Psych - Anxiety Disorders

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Anxiety disorders (6)

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Panic disorder with/without agoraphobia (fear of public, open spaces)
Fear bodily sensations

Specific phobia
fear a specific situation or thing

Social phobia
Fear embarassment

Generalized anxiety disorder
Fear bad things happening

Obsessive-compulsive disorder
Fear a thought (acting on it, coming true)

Post-traumatic stress disorder
Fear external danger.

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Panic attack dx criteria

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Intense fear or discomfort where 4 of these occur abruptly and peak within 10 minutes:

Palpitations
sweating
trembling/shaking
SOB or smothering
choking feeling
chest discomfort
Nausea
Dizziness
Derealization or depersonalization
Fear of losing control or going crazy
fear of dying
parasthesias (numbness or tingling)
chills/hot flashes

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DSM criteria of panid disorder

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A. Need both 1 and 2:

1. Recurrent unexpected panic attacks

2. At least one is followed by a month or more of one or more of the following:
Persistent concern of having more attacks
Worry abt implications of the attack or its consequences (such as losing control, having a heart attack, going crazy)
A signif change in behavior relatd to the attacks.


B. Attacks not due to physiological effects of a substance or medical condition (e.g. hyperthyroidism)

C. Panic attacks are not better accounted for by another mental disorder (e.g. social/specific phobia, OCD, PTSD or separation anxiety disorder)

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Agoraphobia DSM criteria

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Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Such as being outside the home alone, being in a crowd, or standing in line, being on a bridge, and traveling in a bus, train, or automobile.

The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.

The anxiety and phobic avoidance are not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety.

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Components of anxiety

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Physical systems
Noradrenergic discharge and autonomic hyperactivity (rapid pulse, sweating, rapid breathing...)

Behavioral action tendencies
Escape/avoidance, procrastination, jittery behaviors, safety checks

Cognitive processes
Attention shift, uncontrollability, anxiety sensitivity, catastrophizing (seizing upon the worst outcome), and probability overestimation (thinking bad events are more likely to happen)

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Cognitive behavior therapy interventions for anxiety

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PANIC DISORDER


Psychoeducation

Physiological self-regulation skill training

Modification of unhelpful cognition

Exposure to phobic stimuli

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How is fear initially learned and then maintained?

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PANIC DISORDER


Learned through classical conditioning.

Maintained by avoidance behaviors and faulty cognitions.

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Exposure therapy - basic mechanism

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PANIC DISORDER


Repeated and prolonged exposure to a feared stimuli results in a reduction of anxiety.

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Interoceptive exposure

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PANIC DISORDER


Repeated exposure to feared bodily sensations evoked through various exercises. E.g.:

Running in place, holding breath, shaking head, spinning, hypervent, straw breathing, etc.

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Social phobia (what is the fear of and the DSM criteria)

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Fear is embarrassment

Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack.

The person recognizes that the fear is excessive or unreasonable.

The feared social or performance situations are avoided or else endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared social or performance situations interferes significantly with the person’s functioning or social activities or relationships, or there is marked distress about having the phobia

The fear or avoidance is not due to the direct physiological effects of a substance or general medical condition.

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Specific phobia DSM IV criteria

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Marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack.

The person recognizes that the fear is excessive or unreasonable.

The phobic situation is avoided or else endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationship, or there is marked distress about having the phobia.

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Generalized anxiety disorder

Fear and DSM criteria

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Fear is bad things happening. Anxiety is lower than panic, but is more continuous.

Excessive worrying
More days than not for 6 month or longer
Worry about several domains
Difficult to control worrying
Worry accompanied by 3 of 6:
Restlessness/Fatigue
Impaired concentration
Muscle tension
Sleep disturbance
Irritability
Significant impairment/distress
Not solely due to depression, psychotic disorder, developmental disorder
Not due to medical condition or effects of substance

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Etiology of GAD

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Uncontrollable negative life events as a child

Parental modeling

Heritability-anxiety diathesis

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Nature of worry in GAD

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The content of worrying is normal (finances, health, job, family)

But the duration, freq, sense of controllability/validity etc. is much worse.

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Symathetics in GAD

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Suppressed. (shown to have less variability in HR and "SC."

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1 complication of GAD

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Polymyalgia rhematica. Painfull inflammation if large arteries.

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OCD fear

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Fear is thought (compulsions neutralize the threat posed by the thought) (e.g. is the doorknob dirty? did i turn off the stove? if i use a knife, i will stab my wife...)

even if things aren't done in order, something bad will happen. so i will do them over until i get it right...

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OCD DSM

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Either obsessions or compulsions

At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable

Cause marked distress, are time consuming (> 1 hr./day) or significantly interfere with normal routine.

Content not related to another Axis I disorder (e.g.g eating disorder, trichotillomania (hair pulling until it falls out), BDD (body dysmorphic disorder), hypochondriasis, substance abuse, paraphilias)

Not due to substance use or medical condition

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Obsessions

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Persistent thoughts/impulses/images experiences at some time during the course of the disturbance. Causes anxiety or distress.

Person attempts to ignore them.

Person recognizes they are obsessional and a product of their own mind.

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Compulsions

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Repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession.

They are aimed at preventing/reducing distress or avoiding a dreaded event/situation.

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Name of disorder when anxiety is due to medical illness

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Anxiety Disorder Due to a General Medical Condition

Often due to hypoxia, COPD, delirium, hyperthy, acidosis, hypoglycemia.

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Name of disorder when anxiety is due to drug/toxin withdrawal

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Substance Induced Anxiety Disorder

Alcohol, caffeine, amphetamines and other adrenergic drugs, cocaine, benzos, etc.

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Locus coeruleus

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Activation of diffuse central noradrenergic pathways and overall CNS arousal

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Amygdala

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Implicated in basic models of conditioned fear

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Orbito-Frontal

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Basal ganglia networks - implicated in OCD

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NTs involved in anxiety

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Noradrenergics

Serotonin (hypersensitive CO2 chemoreceptors so a false suffocation alarm)

GABA

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Tx of panic disorder with/without agoraphobia

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Most common - Cognitive restructuring and exposure

Optimum - Combo of pharm and behavioral tx

Pharm used - SSRIs, tricyclics. Also can use propanolol, clonazepam and alprazolam.

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Facial diff between panic attack and GAD

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Panic attack - sheer terror on their faces

GAD - appears worried and tense

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Tx of GAD

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Most common - CBT, meditation and pharmacotherapy.

Pharm used - Benzos and busipirone. Beta blockers also also good though because they reduce peripheral manifestations of anxiety.

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Tx of social or specific phobias

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CBT (this includes exposure and cognitive restructuring).

Propanolol can also be helpful (e.g. stage fright)

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Tx of OCD

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CBT (includes exposure and response prevention and cognitive therapy) and drugs

Drugs - Clomipramine (tricyclic with serotonin reuptake blocking activ.) and SSRIs (fluoxetine and fluvoxamine).

Severe OCD can be treated with psychosurgery, but this is very rare.