DSA25 - Anxiety Disorders

AUTONOMIC AROUSAL:

-Tachycardia

-Tachypnea

-Diarrhea

-Diaphoresis

-Lightheadedness

List potential PHYSICAL Sx of Anxiety

-"Being on edge"

-Terror

-"Going to Die"/"Lose Control"

List potential AFFECTIVE Sx of Anxiety

-Worry

-Apprehension

-Obsesssions

-Thought about body/emotional damage

List potential COGNITIVE Sx of Anxiety

-Avoidance

-Withdrawal from Activities

List potential BEHAVIOR Sx of Anxiety

- Loss of Autonomy (no or minimal trigger)

- Intensity of attack exceeds capacity to bear discomfort

- More persistent vs transient duration

- Coping impaired through avoidance and withdrawal

When does Anxiety become pathological?

List the Neurophysiology Etiology of Anxiety Disorders

-Central Noradrenergic Systems

-GABA

-Serotonergic & Neuropeptides

List the Cognitive Behavioral Formulation Etiology of Anxiety Disorders

-Certain Thoughts and Beliefs

-Avoidance and Escape Responses

What is the Psychodynamic Formulation Etiology of Anxiety Disorders?

Signal of threat to the ego

Generalized Anxiety Disorder (GAD)

Define Condition:

Anxiety w/o specific triggers - "worriers" of the world; Excessive & Uncontrollable worry > 6 mo

-Sx: > 3 of 6 Sx

•Restlessness

•Easily fatigued

•Difficulty concentrating

•Irritability

•Muscle tension

•Sleep disturbance

-PE: Causes significant distress/impairment

-Hx:

> More in FEMALES (2:1)

> Age = 20s-30s

> Often a/w other psychiatric or medical Dx

> May be a/w negative life events

-Path:

> Not from substance use

> Not from another medical condition

> Not better explained by another medical disorder

-Tx:

> Pharm:

>> Antidepressants: SSRIs, SNRIs, TCAs, MAOIs

>> Antiepileptic agents: Gabapentin, pregabalin

>> Antihistamines: Hydroxyzine

>> Beta Blockers: often propranolol

>> Buspirone

>> Clonidine (alpha blockade)

>> Benzodiazepines (short term)

> Psych:

>> CBT

>> Insight oriented

>> Psychodynamic

-Prog:

> CHRONIC condition

> 25% will have co-morbid Panic D/O

> 50% co-morbid MDD and/or SUD

Panic Disorder

Define Condition:

Recurrent & Unexpected Episodic bouts of unprovoked panic

Abrupt surge of intense fear/discomfort --> Persistent worry about next attacks + Maladaptive change in behavior related to attacks

-Sx: > 4 of 13 Sx

•Palpitations

•Sweating

•Trembling or shaking

•Shortness of breath

•Feeling of choking

•Chest pain or discomfort

•Nausea or abdominal distress

•Dizziness, unsteady or lightheadedness

•Chills or heat sensations

•Paresthesias

•Derealization or depersonalization

•Fear of losing control or going crazy

•Fear of dying

-Hx:

> More in FEMALES (2:1)

> Age = 20-24 (20-30) (unusual after 40)

-Path:

> Often a/w life events 6 mo prior

> 78% of initial attacks have NO TRIGGER

> Not from substance use

> Not from another medical condition

-Tx:

> Pharm:

>> SSRIs

>> SNRIs

>> TCAs

>> MAOIs

>> Benzodiazepines

>> Anticonvulsants

>>> Gabapentin

>>> Pregabalin

> CBT

> Psycho-education + Support

> Combo Tx & Strategies

-Prog:

> UnTx --> Chronic but Waxes & Wanes

> Episodic outbreaks w/ years of remission or continuous sx

> Co-morbid w/ other Anxiety D/O, Depressive D/O & Bipolar D/O

Agoraphobia

Define Condition:

-Sx: Anxiety about > 2 of 5

•Using public transportation

•Being in open spaces

•Being in enclosed places

•Being outside of the home alone

•Standing in line or being in a crowd

-PE:

> Anxiety out of proportion to actual danger

> Fears/Avoids situations b/c of thoughts that escape

> Worried about incapacitating or embarrassing Sx

-Path:

> Sx > 6 mo

> Not from substance use

> Not from another medical condition

-Hx:

> More in FEMALES (2:1)

> Age = Teens to Early Adult

-Prog:

> Persistent and Chronic (complete remission rare)

> 75% have Panic D/O (S/S of Anxiety & Agoraphobia BEFORE onset)

> Risk of developing MDD and/or SUD

Social Anxiety Disorder (SAD/Social Phobia)

Define Condition:

