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Anxiety Disorder


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What are the anxiety disorders?
Post Traumatic Stress Disorder
Generalized Anxiety Disorder
Anxiety Disorder due to a Medical Condition
Substance- Induced Anxiety Disorder
Anxiety Disorder NOS
Panic Disorder
Specific Phobia
Social Phobia
Obsessive-Compulsive Disorder
Acute Stress Disorder
Autonomic nervous systems starts in the ....
Sympathetic Nervous System =
fight or flight
What is the physiological reaction to acute stress?
Bronchial Tubes dilate
Blood Vessels constrict
Fibrinogen released
Glucose released
Endorphins Released
How does HPA Axis work?
Hypothalamus( influences mood) secretes hormone:corticotropin-releasing factor
CRF travels to pituitary gland
Pituitary secretes adrenocorticotropic hormone
ACTH circulates in blood to adrenal glands
Adrenals release hormone, cortisol
Cortisol( is a glucocorticoid)>rush of energy and alertness, effects cardiovascular& immune systems
Consequences of chronic stress
Menstrual/fertility difficulties
Decreased testosterone levels
erectile problems
Loss of libido
^ risk of auto-immune diseases
^ risk of infectious diseases
Anxiety Disorders
Inefficient energy use
^ severity of adult onset diabetes
^ risk of ulcers
^fat deposition, obesity
Psychogenic dwarfism
^ risk of diabetes,
Amygdala's fxn with stress and anxiety...
is associated with emotions and fear
Hippocampus' fxn with stress and anxiety...
processes emotions and long term memories
Locus Ceruleus fxn with stress and anxiety...
helps determine which stimuli deserve attention
Cerebral Cortex fxn with stress and anxiety...
evaluates data about a perceived threat and forms judgments
Chronic Stress and the Brain
Impairment of formation and retrieval of Long Term Memory
Decreased neurogenesis
Prolonged depression
Dopamine depletion, receptor disregulation
Impaired judgment
Chronic Stress and the Brain
Increased anxiety and robust fear conditioning
Chronic Stress and the Brain
Dopamine depletion in the Ventral tegumentum/
nucleus acumbens: the reward system
Neurotransmitters Related to Anxiety
-modulates other neurotransmitters, lowers anxiety
Neurotransmitters Related to Anxiety
regulates emotions, sleep, appetite, libido, inhibits pain
Neurotransmitters Related to Anxiety Norepinephrine-
affects mood, sleep, attention, learning, memory
Neurotransmitters Related to Anxiety
stress response
Neurotransmitters Related to Anxiety
-affects complex movement, motivation, cognition, emotional response
Neurotransmitters Related to Anxiety
controls sleep/wake cycles
Neurotransmitters Related to Anxiety
-excitatory-too much>neurotoxicity
Genes and Relationship to Anxiety
Early evidence of genetic predisposition
Unlikely to be a single “anxiety gene”
5-HTT gene, regulates serotonin -more prevalent in GAD and OCD
Potential markers on Chromosome 15, 11 and 1, seen more frequently in Panic and Phobias
No genetic tests available
Genes are not Destiny
Personality Traits that Contribute to anxiety Disorders
Anxiety sensitivity
Avoidant personality
Life Experiences & susceptibility to Anxiety
HPA axis becomes hypersensitive
Smaller hippocampus
Amygdala becomes hypersensitive
Traumatic events
especially early in life
Abuse, neglect, emotional deprivation
Maternal separation
Being unwanted
Symptoms Characteristic of All Anxiety Disorders
Hypersensitive to possibility of danger
Feelings of dread, fear or danger are irrational
Physical Symptoms: agitation, trembling, nausea, dizziness, shortness of breath, hot or cold flashes, freq urination
Anxiety Interventions on 3 Levels
1. Reduce physiologic activity
2. Eliminate avoidance Behavior
3. Change subjective interpretations
which perpetuate worry.
What are 1st line medications for anxiety?

