Subject Topic Date Lecturer

Psychiatry
Anxiety Disorders June 18, 2010 Dr. Sanchez-Antonio
Pages

AY 2010-2011

Transcriber Fab Editor

Lester

Anxiety Disorders
I. II. Anxiety Panic Disorders Panic Attacks Panic Disorder with (or without) Agoraphobia Agoraphobia III. Specific Phobia IV. Obsessive-Compulsive Disorder V. Posttraumatic Stress Disorder VI. Generalized Anxiety Disorder VII. Adjustment Disorder Adjustment Disorder Due to General Medical Condition Substance-Induced Anxiety Disorder VIII. Biological Treatment : Anxiety Disorder Catecholamine Theory GABA Theory Serotonin Theory Opioid Peptide Theory Cognitive-Behavioral Therapy IX. Separation Anxiety Disorder (SAD) X. Selective Mutism

From: Powerpoint, Kaplan (some of the points may not be really under DSM-IV-TR, sorry)

I. NORMAL ANXIETY

Diffuse, unpleasant, vague sense of apprehension Accompanied by autonomic symptoms headache, perspiration, palpitations, tightness in the chest, and mild stomach discomfort Symptoms vary among individuals Warning of internal or external threat anxiety is adaptive and is life-saving Prompts a person to take the necessary steps to prevent the threat or to lessen its consequences

FEAR
Response to a known, external, definite, or non-conflictual threat

ANXIETY
Alerting signal Warns of impending danger Response to an unknown, internal, vague or conflictual threat.

Psychoanalytic theory Freud ultimately redefined anxiety as a signal of the presence of danger in the unconscious Viewed as a result of psychic conflict between the unconscious sexual or aggressive wishes and corresponding threats from the superego or external reality The goal of therapy is to increase the anxiety tolerance Behavioral Theory Anxiety is a conditioned response to a specific environmental stimulus Ex: a girl raised an abusive father may become anxious as soon as she sees her abusive father In the social learning model, a child may develop anxiety response by imitating anxiety in their environment, such as anxious parents Existential Theory Provide models for generalized anxiety, in which no specifically identifiable stimulus exists for a chronically anxious feeling. The central concept is that persons experience feelings of living in a purposeless universe. Anxiety is their response to the perceived void in existence and meaning.

ANS The autonomic nervous system of some patients with anxiety disorders, especially those with panic disorder, exhibit increased sympathetic tone, adapt slowly to repeated stimuli, and respond excessively to moderate4 stimuli
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 Neurotransmitters Three major neurotransmitters associated to anxiety are Norepinephrine, GABA, and Serotonin Norepinephrine - Chronic symptoms experienced by patients with anxiety disorders are characteristic of increased noradrenergic function. - Cell bodies of noradrenergic system are primarily localized to the locus ceruleus - Stimulation of the locus ceruleus produces fear in animals - 2 adrenergic agonists and 2 receptor antagonists can provoke frequent or severe panic attacks - Conversely clonidine 2-receptor agonist reduces anxiety symptoms Serotonin - cell bodies for the serotogenic neurons are located in the raphe nuclei in the rostral brainstem - Increases anxiety in patients with anxiety disorders GABA role in anxiety disorders is strongly supported by the efficacy of benzodiazepines which enhances the activity of GABA at the GABA type A receptor in the treatment of anxiety disorders Brain Imaging Studies CT scan and MRI occasionally show some increase in ventricles In one MRI study, a specific defect in the temporal lobe was noted in patients with panic disorder Genetic Study Heredity has been recognized as a predisposing factor in the development of anxiety disorder Almost half of all patients with panic disorder at least have one affected relative Brain Imaging Studies CT scan and MRI occasionally show some increase in ventricles In one MRI study, a specific defect in the temporal lobe was noted in patients with panic disorder

ANXIETY DISORDERS

Panic Disorder and Agoraphobia Specific and Social Phobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder and Acute Stress Disorder Generalized Anxiety Disorder Anxiety Disorder Due to General Medical Condition Substance-Induced Anxiety Disorder Anxiety Disorder Not Otherwise Specified (NOS) Mixed Anxiety-Depressive Disorder Adjustment Disorder with Anxiety

