Anxiety+Disorders

=Reading= Andreason or Sadodck & Sadock, Kaplan's...pp 150-164

=Goals=

3. Know the brain regions peripheral systems, and neurotransmitters involve din anxiety
==4. Recgonize the clinical description of a panic attack. Know the difference between a panic attack and a panic disorder. Recognize medical illnesses in the differential diANGOSIS OF A PANICK ATTACK. Describe the course and treatment f panic disorder.== ==5. Recognize the clincial descroiption, course, and treatment of agoraphobia. understand the relationship between panic disorder and agoraphobia--

8. Recognize medicaqlconsidtions and substances commonly associateated with anxiety symptoms
Definition of anxiety: an npleasant state of anticipation, aprehension, fear, or dread often accopanied by a physiologic state of autonomic arousal, alertness, and motor tension

Fear, apprehension, dread, sense of impending doom worry, rumination, obsession nervousness, uneasiness, distress Derealization ( the world seems distorted or unreal), depersonalitzation( one's body feels unreal or disconnected)

Derealization: Occurs quite commonly in context of reality of all the exams....really less riding on it

//two boxes: neurology exam, psych exam Read the first one--Ddn't have a clue Moved on second... two pages of questions... finally came to the conclusion had given me the wrong exam

One was in blue, the other in brown ink I looked at the cover, everywhere, but I couldn't read it//

physical symptos:
 * diaphoresis,
 * diarrhea,
 * dizziness,
 * flushing, chills,
 * hyperreflexia,
 * hyperventilation,
 * lightheadedness
 * numbness
 * palpitations (pounding heart)
 * pupil dilatation
 * restlessness
 * Shortness of breath (Non-physiologial)
 * Syncope
 * tachychardia
 * tremor
 * upset stomach ("butterflies")
 * Urinary frequency

physically addressing can help stop, take deep breath addressing restlessness, tremor... in many ways adaptive When maladaptive?


 * Response disproportionalte to stres or threat
 * Stress is nonexistant, imaginary, or misinterpreted
 * symptoms interfere with adaptation or response to stress or threat
 * Symptoms interfere with other life functions

Neurobiology of anxiety: CNS: Frontal Cortex: > Interpretation of complex stimli > declarative memory > learning > extinction of condition gear and emotional memory allows you to override impulses from elsewhere in the brain

//example: walking through the Detroit Zoo, hear lion roar immediate jump frontal cortex kicks in: We're at the zoo! fear translated into excitement//

Limbic Syste Striatum, thalamus, amygala, hippocampus, hypothalamus > Emotional memory--Amygdala > fear conditioning > anticipatory, anxiety newborn sees adult run from deer, will adopt response for rest of life

Brainstem Raphe Nuclei, Locus Ceruleus > Arousal, attention, startle > COntrol of autonomic nervous system > Respiratory control startle response before conscious of stimuli most physiologial symptoms Peripheralsystmes > Autonomic Arousal ( tachycardia, tachypnea, dairrhea) > Hypothalamic-pituitary-adrenal axis activation > visceral sensory activation waiting for norepinephrine titer to kick-in rate at which body uses O2 wears off

Neurotransmitters
 * Norepinephrine:: Locus Cerueus projections to frontal cortex, limbic brainstem, and psintal cord...
 * GABA
 * GABA

Difference in episode bvs attack takes a pattern Panic attack: discrete period of intense fear accompanie by physical and psychological syptoms Onset is rapid: seconds to minutes Peak symptoms are reachd within 10 minutes Symptoms ay be spontaneous or in response to a stimulus...crowds, driving, elevators

Panic Attack May occure in context of panic disorder, social phobnia, speicifc fobias, other anxiety disorders, or isolated incident

Differential diagnosis....long list Anemia angina arrythmia CHF HTN Mitral Valve prolaps Infarction Tachycardia asthma hyperventilation PE TIA Encephalitis Hyntington's Infection Meniere's Migraine MS Seizure Tumor Up to age 45, panic attacks are more disabling than heart disease

Usually secondary to panic disorder often extremely debilitating up to 1980s, data based off who shows up to clinic what about people who dontcome out for treatment knocked on doors of 15000 homes

Panic DIsorder Recurrent panic attacks, accompnied by at least one month of persistent concern about having another attack, or a change n behavior due to the attacks

Panic Disorder with or without agoraphobia

Lifetime risk is about 1% population Onset in young adulthood panic attacks come and go, but agoraphobia tends to worsen if panic attacks are persistent don't wait around!

