anxiety disorders- chpater 9 Flashcards
what is the deifference between fear and anxiety?
the main difference is the suddenness of fear and the insidiousness of anxiety.
fear is a response to a known, external noncoflictual threat, and anxiety to unknown, internal, conflictual.
Freud did not distinguish between them. fear can also be caused by conflict- such as displacement.
differentiation is post freudian.
peripheral manifestations of anxiety
diarreah, light headedness and dizziness, hyperhidrosis, palpitations, mydriasis, syncope, tachycardia, tingling, tremor, upset stomach (butterflies), urinary frequency, hesitatncy, urgency
psychological mechanism for chronic anxiety
dysfunctional ego- imbalance between internal drives and external events(external-usually interpersonal) or conscious(internal-intrapsychic)
epidemiology of anxiety disorders
1 of 4 will develop anxiety
12 month prevalence of 17%.
LTP- Women- 30%, men -19%.
prevlence lower in higher socioechonomic status
superego anxiety
the highest level of anxiety- guilt about not living up to standards
anxiety- psychoanalytic theory
Freud changed his views from anxiety being a consequence of builtup libido to anxiety being a manifestatin of threat in the unconscious.
anxiety causes repression, and not the opposite.
The purpose of the anxiety is to signal the ego that a forbidden drive is pushing for conscious expression, and to alert the ego to strengthen its defenses against instinctual force.
purpose of psychoanalysis in treating anxiety
purpose of treatment- not elimination anxiety but tolerating it and identifying the signal.
anxiety- existenial
no identified stimulus- generalized. fear of pouposeless universe. may have increased after bioterrorism/ nuclear.
neurotransmitters in anxiety
serotonin, neurepinephrin, GABA
animals performance when exposed to conflicting stimuli
increased when receiving GABA, decreased with amphetamines.
activating/blocking which adrenergic receptors cause anxiety?
activating which adrenergic area causes anxiety?
beta(isoproteronol), and alpha2 blockage (yohimbine)
activation of LC (ablation eliminates fear response)
cortisol functions
replenish enery stores
increase arusal and attention adn memory formation
inhibition of growth and reptoductive system
containment of immune response
HPA in panic
blunted ACTH response to CRF (in some studies but not others)
CRH
increased in stress- release of DHEA and cortisol.
inhibits some neurovegetative functions- food intake, sexual activity, growth and reproduction
Serotonin in anxiety
acute setress causes increased 5HT turnover in : prefrontal c.,nucleus accumbens, amygdala, lateral hypothalamus.
serotonergic antidepressants, including buspirode(5HT1A agonist) help.
on the other hand- serotonergic agent cause anxiety: MCPP, funfluramine, LSD, MDMA(acute and chronic)
in panic- no clear panic. some found decreased 5HT
projections of LC
cortes, limbic system, brain stem, spinal cord
projection of the nucleus raphe
cortex, limbic(amygdala and hypocampus), hypothalamus.
Which GABA agonists are good for GAD and which for panic?
low potency- GAD high potency(clonex, xanax)- panic disorder
what is beta caroline 3 carboxylic acid and what does is cause, as opposed to flumazenil?
BCCA causes anxiety even in patients without anxiety disorder(an inverse agonist of GABA)
flumazenil causes panic in patients with panic disorder
what changes did conditioning cause in the aplysia?
presynaptic facilitation resulting in increased amounts of neurotransmmitter
peptides in anxiety, and other functions.
NPY- 36 aa, invovlved in anxiety, depression, fear
galanine- 30 aa. learning and memory, pain control, food intake, neuroendocrine control, cardiovascular regulation, anxiety.
npy in anxiety
anxiolytic
counterregulatory on LC, amygdala,
Npy-y1 receptor.
when increaesd amount in stress- >better performance
galanin in anxiety
its administration (centrally)has shown to modulate anxiety
where is the galanin fiber system?
densely in the LC , innervating midbrain and forebrain- hippocampus, hpothalamus, amgdala, prefrontal cortes,
brain imagery(anatomical) in anxiety
increased ventricles(some correlated with use of BZ) right temporal lobe defect )or atrophy) in panic abnormal right hemisphere cerebral assymetry
functional imagery and EEg in anxiety
abormalities in frontal, occipital and temporal cortices.