II. PANIC DISORDERS

Panic Attack: DSM-IV-TR Diagnostic Criteria A discrete period of intense fear or discomfort Four or more of the following developing abruptly, reaching a peak within 10 minutes: Palpitations or accelerated heart rate Nausea or abdominal distress Sweating Feeling dizzy, unsteady, lightheaded or faint Trembling or shaking Paresthesia (numbness or tingling sensations) Sensations of shortness of breath or Chills or hot flushes smothering Derealization or depersonalization Feeling of choking Fear of losing control or going crazy Chest pain or discomfort Fear of dying Not a codable disorder First panic attack is often completely spontaneous Clinicians should attempt to ascertain any habit or situation that commonly precipitates a panic attack (use of caffeine, alcohol, nicotine or other substance; unusual sleeping pattern, or harsh lighting at work) Attack often begins with a 10-minute period of rapidly increasing symptoms. Major mental symptoms are extreme fear and a sense of impeding death and doom. Patients cannot usually name the source of fear Physical signs include tachycardia, palpitations, dyspnea, and sweating Somatic concerns of death from the cardiac or respiratory problem may be the major focus of patients attention during panic attacks Patients believe that palpitations and chest pain indicate that they are about to die
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Panic Disorder with (or without) Agoraphobia DSM-IV-TR Diagnostic Criteria Both recurrent and unexpected panic attacks At least one of the attacks has been followed by 1 month of one (or more) of the following: Persistent concern: additional attacks Worry: implications of the attack and its consequences Significant change in behavior related to the attack Absence (or Presence) of Agoraphobia NOT due to the direct physiological effects of a substance or a general medical condition NOT better accounted for by another mental disorder (social or specific phobia, obsessive-compulsive do, PTSD or separation anxiety) The fear of having a panic attack in a place where escape would be formidable In general, a chronic disorder Agoraphobia DSM-IV-TR Diagnostic Criteria 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 a panic attack Situations are avoided or endured with marked distress or anxiety of having a panic attack, or having a companion Not accounted for by another mental disorder Can be the most disabling of phobias because it can significantly interfere with the persons ability to function in work and social situations outside home. Patients with agoraphobia rigidly avoid situations in which would be difficult to obtain help In general, a chronic disorder Often improves in time when the panic disorder is treated

III. SPECIFIC PHOBIA

DSM-IV-TR Diagnostic Criteria Marked & persistent fear (excessive or unrealistic) in the presence or anticipation of a specific object or situation Exposure immediate anxiety response: may be situationally-bound or situationally- predisposed panic attack. In children: crying tantrums, freezing or clinging Recognizes that the fear is excessive (may be absent in children) Phobic situation is avoided or is endured with marked anxiety Avoidance, anxious anticipation or distress significantly affect normal routine, social or occupational functioning OR marked distress of having the phobia Under age 18 years, duration at least 6 months Not better accounted for by another mental disorder Specify type: Animal type Natural environment type Blood-injection-injury type Situational type Other type (e.g. fear of choking, vomiting or contracting an illness; in children, fear of loud sound or costumed characters) More common than social phobia Most common mental disorder in women and second most common among men Development may result from the pairing of a specific object or situation with the emotions of fear and panic In general, a nonspecific tendency to experience fear or anxiety forms the backdrop; when a specific event (e.g., driving) us paired with an emotional experience (e.g., accident), the person is susceptible to a permanent emotional association with driving or cars and fear or anxiety Common treatment is exposure therapy where therapists use a series of gradual, self placed exposures to the phobic stimuli and they teach the patient various techniques to deal with the anxiety

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IV. SOCIAL PHOBIA

DSM-IV-TR Diagnostic Criteria Fear 1 or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. o Fears that he will act in a way (or show anxiety sxs) that will be humiliating or embarrassing o In children: must be evidence of the capacity for age-appropriate social relationships w/ familiar people (peer setting) Criteria b, c, d, e, f, g same as Specific Phobia If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g. the fear is not of stuttering, trembling in Parkinsons Disease Females are more affected than males Peak onset is in the teens May have a history of other anxiety disorder, mood disorder, substance related disorders and bulimia nervosa Both psychotherapy and pharmacotherapy are useful in treatment Specify if: Generalized: includes most social situations (consider additional diagnosis of Avoidant Personality Disorder)

