Anxiety Disorders Flashcards
When do anxiety disorders tend to begin and how do they progress over a lifetime?
Tend to begin early teens or early 20s, waxing and waning over the course of a lifetime
What is the adaptive function of anxiety?
An alerting signal which helps prevent consequences
-> helps motivate and improve performance in moderate doses
What are the two components of anxiety and what is it critical to determine?
- Physiological sensations - i.e. palpations
- Feeling of nervousness or fright
Important to determine which comes first and causes the other symptoms
What is the neurochemical model of the etiology of anxiety?
Anxiety comes from activation of the autonomic nervous system, either primarily or secondary to a learned stimulus
-> causes release of NE, 5-HT, and GABA
What is the neuroendocrine model of anxiety etiology? Best piece of evidence?
HPA axis dysregulation accounts for anxiety
Cortisol levels are overly suppressed in PTSD
What is the genetic model of anxiety? What is one type of anxiety where this holds true?
Higher rate of concordance between monozygotic vs dizygotic twins
Finding: Specific phobias were more likely to occur within a family (although all these specific phobias may be different)
What is the psychodynamic model of anxiety and was it ever supported?
Anxiety is viewed as a signal of danger in the unconscious -> never supported (id vs superego idea)
What is the behavioral vs cognitive-behavioral anxiety model?
Behavioral - anxiety is a conditioned response to specific environment stimuli
Cognitive-behavior - adds on to the behavioral model by saying cognitive distortions / automatic thoughts guide our response to these environmental stimuli -> we overestimate the danger and underestimate the coping skills
How are agora and specific phobias treated with therapy? OCD?
Agora / specific phobias - Exposure with graded desensitization
OCD - Exposure plus response prevention
What are a couple types of medications which are known to precipitate anxiety?
Corticosteroids (also in inhalers)
Oral contraceptives
Others which are obvious dont be an idiot
What should you always give a patient who comes in with anxiety and what do you tell them?
Always give them a definitive diagnosis and some reading material to go over later when they are at home
Tell them side effects of the drugs and to come back in 7-10 days to make sure they’re adherent
What are the diagnostic criteria groups for panic disorder?
- Recurrent panic attacks
or - At least 1 month of persistent concern of having another panic attack, causing behavioral change
Typical other DSM criteria
If you have a panic attack do you have panic disorder? What is it often comorbid with?
No, must be recurrent or associated with significant worry / behavioral change
Better than 50% will have depression
What part of the brain is responsible for anticipatory anxiety? What types of anxiety manifestations do the following brain areas cause: prefrontal cortex? brain stem?
Amygdala / limbic system
Prefrontal cortex is responsible for avoidance behaviors
Brain stem: autonomic symptoms
What types of diseases are typically on the differential diagnosis for anxiety / panic disorders?
Cardiovascular / respiratory dysfunction to cause the physiological symptoms, endocrine dysfunction for stress hormones, etc
What, in general, are the diagnostic criteria for agoraphobia?
Fear of public spaces where escape might be difficult or help unavailable for greater than 6 months.
Anxiety is out of proportion to the actual threat posed, and thus these situations are avoided or endured with extreme anxiety
What are the pharmacotherapeutic interventions for panic disorder and agoraphobia / specific phobias?
Panic disorder - SSRIs are first line
Agoraphobia / panic disorders - exposure therapies, no pharmacotherapeutics indicated
What is the most common type of anxiety disorder and a very classic subtype?
Specific phobia disorder - causes panic attacks during exposure or anticipation of exposure
Blood-illness-injury phobia is classic -> vaso-vagal passing out due to shots
What, in general, is social anxiety disorder? What is the normal age of onset?
A fear or avoidance of social / interactional situations which lasts more than 6 months, can be as small as eating / using bathroom in public
Typically in teen years
What two things are frequently co-morbid with social anxiety disorder?
- Depression
2. Alcohol dependence
What response is intensified in social anxiety disorder? Can they tell accurately between emotions?
Activation of brain areas in response to harsh faces
-> they are able to tell between different emotions just as well
What, in general, is generalized anxiety disorder?
Excessive anxiety and worry more days than not for at least 6 months
-> Requires associated physiological / psychological symptoms
What is the requirement for something to be considered a triggering event for PTSD?
Exposure to death, serious or sexual violence via:
Direct experience, witnessing experience, learning of the experience from someone close to them, experiencing repeated / extreme exposure to aversive details of trauma
What are the four core features of PTSD? How long must they be present?