Social avoidance + Extreme Nervousness when needing to perform OR in social situations

-Hx:

> Most prevalent Psych D/O

> Age = 16 y/o (rare after 25 y/o)

> Often in Women of Lower SES + Never Married/Lives with Parents

-Path:

> Sx > 6 mo

>Can occur after stressful or humiliating experience (develop slow or insidiously) --> May diminish after repeated exposure to social situations

> Not from substance use

> Not from another medical condition

-Sx:

> Individual fears they will act in a way that will be negatively evaluated

> Social situations almost always provoke fear/anxiety --> Avoided

> Fear/Anxiety out of proportion to actual threat

> Clinically significant distress or impairment of functioning

> If another condition present, anxiety is unrelated or excessive

-Tx:

1. Pharm = SSRIs, SNRIs, TCAs, MAOIs, BZDs, Beta-Blockers

2. CBT

3. Combo Tx

-Prog: Depends on extent of functional impairment and presence of Co-Morbid D/Os

> A/w Substance abuse is low

> Course can take several years

> 50% experience remission in a few years

Specific Phobia

Define Condition:

Fear d/t certain situations or objects

-Hx:

> Common D/O in LATE LIFE (Develops at ANY AGE)

> More in FEMALES

> Age (usual onset) = 25 y/o

>> Childhood onset often remit spontaneously

>> Blood injury begins in adolescence

-Path:

> Can occur after traumatic experience

> Not from substance use

> Not from another medical condition

-Sx: Persistent for > 6 mo

> Consistent, Immediate anxiety that is out of proportion

> AVOIDANCE

> Clinically significant distress or impairment of functioning

-Tx:

> Pharm: (usually PRN)

>> BZDs

>> Beta blockers

> Exposure/Behavior Therapt

> Relaxation Techniques

-Prog:

> Course can take several years

> If persists into adulthood, unlikely to remit

> SITUATION SPECIFIC --> LATER AGE ONSET (compared to natural environment, animal, or blood injury)

> Common to SELF-MEDICATE w/ ETOH

Substance/Medication-Induced Anxiety Disorder

Define Condition:

Panic attacks or Anxiety after substance intoxication or withdrawal

-Path:

> Not better explained by other anxiety disorder

> Not only during delirium

-Sx:

> Clinically significant distress or impairment of functioning

Anxiety Disorder d/t Another Medical Condition

Define Condition:

Panic attacks or Anxiety d/t consequence of another medical condition

-Hx:

> Age > 35 y/o

> LACK of PMHx or FHx of Anxiety D/O

> LACK of Childhood Hx of Separation Anxiety D/O

> LACK of life events causing exacerbation of anxiety

> LACK of avoidance behavior

> Poor response to recommended medication mgmt

> Medical Conditions

>> CVDs

>> Resp Issues

>> Endocrine Issues

>> Drug Intoxication and Withdrawal

>> Neuro Issues

-Path:

> Not better explained by other anxiety disorder

> Not only during delirium

-Sx:

> Clinically significant distress or impairment of functioning

-Dx: Evidence from Hx, PE, or Lab findings

-Separation Anxiety Disorder (SAD)

-Selective Mutism

What Anxiety D/Os are only seen in Childhood?

•Often with more than one medication that boosts CNS levels

•Typical symptoms include CNS, neurologic and autonomic

•Can be fatal if untreated

Describe Serotonin Syndrome

•Onset days to weeks after stopping medication (dependent on ½ life of medication)

•Can be mitigated by taper rather than abrupt discontinuation

•Fluoxetine self tapers

Describe SSRI Discontinuation Syndrome

•Subjective sense of restlessness

•Treated with Mirtazapine, anti-Parkinson's agents, beta blockers or benzodiazepines

Describe Akathisia (SSRI S/E)

•Reversible with medication discontinuation

•Switch, DC, reduce dose

What should be done regarding Sexual S/Es of SSRIs (very common)?

•Socratic questioning

•Guided discovery

> Examining the Evidence

> Examining advantages & disadvantages

•Thought change records

•Identifying cognitive errors

•Generating rational alternatives

•Imagery

•Role playing

What are some cognitive Tx methods (part of CBT) for Anxiety?

•Exposure (especially systematic desensitization)

•Breathing Retraining

•Progressive Muscle Relaxation

•Relaxation Training

•Flooding

•Activity Scheduling

•Graded task assignments

•Coping Cards

•Rehearsal

What are some behavioral Tx methods (part of CBT) for Anxiety?

•Exercise

> Cardiovascular

> Strength training

•Herbal supplements

•Mindfulness/Meditation

•Massage

•Acupuncture

What are some Alternative Tx for Anxiety?