Anxiety Disorders

Question 1

Anxiety

Definition

Answer 1

• A diffuse, unpleasant, vague sense of apprehension often accompanied by autonomic sx
  
  • Palpitations, tightness in chest, sweating, muscle tension, diarrhea, tingling in extremities
• One of the most prominent sx of psychological discomfort
• “Anxiety” has played a central role in psychodynamic theory
• Most behavior theorist have focused on therapies for reducing anxiety

Question 2

Physiological Role of Anxiety

Answer 2

• Anxiety is an alerting signal which warns of impending danger
• Important for survival & evolution
• Fear is a response to a known, external, definite, or nonconflictual threat
• Anxiety can be adaptive

Question 3

Yerkes‐Dodson Curve

Answer 3

The relation of strength of stimulus to rapidity of habit‐formation.

Question 4

Theories of Anxiety

Answer 4

• Is anxiety peripheral in origin or is it central?
  
  • James-Lange: Anxiety is bottom-up (peripheral)
  • Cannon-Bard: Emphasis on roles and beliefs in development of anxiety (central)
• Psychoanalytical Theories:
  
  • Anxiety was described by Freud to be a signal of threat to the ego
  • These signals are solicited because current events have similarities, actual or symbolic, to threatening developmental experiences
  • Repression is most common defense mechanism against threats to ego.
  • When repression doesn’t work, anxiety occurs
• Behavioral Theories:
  
  • Classical Conditioning
  • Social Learning
  • Cognitive Theories
• Existential Theories
  
  • Living in a purposeless universe w/ anxiety being a response to the perceived void in existence and meaning
• Biological Theories

Question 5

Anxiety Disorders

Features

Answer 5

• Common feature of all anxiety disorders:
  
  • Marked fear and anxiety
  • Specific thoughts associated w/ these sx
  • Sx are disproportionate and persistent
  • There is distress and impairment
• Anxiety disorders differ from each other in the types of situations that induce fear, anxiety, or avoidance behavior and the associated cognitive ideation

Question 6

Psychiatric Illnesses

Associated w/ Anxiety

Answer 6

• Mood disorders
• Schizophrenia
• OCD
• Stress‐related disorders
• Dissociative disorders
• Eating disorders
• Somatic Symptom disorders

Question 7

Anxiety Disorders

Epidemiology

Answer 7

• Anxiety and related disorders are among the most common psychiatric disorders
  
  • Lifetime prevalence rates as high as 31%
  • 12‐month prevalence rates of about 18%
• Significant costs in terms of healthcare use, loss of workforce productivity, disability, and quality of life
• Most patients w/ Anxiety Disorders present to their PCP
  
  • Detection of anxiety disorders often poor
• Effective management for each of the anxiety disorders is available, but currently underused, leaving patients in a less‐than‐optimally treated state

Question 8

DSM 5:

Anxiety and Associated Disorders

Answer 8

Question 9

DSM‐5:

Anxiety Disorders

Answer 9

• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobia
• Social Anxiety Disorder (Social Phobia)
• Panic Disorder
• Agoraphobia
• Generalized Anxiety Disorder

Question 10

Separation Anxiety Disorder

Answer 10

• Seen in childhood
  
  • Can be expressed throughout adulthood as well
• Fearful or anxious about separation from attachment figures to a degree that is developmentally inappropriate
• Persistent fear or anxiety about harm coming to attachment figures and events that could lead to loss of or separation from attachment figures
• Reluctance to go away from attachment figures, as well as nightmares and physical sx of distress

Question 11

Selective Mutism

Answer 11

• Seen early on (childhood)
• Consistent failure to speak in social situations in which there is an expectation to speak (e.g., school)
• Individual speaks in other situations
• Failure to speak has significant consequences on achievement in academic or occupational settings or otherwise interferes w/ normal social communication

Question 12

Specific Phobia

Answer 12

• Fearful, anxious about, or avoidant of circumscribed objects or situations
  
  • Almost always immediately induced by the phobic situation, to a degree that is persistent and out of proportion to the actual risk posed
  • Animal; natural environment; blood‐injection‐injury; situational; and others
• One of the most common mental disorders in the US
  
  • ~5-10% of the population, lifetime prevalence 10%
  • # 1 psychiatric d/o among women, #2 men
• Bimodal age of onset
  
  • Childhood peak for animal phobia, natural environment phobia, and blood‐injection‐injury phobia
  • Early adulthood peak for other phobias, such as situational phobia (flying, driving over bridges…)
• Treatment: Behavior therapy, systematic desensitization

Question 13

Social Anxiety Disorder

(Social Phobia)

Answer 13

Fearful, anxious about, or avoidant of social interactions and situations that involve the possibility of being scrutinized.

