Anxiety Disorders

Question 1

why learn about anxiety disorders?

Answer 1

• Most common psychiatric problem that presents to primary care physicians often presenting as a medical complaint (GI, cardiac)
  
  • 40 million adults, 18% of US pop
• lifetime prevalence of 30% in females, 19% in males (2:1)
• These patients are 3-5 x’s more likely to go to the doctor; 60% of anxiety disorder patients go to their PCP
• During primary care setting first interview 80% of anxiety diagnoses are missed

Question 2

when is anxiety pathological

Answer 2

consider the anxiety’s BAID:

• behavior
• autonomy
• intensity
• duration

Question 3

what are the domains of anxiety

Answer 3

• physical
• affective
• cognitive
• behavioral

Question 4

fear vs. anxiety

Answer 4

• Aspects of fear and anxiety overlap, but in general:
  
  • Fear-emotional response to real or perceived imminent threat; autonomic behavior surges for fight or flight, thoughts of immediate danger and/or escape for future danger and cautious or avoidant behavior
  • Anxiety-anticipation of future threat; Muscle tension and vigilance in preparation
• Different anxiety disorders often have both, but may have more of one than the other

Question 5

pathological anxiety

Answer 5

Anxiety can be a normal reaction to identifiable stressors that society considers understandable. Anxiety becomes pathological when any of the following happens:

1. Autonomy- anxiety without obvious reason
2. Intensity- out of proportion response, causes dysfunction and/or is not bearable
3. Duration- lasts longer than expected
4. Behavior- coping mechanisms are not enough and/or patient displays other dysfunctional (usually avoidance) behaviors

Question 6

physical domains of anxiety

Answer 6

• constitutional
• skin
• HEENT
• cardiac
• pulm
• GI
• GU
• musculoskeletal
• neurologic

Question 7

other domains (ABC)

Answer 7

• Affective: ranges from edginess to terror & panic; often viewed as irritability or restlessness
• Cognitive: Worry, apprehension, poor concentration, feeling your mind has gone blank, feeling tense/jumpy, anticipating the worst
• Behavioral: Changes made in an effort to diminish or avoid the distress; responses can be checking behaviors, rituals, avoidance

Question 8

What is the origin of anxiety

Answer 8

• protective response
• common underlying neurophysiology
  
  • integrated with memory
• genetic and experiential factors
• biological and neuroanatomical structures involved:
  
  • autonomic system, mostly sympathetic
    
    • locus ceruleus
  • limbic system-governs emotion/behavior
    
    • amygdala-fear processing center
    • hippocampus-memory formation/recollection
    • hypothalamus-homeostasis

Question 9

common underlying neurophysiology

Answer 9

• biological and neuroanatomical structures involved
• anxiety circuits
  
  • two core symptoms-fear and worry
  • fear (amygdala-centered circuit): panic and phobia-often sudden, known threat
  • worry (cortico-striatal-thalamic-cortical circuit): unknown, vague threat
    
    • anxious misery
    • apprehension
    • expectation
    • obsessions
• NT and anxiety
  
  • Serotonin (5-HT)-produced predominantly by raphe nuclei and modulates many homeostatic responses (mood, sleep, anxiety, appetite, sex drive)
    
    • Low 5-HT has been linked with aggression, impulsivity, depression, suicide attempts, self-injury, intrusive thoughts and repetitive behavior
  • Norepinephrine (NE)-made in Locus Cereleus; associated with orienting, selective attn, hypervigilance, mood, and autonomic arousal
  • GABA-brain’s primary inhibitory NT; Medications that increase GABAergic tone, such as benzodiazepines, alleviate anxiety
  • Glutamate-excitatory NT made in presynaptic neuron terminals; most abundant messenger in brain; involved in learning & memory

Question 10

epidemiology of anxiety disorders

Answer 10

• panic disorder
• agoraphobia
• generalized anxiety disorder (GAD)
• specific phobia
• social phobia/social anxiety disorder
• anxiety disorder due to another medical condition
• substance/medication-induced anxiety disorder (SIAD)
• peds:
  
  • separation anxiety disorder
  • selective mutism
• ***PTSD and OCD are no longer under anxiety disorder

Question 11

Panic attack

Answer 11

• an abrupt surge of intense fear or discomfor that peaks within 10 mins and has FOUR OR MORE of the following symptoms:
• PANICS (p3,a,n2,i2,c4,s4)

