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psychiatry shlav alef > anxiety disorders- chpater 9 > Flashcards

anxiety disorders- chpater 9 Flashcards

1
Q

what is the deifference between fear and anxiety?

A

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.

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2
Q

peripheral manifestations of anxiety

A

diarreah, light headedness and dizziness, hyperhidrosis, palpitations, mydriasis, syncope, tachycardia, tingling, tremor, upset stomach (butterflies), urinary frequency, hesitatncy, urgency

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3
Q

psychological mechanism for chronic anxiety

A

dysfunctional ego- imbalance between internal drives and external events(external-usually interpersonal) or conscious(internal-intrapsychic)

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4
Q

epidemiology of anxiety disorders

A

1 of 4 will develop anxiety
12 month prevalence of 17%.
LTP- Women- 30%, men -19%.
prevlence lower in higher socioechonomic status

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5
Q

superego anxiety

A

the highest level of anxiety- guilt about not living up to standards

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6
Q

anxiety- psychoanalytic theory

A

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.

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7
Q

purpose of psychoanalysis in treating anxiety

A

purpose of treatment- not elimination anxiety but tolerating it and identifying the signal.

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8
Q

anxiety- existenial

A

no identified stimulus- generalized. fear of pouposeless universe. may have increased after bioterrorism/ nuclear.

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9
Q

neurotransmitters in anxiety

A

serotonin, neurepinephrin, GABA

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10
Q

animals performance when exposed to conflicting stimuli

A

increased when receiving GABA, decreased with amphetamines.

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11
Q

activating/blocking which adrenergic receptors cause anxiety?
activating which adrenergic area causes anxiety?

A

beta(isoproteronol), and alpha2 blockage (yohimbine)

activation of LC (ablation eliminates fear response)

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12
Q

cortisol functions

A

replenish enery stores
increase arusal and attention adn memory formation
inhibition of growth and reptoductive system
containment of immune response

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13
Q

HPA in panic

A

blunted ACTH response to CRF (in some studies but not others)

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14
Q

CRH

A

increased in stress- release of DHEA and cortisol.

inhibits some neurovegetative functions- food intake, sexual activity, growth and reproduction

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15
Q

Serotonin in anxiety

A

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

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16
Q

projections of LC

A

cortes, limbic system, brain stem, spinal cord

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17
Q

projection of the nucleus raphe

A

cortex, limbic(amygdala and hypocampus), hypothalamus.

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18
Q

Which GABA agonists are good for GAD and which for panic?

A 
low potency- GAD
high potency(clonex, xanax)- panic disorder
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19
Q

what is beta caroline 3 carboxylic acid and what does is cause, as opposed to flumazenil?

A

BCCA causes anxiety even in patients without anxiety disorder(an inverse agonist of GABA)
flumazenil causes panic in patients with panic disorder

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20
Q

what changes did conditioning cause in the aplysia?

A

presynaptic facilitation resulting in increased amounts of neurotransmmitter

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21
Q

peptides in anxiety, and other functions.

A

NPY- 36 aa, invovlved in anxiety, depression, fear
galanine- 30 aa. learning and memory, pain control, food intake, neuroendocrine control, cardiovascular regulation, anxiety.

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22
Q

npy in anxiety

A

anxiolytic
counterregulatory on LC, amygdala,
Npy-y1 receptor.
when increaesd amount in stress- >better performance

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23
Q

galanin in anxiety

A

its administration (centrally)has shown to modulate anxiety

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24
Q

where is the galanin fiber system?

A

densely in the LC , innervating midbrain and forebrain- hippocampus, hpothalamus, amgdala, prefrontal cortes,

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25
Q

brain imagery(anatomical) in anxiety

A 
increased ventricles(some correlated with use of BZ)
right temporal lobe defect )or atrophy) in panic
abnormal right hemisphere
cerebral assymetry
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26
Q

functional imagery and EEg in anxiety

A

abormalities in frontal, occipital and temporal cortices.
panic- parahipocampal gyrus
caudate- OCD
PTSD- increased activity in amygdala

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27
Q

Geetic linkage in anxiety

A

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

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28
Q

stathmin

A

knockout of this gene in mice causes less learned fear, they take risks and explore environment

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29
Q

areas inlimbic cortex and anxiety

A

increased activity in septohippocampal pathway

OCD- cingulate gyrus

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30
Q

temporal lobe and anxiety

A

similarity has been found clinicaly and in EEG between TLE and OCD

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31
Q

Dacosta syndrome

A

irritible heart syndrome=panic

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32
Q

epidemiology of panic disorder

A 
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
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33
Q

comorbidity of panic disorder

A 
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)
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34
Q