• Cognitive ideation is of being negatively evaluated by others, embarrassed, humiliated, rejected, offensive.
• Median age at onset 13 y/o, 75% between 8-15 y/o
• May have hx of other anxiety disorders, mood disorders, substance‐related disorders, and bulimia nervosa
• Treatment: psychotherapy and pharmacotherapy
  
  • SSRIs, benzodiazepines, Venlafaxine (SNRI), Buspirone

Question 14

Panic Disorder

Overview

Answer 14

• Recurrent unexpected panic attacks
• Persistently concerned or worried about having more panic attacks
• Changes behavior in maladaptive ways because of the panic attacks
• Panic attacks are abrupt surges of intense fear or intense discomfort
  
  • Reach a peak within minutes
  • Accompanied by physical and/or cognitive sx

Question 15

Panic Attack

Symptoms

Answer 15

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of SOB or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light‐headed, or faint
• Chills or heat sensations
• Paresthesias
• Derealization (feelings of unreality) or depersonalization (being detached from one‐self)
• Fear of losing control or “going crazy”
• Fear of dying

Question 16

Panic Disorder

Course

Answer 16

• Onset in late adolescence or early adulthood
  
  • Increased psychosocial stressors implicated w/ onset
• Generally a chronic disorder
• Course is variable
  
  • 30-40% of pts seem to be sx free at long‐term follow‐up
  • 50% have sx that are sufficiently mild enough not to affect their lives significantly
  • 10-20% continue to have significant sx

Question 17

Panic Disorder

Comorbidities

Answer 17

• Depression (40-80%)
• Increased risk for suicide
• Alcohol and other substance dependence (20-40%)
• OCD

Question 18

Panic Disorder

Differential Diagnosis

Answer 18

• Cardiovascular: MI, Angina, arrhythmias, anemia, MVP
• Pulmonary: Asthma, PE, COPD
• Neuro: CVA, Epilepsy, Migraine
• Endocrine: Hypoglycemia, Hyperthyroidism, Pheochromocytoma

Question 19

Panic Disorder

Treatment

Answer 19

• Pharmacotherapy
  
  • Alprazolam and paroxetine
  • Superiority of SSRIs and clomipramine over benzodiazepines, MAOIs, and TCAs
• Cognitive‐behavioral therapy
• Family and group therapy

Question 20

Agoraphobia

Characteristics

Answer 20

• Fearful and anxious about two or more of the following situations:
  
  • Using public transportation
  • Being in open spaces
  • Being in enclosed places
  • Standing in line or being in a crowd
  • Being outside of the home alone in other situations
• Fears that escape might be difficult or help might not be available in the event of developing panic‐like sx or other incapacitating or embarrassing sx
• Almost always induce fear or anxiety and are often avoided or require the presence of a companion

Question 21

Agoraphobia

Epidemiology

Answer 21

• ⅔ of all cases start before the age of 35
• Women > Men
• Panic attacks and Panic Disorder precede Agoraphobia in 50% of cases.
  
  • Treatment of Panic Disorder improves Agoraphobia
• Course of agoraphobia without panic disorder is persistent and chronic
• Complete remission is rare (< 10%) without treatment

Question 22

Agoraphobia

Treatment

Answer 22

• Benzodiazepines
• SSRI’s
• TCA & MAOI
• Psychotherapy
  
  • Behavior Therapy
  • Cognitive Therapy
  • Insight Oriented Psychotherapy
  • Virtual Therapy

Question 23

Generalized Anxiety Disorder (GAD)

Definition

Answer 23

Persistent and excessive anxiety and worry about various domains, including work and school performance, that the individual finds difficult to control.