panic- parahipocampal gyrus
caudate- OCD
PTSD- increased activity in amygdala
Geetic linkage in anxiety
50% have a first degree relative with anxiety
no adoption studies, twin studies show hereditability
4% in general population -polymorphic variable of serotonin transporter- have less transportar and more anxiety
stathmin
knockout of this gene in mice causes less learned fear, they take risks and explore environment
areas inlimbic cortex and anxiety
increased activity in septohippocampal pathway
OCD- cingulate gyrus
temporal lobe and anxiety
similarity has been found clinicaly and in EEG between TLE and OCD
Dacosta syndrome
irritible heart syndrome=panic
epidemiology of panic disorder
1-4% 6 month prevalence- 0.5-1% 3-5.6% for panic attck F times2-3 than men/ no racial differences only social factor- recent divorce. onset- average 25- usually early adulthood or late adolescence
comorbidity of panic disorder
91% have comorbid disorder 1/3- had MDD before onset, 2/3- panic during or after MDD up to 30%- OCD 15-30% social anxiety 15-30%- GAD 2-20%- specific phobia 2-10% PTSD and other comorbidities. (personality, hypochondriasis,substance)
Genetic factors in panic
*4-8-fold for panic disorder than other psychiatric disorders in first digress relative with panic disorder
Twin studies
Psychoanalytic theory of panic
Unsuccessful defense against anxiety provoking impulses
Psychosocial stresses in panic attacks
Higher incidence of stressful life events, especially loss, in months before attack
Greater to stress about life events
Separation from mother early in life
60% of women with panic have history of Childhood abuse, as opposed to 31 in other anxiety disorders
Response to lactate in patients with panic after CBT
Lactate infusion no longer caused panic
Psychodynamic themes in panic disorder
Difficulty tolerating anger
Separation from significant person in childhood or adult life
Increased work responsibilities
Perception of parents as controlling critical and demanding
Internalization of abusive relationship
Chronic sense of feeling trapped
Vicious cycle of anger and parental rejecting behavior followed by anxiety that the fantasy will destroy the tie to parents
Failure of signal anxiety function and ego related to self fragmentation and self-other boundary confusion
Defense mechanisms and panic disorder
Somatization
Undoing
Reaction formation
Externalization
SURE
Situationally pre-disposed panic attacks
Panic attacks that are either expected or unexpected
Habits and activities that commonly precede panic attacks
Caffeine, alcohol, nicotine, other substances,
unusual patterns of sleeping or eating, harsh lighting at work
Physical exertion ,sexual activity ,excitement, mild emotional trauma
Timing of panic attack
Starting with 10 minute rapidly increasing symptoms last usually 20-30 minutes and rarely more than an hour
Mental status during panic attack
DRuMS DeDe
Rumination ,difficulty speaking (stammering), impaired memory, depression, depersonalization or derealization
Diagnosis of panic attack
Abrupt surge of intense fear that reach a peak within minutes and include
4/13:
My dizzy fluffy pal abandoned the shore and decided to switch to the true church
(dizziness, fear of death, fear of losing control, palpitations, paresthesias, abdominal discomfort and nausea, shortness of breath, derealization or depersonalization, sweating, chest discomfort, tremor, choking, chills)
Which culture specific symptoms may accompany a panic attack and should they count as one of required symptoms for panic?
Tinnitus, neck soreness, headache, uncontrollable screaming or crying.
Should not count as one of required symptoms.
What is criterion b in panic disorder
At least one of the attacks has been followed by at least one month of either worry of additional attack or maladaptive changes in behavior related to the attack
There is no additional criteria for distress/functional disability
Syncope and panic attacks
20%
Clues for underlying medical etiology to panic symptoms
Atypical features such as ataxia, alterations of consciousness, bladder control.
Onset later in life
Symptoms of medical disorder
Organic dd for panic disorder
Anemia, hyperactive beta-adrenergic state, hypertension, MVP, paradoxical atrial tachycardia, Huntington, Ménière’s disease
Multiple sclerosis, Wilson’s disease, Addison, carcinoid, Cushing, menopause, premenstrual syndrome, hyperthyroidism, hypoparathyroidism
Amil nitrate, anticholinergic, hallucinogens, nicotine, theophylline,
alcohol/bz/opiates/antihypertensives withdrawal,
In text also hypothyroidism and hyperparathyroidism are mentioned, and vestibular disorders
Prognosis of panic disorder
30 to 40% become symptom-free
50% Mild, doesn’t significantly affect life
10 to 20% significant symptoms
10-20-30-40-50 (bad bad good good mild)
Depression and panic patients
40 to 80%, increased risk for suicide
Alcohol and substance dependence in panic disorder
20 to 40%
alcohol is four times more common in panic dis than general population
Which antidepressants are superior to others
SSris,Clomipramine better than BZ, Maoi, tca, tetracyclics
Venlafaxine and buspirone in panic
Venlafaxine is approved
For gad, can be given as an addative for panic combined with depression.
