Anxiety Disorders

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Anxiety disorders

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-have high rates of comorbid psychiatric disorders, alcohol and rug abuse and suicide
-assoc. with an increased risk for cardiovascular morbidity and mortality

Front 2

what is anxiety

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-an unpleasant emotional and physical state characterized by fear, apprehension, restlessness, tensions, over-activity of the ANS, cardiac and pulmonary sensations, and the expectation on impending diaster

Front 3

What causes anxiety?

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`1. Chatecholamines: dec activation of serotonin and inc activation of noreepinehprine
2. Neuroexcitability: inc NMDA activity and dec GABA activity
3. The amygdala: mediator of the "fight or flight response"; stimulated by conscious input from the cortex and subconscious input that bypasses the cortex

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what causes anxiety- the endocrinological answer

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1. the HPA axis: Physical or emotional stress causes an increase in release of CRF, which causes a release in Corticotropin, which causes a release of stress hormones (ie Cortisol, Norepinephrine) from the adrenal cortex.

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What is an anxiety disorder?

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1. a psycho-neuro-endocrinologic illness that often manifests with psychologic and somatic sx
2. and illness that produces:
-intense, excessive and prolonged states of apprehension and fear
-autonomic arousal
-physical discomfort (HA, N, dizzines, abd pain)

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Generalized anxiety disorder

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-excessive anxiety and worry about a number of events or activities (ie school performance)
-person finds it difficult to control the worry
-anxiety and worry associated with at least 3 of the following:
1. restlessness/feeling on edge
2. being easily fatigued
3. difficulty concentrating
4. irritability
5. muscle tension
6. sleep disturbance

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Panic disorder

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-recurrent panic attacks
-panic attack: discrete periods of intense discomfort or fear accompained by somatic complaints
-onset is abrupt
-peak is generally within 10 min
-duration generally b/t 5-30 min

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psychological presentation of panic attacks`

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1. intense fear of dying
2. intense fear of losing control
3. derealizaiton

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physical presentation of panic attacks

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1. chest pain
2. palpitaitons, tachycardia
3. dizziness, lightheadedness
4. sweating
5. SOB
6. trembling
7. hot flashes or chills
8. paresthesias

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phobic disorder

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-irrational and persistent fear od specific situations or objects
-fear is out of proportion to the actual danger
-presents in same manner as panic attack
-common phobias: Insects, height, water, blood, needles, closed spaces, public speaking

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psychological and physical presentation of phobias

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-same as panic attacks

Front 12

social anxiety disorder

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-a persistent fear of social/performance situations in which one is exposed to unfamiliar people or possible scrutiny
-the individual fears that he will act in an embarrassing way
-the person recognizes the fear is unreasonable or excessive
-The feared situations are avoided or endured with intense distress
-interferes with nml routine and occupational/academic/social functioning

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PTSD

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-anxiety that develops after exposure ot an event that causes feelings of intense fear, helplessness or horror
-most common causes: sexual assault, war

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PTSD- presentation

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1. re-experiencing: Intrusive thoughts, images, flashbacks, nightmares, or stress from cues
2. Avoidance: Avoiding thinking/talking about the event, affective numbing, amnesia, decreased interests, derealization/depersonalization, restricted emotions
3. Hyperarousal: Insomnia, hypervigilance, exaggerated startle response, difficulty concentrating, anger

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OCD

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-presence of obsessions and/or compulsions
-obsessions: Recurrent thoughts, impulses, or images that are experienced as intrusive and inappropriate
-compulsions: Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession.

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OCD presentation

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1. obsessions: contamination, pathologic doubt, need for symmetry, aggressive/violent, sexual

2. compulsions: cleaning, checking, arranging, confessing, counting, praying

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OCD pathophys

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1.genetics:
-anxiety sensitivity: An individual’s response to physiological alterations associated with anxiety and fear.
-biology: abnormalities in serotonin transmission in CNS
2. psychology:
-Obsessions: A neutral stimulus gains fear producing properties (“Classical Conditioning”)
-Compulsions: Avoidance behavior reinforces the unrealistic belief (“Negative Reinforcement”)

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What causes an anxiety disorder?

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1. the catecholamine hypothesis
2. the NMDA/GABA hypothesis
3. Overactivation of, or lowered threshold for stress by, the amygdala
4. Failure of the negative feedback loop of the HPA Axis

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What are the risk factors for anxiety disordeR?

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1. genetics
2. familial factors: First-degree relatives of patients with panic disorders have up to a 7-fold increased probability of having panic disorder
3. enviornment
4. stress

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How do we diagnose anxiety disorders?

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1. history:
-social drugs, prescription drugs, OTC drugs, drug withdrawal
2. PE:
-HEENt, Cardiac, pulmonary, neuro, endocrine
3. Labs
4. formal psychiatric interview
5. objective assessments (HAM-A)
6. Subjective assessments
7. ASK!

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How do we treat anxiety disorders?

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1. cognitive behavioral therapy
2. relaxation techiniques
3. exposure and desensitization
4. response prevention
5. SSRIs (Prozac, Lexapro)- FIRST LINE TX! (starting dose lower than for depression, SE more common than in depression)
6. SNRIS:
7. tricyclic antidepressants
8. Serotonin partial agonists: for GAD
9. Benzos: not first line but has more immediate onset
10. antihypertensives, anticonvulsants, antipsychotics

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Psychosurgery

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-anterior cingulotomy: Used in cases of severe, medication-resistant Obsessive-Compulsive Disorder
-uses radio-freq waves to destroy a small amt of brain tissue to interrupt a specific circuit in the brain
-typical pt has failed several trials of numerous meds and many months or yrs of cognitive-behavioral therapy