Individual experiences physical sx:

• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance

Question 24

Generalized Anxiety Disorder (GAD)

Course

Answer 24

• Median age of onset: 30 y/o
• Starts later than most other anxiety disorders
• More prevalent in people of European decent as compared to Asians, Hispanics, AA
• Two thirds of patients are females
• Chronic course w/ remissions and relapses
• Worry tends to be age appropriate

Question 25

Generalized Anxiety Disorder (GAD)

Etiology

Answer 25

Biological Factors: Efficacy of Benzodiazepines and Buspirone suggests involvement of GABA and Serotonin

Cognitive‐Behavioral: theories focus on distorted interpretation of perceived threats

Psychoanalytic theories hypothesizes that anxiety is a symptom of unresolved, unconscious conflicts

Question 26

Generalized Anxiety Disorder (GAD)

Clinical Features

Answer 26

• Sustained and excessive anxiety and worry accompanied by either motor tension or restlessness
• Excessive and interferes w/ other aspects of a person’s life
• Motor tension is most commonly manifested as shakiness, restlessness, and headaches
• Anxious for as long as they can remember
• Seek out treatment usually in their 20’s
• Use. will seek out a general practitioner or internist for help w/ a somatic symptom
• Course is often chronic
• Multiple psychiatric comorbidities – depression, other anxiety disorders

Question 27

Generalized Anxiety Disorder (GAD)

Treatment

Answer 27

• Pharmacotherapy
  
  • SSRI’s
  • Venlafaxine
  • ? Benzodiazepine
  • Buspirone
  • Tricyclic’s, MAOI
• Psychotherapy
  
  • CBT has the most evidence base

Question 28

Other Anxiety Disorders

Answer 28

Anxiety Disorders secondary to other medical conditions

Anxiety Disorders secondary to substance use or withdrawal

Question 29

Obsessive‐Compulsive and Related Disorders

Answer 29

1. Obsessive‐compulsive disorder (OCD)

2. Body dysmorphic disorder

3. Hoarding disorder

4. Trichotillomania (hair‐pulling disorder)
5. Excoriation (skin‐picking) disorder
6. Substance/medication‐induced obsessive‐compulsive and related disorder
7. Obsessive‐compulsive and related disorder due to another medical condition
8. Other specified obsessive‐compulsive and related disorder and unspecified obsessive‐compulsive and related disorder (e.g., body‐ focused repetitive behavior disorder, obsessional jealousy).

Question 30

Obsessive–compulsive disorder (OCD)

Definition

Answer 30

Common, disabling psychiatric disorder characterized by:

• Obsessions
  
  • Recurrent and persistent thoughts, images, or urges
  • Experienced, at some time, as intrusive and unwanted
  • Cause marked anxiety or distress
  • Attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them w/ some other thought or action (i.e., by performing a compulsion)
  • Types of Obsessions: Doubts, Images, Thoughts
• Compulsions
  
  • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently)
  • Individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
  • Aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation
  • Are not connected in a realistic way or are clearly excessive
  • Types of Compulsions: Yielding, Controlling

Question 31

OCD

Etiology

Answer 31

• Biological factors:
  
  • Genetic predisposition likely
  • Dysregulation of 5-HT is involved in the sx formation of obsessions and compulsions in the disorder
    
    • SSRI’s are most effective in tx OCD
  • Link between GAS strep infection and OCD
  • Altered function in the neurocircuitry between orbitofrontal cortex, caudate, and thalamus
• Psychological:
  
  • Psychoanalytic theories view OCD as a regression to the anal stage
  • Learning Theory:
    
    • Obsessions are conditioned stimuli ⇒ neutral objects and thoughts become conditioned stimuli capable of provoking anxiety or discomfort
    • Compulsions are reinforced ⇒ ritualistic behaviors reduce the anxiety
• Developmental factors:
  
  • Emotional, physical, and sexual abuse or neglect, social isolation, teasing, or bullying
  • Other stressors include pregnancy and the postnatal period

Question 32

OCD

Comorbidities

Answer 32

• Depression
• Tourette’s Disorder
• Schizophrenia
• Other Anxiety Disorders

Question 33

OCD

Treatment

Answer 33

• Pharmacotherapy
  
  • SSRI’s
  • Clomipramine
  • Benzodiazepines
  • TCA, MOAI, Neuroleptics
• Psychotherapy
  
  • Cognitive behavioral therapy that includes “exposure and response prevention”
• For severe incapacitating OCD:
  
  • Deep Brain Stimulation
  • Ablative neurosurgery (e.g., capsulotomy and cingulotomy)