V. OBSESSIVE-COMPULSIVE DISORDER DSM-IV-TR Diagnostic Criteria

VI. POST-TRAUMATIC STRESS DISORDER

Either obsessions or compulsion Obsessions as defined by: Recurrent and persistent thoughts, impulses or images; experienced at some time as intrusive a inappropriate & that caused marked anxiety or distress Not simply excessive worries about real-life problems Attempts to ignore or suppress such thought, etc., or to neutralize them with some other thought or action Recognizes that the obsessional thoughts are a product of his own mind (not thought insertion) Compulsions as defined by: Repetitive behaviors or mental acts that he feels driven to perform in response to an obsession, or according to rules that must be applied rigidly Acts: aimed at preventing or reducing stress or preventing some dreaded event but are NOT connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive At some point, the persons recognizes that the obsessions or compulsions are excessive or unreasonable (does NOT apply in children) Obsessions or compulsions caused marked distress, time-consuming (> 1 hour/day) and significantly interfere with functioning If another Axis I Disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with physical appearance in Body Dysmorphic Disorder, etc.) NOT due to effects of a substance or General Medical Condition Specify if: With poor insight: person does not recognize that obsession & compulsion are excessive or unreasonable

DSM-IV-TR Diagnostic Criteria: Exposure to a traumatic event in which both of the ff are present: Person experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others Response: intense fear, helplessness, or horror (in children: disorganized or agitated behavior) Traumatic event is persistently re-experienced in 1 or more of the following ways: Recurrent and intrusive recollections (in children: repetitive play) Recurrent & distressing dreams (in children: no recognizable content) Acting or feeling as if the event was recurring (a sense of reliving, illusions, hallucinations, & dissociative flashbacks including during awakening or when intoxicated) In children: trauma-specific reenactment Exposure to cues that symbolize or resemble the event intense psychological distress Exposure to cues.. Physiological reactivity Persistent avoidance of stimuli assoc with trauma or numbing of general responsiveness, as indicated by 3 or more of the ff: Efforts to avoid thoughts, feelings or conversations associated with the trauma Efforts to avoid activities, places or people that arouse recollections of the trauma Inability to recall important aspect of trauma Markedly diminished interest or participation in significant activities. Feeling of detachment or estrangement from others

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Restricted range of affect (e.g. unable to have loving feelings) Sense of foreshortened future Persistent symptoms of increased arousal as indicated by 2 or more of the ff: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Duration of symptoms in Criteria B,C and D is more than 1 month Cause significant impairment in functioning Specify if: o Acute: duration of symptoms is less than 3 months o Chronic: duration is 3 months or more Specify if: o stressor

VII. GENERALIZED ANXIETY DISORDER

DSM-IV-TR Diagnostic Criteria Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (e.g. work or school performance) The person finds it difficult to control the worry The anxiety and worry are associated with 3 or more of the following 6 symptoms (w/ at least some sxs present for more days than not for the past 6 months) For children: only 1 item is required: Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance Focus of the anxiety & worry is not confined to features of an Axis I Disorder, e.g. anxiety not about having a panic attack as in Panic Disorder Causes significant impairment in functioning NOT due to direct physiological effects of a substance or a GMC & does not occur exclusively during a mood disorder, psychotic disorder or pervasive developmental disorder DSM-IV-TR Diagnostic Criteria Emotional or behavioral symptoms in response to a stressor occurring within 3 months of the onset of the stressor Symptoms are marked by the ff: marked distress that is in excess of what is expected from exposure to the stressor Impairment in functioning Does NOT meet criteria for another Axis I, NOT mere exacerbation of Axis I or II diagnosis Does NOT represent Bereavement Stressor (or its consequences) terminated symptoms do NOT persist beyond an additional 6 months Specify if: With depressed mood With anxiety With mixed anxiety & depressed mood With disturbance in conduct With mixed disturbance of emotion and conduct

VIII. ADJUSTMENT DISORDER

IX. ANXIETY DISORDER DUE TO GENERAL MEDICAL CONDITION (GMC)

DSM-IV-TR Diagnostic Criteria Prominent anxiety, panic attacks or obsessions or compulsions Evidence from the history, PE and lab findings: direct physiological effects of GMC Not better accounted for by another mental d/o Does not occur exclusively during delirium Significant impairment in functioning Specify if: With generalized anxiety With panic attacks With obsessive-compulsive symptoms Coding example: Axis I: Anxiety D/O Due to Pheochromocytoma, with generalized anxiety Axis III: Pheochromocytoma

