Anxiety Disorders & PTSD 😰

what is a common finding with anxiety disorders?

comorbidity with another disorder

often mood like depressive

what is the psychodynamic theory about anxiety disorders?

describes anxiety as rooted in unconscious conflict

freud used the term angst to describe intrapsychic response to internal or external threat

what is the learning theory of anxiety d/o?

2 forms of learning: classical conditioning and operant conditioning

anxiety d/o develops when environmental cues become associated with anxiety producing events

what anxiety d/o supports learning theory and how?

• GAD: worry and fear become conditioned and repeated to avoid

intermittent negative reinforcement

• Traditional behavioral therapy of anxiety involved uncoupling of conditioned response from associated stimulus*

what is classical conditioning?

think: pavlov's dogs

repeated stimuli to elicit a response

what is operant conditioning?

Positive reinforcement: particular behavior results in a reward

Negative reinforcement: specific behavior results in aversive event

what is the cognitive theory of anxiety d/o?

cognitive triad

• Abnormal emotional states (e.g., anxiety, depression) are result of

distorted beliefs about self, the world, and future

• Anxiety d/o involve incorrect beliefs that interpret events in

exaggeratedly dangerous or threatening manner

what is CBT?

- elements of classical behavioral approaches such as systemic desensitization

- treatment extended to discovery and correction of distorted cognitive schema

• Absence of exaggerated misinterpretations of cues → reduction in symptom formation

what do anxiety and fear have high adaptive value in animals?

because they ↑ capacity for survival

what major subtypes of anxiety d/o are familial?

panic d/o, phobia d/o, GAD, and OCD

panic d/o and spectrum show strongest genetic determinants

when does anxiety become pathologic and not just a normal emotion?

when normal psychological adaptive processes have been overwhelmed to the point that daily functioning is impaired

what are possible medical illness differentials of anxiety disorders?

cardiac (angina, chf)

endocrine (hyperthyroid, cushings)

neurological (huntington, meniere)

pulmonary (asthma, embolism)

psych (MDD, developmental d/o, dissociative)

what is panic d/o?

Panic-related phenomenon (isolated panic attacks, limited-symptom attacks) are much m/c

what may panic d/o be misdx for?

as conduct d/o in childhood

what evidence supports the biological foundation of panic disorder?

anxiolytic and antidepressant drugs can block attacks, certain substances can provoke attacks

what is cognitive theory in panic disorder?

due to strong sensitivity to (and misinterpretation of) physical sensations

what does panic disorder have an association with that is higher than all other anxiety disorders?

strongest familial clustering and genetic underpinning of all anxiety disorders

(half or more pf pts have (+) FHx)

what are s/sx of panic disorder characterized by?

• Characterized by recurring, spontaneous, unexpected anxiety attacks with rapid onset and short duration

• Due to physical symptoms, patients likely fear they are having an MI or CVA

what do panic attacks consist of?

- severe anxiety sx of rapid onset

- max severity within 10 minutes but can speak within seconds

what are symptoms that must be met to be labeled a panic attack?

need at least 4

SOB,

tachypnea,

tachycardia,

tremor,

dizziness,

hot/cold

sensations,

chest discomfort,

feelings of depersonalization or derealization

what will happen if panic attacks are left untreated?

• Left untreated, will likely continue to occur

• Repeated visits to HCPs and EDs are common

• Pt often seek help from professionals, counselors, therapists, and others

pts will usually begin to avoid places where their panic attacks happen from embarrassment

what can occur when panic d/o pts start to avoid places where they had a panic attack?

can progress to agoraphobia

you can have panic d/o w or w/out agoraphobia its a symptoms some people may not have

but it usually comes with the progression of panic disorder

what is agoraphobia?

• Most pt find particular situations stimulate panic so they avoid these situations

• Sxs likely reduced in "safe places" (ex: home) or with "*safe

people*" (ex: spouse, parent)

what are the lab findings of panic disorder?

pts respond well to inhalation of CO2

not diagnostic just a common finding

what is important in course of illness in panic disorder?

