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39 Cards in this Set
- Front
- Back
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What is anxiety?
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Fear:
-A response to an identifiable threat -Fight or Flight response, reflexive, autonomic sympathetic arousal Anxiety: -Is a emotion which occurs in the absence of an obvious threat. -Definition: “an apprehensive uneasiness of the mind” -Is a normal part of life -Can be adaptive -James-Lange Theory of Anxiety – Brain’s interpretation of physical manifestations of arousal Pathological or “Clinical” Anxiety - “presence of fear or apprehension that is out of proportion to the context of the life situation” |
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Secondary Anxiety and ‘Overlap’ Conditions
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Anxiety due to General Medical Condition – (Specify)
Psychological Factors effecting Physical Condition Hyperthyroidism Cardiac Arrhythmias Heart Failure/MI Asthma and COPD Irritable Bowel Syndrome ? Hypoglycemia |
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DSM-IV anxiety disorders
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Panic Disorder (With and Without Agoraphobia)
Generalized Anxiety Disorder Specific Phobia Social Phobia Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Acute Stress Disorder |
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Panic disorder epidemiology
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2.5 times as common in women than in men
2.5% of females 15-24 |
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Panic disorder biological theories
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Noradrenergic Over activity/Sensitivity
-locus caeruleus (“blue spot”) – Has 90% of all NE Cell bodies -Electrical Stimulation in animals mimics Panic symptoms -Other provocative interventions include: Inhaling CO2, IV Lactic Acid, Yohimbine (α-2 Adrenergic antagonist) Limbic Serotonin over activity -Added to initial locus caeruleus theory (primarily due to efficacy of SSRIs) -Thought to primarily mediate “fear” and excessive worry |
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Panic attack overview
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Also referred to as an “anxiety attack”
Sudden intense feelings of severe anxiety with accompanying physical symptoms “Crescendo” – Anxiety develops abruptly and reaches a peak within seconds to minutes Classically lasts 10-20 minutes |
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Panic attack physical symptoms
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Sweating, hot flashes, chills
Trembling or shaking Sensations of shortness of breath, smothering, can’t get enough air (Dyspnea) Dizzy, unsteady, lightheaded, or faint (not vertigo) Paresthesias (numbness or tingling sensations), generally perioral and finger tips Feeling of choking Palpitations, pounding heart, tachycardia Chest pain or discomfort Nausea or abdominal discomfort Panic attacks may be: -spontaneous -sometimes precipitated -always precipitated, If panic only occurs in response to a specific stimulus this suggests a Phobia |
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Panic attack psychological symptoms
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Intense anxiety
Derealization Depersonalization Fear of losing control or going crazy Fear of dying |
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Panic disorder criteria
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Panic attacks that have been spontaneous
Either: -Recurrent unprecipitated panic attacks -One unprecipitated attack followed by the fear of another May or may not be associated with agoraphobia -Anxiety about being in places from which escape would be difficult (or embarrassing) or where help would not be readily available -Agoraphobia nearly always associated with Panic Disorder -Agoraphobia – “Fear of the Market Place” -Can be severely disabling |
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Panic disorder comorbidities
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Specific and Social Phobias
Generalized Anxiety Disorder Major Depressive Disorder Substance Use Disorders Suicidal Thoughts |
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Panic disorder course
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Typically begins in late adolescence or early adulthood (especially in patients with family history for Panic Disorder)
May begin with “limited symptom attacks” Patient typically has one or more ED visits If undiagnosed/untreated patient may develop phobias, avoidance behavior, depression (demoralization) and/or substance use disorders May culminate in suicidal thoughts/actions Typically demonstrates a progressive course |
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Panic disorder differential diagnosis
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Medical Conditions
-Hyperthyroidism, Pheochromocytoma, Sypathomimetics Other Psychiatric Disorders -Primarily other Anxiety disorders and Substance Abuse Malingering |
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Panic disorder treatment
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Pharmacological
-Antidepressants -Benzodiazepines -Noradrenergic Suppressors Non-pharmacological -Cognitive Behavioral Therapy -Desensitization -? Psychodynamic Psychotherapy |
