Anxiety (wk 6) Flashcards
“true” anxiety disorders vs “anxiety like” disorders
“True” anxiety disorders: * Panic disorder
* Agoraphobia
* Specific phobia
* Generalized anxiety disorder
“Anxiety-like” disorders (no longer strictly considered
as part of the anxiety disorder spectrum)
* Obsessive-compulsive disorder
* Post-traumatic stress disorder
how many people have had an anxiety disorder
17%
panic disorder criteria
need to have periods in between attacks where patient a) fears another attack or b) does maladaptive things to avoid another attack
- Need at least 1 month history of avoidance or fear of another panic attack
panic attacks need how many symptoms and give examples
4 of;
▪ Palpitations, pounding heart, or accelerated heart rate
▪ Sweating
▪ Trembling or shaking
▪ Sensations of shortness of breath 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 (numbness or tingling sensations)
▪ Derealization (feelings of unreality) or depersonalization (being detached from oneself)
▪ Fear of losing control or “going crazy.”
▪ Fear of dying
GAD diagnostic criteria
▪ Excessive anxiety for more days than not for 6 months
▪ Individual has difficulty controlling the anxiety
how many symptoms for GAD
3-6 of
▪ Restlessness or feeling “keyed up” or on edge
▪ Being easily fatigued
▪ Difficulty concentrating or mind going blank
▪ Irritability
▪ Muscle tension
▪ Sleep disturbance
- As with all psychiatric diagnoses, the anxiety, worry, or physical symptoms must:
▪ Cause clinically significant distress OR
▪ Impairment in social, occupational, or other important areas of function
agoraphobia
fear of being out-of-doors or being in a crowd or being in a place where they can’t escape from or may suffer embarrassment
i.e. public stransport
how long for agorphobia
The fear or anxiety needs to be present for > 6 months and needs to cause significant distress or impairment in social or occupational functions
specific phobias
i.e. spider, blood, clown
fears of specific objects or situations that go beyond the true threat of the stimulus and cause avoidance and functional impairment
how long does specific phobia need to be present for
> 6 months
social anxiety disorder
▪ One is exposed to unfamiliar people or to possible scrutiny by others
▪ One is afraid that fearing he/she will act in a way that maybe humiliating or embarrassing
* e.g. public speaking, initiating or maintaining conversation, dating eating in public
▪ Out-of-proportion fear that they will be harshly judged by their interpersonal interactions
post traumatic stress disorder
men and women common causes
exposure to actual death, threatened death, physical or
sexual violence, serious injury
men- combat
women- abuse
First responders, healthcare personnel, law enforcement are a growing demographic affected by this disorder
symptom categories of PTSD
- intrusion symptoms
- avoidance behaviour
- cognitive and mood symptoms
- arousal and reactivity symptoms
▪ Intrusion symptoms
* Intrusive, distressing memories, flashbacks, dreams ▪ Avoidance behaviour
* Avoidance of situations or events that are associated with the inciting trauma
* Can also involve avoiding people, places, or conversations that arouse memories or feelings associated with the event
▪ Cognitive and mood symptoms
* Memory deficits, negative emotions, guilt, shame
* Detachment from others, loss of interest in people or activities
▪ Arousal and reactivity symptoms
* Difficulty sleeping, exaggerated startle responses
* Anger, irritability, increased risk-seeking behaviour
intrusion symptoms of PTSD
i.e. falshbacks
▪ Recurrent, involuntary distressing memories or dreams of a
traumatic event (they “intrude” on the sufferer’s mind)
▪ Dissociative reactions where the individual feels as if the event was occurring
* Known as a flashback – different than a memory
▪ Marked physiological reactions or distress at exposure to cues
that resemble the traumatic event
PTSD alterations in arousdal and reactivity examples
▪ Irritable behaviour or angry outbursts with little or no provocation
▪ Hypervigilance or exaggerated startle responses to everyday stimuli
▪ Sleep disturbances or difficulty concentrating
▪ Reckless or self-destructive behaviour
PTSD negative alterations in cognitions or mood
▪ Inability to remember important aspects of the traumatic
event
▪ Negative beliefs about oneself or the world in general
* These could be linked to or independent from self-blame about the traumatic incident
▪ Persistent inability to experience positive emotions
▪ Diminished interest or participation in general day-to-day,
essential activities
▪ Detachment or estrangement from other people
how long must PTSD symptoms be present
> 1 month
impair life.