Question 12

Panic disorder

Answer 12

• recurrent, unexpected panic attacks without and identifiable trigger
• at least one attack has been followed by A MONTH OR MORE of the following:
  
  • **anticipatory anxiety
    
    • ​persistent concern/worry about additional panic attacks or the consequences of the panic attack
    • “Im going crazy” or “Im going to have a heart attack”
  • significant, maladaptive change in behavior related to the attacks
• attacks are not better accounted for by another mental disorder or general medical condition
• age of onset-usually late teens to early 20s, median age 24
• course-untreated, waxes and wanes over time
• moderate genetic component
• usually co-morbid with another psychiatric comorbidity
  
  • 1st-agoraphobia, 2nd-GAD (generalized anxiety disorder)
  • MDD=most non-anxiety disorder

Question 13

Panic disorder course

A. Age of Onset

B. Frequency and Severity

C. Sans tx

Answer 13

• A. Age of Onset
  
  • Median age of onset 20-24 years old;
  • Rare to start in childhood& starting after age 45 y/o is unusual
  • In older adults low prevalence is due to age related “dampening” of the autonomic nervous system response. Disorder often appears to recede later in life
• B. Frequency & severity of panic attacks very widely
  
  • Frequency: may be consistent for a time (1/week), have bursts (daily attacks), separated by months with no attacks
  • Severity: may have full symptom attacks (4 or more symptoms) or limited symptom attacks (<4 symptoms); the number and type of panic attack symptoms frequently differ from one attack to the next
• C. Without tx: waxing & waning course of illness
  
  • < 20% ongoing major impairment
  • ~50% mild impairment
  • ~ 33% recover

Question 14

Panic disorder-other numbers

Answer 14

• Panic attacks & panic disorder diagnosis in the prior 12 mo= suicide RF
• Highest number of medical visits among the anxiety disorders
  
  • Each yr in U.S. : ~200k nml coronary angiograms-33% of these pts have panic disorder.
  • When symptoms are less typical of CAD & pts are referred for non-invasive testing: > 50% of patients with negative tests have panic disorder.
  • Patients investigated for vestibular disorders due to complaint of dizziness: 33% have panic disorder

Question 15

Panic disorder Etiology (2)

Answer 15

• Neurocircuitry model theory: abnormally sensitive fear network, centered in amygdala
• GABA, serotonin, NE, implicated

Question 16

Panic Disorder Tx

Answer 16

• CBT
• Meds:
  
  • 1st line-SSRI’s, SNRI’s,
  • 2nd/3rd line: TCA’s, MAO-I’s
  • BZ-use while waiting for anti-depressant effect
  • **Do not use Bupropion (Wellbutrin)

Question 17

Agoraphobia

Answer 17

• marked fear/anxiety about at least 2 of the following situations (5 total)
• tx: systemic desensitization!

Question 18

GAD

Answer 18

• Excessive anxiety + worry a/b a number of events and activities
  
  • occurring most days for at least 6 mo.
  • Despite having insight into the unrealistic and excessive nature of the worrying, the pt finds it difficult to control the worry and the thoughts interferes with focus
  • Intensity, duration or frequency of the anxiety and worry is out of proportion to likelihood or the anticipated event.
• This worry is accompanied by three or more somatic symptoms:

Question 19

GAD, Specific Phobia, Social Phobia

Answer 19

• all 3:
  
  • F>M (2:1); >6 mo symptoms
  • co-morbidity: other anxiety disorder, depression, substance use disorder
  • prevalence: specific>social>GAD
  • age of onset: specific (children), social (teens), GAD (adults)
• differences:
  
  • course: GAD wax/wane, persists; full remission is low
  • specific: wax/wane, if persist into adulthood=low full remission
  • social: 60% persists for yrs in adulthood; 30% lasts <1 yr
• Tx:
  
  • Agoraphobia: CBT, systemic desensitization
  • GAD: Buspirone
  • Social Phobia: Propranolol
  • specific phobia: usually no meds, CBT, systemic desens.
  • **systemic desens=a type of CBT

Question 20

Specific phobia

Answer 20

• ***pt tend to have >1, avg. 3
• ***blood/injction/injury: M=F

Question 21

Social Anxiety Disorder (Social Phobia)

Answer 21

• Clinically significant fear or anxiety about one or more social situations in which pt is exposed to the scrutiny of others.
• May include:
  
  • social interactions (having a conversation, meeting new ppl)
  • being observed (eating in a public place)
  • performance (public speaking, oral exam)
• Pt is concerned about behaving (showing their anxiety) in a manner that will be humiliating/embarrassing.
• These social situations almost always provoke fear + anxiety
• Blushing=hallmark symptom of this disorder.