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Panic disorder and antidepressants
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Monoamine Oxidase Inhibitors
Tricyclic Antidepressants – especially Imipramine Selective Serotonergic Reuptake Inhibitors (SSRIs) -first line of treatment Norepinephrine-Serotonin Reuptake Inhibitors (NSRIs) Advantages – Can be quite effective, no risk of abuse or dependence, can be taken long-term with no obvious detrimental effects Disadvantages – Troubling side-effects, delayed response, some times ineffective |
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Panic disorder and benzodiazepines
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Most commonly Alprazolam (Xanax) or Clonazepam (Klonopin)
Advantages – tolerability, rapidly effective Disadvantages – sedation, psychomotor impairment, dependence, abuse potential, and memory/cognitive impairment |
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Panic disorder and noradrenergic suppressors
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Beta-blockers – Propranolol (Inderal) for “performance anxiety” and tremors
Selective (hydrophilic) beta-blockers (e.g. Atenolol or Nadolol) don’t cross the blood-brain barrier hence may have less CNS “depressant” effect Clonidine (presynaptic α2 agonist) – surprisingly not useful in Panic Disorder |
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Panic disorder and Cognitive behavioral therapy
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Clarify the nature of the disorder and symptoms
Eliminate cognitive distortions e.g. catastrophic thinking Self-monitor and identify patterns Create sense of control e.g. “plan B” Relaxation training Breathing exercises |
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Panic disorder and desensitization
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Progressive exposure, especially useful for agoraphobia and avoidance
Involves progressive approximations of the feared activity, e.g. going to the Mall or driving |
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Generalized anxiety disorder definition
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A general pattern of frequent, persistent worry that is out of proportion to the impact of events or circumstances
Patients may or may not acknowledge the excessive nature of their worry but are troubled by the worry/anxiety At least 6 months in duration |
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Generalized anxiety disorder symptoms
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Feelings of restlessness
Fatigue Muscle tension Insomnia Often accompanied by depression Tends to be a chronic disorder (waxing and waning course) Can be related to psychosocial stressors Much like “pain” it is subjectively assessed for severity by the patient |
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Generalized anxiety disorder antidepressant pharmacotherapy
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MAOIs
-Including Phenelzine (Nardil) -Almost never prescribed Tricyclics -Including Imipramine (Tofranil) and Clomipramine (Anafranil) -Almost never prescribed SSRIs -Including Paroxetine (Paxil) and Sertraline (Zoloft) Dual Mechanism Agents -Including Venlafaxine (Effexor) and Duloxetine (Cymbalta) |
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Non-benxodiazepine anxiolytics
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Buspirone (Buspar) – Partial 5-HT1a agonist, modest anxiolytic effect, no impairment, dependence or abuse potential. No benefit in Panic d.o.. Notable “anti-irritability” effect
Beta-blockers – Useful for “performance anxiety”, in pts. with cardiac “triggers” and/or tremor Antihistamines – Modest anxiolytic effect with no dependence or abuse potential. Can be useful for insomnia, e.g. diphenhydramine |
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Benzodiazepines pros and cons
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Pros
-Potent anxiolytics -Quick onset of action -Favorable side effect profile Cons -Psychological and Physical dependency -Sedation (generally time limited) -Cognitive and Psychomotor impairment -Abuse potential |
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Posttraumatic stress disorder definition
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Characteristic symptoms which occur after exposure to a trauma
The trauma must involve -Witnessing or experiencing threatened death or injury -Witnessing or experiencing threats to physical integrity |
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PTSD - symptoms: arousal, re-experiencing, numbing
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Arousal:
-Trouble falling or staying asleep -Irritability -Trouble concentrating -Hyper vigilance -Exaggerated startle response Re-experiencing the trauma: -Intrusive recollections -Distressing dreams of the trauma -Flashbacks Avoiding stimuli associated with the trauma -Places, Activities, Smells, Sounds Numbing: -Feeling detached from others -Unable to have certain feelings (e.g., loving feelings) -Trouble remembering events related to the trauma -Sense of foreshortened future |
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PTSD onset
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Can occur at any age
Symptoms usually being in 1st 3 months after trauma -May start years later Can develop in anyone if the stress is severe enough -Some people may be more at risk Symptoms must be at least one month in duration |