• Chronic, usually long-term is good

• Should be tx early as possible

• Close attention should be paid to co-morbid d/o such as depression as it may negative affect outcome

what disorders does panic disorder share features with?

OCD, specific phobias, MD, psychotic d/o, and some personality d/o that exhibit social avoidance

what sets panic d/o apart from the other d/o that share features?

those disorders do NOT have spontaneous panic attacks

absence of spontaneous panic attacks distinguishes other d/o with somatic fears including OCD, GAD, and somatization disorders

is dx of panic disorder usually difficult?

usually straightforward but pt often go through extensive medical workup

how are mild cases of panic disorder treated?

managed with psychotherapy alone (usually behavioral or CBT)

medication can be considered if there is functional impairment

when would medication be indicated in mild panic disorder?

functional impairment

• Agoraphobia

• MD (current or h/o) or personality d/o

• Suicidal ideation

• Strong patient preference

what class of drugs is effective but rarely used any why for panic disorder?

TCA's are effective but rarely used because of side effect profile

what side effects are possible with TCA use in panic disorder?

potential for transit anxiety, other SE

which TCA's have reasonable evidence fo rather efficacy in panic disorder?

imipramine, amitriptyline, clomipramine

what MAOI's may be used in panic disorder?

phenelzine

also rarely used because of side effects and safety profile

what can MAOI's do in panic disorder?

• ↓ frequency and intensity of panic attacks

• Substantial anxiolytic and antiphobic effect

what are the most commonly used drugs for panic disorder?

SSRIs/SNRIs

start low and go slow

standard for pharmacologic tx and have supplanted other antidepressants and benzos

How are benzodiazepines used in the treatment of panic disorder?

Benzos work very well and make people feel better.

what benzos may be used in tx of panic disorder?

high-potency benzos

like alprazolam and clonazepam have specific anti-panic effects

What is a significant risk associated with continuous use of benzodiazepines?

Nearly all patients will have or develop some degree of physical dependency.

What happens if benzodiazepines are abruptly discontinued?

They come with withdrawal effects and symptoms, as well as a rebound of panic symptoms.

Do benzodiazepines fix the underlying problem of panic disorder?

No, they treat the symptoms but do not fix the problem.

What is a major concern regarding benzodiazepines in terms of addiction?

They have a high potential for addiction.

when do we avoid use of benzodiazepines in tx of panic disorder?

in patients with h/o EtOH or drug abuse

what psychotherapeutic interventions are effective in panic disorder?

traditional behavioral treatment and CBT

what does CBT do for pts with panic disorder?

helps pts recognize relationships between specific thoughts and anxiety they produce

what does successful psychotherapeutic tx help panic disorder pts do?

discover a true relationship between specific internal or external cues and their anxiety

what practices may be used with CBT of panic disorder?

interoceptive exposure

Experimental manipulations of physical sensations to induce sx that are often misinterpreted

• Spinning in place

• Hyperventilating

• Ingesting large amounts of caffeine

what are the types of phobic disorders?

specific phobia and social phobia

why may phobic disorders develop?

because of pairing anxiety with specific environmental events or experiences

majority of individuals will not report events that lead to the disorder (making etiology unknown)

what is specific phobia?

an intense, irrational fear or aversion to a

particular object or situation (other than a social situation)

what may pts with specific phobia be avoiding?

• Animals or insects (especially spiders)

• Natural environment

• Blood or infection

• Situations (ex: heights, flying, roller coasters, etc.)

what is social phobia?

characterized by extreme anxiety response in situations where affected person may be observed by others

• Usually fear they will act in an embarrassing or humiliating way

• Social situations are avoided or endured with severe anxiety

how are phobic disorders differentiated from panic disorder and agoraphobia?

in phobic disorder, anxiety and fear are restricted to particular object or situation

whereas panic disorder is characterized by severe, unexpected anxiety attacks, and agoraphobia needs to be associated with panic disorder

how is phobic disorder differentiated from avoidant personality disorder?

it can often be co-morbid with phobic disorder, there is an equivalent pathologic shyness, or the fear of being shamed or ridiculed (confined to performance situations in social phobia)

how can we differentiate phobic disorder from psychotic disorders?

