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Med 3B
ANXIETY
Emotional state in which person feels uneasy,
apprehensive, or fearful. Usually experiences
of anxiety occurs in events they cannot control
or predict, or about events that seem
threatening or dangerous.
1. motor tension,
2. autonomic hyperactivity,
3. vigilance and scanning and
4. apprehensive expectation
Dopaminergic System
Increased concentrations of dopamine plasma
and urine
CRF and PTA Axis
Low plasma and urinary free cortisol
concentrations in PTSD patients
Exogenous CRF blunted ACTH response but
normal cortisol response vs those of controls
Cortisol suppression with low dose
dexamethasone enhanced in PTSD
CRF concentrations in CSF higher in PTSD
patients
Hypothalamic Pituitary Thyroid
Axis
Higher T3 levels
High rate of blunted TSH response to TRH
stimulation
OBSESSIVE COMPULSIVE DISORDER
Characterized by repetitive thoughts,
impulses, or images that are intrusive and
inappropriate and cause anxiety or distress, or
repetitive behaviors that the person feels
driven to perform in response to an obsession
or rigid rules that must be applied
Noradrenergic System
Clonidine admin decreased severity of OCD
symptoms
Neuroendocrine System
Increased CSF oxytocin correlated with
severity of OCD
Higher somatostatin levels in CSF of OCD
patients
Cytokine IL-6 correlates with severity of
compulsive symptoms
Neuroimmunology
Possible link between strep infection and OCD
Anxiety Disorders:
Genetics
Twin, adoption and DNA marker studies can
provide definite evidence of genetic
contribution
Heritability proportion of the liability for a
disorder that is estimated to be due to genetic
factors
PANIC DISORDER AND AGORAPHOBIA
Best studied anxiety disorder with respect to
intergenerational transmission
Heritability estimates 0.3-0.6 percent; mode
of transmission unknown
Twin + Family Studies
Four twin studies 3 have greater concordance for MZ twin
pairs than DZ twin pairs
Helpful in understanding
the meaning of
psychosocial triggers that
exacerbate these
symptoms, which almost
always have interpersonal
meanings that must be
addressed
Freud postulated response to
overwhelming assault on the
individuals stimulus barrier
regression
Suggested that external trauma
reawakened infantile trauma
Abraham Kardiner and Herbert
Spiegel
Suggested that the external
factors related to the trauma were
most decisive
Preexisting conflict might be
symbolically reawakened by the
traumatic event
As the intensity of a violent
event increase, so does the
number of individuals
traumatized by that event
Certain types of events appear to be more likely to create
traumatic reactions in victims than others
More likely to develop the disorder have
History of early separation from parents
Family history of anxiety and neuroticism
Preexisting depression or anxiety
Personal predisposition is necessary to develop PTSD in
the face of trauma
Result from psychic trauma revolve around three different
symptom clusters:
Intrusive and repetitive re-experiencing of the trauma
Avoidance of this re-experiencing
Overactivation of the autonomic nervous system: sleep
difficulties, hypervigilance, startle reactions, and difficult
concentrating
Other patients adapt to psychic trauma
shutting down any affective development
cannot use affects as signals
Powerful feelings are viewed as a threat use
somatization as a defense but do so at a cost
They cannot soothe themselves or relax
Often deficient in self-care
Trauma shatters the individuals view of the
world as a place that is safe, predictable, and
controllable
Forces a confrontation with ones own vulnerability
Many defenses are marshaled by the ego
(primitive or immature) regression to a
developmentally earlier modes of dealing with
helplessness, vulnerability, fear, and anger
Use denial to avoid facing the severity of the
trauma or the extent of distress
Sense of rage at being victimized may be
disavowed and projected into others
Become hypervigilant in an effort to protect
themselves from the aggression they perceive in
others
Guilt (ex: rape victims)
feel responsible for
what happened to
them
Beneath this guilt and
responsibility feel
completely helpless in
a malevolent universe
where violence is
random
Treatment goals of dynamic psychotherapy
Reducing anxiety
Integrating and accepting the trauma as apart of the self
Regaining a sense of mastery
Re-establishing a sense of personal integrity
Moving away from a sense of being haunted by the past
toward feeling fully engaged in the present
Involves striking a balance between
Forcing the patient to reconstruct a complete picture of
the trauma
Assuming an observing, detached posture that allows
much information to be left out
Relatively new diagnostic entity
Shares many of the symptoms of PTSD but occurs
within 4 weeks of the traumatic event
PTSD has its onset at least one month after the trauma
Many of the same principles involved in the
psychodynamic treatment of PTSD apply to acute
stress disorder as well
Individual who has experienced the trauma must be
helped to integrate and process it so that some
mastery is gained over the experience
Specific work on grief and loss may be extremely
beneficial to patients who have experience an
overwhelming trauma.
