress
Tx:
- psychopharmacology: serotonin reuptake inhibitors, augmentation strategies
- psychotherapy: CBT
PTSD
Key feature: Hx of a traumatic event that is persistently re-experienced in a painful manner
- potentially chronic, debilitating disorder
- comorbid depression and suicide is common
Dx Criteria:
Hx of traumatic event
1: event is persistently re-experiences as: intrusive memories, nightmares, flashbacks, anxiety reactions to cues
2: avoidance of stimuli related to the trauma
3: negative cognition and mood:
-distorted blame of self or others
-estrangement from others
-diminished interest
-inability to remember aspects of trauma
-persistent negative beliefs and expectations
-persistent negative trauma-related emotions
-persistent lack of positive emotions
4: Persistent Symptoms of hyperarousal
-insomnia
-irritability or aggressive behavior
-dec. concentration
-hypervigilance
-exaggerated startled response
-self destructive or reckless behavior
Tx:
- should be initiated early
- CBT, group therapy, psychodynamic therapy
- SSRIs (clonidine-alpha 2 agonist)
- MAOIs (prazosin-alpha 1 antagonist)
- lithium/anticonvulsants (atypical anti-psychotics)