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Acute stress disorder definition
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Similar to PTSD except that duration of symptoms is less than 1 month
-Occurs within 4 weeks of trauma May or may not proceed to PTSD |
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Obsessive and compulsive definitions
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Obsession: Recurrent thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety and distress
-Not simply excessive worries about real life problems Compulsions: Repetitive behaviors or mental acts that the person feels driven to perform or according to rules that must be rigidly applied that the person recognizes are excessive or unreasonable. The acts are aimed at preventing or reducing distress or preventing some dreaded event but the acts are not connected in a realistic way with what they are designed to prevent or they are clearly excessive |
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OCD symptoms
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Obsessions
-blasphemous -causing harm -leaving something undone Compulsions -Behaviors: Hand washing, ordering, checking -Mental acts: Counting, praying, repeating words silently Person may eventually begin to lose insight into the unreasonableness of the acts Can reach “psychotic” proportions |
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OCD comorbidities
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Other Anxiety Disorders
-Panic disorder, phobias Eating Disorders Major Depressive Disorder Questionable relationship to Tourette’s disorder |
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OCD course
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Typically starts in adolescence or early adulthood
-Often first symptoms around age 8 Usually a chronic course -Waxes and wanes, possibly related to stress 15% have progressive deterioration in functioning (still an indication for psychosurgery) |
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OCD treatment
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Cognitive Behavioral Therapy
Pharmacotherapy -Serotonin specific antidepressant -SSRIs or Clomipramine (Anafranil) -May require higher doses and longer duration than in depression -Very minimal placebo response in trials |
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Phobia definition
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“Excessive fear of a specific object, circumstance, or situation"
Three types of phobias -Agoraphobia -Specific Phobias -Social Phobia For diagnosis of a Disorder, the fear must interfere with functioning or cause marked distress |
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Specific phobia
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Fear is circumscribed to a specific object/situation
Types -Animal type -Natural environment type -Blood-injection type -Situational Type -Other Rare for patients to seek treatment for a single specific phobia -People typically adjust their lives -May be diagnosed as a comorbidity -Treatment generally involve Systematic Desensitization or “Flooding” |
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Specific phobia epidemiology
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Community sample 1 year prevalence rate of about 9%
Bimodal peak of onset -Childhood --animals, natural environment, blood-injury -mid-20s --situations May be precipitated by a traumatic event |
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Social phobia
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Fear of social situations
-Including performance situations Exposure to situation may be accompanied by panic attack May be confined to specific situations or may be generalized -Specific type -Generalized type Most commonly feared situations: -#1 Public Speaking -#2 Speaking to strangers/meeting new people -Less Common --eating or writing in public --using a public restroom -Most people presenting clinically have more than one feared situation |
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Social phobia course
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Typical onset in mid-teens
-May have been shy as a child Course usually continuous -may attenuate in adulthood - or person avoids phobic situations Best treatment is thought to be Group Therapy |
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Anxiety disorders due to a general medical condition
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Endocrine disorders
-Hypo- and hyperthyroid states -Hyperparathyroidism -Pheochromocytomas -Episodic hypoglycemia associated with insulinomas Neurologic disorders -Seizure disorders -Vestibular dysfunction -Neoplasms Cardiovascular conditions -Congestive heart failure -Pulmonary embolism -Arrhythmia Pulmonary Disorders -COPD -Asthma -Pneumonia |
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Substance induced anxiety disorders
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Many medications and illicit drugs can have anxiety as a side effect
-Cocaine, stimulants e.g. “speed, crank”, crystal meth”, marijuana (especially in naive users), caffeine -Sympathomimetics, steroids, theophylline -Usually a clear temporal relationship -Can also be associated with withdrawal from alcohol or sedatives |