Genetic factors in panic

A

*4-8-fold for panic disorder than other psychiatric disorders in first digress relative with panic disorder
Twin studies

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35
Q

Psychoanalytic theory of panic

A

Unsuccessful defense against anxiety provoking impulses

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36
Q

Psychosocial stresses in panic attacks

A

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

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37
Q

Response to lactate in patients with panic after CBT

A

Lactate infusion no longer caused panic

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38
Q

Psychodynamic themes in panic disorder

A

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

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39
Q

Defense mechanisms and panic disorder

A

Somatization
Undoing
Reaction formation
Externalization

SURE

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40
Q

Situationally pre-disposed panic attacks

A

Panic attacks that are either expected or unexpected

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41
Q

Habits and activities that commonly precede panic attacks

A

Caffeine, alcohol, nicotine, other substances,
unusual patterns of sleeping or eating, harsh lighting at work
Physical exertion ,sexual activity ,excitement, mild emotional trauma

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42
Q

Timing of panic attack

A

Starting with 10 minute rapidly increasing symptoms last usually 20-30 minutes and rarely more than an hour

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43
Q

Mental status during panic attack

A

DRuMS DeDe

Rumination ,difficulty speaking (stammering), impaired memory, depression, depersonalization or derealization

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44
Q

Diagnosis of panic attack

A

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)

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45
Q

Which culture specific symptoms may accompany a panic attack and should they count as one of required symptoms for panic?

A

Tinnitus, neck soreness, headache, uncontrollable screaming or crying.
Should not count as one of required symptoms.

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46
Q

What is criterion b in panic disorder

A

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

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47
Q

Syncope and panic attacks

A

20%

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48
Q

Clues for underlying medical etiology to panic symptoms

A

Atypical features such as ataxia, alterations of consciousness, bladder control.
Onset later in life
Symptoms of medical disorder

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49
Q

Organic dd for panic disorder

A

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

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50
Q

Prognosis of panic disorder

A

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)

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51
Q

Depression and panic patients

A

40 to 80%, increased risk for suicide

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52
Q

Alcohol and substance dependence in panic disorder

A

20 to 40%

alcohol is four times more common in panic dis than general population

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53
Q

Which antidepressants are superior to others

A

SSris,Clomipramine better than BZ, Maoi, tca, tetracyclics

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54
Q

Venlafaxine and buspirone in panic

A

Venlafaxine is approved
For gad, can be given as an addative for panic combined with depression.
Also buspar can be added.

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55
Q

BZ in panic

A

Xanax, Lorivan and clonex and valium

Give while titrating antidepressant after 4 to 12 weeks ;taper over 4 to 10 weeks

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56
Q

Medications for panic

A

Ssri( first line), tca( clomipramine, imipramine- most , but also desipramine), bz, maoi( phenelzine, tranylcypromine, moclibemide, brofaromine), venlafaxine, depalept, inositol( 6000 bid)

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57
Q

How long will it take to achieve full dosage in tca and maoi for panic?

A

8-12 weeks

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58
Q

Advantage of MAOi for panic over SSRi and tca

A

Less likely to cause overstimulation but takes time to be effective
Note: phelezine most researched

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59
Q

Which treatments can be added in panic disorder after treatment failure

A

Bz, lithium,
Case reports: carbamazepine, depalept, ccb
buspirone(augmentation)

60
Q

Length of treatment for panic disorder

A

8 to 12 months

61
Q

Relapse and panic disorder

A

30 to 90% relapse after successful treatment with medication discontinued especially if they received bz.

62
Q

Epidemiology of agoraphobia

A

2 to 6%

And persons older than 65 0.4%

63
Q

Coexistence of panic and agoraphobia

A

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

64
Q

Diagnostic criteria for agoraphobia

A 
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
65
Q

The differential diagnosis of agoraphobia

A

Depression, schizophrenia, paranoid personality disorder, avoidance personality disorder, dependent personality disorder.

66
Q

Prognosis of agoraphobia

A

If with panic responds better when panic is treated

agoraphobia without panic- incapacitating and chronic, complicated with depression and alcohol

67
Q

Treatment for agoraphobia

A

Benzodiazepines
SSRI same doses as depression but start with lower initial dose is to minimize initial anxiolytic effect
Tca or tetracyclics

68
Q

SSRI withdrawal

A

appears2 to 4 days after medication cessation -includes :anxiety ,irritability ,tearfulness ,,dizziness or lightheadedness ,malaise ,sleep disturbance ,concentration difficulties.