SSRIs are...
What are 2nd line choices for anxiety?
Dual reuptake Inhibitor
Beta Blockers
CBT includes
Relaxation training
Cognitive restructuring
Alternative Treatments for Anxiety....
EMDR -(eye movement desensitization and reprocessing)
Anxiety Disorders DSM-IV
Specific Phobia
Social Phobia(Social Anxiety Disorder)
Obsessive- Compulsive Disorder
Acute Stress Disorder
Post Traumatic Stress Disorder
Generalized Anxiety disorder
Anxiety Disorder Due to a General Medical Condition
Substance Induced Anxiety Disorder
300.01 Panic Disorder without Agoraphobia
Recurrent, Unexpected Panic Attacks
Persistent concern, for at least a month about having another attack
Worry about the implications or consequences of the attacks
Behavioral change related to the attacks
300.21 Panic Disorder with Agoraphobia
Sx of panic disorder + presence of agoraphobia
Panic attacks not due to physiological effects of a substance or a general med condition
And are not better accounted for by another mental disorder
300.22 Agoraphobia without HX of Panic Disorder
Similar to Agoraphobia WITH panic disorder EXCEPT:
Never had a full blown Panic Attack
Fear is on the occurrence of an incapacitating or very embarrassing situation
Sx not due to substance
If general med condition-fear is in excess for that usually associated with the condition
Treatments for Panic Disorder
Short course benzodiazepines
Tricyclic antidepressants
Specific Phobia 300.29
Marked, persistent excessive fear, cued by presence or anticipation of a specific object or situation
Exposure to above invariably provokes an immediate anxiety or panicked response
Person recognizes the response as unreasonable
Causes distress and interferes with functioning and relationships
Common subtypes: flying, heights, insects, injections, blood
Associated Features Specific Phobia
Causes: Traumatic events, genetic predisposition
10% of population have this
Women have slightly higher risk
Effective Treatments: Behavioral Therapy-desensitization, relaxation/breathing, benzodiazepines
Social Phobia
Marked, persistent fear of social or performance situations where one is exposed to unfamiliar people or scrutiny.
Avoidance of exposure
significant anxiety/panic
Recognition that fear is excessive
Interferes significantly with life
Associated Features
Social Phobia
4% of Americans have this
Twice as common in women
Children, adolescents and young adults have highest risk, rarely starts after 25
Causes:decreased levels of serotonin and dopamine, sensitive amygdala
Treatments for Social Phobia
Combination with benzodiazepines
CBT: anxiety management training and cognitive restructuring
Group CBT to improve social skills
300.3 OCD
Recurrent Obsessions or Compulsions that are severe enough to be time consuming, cause marked distress, significant impairment, and are recognized as unreasonable
Persistent ideas, thoughts, images, or impulses that are intrusive, ego-dystonic, and are recognized as the product of one’s own mind
Repetitive, driven behaviors
a)Prevent the experience of anxiety or stress
b)reduce distress
c)prevent dreaded situation or event
Behaviors are disconnected with what they are trying to neutralize
Recognized at some point that they are excessive or unreasonable
Associated Features of OCD
1% of Americans
About equal in males and females
1 in 50 adults and 1 in 200 children
Most common in young adults and adolescents
Commonly seen: with Anxiety Disorders. Tourette’s, Major Depression, Eating Disorders, Learning Disorders
Causes:Abnormal activity in the basal ganglia(effects motor function, ritualistic, repetitive behavior))
Low levels of serotonin and high levels of dopamine
Complication of brain infections or head trauma
Treatments for OCD
SSRIs-alone or in combination with tricyclics and/or benzodiazapines
VERY RARE -neurosurgery to sever brain circuitry from basal ganglia
Acute Stress Disorder
Similar to PTSD but shorter duration- lasts 2 days to less than 1 month after the traumatic event and occurs within 4 weeks of the event
Person experienced, witnessed or was confronted with events that involved death, serious injury or threat to physical integrity of the self or others.
The response involved intense fear, helplessness or horror
During or after the event the individual experienced dissociative symptoms
Dissociative Symptoms
Numbing, detachment, absence or emotional responsiveness
Being in a daze-less aware of surroundings
Dissociative amnesia( unable to recall aspects of the traumatic event
Symptoms of Acute Stress Disorder
Recurring images, flashbacks, dreams, intrusive thoughts
Avoidance of stimuli that remind one of the event
Marked sx of anxiety: increased arousal-difficulty sleeping, irritability, poor concentration, hypervigilance, ^ startle response
Significant distress
impairment of functioning
Associated Features of Acute Stress Syndrome
14%-33% of individuals exposed to trauma
Risk factors: mental disorders, lack of supportive relationships, emotional deprivation during childhood.
Treatment for Acute Stress
Brief Psychotherapy
CBT-cognitive restructuring
Short term meds for sleep and anxiety
Do not require processing of memories and associated affect in immediate aftermath of event:
may compound the stress reaction
may cause over-consolidation of traumatic memories
may activate anxiety without allowing for habituation
Generalized Anxiety Disorder
Persistent and excessive worry about several different things , more days than not, for at least 6 months
Difficulty controlling worry
Feeling restless, on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep problems
Significant distress and impairment of functioning
Features Associated with GAD
Appears between childhood and middle age
Causes:low level of GABA, serotonin, increased activity is seen in the cortex and decreased activity in the basal ganglia may prime the pump for overreaction
Treatments: anti-anxiety/depressants CBT
5% develop this disorder
Genetic predisposition: family members with mood disorders or having a mood disorder
History of anxiety as a child
Symptoms worsen under stress
293.89 Anxiety Disorder due to a General Medical Condition
Prominent anxiety, panic attacks or obsessions
Evidence from history, physical, lab findings that the disturbance is the direct physiological consequence of a medical condition
Is not accounted for by another mental disorder does not occur exclusively during delerium
Causes significant impairment in functioning
Associated General Medical Conditions with anxiety
Endocrine: hyper and hypo-thyroidism,Pheochromocytoma, hypo and hyperglycemia, diabetes hypoadrenocorticism
Cardiovascular: congestive heart failure, pulmonary embolism, arrhythmias,valve disease, angina, MI
Respiratory: Asthma, COPD, pneumonia,hyperventilation syndrome
Metabolic:vitamin(B12) or mineral deficiency, porphyria
Neurological: vertigo, seizures, stroke
Severe allergic reactions, anaphylactic shock
Substance Induced Anxiety Disorders
Prominent anxiety, panic attacks, obsessions or compulsions( agitation and increased heart rate and BP)
evidence from history, physical exam or lab findings of:
Sx developed during, within 1 month of substance intoxication or withdrawal
Medication use is etiologically related to the disturbance
Substances Causing Anxiety
Asthma meds
Overuse of benzodiazepines
Abrupt withdrawal from benzodiazepines, sometimes from SSRIs and tricyclics
Withdrawal from heroin
Gasoline, paint, pesticides, carbon monoxide, fluorocarbons
Alcohol, caffeine, nicotine, cocaine, otc diet pills, decongestants,
Stimulants: ritalin, dexedrine, amphetamines
Cardiovascular meds, Corticosteroids,

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