obsession and compulsion definition
- Obsession: intrusive and unwanted repetitive thoughts, urges, or impulses that lead to a marked increase in anxiety or distress
- Compulsion: repeated behaviors or mental acts that are done in response to obsessions, or in a rigid rule-bound way (i.e. ritual)
▪ Act may attempt to “suppress” the obsession
obsession examples
Fear of contamination
Pathological doubt (i.e. something was missed leading to catastrophic consequences)
Fear of causing harm to others
Need for symmetry or exactness
Superstitious obsessions (can include religious obsessions)
compulsion examples
Cleaning or washing rituals
Repetitive checking
Ordering, rearranging objects
Superstitious rituals (i.e. repeating things a certain number of times)
how long must OCD take place in a day
▪ Obsessions and compulsions must take > 1 hour/day or cause significant distress or impairment in social, occupational, or other areas of functiona
True or false
OCD people are aware that their obsessions and compulsions are illogical and not based in fact
TRUE
▪ This is known as insight
▪ Most patients with delusions and hallucinations have poor
insight (i.e. schizo)
what other disorders share similar neurobiology to OCD
▪ Hoarding disorder
▪ Skin-picking or trichitomania (hair-pulling/plucking) disorders
▪ Body dysmorphic disorder
neurobiology of anxiety disorders
what part of the brain does the fear response activate and which neuortransmitter does it release
locus coerulus (a midbrain nucleus)
norepinephrine
how does the amygdala get activated in a fear response
from the locus coeurluls and norepinephrine release
in a fear response what gets activated after the amygdala
hypothalamus and reticular activating system
▪ Activation of the hypothalamus – activation of the sympathetic nervous system and cortisol release
▪ Activation of the reticular activating system in the brainstem – increased arousal
which neurotransmitters in which part of the brain can have a modulatory effect on mood, memory and fear and stress
The serotonin-releasing nucleus in the brainstem (the raphe nucleus)
what 3 pathways are effected in anxiety disorders
Noradrenergic, Dopaminergic, Serotonergic Pathways →Brainstem Nuclei
what is a normal anxiety response
“Normal” – areas activated include the locus coeruleus, amygdala→activation of the sympathetic nervous system and temporary increased release of cortisol
* Helps us deal with threats – the prefrontal cortex is able to regulate mood, negative cognition, and general worry
what is abnormal anxiety response
▪ “Abnormal” – areas activated OR inactivated include an area close to the amygdala (stria terminalis) and other midbrain nuclei like the dorsal raphe nucleus as well as the locus coeruleus
* Poorer regulation of mood, fear/worry by the prefrontal cortex
* Excessive long-term activation of cortisol release by activation of the hypothalamic pituitary axis as well as excessive chronic activation of the sympathetic nervous system
what brain part does OCD involve mainly
basal ganglia
–> direct and indirect pathways via extrapyramidal motor system
which pathway is over active in OCD
direct pathway in basal ganglia
over-activation of the direct pathway and poor activation of the indirect pathway as they modulate activity of the orbitofrontal cortex
- Inhibitory dopaminergic transmission transmission (D2 receptors) may be implicated
treatment for OCD
high dose SSRIs
eating disorder in femalee vs male
10:1
who is at high risk for ED
▪ display “perfectionist” traits
▪ Have a past history of sexual abuse
▪ feel that they lack control in other dimensions of their lives
▪ Expectations (i.e. athletic) regarding weight * Gymnasts, dancers
* Wrestlers
anorexia diagnostic crieria
- low energy intake and low weight
- fear or behaviour of becoming fat
- perception; doesn’t think is underweight
intake and weight: restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
▪ Significantly low weight → a weight that is less than minimally normal