people with psychotic disorders may experience abnormal fears and avoid others, but they are usually characterized by delusional beliefs not seen in phobic disorder

how can phobic disorder be differentiated from somatoform disorder (hypochondriasis)?

somatoform pts may experience anxiety and avoidance that can be confused with phobic, but phobic do not have same delusions of their body

how can social avoidance in MD be differentiated from that in phobic disorder?

it is not related to performance anxiety like it is in phobic

how can OCD be mistaken for phobic disorder?

pts may avoid situation to prevent stimulation of obsessions and compulsions

what is typical tx of phobia disorder?

usually psychotherapeutic, but drug tx occasionally used

what tx may be used to reduce anxiety associated with specific and social phobias?

benzodiazepines

what may BB's like propranolol be used for in phobic disorder?

to reduce autonomic hyperarousal and tremor in performance situations

what tx may be useful in tx of social phobia?

antidepressants, especially SSRI's

what is tx of choice in phobic disorders?

behavioral or CBT

what is the difference between behavioral therapy and CBT?

Behavioral therapy focuses on changing harmful or learned behaviors, while cognitive-behavioral therapy (CBT) is a broader approach that combines changing behaviors with challenging and changing negative thought patterns

what is the typical tx regimen of phobic disorders?

relaxation training, usually coupled with visualization of phobic stimulus and progressive desensitization through repeated exposure

what are the complications of phobic disorder? compare to panic disorder

• Specific and social phobias are common and relatively benign vs. panic d/o

• Phobias may occasionally have disabling effect

• Behavioral tx may be anxiety provoking, but often produce

significant results

what is generalized anxiety disorder (GAD)?

persistent worry of variable severity across time

seen more often in general medical practice vs psych practice and there is a high rate of co-morbid depression

what is the difference between panic disorder and generalized anxiety disorder (GAD)?

panic disorder is spontaneous attacks, not a constant feeling of panic/worry

GAD is always worried, their baseline feeling is worry

what role do genetics play in GAD?

mild-to-moderate familial aggregation

what are the s/sxs of GAD?

syndrome of persistent worry couple with sxs of hyperarousal

• Feeling restless, wound-up, or on-edge

• Being easily fatigued

• Having difficulty concentrating; mind going blank

• Being irritable

• Having muscle tension

• Difficulty controlling feelings of worry

what will the features of GAD like persistent hyperarousal coupled with obsessive thoughts incline in ddx?

these are common in other psych disorders like MD

what types of psych disorders can be confused with GAD and why?

psych disorders with obsessive thinking that are associated with persistent fear, apprehension, and worry (OCD, eating d/o, personality d/o)

what should be considered in ddx if GAD pts worries chronically?

depression

what is the danger with giving benzos to GAD pts?

many clinicians worry about potential for benzodiazepine abuse

studies demonstrate that legitimate clinical use outweighs abuse potential

Abuse typically seen when used to counteract adverse effects of psychostimulants (ex: cocaine), augment euphoric effects of other sedatives (ex: EtOH), or self-medicate alcohol withdrawal

when are benzos indicated for GAD?

especially when sxs are severe, but are generally not used alone, instead serve as adjuncts to tx

who should we avoid giving benzodiazepines to for GAD?

pts who have PMHx or strong 1º relative FHx of drug or EtOH abuse

some pts develop psychological dependence

what are the adverse events of benzodiazepines?

• Daytime sedation

• Ataxia (→ dangerous falls in elderly)

• Accident proneness (ex: MVAs)

• HA

• Memory problems

• Paradoxical excitement/anxiety

these are usually seen in elderly because they do not metabolize the drugs as well, but can really happen to any pts

what is buspirone?

5-HT1A partial agonist and anxiolytic

what are the benefits of using buspirone?

