ICL 9.4: Adult Anxiety Disorders

Question 1

what is the behavioral theory of anxiety?

Answer 1

aka learning theory –.> child learns to be afraid; they learn that a certain stimulus is dangerous and they have to act in a way that shows that fear response

so it’s a conditioned learned response to a repeated environmental stimuli; the pairing of the stimulus with some bad outcome then leads to a fear response to that stimulus when it’s presented again even if there is no bad outcome

anxiety is a conditioned (learned) response to repeated environmental stimuli!

anxiety results from copying parents’ behaviors that shows the parents are afraid because if the big adult is scared then i should be too (social learning)

Question 2

what is the cognitive theory of anxiety?

Answer 2

it’s based on appraisal

the person looks at a situation and decides that it’s dangerous and then the danger is actually not an extreme danger, it might be a neutral stimuli that’s appraised as danger – so the person overestimates the degree of danger and underestimates their own ability to cope

the combination of these 2 things is related to the health belief model! people perceive their symptoms in a certain way and then they decide if they’re in danger and how they’re going to deal with the danger

so an overestimation leads to anxiety while underestimation will lead to a bad outcome

Question 3

what is a phobia?

Answer 3

an irrational, persistent, excessive fear of objects, places or situations, activities and a conscious avoidance of the feared object or situation

the object/place/situation must elicit severe distress or impairs function

phobias often develops after a frightening event that is not followed by habituation or learning so the person responds to subsequent exposure as if it is the first time

Question 4

what are the categories of phobias?

Answer 4

1. animal type (more common in kids)
2. natural environment (storms)
3. situational (heights)
4. blood injury

Question 5

what is a blood injury phobia?

Answer 5

fear of needles, blood, shots etc.

it’s the vasovagal reflex! so a strong sympathetic response which is the stress response to the sight of the needle or blood followed by a strong overcompensated parasympathetic response where the BP drops and syncope

Question 6

how do you treat a specific phobia?

Answer 6

primary treatment is exposure therapy; either actual or virtual

this works by teaching:
1. relaxation

2. breath control
3. gradual exposure to the feared object or situation

you’re trying to destabilize the fear memory

every time the person had been exposed to the fear stimulus it becomes more engrained in their memory; so the exposure part reactivates the fear system but by doing breath control and relaxation, the fear memory becomes destabilized and eventually they realize this isn’t going to hurt me

Question 7

what is social anxiety disorder?

Answer 7

it’s a social phobia!

it’s an excessive fear of social or performance situations like embarrassment humiliation –> the phobia interferes with functioning and/or causes distress

the person is self focused and does NOT direct conversation to others; they don’t know how to make small talk! so it’s not just public speaking or performance on a stage

the person realizes that the fear is excessive

this involves social situations, public speaking, etc.

Question 8

how do you treat social anxiety disorder?

Answer 8

1. cognitive restructuring; discuss feared social events, learn coping skills
2. social skills training; practice conversations; lessen focus on oneself and they learn to let the other person talk about themselves
3. pharmacotherapy: anti-anxiety agents

Question 9

what is a panic attack?

Answer 9

must have at least 4 symptoms:

1. dizzy
2. de-realization
3. trembling
4. shortness of breath
5. choking
6. paresthesias
7. chest pain
8. de-personalization
9. fear of losing control
10. fear of dying
11. chills/hot flashes

the attack is followed by 1 month of distress, worry or changes in behavior like avoidance of the place where the panic attack happened

Question 10

what is panic disorder?

Answer 10

1. repeated and unexpected panic attacks; one is not enough to meet criteria!
2. abrupt onset; peaks within 10 minutes but resolves back to baseline on their own
3. not due to substances (coffee, energy drinks)

no loss of consciousness or loss of bodily functions
onset usually before age 40

Question 11

what are panic attack specifiers?

Answer 11

attacks may come on during awakening but most occur throughout the day

attacks may occur during another mental illness

Question 12

what is agoraphobia?

Answer 12

marked fear or anxiety and avoidance of two or more of these situations for a 6 month duration:

1. open spaces
2. being in a crowd
3. closed-in spaces
4. being outside or home alone
5. using public transportation

these are all so different but what do they have in common? the person believes that they are without help!