69
Q

Psychotherapy for agoraphobia

A

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

70
Q

epidemiology of specific phobia

A

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

71
Q

Age of onset of phobia

A

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

72
Q

Prevalence of phobias

A

Ash made me ill I got injured and died

Animals, storms, height, illness, injury, death.

73
Q

Phobia comorbidity

A

50 to 80%.
Anxiety, mood, substance related disorders.
alcohol is twon and a half times more common than general population

74
Q

Little Albert

A

An infant with an induced conditioned response to rats and rabbits. By John Watson.

75
Q

Behavioral mechanism for phobia

A

Initially classical conditioning. Later operant conditioning, patient develops avoidance patterns that get reinforced since they reduce anxiety.

76
Q

Psychoanalytic factors in phobia

A

SPADes
unresolved Oedipal conflict. Anxiety is fear of castration.
auxiliary defenses: displacement,
Symbolization, avoidance, projection.

77
Q

Psychoanalytic anxiety in agoraphobia

A

Separation anxiety

78
Q

Psychoanalytic anxiety in erythrophobia

A

Superego anxiety( shame)

79
Q

Environmental and genetic interaction in phobia

A

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.

80
Q

Psychodynamics of social phobia

A

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.

81
Q

Counter phobic attitude

A

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

82
Q

Development of specific phobia

A

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

83
Q

Genetics of specific phobia

A

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

84
Q

injection injury type phobia vs other phobias

A

bradycardia and hypotension often follow he initial tachycardia.

85
Q

Space phobia

A

Fear of falling when there is no support. May have abnormal right hemisphere function resulting in visuospatial impairments. Rule out balance disorders

86
Q

Amoxophobia

A

Fear of society as a whole

87
Q

Mysophobia

A

Fear of dirt and germs

88
Q

Phobia comorbidity

A

One third have major depression substance related disorder particularly alcohol

89
Q

Phobia in mental status examination

A

Irrational and egodystonic fear

90
Q

Course and prognosis of specific phobia

A

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

91
Q

Phobia and Freud

A

Freud and Sandro ferenczi recognized the therapist had to go beyond analytic rolls and actively urge patients to expose themselves to the feared situation.

92
Q

Key aspects of successful treatment of phobia are

A

the patients commitment to treatment, clearly identify problems, alternative strategies for coping with feelings.

93
Q

Exposure in blood injection injury phobia

A

Patients are recommended to tense their bodies and remain seated during exposure to help avoid fainting

94
Q

Pharmacotherapy in phobia

A

Beta blockers especially when phobia is associated with panic attacks.
BZ can help

95
Q

Epidemiology of social phobia

A

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

96
Q

Etiology of social phobia

A

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

97
Q

Neurochemical factors and social phobia

A

Norepinephrine and dopamine.
Lower HVA
In SPECT -decreased dopamine reuptake sites density
MAOI more effective than tca ( pointing out to dopamine role)

98
Q

Genetic factors in social phobia

A

1st° relative three times more likely to be affected.

Concordance evident in Some monozygotic twins studies( but no controlling adoption studies)

99
Q

Time needed For diagnosis of specific phobia , social phobia , GAD , and agoraphobia

A

six months

100
Q

How common is self consciousness ( not social anxiety), and when does it appear?

A

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

101
Q

Which specifier is there for social phobia

A

Performance only

102
Q

Social phobia and children

A

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

103
Q

Pharmacotherapy in social phobia

A

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.

104
Q

Comorbidity of social phobia

A

Other anxiety disorders, mood disorders, substance related disorders, bulimia.

105
Q

Epidemiology of generalized anxiety disorder

A

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.

106
Q

GAD comorbidity

A

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

107
Q

familial relative risk of:
panic disorder
GAD
OCD

A

panic disorder 2-20
GAD-6
OCD-3-5

108
Q

the occipital lobe and GAD

A

has the highest concentratino of GABA receptors- oresumed to be invlved in GAD

109
Q

neurotransmitters in GAD

A

GABA
abnormal serotonin regulation
subsensitivity of alpha 2 receotirs
NA, glutamate, CCK

110
Q

GAD and GH

A

blunted release after clonidine injection

111
Q

PET and GAD

A

lower metabolic rate in basal ganglia and white matter

112
Q

genetic linkage in GAD

A

in woman- genetic relation to depression
men- alcohol
25% of first digree relatives
twin: MZ- 50%, DZ- 15%

113
Q

EEG in GAD

A

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.