Recognized as a disorder in
1987
Associated with the highest
rate of comorbidity of any of
the other anxiety disorders
Additions of specific somatic
symptoms fairly high
degree of construct validity
Chronic worriers
Lifetime prevalence of
generalized anxiety disorder
is thought to range from 4.1-
6.6%
Tends to be chronic
significant amount of
disability and impairment in
the quality of life
Begun to identify specific interpersonal issues
and traumatic events connected to the
diagnosis of generalized anxiety disorder
Affected patients also tend to avoid thinking
about the past events they consider
traumatic
Worrying appears to distract these patients
with superficial matters prevent them
from worrying about more disturbing
underlying concerns
Characteristic defensive pattern of avoidance
Linked to an insecure on conflicted attachment
in childhood
Focus a great deal on symptoms, especially
those related to the body
Therapist should encourage the patient to think
in broader terms and to include broader patterns
of adaptation to work and to love relationships
When attention is drawn away from the somatic
focus of worrying, patient often feel that they
have renewed energy to devote to the true
underlying conflicts
Anxiety Disorders
Clinical Features
Outline
I. Panic Disorder and Agoraphobia
II. Specific and Social Phobias
III. Obsessive-Compulsive Disorder
IV. Posttraumatic Stress and Acute Stress
Disorders
V. Generalized Anxiety Disorder
VI. Substance-Induced Anxiety and Anxiety Due to
a General Medical Condition
VII. Anxiety Disorder not otherwise Specified
Panic Disorder and Agoraphobia
DSM IV
Panic attack
Episode of abrupt
intense fear that is
accompanied by
atleast 4 autonomic
or cognitive
symptoms
Panic Disorder and Agoraphobia
ICD 10
Panic Disorder and Agoraphobia
3 types:
i. Spontaneous panic attack occurs without cue
or warning
ii. Situationally bound panic attacks upon
exposure to
iii. In anticipation of
Panic Disorder and Agoraphobia
Ms. S. was a 25-year-old student who was referred for a psychiatric
evaluation from the medical emergency room at a larger university-based
medical center. Ms. S. had been evaluated three times over the preceding 3
weeks in this emergency room. Her first visit was prompted by a paroxysm
of extreme dyspnea and terror that occurred while she was working on a
term paper. The dyspnea was accompanied by palpitations, choking
sensations, sweating, shakiness, and a strong urge to flee. Ms. S. thought
that she was having a heart attack, and she immediately went to the
emergency room. She received a full medical evaluation, including an
electrocardiogram (ECG) and routine blood work, which revealed no sign of
cardiovascular, pulmonary, or other illness. Although Ms. S. was given the
number of a local psychiatrist, she did not make a follow-up appointment,
since she did not think that her episode would recur. She developed two
other similar episodes, one while she was on her way to visit a friend and a
second that woke her up from sleep. She immediately went to the
emergency room after experiencing both paroxysms, receiving full medical
workups that showed no sign of illness.
Panic Disorder and Agoraphobia
DSM IV
Agoraphobia
Developing fear or
anxiety of places
where escape might
be difficult
Panic Disorder and Agoraphobia
ICD 10
Specific and Social Phobias
Phobia
Intense anxiety
Fear interferes with functioning or causes marked
distress
Feared object is either avoided or endured with a
great difficulty
Specific and Social Phobias
Specific Phobia
Fear is
circumscribed to
a specific object.
4 subtypes
Animal type
Natural
environment
Blood Injection
Situational type
Specific and Social Phobias
Mr. A. was a successful businessman who presented for treatment
following a change in his business schedule. While he had formerly
worked largely from an office near his home, a promotion led to a
schedule of frequent out-of-town meetings, requiring weekly flights. Mr.
A. reported being deathly afraid of flying. Even the thought of getting on
an airplane led to thoughts of impending doom as he envisioned his
airplane crashing to the ground. These thoughts were associated with
intense fear, palpitations, sweating, clammy feelings, and stomach upset.
While the thought of flying was terrifying enough, Mr. A. became nearly
incapacitated when he went to the airport. Immediately before boarding,
Mr. A. often had to turn back from the plane and run to the bathroom to
vomit.
Specific and Social Phobias
Social Phobia
Fear of a social
situation
E.g. Gathering, oral
presentation,
meeting new people
Fear of
embarrassing
themselves in a
social situations.
Specific and Social Phobias
Afraid of encountering
people Afraid of situations from
which escape would be
Flees other people
difficult
Reassured in the presence
of other people
Specific and Social Phobias
Ms. M. was a successful secretary working in a law firm. While she
reported a long history of feeling uncomfortable in social situations, Ms.
M. came for treatment when she began to feel that her uneasiness was
interfering with her social life and job performance. Ms. M. reported that
she noticed herself feeling increasingly nervous whenever she met a new
person. For example, upon meeting a new member of the law firm, she
described feeling suddenly tense and sweaty, noticing that her heart was
beating very fast. She had the sudden thought that she would say
something foolish in these situations or commit a terrible social gaffe
that would make people laugh at her. At social gatherings she described
similar feelings that led her to either leave the gathering early or decline
invitations to attend.
Obsessive-Compulsive Disorder
Obsessions Compulsion
Persistent ideas, thoughts, Repetitive acts, behavior
images that are that are designed to
experienced as intrusive counteract the anxiety
and inappropriate. associated with obsessions.
3 domains
1. Reexperiencing the trauma
2. Avoiding stimuli
3. Experiencing symptoms of increased autonomic
arousal
Posttraumatic Stress and Acute
Stress Disorders
Posttraumatic Stress and Acute
Stress Disorders
Mr. F. sought treatment for symptoms that he developed in the wake of an
automobile accident that had occurred about 6 weeks prior to his psychiatric
evaluation. While driving to work on a mid-January morning, Mr. F. lost
control of his car on an icy road. His car swerved out of control into oncoming
traffic in another lane, collided with another car, and then hit a nearby
pedestrian. Mr. F. was trapped in his car for 3 hours while rescue workers cut
the door of his car. Upon referral, Mr. F. reported frequent intrusive thoughts
about the accident, including nightmares of the event and recurrent intrusive
visions of his car slamming into the pedestrian. He reported that he had
altered his driving route to work to avoid the scene of the accident, and he
found himself switching the television channel whenever a commercial for
snow tires appeared. Mr. F. described frequent difficulty falling asleep, poor
concentration, and an increased focus on his environment, particularly when
he was driving.
Generalized Anxiety Disorder
Pattern of persistent worry and anxiety that is
out of proportion.