More than 1 month
- Intrusive symptoms -> i.e. memories, nightmares, physiologic response
- Avoidance behavior -> avoidance of triggers
- Negative mood / cognitions -> includes forgetting important aspects / distorted cognitions
- Hyperarousal symptoms -> exaggerated startle, irritable behavioral, sleep problems
What are two important specifiers of PTSD?
- With dissociative symptoms -> i.e. depersonalization
2. With delayed expression -> does not start until 6 months after event (i.e. holocaust victims until retirement)
What are the noradrenergic and HPA findings in PTSD?
Noradrenergic - increased epinephrine concentrations in urine + downregulation of platelet alpha-2 receptors
HPA - low plasma / urinary cortisol, which cannot be stimulated easily with CRF and is enhanced suppression by dexamethasone (opposite of depression)
What area of the brain which regulates affect is found to be hypoactivated in PTSD?
medial prefrontal cortex, including orbitofrontal cortex and anterior cingulate cortex
What area of the brain is smaller in PTSD?
Hippocampus
What is the first-line treatment for PTSD? Does debriefing following trauma help?
Trauma-informed CBT
Debriefing following trauma does not help
How does acute distress disorder differ from PTSD? What is the treatment?
Acute stress disorder is from 3 days to 1 month after trauma, although it has the same symptoms
-> becomes PTSD after 1 month
Treatment unknown, just CBT
What are the criteria for an adjustment disorder?
Emotional or behavioral symptoms in response to a stress occurring within 3 months of a stressor, which will not persist for more than 6 months after stress is removed.
- > cause marked distress out of proportion to severity / intensity of stressor
- > cause significant impairment
What is important to include in an adjustment disorder diagnosis? What is one which you might not think of?
A specifier, like depressed mood, anxiety, mixed states
-> might not think of “disturbance of conduct” i.e. fighting, skipping school, vandalizing
What condition is most comorbid with adjustment disorders?
Personality disorders or substance abuse
Is adjustment disorders considered a trauma-related disorder?
Yes, oddly enough
What is the very basic definition of obsessive compulsive order (criteria)?
Presence of obsessions, compulsions, or both which are time consuming or cause significant stress / impairment in function
What is an obsession vs a compulsion?
Obsession - recurrent thought or urge which individual must try to suppress or neutralize
Compulsion - repetitive behavior or mental act (i.e. counting) which can be used to neutralize the obsession
What are the important specifiers for OCD?
They relate to the patient’s insight:
Good / fair
Poor
Absent
How well the patient understands that their beliefs are not true. Absent = patient is completely convinced they are true
What is one anxiety-related disorder where the male:female affected ratio is equal?
Obsessive-compulsive disorder
What conditions are commonly co-morbid with OCD, and one unique one?
Anxiety disorders or mood disorders
Unique - up to 30% have co-morbid tic disorders, and with Tic can be used as a specifier for the OCD
What is PANDAS?
Abrupt onset of OCD in children following Streptococcus infection (Group A Strep)
-> analogous to Syndenham’s chorea, due to autoimmune condition
What two neurosurgeries can be used for OCD?
Cingulotomy - bilateral lesioning of the anterior cingulate gyrus between orbitofrontal cortex (seat of wisdom) and limbic system
Capsulotomy - anterior limb of internal capsule - relay between cortical structures and thalamus
What mental disorder has an extremely high prevalence in dermatology patients and cosmetic patients? What is the treatment?
Body dysmorphic disorder
Treatment is CBT or SSRIs
What are the diagnostic criteria for body dysmorphic disorder?
- Preoccupation with physical appearance flaws not observable or appear slight to others
- Has done repetitive actions like mirror checking or mental actions such as comparison
- Impairment of function, and not better explained by eating disorder
What is one OCD-related disorder when the prevalence in men is more than women and its diagnostic criteria basically?
Hoarding disorder
- > holding onto items regardless of value, accumulating as clutter in living areas which prevents their intended use.
- > Causes distress to discard the items
What OCD disorder has women FAR outnumbering men in terms of prevalence? What are the criteria?
Trichotillomania
Pulling out of one’s hair causing hair loss, with REPEATED attempts to decrease / stop.
-> was previously classified impulse-control disorder
Why does hairpulling continue and when does it start?
Typically starts in 11-13 year olds and is lifelong
-> response to negative emotions and is positively reinforced because it feels good
What dirty drug is good for treating trichotillomania and OCD?
Clomipramine - a tricylic antidepressant
What is skin-picking disorder called? What are the criteria?
Excoriation -> basically same as trichotillomania
Must result in skin lesions, and must continue despite repeated attempts to decrease or stop