114
Q

most common motor features of GAD

A

shakiness, restlesness, headaches.

115
Q

what are the main features of GAD

A

excessive worry for 6 months, with accopanied motor symtoms or reslessness.
The worry is difficult to control and causes impairment.

116
Q

criteria C symptoms in GAD

A 
3/6 (but only one in children):
Mrs. Fic:
Muscle tension
Restlessness
Sleep disturbances
Fatigue
Irritability
Concentration dificulty
117
Q

sleep disturbance in GAD

A

difficulty falling/staying asleep, resltess or unsatisfying slee.

118
Q

When do GAD patients seek treatment?

A

usually go to clinician in their 20s (usually i general medicine), only a 1/3 seek psychiatric help

119
Q

course and prognosis of GAD

A

life events are associated with onset.

generally a chronic disorder

120
Q

psychotherapeutic strategies for GAD

A

CBT, supportive, insight oriented.

CBT proven to have short and long term efficacies.

121
Q

main techniques of CBT in GAD

A

biofeedback and relaxation.
behavioral approaches address somatic symptoms. Cognitive distortions.
combined cognitive and behavioral better than each alone

122
Q

phartmacothaerpy in GAD

A

dont prescribe in first visit

major drugs: BZ, SSRI, venlafaxine, buspirone(azapirone) as primary treatments.

123
Q

length of treatment of GAD and relapse

A

6-12 months, till life long.
25% relapse after 1 month of discontinuation,
60-80% relapse within a ear

124
Q

BZ in GAD

A

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

125
Q

effectiveness of buspirone in GAD

A

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)

126
Q

buspirone mechanism

A

5HT1A partial agoist

127
Q

venlafaxine in GAD

A

treats somatic complaints in GAD

has Ser, Ne reuptake inhibition, and a little dopamine

128
Q

SSRI for GAD

A

good with comorbid depression. Preferably citalopram, sertraline and paroxetine. cn=an start with BZ and taper after 23 wks.

129
Q

which is the most common anxiety sndrome in anxiety due to a medical condition

A

panic disorder (and phoia is the least).

130
Q

wh haas the highest incidennce of panic disorder due to a general medical condition?

A

crdiomyopathy- 83% of the waiting for heart transplant reported

131
Q

symptoms of panic disorder in parkiinson and COPD

A

25%

132
Q

panic in epilepsy

A

especialy when focus is in right paarahippocampal gyrus

133
Q

anxiety symptoms in chronic pain and primary biliary cirrhosis

A

can be panic

134
Q

Highest incidence of GAD like syndrom edue to a general medical condition?

A

in GRAVE’s disease- 2/3!

high incidence also in sjgren- due to cortical, subcortical, and thyroid effects.

135
Q

social phobia due t0 a general medical condition?

A

parkinson- 17%

136
Q

exclusion criteria in anxiety due to a general medical condition

A

not during a course of delirium

137
Q

mixed anxiety depression

A

do not fulfill criteria for either anxiety of mood dis, but have features of both.
called neurasthenia i europe and china

138
Q

prevalence of mixed anxiety-depression

A

no consistent data- range from 1%, to 10%, to 50% in primary care setting

139
Q

comorbid MDD and anxiety

A

2/3 of MDD patients have proinent anxiety features

in some studies- anxiety and depression symptoms are linked in some families.

140
Q

symptoms f mixed anxiety -depression

A

depressive symptoms
anxiety symptoms
sutonomic symptoms- palpitations, dry mouth, sensation of churning stomach

141
Q

which anxiety dis most commonly overlaps with mixed anxiety-depression?

A

GAD

142
Q

mood dis. most commonly overlapping with mixed anxiety depression

A

dysthymia, minor deressive disorder

143
Q

dd of mixed anxiety depreseeion- personality disorders?

A

ocpd, dependent, avoidant

144
Q

pharmacotherapy for mixed anxiety disorder

A

effexor- since approved for both GAD and depression- the drug of choice.
triazolbenzodiazepines (xanax)- since both anxioltic and antidepressive effects.
serotonergic agents.

145
Q

neuroendocrine findings in mixed anxiety depression

A

simiilar to panic(particularly) and depression:
blunte cortisol to ACTH response,
blunted GH to clonidine response
blunted TSH and prolactin resonse to TRH

146
Q

other specified anxiety disorders

A

limited symptom attacks
GAD not occuring more days than not
KHAL CAP (wind attack)
Attaque de nervios

psychiatry shlav alef (22 decks)

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