Anxiety Disorders: Biophyschosocial Aspects and Clinical Manifestations Flashcards
Major mediators of the sx of anxiety disorders
- Locus coeruleus-norepinephrine system
- serotonin
- dopamine
- GABA-benzodiazepine receptor complex
Serotonin deficiency seen in ________. Serotonin overactivity seen in _______ states
depression; anxiety
•Locus Coeruleus central to modulating _____
•vigilance, attention and anxiety or fear
The amygdala receives what type of input?
excitatory glutamatergic thalamic and cortical input
The amygdala sends caudal projections to…
- NA neurons of LC
- DA neurons of VTA
- 5HT neurons of raphe nuclei
Amygdala connections
- Cortical areas – fear, cognitive misappraisal
- PAG – escape and freezing
- Parabrachial nucleus – Hyperventilation
- Lateral hypothalamus – Sympathetic activation
- PVN of hypothalamus – Endocrine activation
- DMN of the vagus – GI distress
- Nucleus Caudalis pontis - ↑ startle
- Striatum – Motor activation
•Panicogenic agents
- Sodium Lactate in 2/3 of those with PD
- 5% Carbon dioxide inhalation- CO2 hypersensitivity
- Sodium bicarbonate
- Isoproterenol (Isuprel)
- Doxapram (adrenergic agonist/carotid chemoreceptor)
•H-P-A activating anxiogens
- Yohimbine- alpha 2 antagonist
- M-chlorophenylpiperazine (mCPP)
- Fenfluramine
- Beta- carboline
- CCK-cholecystokinin agonists
- ↑firing in LC, + HPA axis, interacts with GABA
Respiratory panic inducing substaNCES CAUSE RESPIRATORY STIMULATION AND A SHIFT IN THE _________.
ACID BASE BALANCe; INCLUDING CARBON DIOXIDE 5% TO 35% SOD LACTATE BICARBONATE.
Panic disorder PET scan
- ↑flow R parahippocampal
- ↓serotonin type 1A receptor binding in anterior & posterior cingulate/raphe
Panic disorder MRI scan
•↓temporal lobe volume despite normal hippocampal volume
Panic disorder CSF
•↑ orexin, aka hypocretin, which is thought to play an important role in the pathogenesis of panic in rat models
Cognitive theory of panic
that pts. have a ↑ sensitivity to internal autonomic cues (eg, tachycardia)
•Anxiety is neutralized by _________ or _________.
avoidance or compulsions
Freud: Panic disoders
- A signal of threat to the ego
- Symbolic or current events are similar to threatening developmental events (traumatic anxiety)
- Repression was the primary defense against anxiety
- When repression fails- hysteria, phobias and obsession-compulsions erupt
- Superego anxiety, castration anxiety, separation anxiety and impulse anxiety
Separation anxiety disorder
Developmentally inappropriate, XS fear or ANXIETY/WORRY ABOUT SOMETHING HAPPENING TO THE MAJOR ATTACHMENT FIGURE (MAF)
SAD Symptoms
at least 4 WEEKS in children/adolescent; 6 months or more in adults
SAD- at least 3 of 8 symptoms/signs
- Distress or reluctance
- anticipating/experiencing SEPARATION from home or major attachment figures (MAF)
- about losing MAF
- About experiencing an UNTOWARD EVENT (e.g., getting lost, kidnapped, becoming ill) separation from the MAF
- to go out
- about BEING ALONE
- To SLEEP AWAY FROM HOME or to go to sleep w/o MAF
- Repeated NIGHTMARES @ SEPARATION
- Repeated complaints of PHYSICAL SX WHEN SEPARATED
Risk and prognostic factors: SAD
- Often develops after LIFE STRESS esp. a loss
- DEATH of a relative or pet
- ILLNESS in patient or relative
- CHANGE of schools
- Parental DIVORCE
- MOVE to a new neighborhood
- IMMIGRATION
- DISASTER THAT INVOLVED SEPARATION from major attachment figures
- Heritability 73% in a community sample of 6 yr twins; ↑ F
Selective mutism
}FAILURE TO SPEAK in spec. social situations
}Interferes w/ educational, occup. or social comm.
}DURATION IS AT LEAST 1 MONTH
}Failure to speak is not attributable to a lack of knowledge of or comfort with the spoken language required in the social situation
}Not better explained by a COMMUNICATION DISORDER (e.g., childhood onset fluency d/o)
Panic disorder
- Persistent worry about ANOTHER ATTACK
- Change in behavior because of the attacks
- Peak in 10 min
- Associated with at least 4 other symptoms
Panic disorder comorbidities
- Persistent worry about ANOTHER ATTACK
- Change in behavior because of the attacks
- Peak in 10 min
- Associated with at least 4 other symptoms
Agoraphobia
- Fear and avoidance in being in a situation that escape may be difficulty or they may not be able to get help
- May not leave home or may need a companion
- Can occur with and without panic disorder
Social Phobia
Persistent, irrational fear of social situations
- Marked avoidance of situations (humiliation or embarrassment)
- Or marked anxiety under these situations
- Recognized as not reasonable
Comorbidity for social phobia
- Comorbid with depression
- Alcohol and drug use
- Chronic but fluctuates
- Worsened during stress
•Acrophobia
•Fear of heights
•Agoraphobia
•Fear of open places
•Ailurophobia
•Fear of cats
•Cynophobia
•Fear of dogs
•Mysophobia
•Fear of dirt and germs
•pyrophobia
•Fear of fire
Comorbidity for GAD
•Comorbidity – affective disorder, panic disorder and agoraphobia – most common
DSM-IV-TR criteria for GAD
•Anxiety or worry w/ 3 or more of 6 sx in adults; only 1 item needed in children
- Restlessness or “feeling keyed up” or “ on edge”
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
Panic disorder treatment
- First line:
- SSRIs
•Second line:
- Nefazodone
- Venlafaxine XR
- Mirtazapine
- reboxetine
Social phobia treatment
- Five SSRI
- Paroxetine, fluvoxamine, fluxoetine,sertraline, citalopram
- SNRI, nefazodone
- Second or third line: MAOIs
- bzd
- Beta blockers
Wrokup for panic disorder
- Complete blood cell count
- Chemistry profile
- Thyroid function tests
- Urinalysis
- Urine drug screen
Treatment for Acute anxiety
- ED tx: short course fast acting bzd
- Psychiatric consult- if danger present
- Provide a calm environment
- social support from family, friends, and the emergency staff are ideal.
Chronic Anxiety Treatment
- requires a comprehensive approach
- the best pharmaco tx varies for each
- outpt f/u with a psychiatrist is recommended.
- discharged on a short course of bzd until they see a psychiatrist.
- S/HI -emergent psychiatric eval in the ED.