Also buspar can be added.
BZ in panic
Xanax, Lorivan and clonex and valium
Give while titrating antidepressant after 4 to 12 weeks ;taper over 4 to 10 weeks
Medications for panic
Ssri( first line), tca( clomipramine, imipramine- most , but also desipramine), bz, maoi( phenelzine, tranylcypromine, moclibemide, brofaromine), venlafaxine, depalept, inositol( 6000 bid)
How long will it take to achieve full dosage in tca and maoi for panic?
8-12 weeks
Advantage of MAOi for panic over SSRi and tca
Less likely to cause overstimulation but takes time to be effective
Note: phelezine most researched
Which treatments can be added in panic disorder after treatment failure
Bz, lithium,
Case reports: carbamazepine, depalept, ccb
buspirone(augmentation)
Length of treatment for panic disorder
8 to 12 months
Relapse and panic disorder
30 to 90% relapse after successful treatment with medication discontinued especially if they received bz.
Epidemiology of agoraphobia
2 to 6%
And persons older than 65 0.4%
Coexistence of panic and agoraphobia
In psychiatric settings at least three quarters of agoraphobic have panic disorder
In community samples -half have agoraphobia without panic disorder
If both agoraphobia and panic disorder exist give two separate diagnoses
Diagnostic criteria for agoraphobia
Marked anxiety about two out of five: Public transportation Open spaces Enclosed spaces Standing in line or being in a crowd Outside of home alone
The differential diagnosis of agoraphobia
Depression, schizophrenia, paranoid personality disorder, avoidance personality disorder, dependent personality disorder.
Prognosis of agoraphobia
If with panic responds better when panic is treated
agoraphobia without panic- incapacitating and chronic, complicated with depression and alcohol
Treatment for agoraphobia
Benzodiazepines
SSRI same doses as depression but start with lower initial dose is to minimize initial anxiolytic effect
Tca or tetracyclics
SSRI withdrawal
appears2 to 4 days after medication cessation -includes :anxiety ,irritability ,tearfulness ,,dizziness or lightheadedness ,malaise ,sleep disturbance ,concentration difficulties.
Psychotherapy for agoraphobia
Supportive psychotherapy -adaptive defenses encouraged, maladaptive ones discouraged , assist reality testing, advice , therapeutic alliance
Insight oriented therapy- insigt into psychological conflict
Behavioral therapy -does not need insight
Cognitive therapy
Visual therapy- computer program- identify with avatars in feared places- learn to master anxiety through deconditioning
epidemiology of specific phobia
Most prevalent disorder among women second prevalent in men after substance related disorder
Ltp: 10%- women rates are 14 to 16%, double than men- 5-7%
But blood injection injury type-1:1
Age of onset of phobia
Natural environment , animals, and blood injection injury types peak is 5 to 9 years
Age for situational tonight (except fear of heights ) in the mid-20s , like agoraphobia
Prevalence of phobias
Ash made me ill I got injured and died
Animals, storms, height, illness, injury, death.
Phobia comorbidity
50 to 80%.
Anxiety, mood, substance related disorders.
alcohol is twon and a half times more common than general population
Little Albert
An infant with an induced conditioned response to rats and rabbits. By John Watson.
Behavioral mechanism for phobia
Initially classical conditioning. Later operant conditioning, patient develops avoidance patterns that get reinforced since they reduce anxiety.
Psychoanalytic factors in phobia
SPADes
unresolved Oedipal conflict. Anxiety is fear of castration.
auxiliary defenses: displacement,
Symbolization, avoidance, projection.
Psychoanalytic anxiety in agoraphobia
Separation anxiety
Psychoanalytic anxiety in erythrophobia
Superego anxiety( shame)
Environmental and genetic interaction in phobia
Interaction between genes and environment. Behavioral inhibition to the unfamiliar temperament combined with stress creates phobia.
Such stressors are: death of a parent, separation from a parent, parental fights, criticism or humiliation by older sibling, violance at home.
Psychodynamics of social phobia
If raised in problematic family -A characteristic pattern of internal object relations is externalized into Social situations.
anticipation of humiliation, criticism is projected in the environment.
Shame and embarrassment are principal affect states.
Counter phobic attitude
Otto fenichel.
Denial of fear by confronting it- they seek it out dangerous situation like flying a parachute , jumping etc.