• No motor, memory, or concentration impairments

• No abuse potential, dependency, or withdrawal

• Nearly an ideal anxiolytic

practical alternative for benzos esp for this who have never been on benzos before

which TCA's have shown benefits for GAD? why are or aren't they used?

imipramine and venlafaxine

therapeutic effect is delayed, but seriously anxious patients seem to improve

why are or aren't antipsychotics used to reduce anxiety in GAD?

they can reduce anxiety, but risk of TD outweighs the benefits of use

how is behavioral therapy used in GAD?

can teach progressive deep muscle relaxation while imagine anxiety-inducing stimuli

how is CBT used in GAD?

assumes anxiety associated with GAD is result of persistent distortions about self, others, and future

- helps with misinterpretations that contribute to anxiety

- helps to recognize relationships between specific situations and pathogenic distortions

what is the major complication of GAD?

highly co-morbid condition (most commonly with MD)

what should always be examined when considering dx of GAD?

existence of comorbid d/o

what is the prognosis of GAD?

- left untreated: chronic pattern of waxing and waning severity

- pharm tx will help with sxs, but sxs re-emerge with d/c of tx

- psychotherapeutic management helpful in reducing chronicity

what can PTSD affect?

cognition, mood, somatic experiences, and behavior

what is the epidemiology of PTSD?

at least one episode of extreme stress exposure

what is an example of the two factor model of the fear conditioning and learning of PTSD?

after exposure to a roadside IED in Iraq, a veteran may

experience fear and autonomic arousal when exposed to

modality specific (ex: loud sound) or contextual stimuli (ex:

dirt road), which previously were neutral

Typically, fear-conditioned memories extinguish over time if

survivors systematically expose themselves to these stimuli in a safe environment

what doe the fear conditioning and learning model of PTSD fail to consider?

that a stimulus does not always produce the same response

bases on models that involve processing information and emotions, how are individuals more likely to appraise a traumatic situation?

as threatening or out of their control, and thus, develop trauma-relates psycopathology, storing the memories of these events along with associated cues in "fear structures"

what are examples of microbiological models that have been proposed for PTSD?

polymorphisms of serotonin transporter gene,

norandrenergic system sensitization, exaggerated fear

conditioning, insufficient cortical inhibition of limbic activity,

etc.

Possible link to preexisting hyperactivity of the amygdala and dorsal anterior cingulate cortex (dACC) is associated with exaggerated fear responses and therefore, likelihood of

developing PTSD

what are protective factors against PTSD?

• Resilience to stress has been correlated with optimism, humor, social support and an active coping style

• Research shows that openness to change and extraversion are positive predictors of growth following traumatic events

what role do genetics play in PTSD?

after controlling for variability in combat exposure, genetic concordance accounted for 13-30% of experiencing sxs

proneness to exposure to traumatic events may also be influenced by familial factors

what are some examples of traumatic event that may have leads to PTSD?

• Some common examples include sexual assault, mass political conflict,

displacement (refugees), military or combat exposure, physical injury, and

medical illness

what type of sxs might be represent with PTSD?

Dissociative symptoms may be present

• Depersonalization (feeling disconnected from one's body)

• Derealization (feeling as if the surrounding world is not real)

what is Criterion A of diagnosis of PTSD?

stressor

Must have exposure to real or threatened death, injury, or sexual violence

what are the ways in which a person can have exposure to violence for criterion A of PTSD dx?

one or more of the following ways:

• direct exposure

• Witnessing the trauma as it occurred to someone else

• Learning about a close individual being exposed to actual or threatened trauma, accident, or violent death

• Indirect exposure to distressing details of the traumatic event (ex: professionals repeatedly exposed to details of child abuse)

(This does not include exposure through digital media)

what is criterion B of PTSD diagnosis?

intrusion symptoms

Presence of one or more of the following sxs related to the trauma and began after the trauma occurred

what are the sxs that must be present for criterion B?

one or more of the following sxs related to the trauma:

• Recurrent, involuntary, and intrusive thoughts associated with the event

• Distressing nightmares may be repetitive and related to the event

• Dissociative reactions, such as flashbacks, in which the individual is reliving the event

• Intense or prolonged psychological distress on exposure to traumatic reminders

• Marked physiological reactivity (ex: increased HR and BP upon exposure to traumatic reminders)