Question 13

how do you treat panic disorders?

Answer 13

1. behavioral approaches

CBT is as effective as medication and great long term!

there is strong support for exposure to the place where they had the panic attack, breathing retraining and relaxation

also homework, education and followup are other important factors for long term maintenance of improvement

2. medications

TCA, SSRIs or benzodiazepines

usually you do CBT with medication together; base it on how impaired a person is

Question 14

what is generalized anxiety disorder?

Answer 14

GAD is excessive anxiety and worry > 6 months that causes significant distress or impairment with 3+ of the following symptoms:

1. restless, keyed up
2. fatigued
3. decreased concentration
4. irritability
5. muscle tension
6. sleep disturbance

for GAD, these symptoms are much more vague and harder to measure symptoms than panic disorder – also when you asked them what they’re afraid of, they tell you they aren’t afraid but they’re anxious about literally everything

Question 15

how do you treat generalized anxiety disorder?

Answer 15

1. first rule out excessive caffeine, stimulant use
2. psychotherapy

CBT, relaxation therapy, biofeedback or psychodynamic

CBT: address the person’s thoughts and beliefs about the situation that’s worrying them one at a time; address present concerns and beliefs

relaxation therapy: decrease the physiological aspects of anxiety; so if someone has a ton of muscle tension or restlessness from high anxiety

psychodynamic: explore the source of conflict with the person with more emphasis on past history
3. medication
4. mindfulness meditation (MBSR)

Question 16

what does MBSR stand for?

Answer 16

Mindfulness-Based-Stress Reduction

Question 17

what is MBSR?

Answer 17

mindfulness meditation

the patients with MBSR rather than education based stress reduction did better! they had greater reduction in baseline anxiety and less stress reactivity!

Question 18

what is your role as a physician in treating anxiety disorders?

Answer 18

you don’t do any of the formal psychotherapy but you can prepare them for the idea of going to therapy

you can also suggest phone apps that will help with meditation and mindfulness

Question 19

what os obsessive compulsive disorder?

Answer 19

1. obsessions
2. compulsions

obsessions or compulsions are time consuming (1 hour per day) so people become very impaired –> they significantly interfere with occupation or usual activities or relationships with others

obsessions or compulsions cause distress or impairment and are time consuming

symptoms wax and wane, not constant severity

Question 20

what are obsessions?

Answer 20

unwanted, persistent thoughts, impulses or images that fill the mind; they’re intrusive/senseless and cause anxiety or distress

the person attempts to ignore, suppress, or neutralize the thoughts or images but they return

some people believe that thoughts make it happen! like if a mom worries about the bully being on the bus and bullying her kid, then the more she thinks about it the more likely that the bully is on the bus so then maybe her child shouldn’t take the bus at all – the thought becomes more and more real until they’re obsessed with it

Question 21

what are compulsions?

Answer 21

repetitive physical acts, behaviors or thoughts that are aimed at reducing distress or preventing dreaded event – but does it actually reduce the distress?

yes the distress is reduced but the effects are only temporary; while the person is performing the action/behavior, they’ll feel less anxious but then the anxiety comes back once they stop

Question 22

is OCD more common in men or women?

Answer 22

occur equally in men and women

this is an outlier from anxiety disorders which are more common in women

Question 23

what are some common obsessions?

Answer 23

1. direct and contamination
2. destructive and injurious behaviors; worried about hurting others
3. order and symmetry
4. daily decisions
5. religious thoughts

Question 24

what are common compulsions driven by the common obsessions?

Answer 24

1. washing - driven by contamination obsession
2. counting – driven by a need for order
3. checking - driven by urge to avoid catastrophe

obsessions that aren’t clearly linked to compulsive behaviors are really hard to treat

Question 25

what is the hyperactive error response theory?

Answer 25

OCD patients show increased neural response to errors/the detection of mistakes –> a mistake would be something like the spice jars aren’t lined up or they didn’t drive in the perfect center of the road or the house isn’t adequately clean enough

the overactive error signal leads to belief that something is wrong when there isn’t actually something wrong –> so then the rituals are directed to correct the perceived error

errors are over valued OCD patients and lead to stronger emotional responses

Question 26

how do you assess for OCD?