Question 22

What are the two main childhood anxiety disorders?

Answer 22

separation anxiety disorder (<12 yrs)

selective mutism-failure to speak in specific social situations; <5 yo, M=F

Question 23

SAD

Answer 23

• fairly common
• course: majority of kids with SAD do not have anxiety disorders over thir lifetime
• can be seen in adults

Question 24

Selective Mutism

Answer 24

Question 25

Approach to diagnosing anxiety disorders-Step 1

Answer 25

rule out substance inuced causes

Question 26

approach to diagnosing anxiety disorders-Step 2

Answer 26

rule out medical conditions \*work up screen: blood glucose, UA, CBC, CMP, ammonia, TSH, B12/folate, RPR, ECG

Question 27

Psychiatric co-morbidities--the BIG 3

Answer 27

* other anxiety disorders-pts often have many features or meet full criteria for other anxiety disorders 1. depression- common comorbi condition wih anxiety 2. substance abuse-frequently co-morbid with anxiety disorders 3. personality traits/disorders-particularly cluster c personality disorders ('worried' cluster) may be comorbid * substances usually more often in men * social disorder is most common comorbid

Question 28

trauma and stress related disorders (3)

Answer 28

1. adjustment disorder 2. acute stress disorder 3. PTSD

Question 29

Adjustment disorder

Answer 29

* In resp to an identifiable stressor that occurred within the past 3 mo, pt develops emotional or behavioral symptoms (anxiety, depressed mood, behavior disturbance) * Symptoms are out of proportion to severity of stressor * Significant impairment in social, occupational, or other area of functioning * Once stressor has ended, symptoms do not persist for more than 6 mo * May be in response to: * a single event (end of a romantic relationship) * multiple stressors (job problems, marital difficulties) * recurrent (seasonal business crises) * continuous (a painful illness, living in a crime-ridden neighborhood) * Course: disturbance begins within 3 mo of the onset of the stressor and ends within 6 mo. after the stressor or its consequences have ceased

Question 30

Acute Stress Disorder

Answer 30

linked to PTSD, one usually leads to the other big diff: PTSD, negative alteration in mood AND cognition; diff duration

Question 31

PTSD

Answer 31

derealization and depersonalization as well, also exaggerated startle response \*\*NO BZ!!!

Question 32

OCD

Answer 32

* recurrent o and/or c that are severe enough to be time consuming (\>1hr/day) * persona understands o/c unreasonable or excessive, but they "just have to do it" * obsessions: persistent ideas, thoughts, images, or urges * experienced as intrusice and inappropriate, cause marked anxiety or distress * "ego-dystonic" (not enjoyable) * dirt/contamination=most common, followed by doubts * compulsions: behaviors or mental acts * co morbidity: tic disorder (especially if OCD childhood onset) * Tx: 1st line SSRIs (\*\*\*high dose)

Question 33

What are the different types of exposure therapy (4)

Answer 33

1. in vivo exposure 1. directly facing a feared object, sitch, or activity in real life 2. Ex: someone with a fear of snakes might be instructed to handle a snake 2. Imaginal exposure: 1. Vividly imagining the feared object, situation, or activity. Ex: someone w/ PTSD might be asked to recall and describe traumatic experience to reduce feelings of fear. 3. Virtual reality exposure: 1. Virtual reality exposure: In some cases, virtual reality technology can be used when in vivo exposure is not practical. Ex: someone with a fear of flying might take a virtual flight in the psychologist's office 4. Interoceptive exposure: 1. Interoceptive exposure: Deliberately bringing on physical sensations that are harmless, yet feared. Ex: someone with Panic Disorder might be instructed to run in place in order to make heart speed up, learn that this sensation is not dangerous.

Question 34

Different pacing of exposure therapy (3)

Answer 34

1. graded 2. flooding 3. systemic desensitization

Question 35

How helpful is exposure therapy?

Answer 35

* habituation * extinction * self-efficacy * emotional processing