Etiology: Strong biological component (15-20% concorddance wth 1st degree relatives). behavioral component is suggested

comorbidity includes major depression, suicide, alchohol abuse

Treatment: SSRIs, TCAs, MAOIs, and benzodiazepines are effective for panic. Behavioral therapies and MAOIs are most effective for agoraphobia. Buspirone is not effective.

Panic attack without agoraphobia: 4% same etiology, better prognosis for anxiety without agoraphobia

Behavioral therapy is indicated

Social Phobia ared and persistent fear of embarrasment in Difference: avoidant personality disorder...a.nxiety regarding intimacy Social Phobia is anxiety about being observed as group gets bigger, social phobia gets worse as group gets smaller, avoidant personality gets worse

Lifetime prevalence 5% 50% higher in women onset is adolescence, often in a shy child couse is typially lifelong and continuous

Etioogy: the disorder is more common among 1st degree relatives, and is associated with high autonomic arousal

Treatmetn: b-blockers for performance anxiety; behavioral therapy; SSRIs, benzodiazpines, MAOIs perform better with b-blockers

Specific phonia 10% prevalence 4x more in woman comorbidtiy vasovagal fainting; alchohol abuse Treatmen: Behavioral *exposure) therapy

patient afraid of spiders Benxodiazepine for schedules exposures...airline flight

Obsessive-Complsive Disorder Differs from OCD Personality disorder! OCPD perfetionism

OCD obsessive thoughts, compusive disorder recurrent and persistent thoughts or behaviors that are recognized as being excessive and unreasonable, and either cause marked distress, are time-consuming, or interfere with the eprson's function //As good as it gets: Jack Nicholson washing hands with bars of soap//

//Pt had to step in the exact center of step, or had to step off bus//

//Pt spent 8 hours a day of washing hands Anything that reminded him of military...afraid of HIV from VA//

other folks, thoughts, got to run through in mind ritualistic

Prevalence: 2-3% of population

Onset usually in early teens, mid twenties for females

Course usually lifelong, with waxing and waning of symptoms causes extreme disability

strong biological componnt

Comorbidity: depression: 30%, eating disorders (20%), schizotypal traits, generalized anxiety, tourettes (5%)

Treatment: SSRIs very affective, and Clomipramine, behavioral therapy in severe cases psychocsurgery...Cingulotomy, subcaudate tactectomy, limbic leukotomy....

PTSD Following severe traumietc event... sexual assault, auto accident, natural disaster, combat experience

person reexperiences the trauma through flashbacks, nightmares, or disturbing memories

Consciously or unconsciously aoids stimuli associated with the trauma

Experience increased arousal

symptos last more than 1 month

Symptoms significantly interfere with person's life

Etiology: eniety, depression, antisocial traits in individual or family are risk factors

Comorbidity: Suicide, major depressive disorder, substance abuse

Treatment: Behavioral therapy, SSRIs, TCA, MAOIs

makes no difference whether person is gone anxiety is likely to go on, even though irrational

gruoup therapy useful

Acute Stress Disorder is similar

Generalized Anxiety Usually a background for something else excesive anxiety andworry about several events 3 somatic or psych symproms lasts 6 motnhs or more interferes with function you //are// worried about something

Comorbidity: Treamtnet: Benzodiazepines, SSRI

Adjustment DIsorder with Anxiety

in response ot specific psychosocial stressor

Due to general medical condition..... in response to physiological effects...hyperthyroidism

Substance induced anxxiety disorder caffeine //first tie on call by self...page went off...panic attack... have to sit there and deep breath... how can this be?

couple years later loaded with soda immediately began having panic attacks always caffeine loaded at beginning of call got into trouble twice for sleeping through pager do a bolus of cafeine, setting self up