Question 34

Body Dysmorphic Disorder

Answer 34

Preoccupation w/ one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

• Repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking)
• Mental acts (e.g., comparing his or her appearance w/ that of others) in response to the appearance concerns
• Eating Disorders are excluded
• The patient’s belief may reach delusional proportions – in which case it is classified as a delusional disorder

Question 35

Hoarding Disorder

Answer 35

• Persistent difficulty in parting w/ possessions
• Results in severely cluttered living spaces, distress, and impairment that are not attributable to another neurologic or mental disorder
• Excessively acquire items they do not need or have space for
• Limited insight into their difficulties
• Reluctant to seek help
• Cognitive behavioral therapy that is specifically tailored to hoarding difficulties

Question 36

Trauma and Stressor‐related Disorders

Answer 36

These disorders have an exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion.

1. Reactive attachment disorder
2. Disinhibited social engagement disorder
3. Posttraumatic Stress Disorder (PTSD)
4. Acute stress disorder
5. Adjustment disorders

Question 37

Reactive Attachment Disorder

Answer 37

• Clinical manifestations:
  
  • Emotionally withdrawn behavior toward adult caregivers
  • Rarely or minimally seeks comfort when distressed
  • Does not responds to comfort when distressed
  • Minimal social and emotional responsiveness to others
  • Limited positive affect
  • Episodes of unexplained irritability, sadness, or fearfulness
• Caused by:
  
  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
  • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
  • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions w/ high child‐to‐caregiver ratios)

Question 38

Disinhibited Social Engagement Disorder

Answer 38

• Clinical manifestations:
  
  • Reduced or absent reticence in approaching and interacting w/ unfamiliar adults
  • Overly familiar verbal or physical behavior
  • Diminished or absent checking back w/ adult caregiver after venturing away, even in unfamiliar settings
  • Willingness to go off w/ an unfamiliar adult w/ minimal or no hesitation
• Caused by:
  
  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
  • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
  • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions w/ high child‐to‐caregiver ratios)

Question 39

Posttraumatic Stress Disorder

(PTSD)

Answer 39

Conditon present for > 1 month

1. Exposure to a traumatic event

Actual or threatened death, serious injury, or sexual violence

Directly experiencing / witnessing in person

Event occuring to a close family member or friend (violent or accidental)

Repeated or extreme exposure to aversive details (police, first responders)

2. Intrusion symptoms associated with the traumatic event

Memories

Dreams

Dissociative reactions (e.g., flashbacks)

Psychological distress to cues

Marked physiological reactions to cues

3. Avoidance of stimuli associated w/ the traumatic event

Avoids distressing memories, thoughts, or feelings

Avoids external reminders

4. Negative alterations in mood and cognition

Inability to remember important details

Negative beliefs or expectations

Distorted beliefs about cause or consequences

Negative emotional state

Diminished interest or participation in significant activities

Detachment or estrangement

Inability to experience positive emotions

5. Alterations in arousal and reactivity associated w/ the traumatic event

Irritable behavior and angry outbursts, expressed as verbal or physical aggression

Reckless or self‐destructive behavior

Hypervigilance

Exaggerated startle response

Difficulty concentration

Sleep disturbances

Question 40

Complications of PTSD

Answer 40

• Social Withdrawal
• Depression
• Suicide
• Alcohol and Substance Abuse

Question 41

PTSD

Treatment

Answer 41

• Pharmacotherapy
  
  • SSRI
  • TCA
  • MAOI
  • Clonidine, Prazosin
• Psychotherapy
  
  • Behavior Therapy
  • CBT
  • Hypnosis
  • Eye Movement Desensitization and Reprocessing (EMDR)

Question 42

Acute Stress Disorder

Answer 42

Difference from PTSD: Duration of Sx

Acute Stress Disorder: 3 days to 1 month

PTSD: > 1 month

Question 43

Adjustment Disorder

Answer 43

• Emotional or behavioral sx in response to an identifiable stressor occurring within 3 months of the onset of the stressor.
• Marked distress that is out of proportion to the severity or intensity of the stressor
• Significant impairment in social, occupational, or other important areas of functioning
  
  • W/ depressed mood
  • W/ anxiety
  • W/ mixed anxiety and depressed mood
  • W/ disturbance of conduct
  • W/ mixed disturbance of emotions and conduct