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X. SUBSTANCE-INDUCED ANXIETY DISORDER

DSM-IV-TR Diagnostic Criteria Evidence from the history, PE, lab of either (1) or (2): symptoms developed during or w/in 1 month of substance intoxication or withdrawal Meds use is etiologically related to the disturbance Not better accounted for anxiety disorder that is NOT substance-induced. Evidences include: Symptoms precede onset of substance use Symptoms persist for a substantial period of time (e.g. about a month) after the cessation of acute withdrawal or severe intoxication or in excess of expected Suggestion of an independent non-substance-related episodes Specify if: o With generalized anxiety o With panic attacks o With obsessive compulsive symptoms o With phobic symptoms Specify if: o With onset during intoxication o With onset during withdrawal

XI. BIOLOGICAL TREATMENT: ANXIETY DISORDERS

Catecholamine Theory There is Increased Autonomic Reactivity Neurotransmitter: Norepinephrine Cell Bodies: Locus Coerulus (Brainstem) Medications: Alpha-2-adrenergic receptor agonist Clonidine Benzodiazepine inhibitory mechanism

GABA Theory There is abnormal functioning of GABA a receptors decreased inhibition of hyperactive noradrenergic, dopaminergic neurons Neurotransmitter: Gamma Amino Butyric Acid (GABA) Medications: Benzodiazepine prolongs synaptic action of GABA Alprazolam (Xanor), Clonazepam (Rivotril) Serotonin Theory Mechanism is unclear, some are contradictory 5HT1A receptor subsensitivity in Panic Disorder Serotonin inhibitory effects on locus coerulus Neurotransmitter: Serotonin Medications: Selective Serotonin Reuptake Inhibitor (SSRI) Fluoxetine (Prozac), Sertraline Tricyclic & Tetracyclic Imipramine, Clomipramine Opioid Peptide Theory Hyperactive endogenous opiate system in PTSD numbing & avoidance symptoms Neurotransmitter: Endogenous opiate Medications: Opioid receptor antagonists Noloxone (Narcan) Nalmefene (Revex

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XII. COGNITIVE-BEHAVIORAL THERAPY Cognitive Approach

to elicit, test and correct distorted perceptions or thought Behavioral Approach learn new strategies and ways of dealing with issues Does not deal with the source of distorted perceptions Behavioral Techniques 1. Systematic Desensitization Feared object approached gradually under a relaxed state Involves relaxation techniques 2. Flooding Exposure to anxiety-provoking experience in vivo or using imagination Aplysia experiment by E. Kandel 2000 Learning changes in gene regulation changes in presynaptic facilitation increase in neurotransmitter release increase in number of synapses Unlearning reverses this process PSYCHOTHERAPY IS A BOTH A LEARNING AND UNLEARNING PROCESS

XIII. SEPARATION ANXIETY DISORDER

Diagnostic Criteria Developmentally-inappropriate and excessive anxiety concerning separation from home or from those to the individual is attached, as evidenced by three (3) or more of the following: Recurrent, excessive distress when separation from home or major attachment figures (MAF) occurs or is anticipated Persistent and excessive worry about losing, or about possible harm befalling MAF worry that an untoward event will lead to separation from MAF Persistent reluctance or refusal to go to school or elsewhere because of fear of separation fearful or reluctant to be alone or w/o MAF at home or w/o significant adults in other settings reluctance or refusal to go to sleep w/o being near MAF or to sleep away from home Repeated nightmares involving the theme of separation Repeated complaints of physical symptoms when separation from MAF occurs or is anticipated Duration: at least 4 weeks Onset: before 18 years of age Causes clinically significant distress or impairment in social, academic & other areas of functioning Treatment: Cognitive-behavioral therapy first line Family interventions School liaison Pharmacotherapy o SSRI Paroxetine, Sertraline, Citalopram o Benzodiazepine Alprazolam, Clonazepam

XIV. SELECTIVE MUTISM

Diagnostic Criteria Consistent failure to speak in specific social situation, despite speaking in other situations Interferes with educational achievement or with social communication st Duration: at least 1 month (not limited to 1 month of school) Not due to lack of knowledge of, or comfort with, the spoken language required Treatment Preschool: therapeutic nursery School age: cognitive behavioral therapy first line Family education Pharmacotherapy when psychosocial interventions does not suffice o SSRI - Fluoxetine

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 From Kaplan: just to check=)

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