Answer 26

Do you have annoying ideas, images or impulses that fill your mind?

Are you compelled to perform behaviors or think thoughts again and again?

Use Yale-Brown Obsessive Compulsive Scale to obtain an actual severity score

Question 27

how do you treat OCD?

Answer 27

1. education
2. pharmacological; SSRIs, TCA
3. supportive psychotherapy

includes exposure and response therapy

4. family therapy; ask them to not assist in performing rituals or quietly refuse obsessive questions
5. behavior therapy
   ex. expose the person to object that aren’t clean and then prevent the excessive washing response

Question 28

what is hoarding?

Answer 28

difficulty discarding possessions

they have a need to save and have distress with discarding

accumulation clutters living areas

hoarding causes distress or impairment

so the person wants the objects and has distress about discarding stuff and then the person gets strep because the person starts having a functional impairment and at some level they know it’s not normal; if they have good insight and realize what they’re doing then there’s a better prognosis

if they have absent insight then they won’t realize anything is wrong

Question 29

what do people hoard and why?

Answer 29

papers, wrappers, bottles, boxes……cats, dogs, and other animals

there’s a dysfunctional primary attachment and the objects become a source of comfort and calm for the person

the core fear of abandonment hasn’t been resolved and the person fears abandonment by people so they then derive comfort from their stuff

it may also be a way to avoid social interaction; people afraid of social interaction and tend to rely on objects instead which will certainly keep people out of their home

Question 30

how do you treat hoarding?

Answer 30

1. bring in the sanitation department and fire department to do a health assessment

ensure that the property complies with standards of health, fire codes, sanitation

2. provide support for those who hoard; no criticism

figure out their degree of insight into the situation

3. implement interventions

CBT and regular follow up to avoid relapse; this will NOT be a fast process

a one time clean out will not work! one time intervention with no followup, lack of inspections and lack of education will not work!!

Question 31

julia is 45 years old. present with problems getting to sleep for the past month, GI distress and recurrence of tension type headaches. 7 months ago julia was promoted, got a raise and now has more responsibilities at work. she is panicked about meeting deadlines. she tells you that she has always been high strung but now julia worries about other things such as what the neighbors think about her new car. she is more irritable at work and at home. she is easily distracted and can’t relax on her days off.

diagnosis?

Answer 31

generalized anxiety disorder

she talks about lots of different fears that are unfocused

she has at least 3 symptoms that are required for diagnosis

Question 32

a 50 year old women complains of 3 episodes of severe anxiety, shortness of breath, apparent brief loss of consciousness and loss of bladder control during the past month. she tells you that she is worried sick about some money that she has to repay.

diagnosis?

Answer 32

non-psychiatric medical disorder

panic disorder usually has onset around 40 years old and they don’t lose consciousness! they don’t lose bowel control or bladder control either

Question 33

brett is a 20 year old DI college pitcher. his team is winning their division and he is their best pitcher. lately bret has been scouted by a major league team and he’s been asked for media interview for the local paper saying that the media should interview the guy with the highest batting average instead of him.

lately he can feel the anxiety when he starts a game and sees that the crowds are getting bigger. he knows that he is skilled but almost wishes he was not as good so that all those people wouldn’t be coming around to talk to me.

diagnosis?

Answer 33

social phobia

Question 34

which of the core fears are evidenced by social phobia?

Answer 34

rejection

most of these habituate over time but not with people who have social phobia

Question 35

george is a 63 year old man who had 17 dogs in his home. the neighbors called for help because his yard was dirty and he stopped letting anyone into the house. questioning by the officers who came to the house revealed that george and his mother had a successful dog breeding business for years. when the mother died, george became overwhelmed, sold few puppies and the number increased.

if george is treated, should george get his dogs returned to him?

Answer 35

2-3 dogs back

george had insight, he didn’t have a psychiatric history, he had recently lost his mom and got overwhelmed so he got attached to the dogs without mom

the interventions worked but we aren’t going to give back 17 dogs