fear or behaviour: intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight
perception: disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
bulimia diagnostic criteria
- binge eating episode
- compensatory behaviour to prevent weight gain (vomit, laxative, fast, exercise)
- at least 1x/ week for 3 months
A. recurrent episodes of binge-eating; an episode of binge-eating is characterized by both of the following:
▪ eating, in a single period of time, an amount of food that is larger than what most individuals would eat during a similar period of time and under similar circumstances
▪ a sense of lack of control over eating during the episode
B. recurrent inappropriate compensatory behaviour in order to prevent weight
gain such as:
▪ self-induced vomiting
▪ misuse of laxatives, diuretics, enemas, or other medications ▪ Fasting
▪ excessive exercise
C. the binge-eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 mo
D. self-evaluation is unduly influenced by body shape and weight
E. the disturbance does not occur exclusively during episodes of AN
dangers of starvation/ calorie restriction
- Hypotension, bradycardia
- Dysrhythmias, congestive heart
failure - Vitamin deficiencies
- Constipation, delayed gastric
emptying - Decreases thyroid hormone,
amenorrhea, osteoporosis - Increased risk of seizure due to
electrolyte abnormalities - Severe restriction can cause renal
failure and edema
dangers of bingin+ purging
- Gastric dilation or rupture
- Esophageal damage/tearing
- Pancreatitis
- Dysrhythmias (due to K+ loss from
vomiting or use of laxatives) * Damage to teeth (purging) - Aspiration pneumonia
- Gastric contents cause pneumonia when they are accidentally “breathed in”w
2 ways that benzodiazepines act
- anxiolytics
- hypnotics
▪ Anxiolytic example: Diazepam (Valium®) * Also used for certain types of seizures
▪ Hypnotic example: Triazolam (Halcion®)
mechanism of action of benzodiazepenes
binds GABA to GABA-R
adverse effects of benzos
–>most common w hypnotics
* Hangover effects
▪ Wake up feeling groggy
▪ More common with long half-life agents
* Early morning rebound insomnia
▪ Wake up too early
▪ More common with short half-life agents
▪ Can lead to taking a second pill during the same sleep cycle, which makes tolerance more likely to develop
what might cause tolerance to benzos
down regulation of GABA receptor
dependence of benzos?
▪ Brain requires the drug to generate normal
amounts of GABA activity
▪ Leads to more severe withdrawal symptoms when drug is discontinued
withdrawal symptoms of benzos
▪ Mild symptoms can occur after short-term use and/or
low-doses, including:
* Extra-sensory awareness
▪ Ex acute hearing
* Muscle twitching or tremors * Rebound excitation
▪ Patients should be counselled to expect a few nights bad sleep at the end of a course of BDZ
* During this time, a new prescription should not be given
- Use of BDZ’s more than 14-21 nights in a row makes tolerance/dependence/several withdrawal symptoms more likely
severe withdrawal of benzos
▪ Severe symptoms usually occur on abrupt discontinuation after long-term use and/or high doses, and include:
* Increased blood pressure, temperature and pulse
* Rage
* Hallucinations and paranoia * Seizures
withdrawal symptoms can also occur during the chronic drug use bc they aren’t getting the impact of the drugs anymore bc the gaba receptors are downregualted
warms of hypnotics for insomnia (benzos)
Abnormal thinking and behavioral changes
* Visual and auditory hallucinations, “sleep-X” events
▪ The need to evaluate for an underlying primary psychiatric and/or medical illness for the insomnia
* Hypnotic use coupled with an underlying primary disorder can cause:
▪ Worsening of insomnia, worsening of depression (including suicidal thoughts), etc
what is the benzodiazepine antagonist
and via what mechanism
flumazenil
competitive inhibition of benzodiazepines
ie for drug overdose or to get off meds
typically how long must someone have the mental health disorder persistently for to be diagnosed
> 6 months
except i.e. PTSD is >1 month
mania is 1 week