Children’s play as doctors- defense mechanism of identifying with the aggressor
Development of specific phobia
Pairing of object with emotions of fear
Modeling -in which a person observes the reaction of another
Information transfer -where a person is taught or warned about dangers
Genetics of specific phobia
Blood injection type is highly familialz 2/3 to 3/4 of affected probands have at least one 1st° relative with same phobia. No twin or adoption study
injection injury type phobia vs other phobias
bradycardia and hypotension often follow he initial tachycardia.
Space phobia
Fear of falling when there is no support. May have abnormal right hemisphere function resulting in visuospatial impairments. Rule out balance disorders
Amoxophobia
Fear of society as a whole
Mysophobia
Fear of dirt and germs
Phobia comorbidity
One third have major depression substance related disorder particularly alcohol
Phobia in mental status examination
Irrational and egodystonic fear
Course and prognosis of specific phobia
Most phobias that begin in childhood and persistent to adulthood will continue to persist.
Severity remains constant as opposed to waxing and waning course in other anxiety disorders
Phobia and Freud
Freud and Sandro ferenczi recognized the therapist had to go beyond analytic rolls and actively urge patients to expose themselves to the feared situation.
Key aspects of successful treatment of phobia are
the patients commitment to treatment, clearly identify problems, alternative strategies for coping with feelings.
Exposure in blood injection injury phobia
Patients are recommended to tense their bodies and remain seated during exposure to help avoid fainting
Pharmacotherapy in phobia
Beta blockers especially when phobia is associated with panic attacks.
BZ can help
Epidemiology of social phobia
Onset is in the teens
Lifetime prevalence between 3 to 13%
Six month prevalence 2 to 3%
In epidemiological studies females are affected more than males but in clinical samples men are more affected than women
International comorbidity study: men -11% women -15%
in the ECAS only 2% men and 3% women
Etiology of social phobia
Pattern of behavior In addition to a trait that’s common in children of parents with panic disorder. They develop shyness.
Parents of children with social phobia were less caring, more rejecting and more overprotective of their children
Neurochemical factors and social phobia
Norepinephrine and dopamine.
Lower HVA
In SPECT -decreased dopamine reuptake sites density
MAOI more effective than tca ( pointing out to dopamine role)
Genetic factors in social phobia
1st° relative three times more likely to be affected.
Concordance evident in Some monozygotic twins studies( but no controlling adoption studies)
Time needed For diagnosis of specific phobia , social phobia , GAD , and agoraphobia
six months
How common is self consciousness ( not social anxiety), and when does it appear?
1/3.
Increases during certain developmental stages, such as adolescence, after life transitions, marriage or occupation changes, etc.
Not considered social phobia- does not cause avoidance or marked distress
Which specifier is there for social phobia
Performance only
Social phobia and children
Anxiety must occur in peer settings , not just during interaction with adults
The fear and anxiety in social situations may be expressed by crying ,tantrum, freezing ,clinging, shrinking or failing to speak in social situations
Pharmacotherapy in social phobia
SSRI first line treatment
Benzodiazepines
Effexor
Buspirone augmentation of ssri
Maoi (phenelzine 45-90 mg, and others) - response rate of 50-70%. Need 5-6 weeks to reach efficacy
Beta blockers- atenolol 50-100 mg, deralin 20-40 mg an hour before speaking, in performance anxiety.
Comorbidity of social phobia
Other anxiety disorders, mood disorders, substance related disorders, bulimia.
Epidemiology of generalized anxiety disorder
In the ECA- lifetime prevalence is 8%.
One year prevalence ranges from 3 to 8%.
Women to men ratio is 2:1, but ratio is 1:1 among patients receiving treatment.
In anxiety disorder clinics 25% with GAD
Prevalence is high in primary care setting.
Onset in late adolescence or early adulthood.
GAD comorbidity
Probably disorder with highest comorbidity with other mental disorders ranging between 50-90%. usually social phobia, specific phobia, panic disorder, depression.
25%- panic disorde
Also associated with substance related disorders and dysthymia
familial relative risk of:
panic disorder
GAD
OCD
panic disorder 2-20
GAD-6
OCD-3-5
the occipital lobe and GAD
has the highest concentratino of GABA receptors- oresumed to be invlved in GAD
neurotransmitters in GAD
GABA
abnormal serotonin regulation
subsensitivity of alpha 2 receotirs
NA, glutamate, CCK
GAD and GH
blunted release after clonidine injection
PET and GAD
lower metabolic rate in basal ganglia and white matter
genetic linkage in GAD
in woman- genetic relation to depression
men- alcohol
25% of first digree relatives
twin: MZ- 50%, DZ- 15%
EEG in GAD
abnormal alhpa and evoked potential
sleep-all decreased(unlike depression): disContinuity, decreased Delta, decreased stage 1 , reduced REM.
because i was anxious and sleepy i broke the rim of one CD.
most common motor features of GAD
shakiness, restlesness, headaches.
what are the main features of GAD
excessive worry for 6 months, with accopanied motor symtoms or reslessness.
The worry is difficult to control and causes impairment.
criteria C symptoms in GAD
3/6 (but only one in children): Mrs. Fic: Muscle tension Restlessness Sleep disturbances Fatigue Irritability Concentration dificulty
sleep disturbance in GAD
difficulty falling/staying asleep, resltess or unsatisfying slee.
When do GAD patients seek treatment?
usually go to clinician in their 20s (usually i general medicine), only a 1/3 seek psychiatric help
course and prognosis of GAD
life events are associated with onset.
generally a chronic disorder
psychotherapeutic strategies for GAD
CBT, supportive, insight oriented.
CBT proven to have short and long term efficacies.
main techniques of CBT in GAD
biofeedback and relaxation.
behavioral approaches address somatic symptoms. Cognitive distortions.
combined cognitive and behavioral better than each alone
phartmacothaerpy in GAD
dont prescribe in first visit
major drugs: BZ, SSRI, venlafaxine, buspirone(azapirone) as primary treatments.
length of treatment of GAD and relapse
6-12 months, till life long.
25% relapse after 1 month of discontinuation,
60-80% relapse within a ear
BZ in GAD
25-30% do not repond
dont give long term- after 2-6 weeks taper for 1-2 weeks.
use intermediate half life (8-15)
effects beyond anxiolytic- become more positive, mild disinhibition
effectiveness of buspirone in GAD
60-80%
people who did not respond to BZ, respond less to buspirone.
doesnt have anxiolytic effect of BZ(muscle relaxation and sense of wellbeing)
buspirone mechanism
5HT1A partial agoist
venlafaxine in GAD
treats somatic complaints in GAD
has Ser, Ne reuptake inhibition, and a little dopamine
SSRI for GAD
good with comorbid depression. Preferably citalopram, sertraline and paroxetine. cn=an start with BZ and taper after 23 wks.
which is the most common anxiety sndrome in anxiety due to a medical condition
panic disorder (and phoia is the least).
wh haas the highest incidennce of panic disorder due to a general medical condition?
crdiomyopathy- 83% of the waiting for heart transplant reported
symptoms of panic disorder in parkiinson and COPD
25%
panic in epilepsy
especialy when focus is in right paarahippocampal gyrus
anxiety symptoms in chronic pain and primary biliary cirrhosis
can be panic
Highest incidence of GAD like syndrom edue to a general medical condition?
in GRAVE’s disease- 2/3!
high incidence also in sjgren- due to cortical, subcortical, and thyroid effects.
social phobia due t0 a general medical condition?
parkinson- 17%
exclusion criteria in anxiety due to a general medical condition
not during a course of delirium
mixed anxiety depression
do not fulfill criteria for either anxiety of mood dis, but have features of both.
called neurasthenia i europe and china
prevalence of mixed anxiety-depression
no consistent data- range from 1%, to 10%, to 50% in primary care setting
comorbid MDD and anxiety
2/3 of MDD patients have proinent anxiety features
in some studies- anxiety and depression symptoms are linked in some families.
symptoms f mixed anxiety -depression
depressive symptoms
anxiety symptoms
sutonomic symptoms- palpitations, dry mouth, sensation of churning stomach
which anxiety dis most commonly overlaps with mixed anxiety-depression?
GAD
mood dis. most commonly overlapping with mixed anxiety depression
dysthymia, minor deressive disorder
dd of mixed anxiety depreseeion- personality disorders?
ocpd, dependent, avoidant
pharmacotherapy for mixed anxiety disorder
effexor- since approved for both GAD and depression- the drug of choice.
triazolbenzodiazepines (xanax)- since both anxioltic and antidepressive effects.
serotonergic agents.
neuroendocrine findings in mixed anxiety depression
simiilar to panic(particularly) and depression:
blunte cortisol to ACTH response,
blunted GH to clonidine response
blunted TSH and prolactin resonse to TRH
other specified anxiety disorders
limited symptom attacks
GAD not occuring more days than not
KHAL CAP (wind attack)
Attaque de nervios
