PTSD and Anxiety (HeadMed - 7/14)

Adjustment Disorder Definition

• Characterized by depressive symptoms, anxiety, and/or behavioral changes without fully satisfying criteria for a proper depressive or anxiety disorder

• Follows an event experienced as stressful

• Marked difficulty implementing adaptive response due to increased demand for cognitive and emotional resources

Adjustment Disorder Clinical Presentation

• Symptoms start within 3 months after stressor

• Last up to 6 months after stressor is removed

• Low mood, anxiety, alterations in mood or behavior (self-harm, self-medication, etc.)

Adjustment Disorder Diagnostic Criteria

1. Emotional and behavioral symptoms develop after exposure to one or more stressful events, occurring within 3 months of exposure

2. Significant clinical impact evidenced by:

   • Pronounced distress disproportionate to the stressor, OR

   • Significant impairment in functioning across life areas (social, occupational)

3. Symptoms of another mental disorder cannot explain the disturbance

4. Symptoms do not represent normal grief

5. Once no longer exposed to stressor, symptoms do not persist beyond 6 months

Adjustment Disorder Treatment

• Psychotherapy: Group and individual formats

• Pharmacotherapy:

  • Anxiolytics (Benzodiazepines)

  • Antidepressants (SSRIs & SNRIs)

Dissociative Disorder Definition

• Loss of mutual integration between systems underlying complex mental activity: consciousness, memory, identity, emotions, and perception

• Normally experienced as continuum and in constant integration; in dissociative disorders these systems disconnect

• Positive symptoms: Unwanted intrusions into consciousness and behavior; loss of continuity of subjective experience

• Negative symptoms: Inability to access information or control mental functions generally easily accessible or controllable

• Dissociative Identity Disorder (formerly "multiple personality disorder"): Two or more distinct personality states; failure of identity integration; each personality state may have separate personal history, self-image, identity, and name

Dissociative Disorder Epidemiology

• 1.4% female, 1.6% male

Dissociative Disorder Risk Factors

• Trauma

• Childhood sexual and physical abuse

Dissociative Disorder Comorbidities

• PTSD

• Borderline personality disorder

• Avoidant personality disorder

• Substance abuse

• Depression

• Somatoform disorder

Dissociative Disorder Diagnostic Criteria

1. Patient has two or more distinct personality states; disruption in identity characterized by marked discontinuity in sense of self and autonomy

2. Recurrent gaps in memory for everyday events, important personal information, and/or traumatic events

3. Symptoms cause clinically significant distress or impairment in social or occupational functioning

4. Disturbance is not part of widely accepted cultural or religious practice

5. Physiological effects of substance or another medical condition cannot explain symptoms

Dissociative Disorder Clinical Presentation

• Feeling like depersonalized observers of own speeches and actions

• Perception of voices

• Strong emotions and egodystonic impulses (thoughts, urges, or behaviors in direct conflict with core values, self-image, or personal identity)

• Sudden changes in attitudes, perspectives, and personal preferences

• Perception of one's body as different

• Non-epileptic seizures or other conversive symptoms

• Dissociative amnesia: Gaps in remote memory of personal life events; memory errors related to acquired procedures; discovery of evidence of daily actions/tasks not remembered performing

• Dissociative fugues: Common in these patients

Dissociative Disorder Treatment

• Psychotherapy:

  • Psychoanalysis

  • Cognitive and behavioral therapy

  • Hypnosis

  • Family therapy

• Pharmacotherapy:

  • SSRIs

  • Tricyclic antidepressants (TCAs)

  • MAOIs

  • β-blockers

  • Clonidine

  • Anticonvulsants

  • Benzodiazepine

Depersonalization Disorder Definition

Psychopathological condition where individual feels detached from themselves, from aspects of own self (feelings, thoughts, body or parts of body, sensations), or divided (out-of-body experience)

Derealization Disorder Definition

State where individual feels as if in fog, in dream, in bubble; as if veil or glass wall between themselves and world

Distinction between Depersonalization and Derealization Disorders

Depersonalization = detached from one's self

Derealization = detached from one's surroundings

Depersonalization and Derealization Disorder Risk Factors

• Acute trauma

• Other psychiatric disorders

• Substance abuse

• Childhood trauma

• Sudden death of loved one

• Growing up with parent with severe psychiatric issues

• Disturbances or doubts about sexual orientation

Depersonalization and Derealization Disorder Comorbidities

• Major depressive disorder

• Anxiety disorders

• OCD

• Avoidant personality disorder

• Borderline personality disorder

Depersonalization and Derealization Disorder Diagnostic Criteria

1. Patient experiences depersonalization, derealization, or both:

   • Depersonalization: Feels detached from own thoughts, feelings, sensations, body, or actions

   • Derealization: Feels detached from surroundings

2. Reality testing remains intact during depersonalization or derealization experiences

3. Symptoms cause clinically significant distress or impairment in social and/or occupational functioning

4. Physiological effects of substance or another medical condition cannot explain disturbance

5. Another mental disorder cannot explain disturbance

Depersonalization Clinical Presentation

• Abnormal body experiences

• Emotional or physical blunting

• Temporal distortion with abnormal subjective memories

• Macropsia: Neurological and optical phenomenon where objects appear larger than they are

• Micropsia: Neurological and optical phenomenon where objects appear smaller than they are

Derealization Clinical Presentation

• Subjective visual disturbances:

  • Blurring

  • Amplified acuity

  • Widening or narrowing of visual field

  • Macropsia or micropsia

• Subjective auditory disturbances:

  • Amplified or muted voices or sounds

Depersonalization and Derealization Disorder Treatment

• Psychotherapy:

  • Cognitive Behavioral Therapy (CBT)

  • Hypnotherapy

• Pharmacotherapy:

  • SSRIs

  • Tricyclic antidepressants (TCAs)

  • Mood stabilizers

  • Typical and atypical antipsychotics

Post-Traumatic Stress Disorder (PTSD) Definition

• Disease occurring in people who have suffered or witnessed a traumatic or violent event, or if traumatic experience happened to loved one

• Triggered by various traumatic events: wars, robberies, child abuse, muggings, kidnapping, terrorist attacks, torture, natural disasters, serious car accidents

• Onset varies: first weeks or several months after event

• Includes emotional and cognitive symptoms and neuro-vegetative alterations

• Characteristic: Re-experiencing traumatic event in recurring, involuntary, and intrusive way with vivid memories associated with sensory, emotional, physical, and behavioral components

• Clinical presentation highly variable: dysphoric component may prevail in some; fear of reliving trauma central in others; dissociative symptoms prevalent in still others

Post-Traumatic Stress Disorder (PTSD) Epidemiology

• Incidence: 8–15% in general population

• Female: 10%; Male: 4%

• 30–50% of people exposed to violence, genocide, war veterans, medical providers, police and firefighters

Post-Traumatic Stress Disorder (PTSD) Prognosis

• Typically chronic: 1/3 recover within year; 1/3 continue to have symptoms after 10 years

• Positive prognostic factors:

  • Rapid onset

  • Duration less than 6 months

  • Good previous functioning

  • Good social support

  • Absence of other comorbidities

• Has consequences in multiple areas: marriage, employment, suicidality

Post-Traumatic Stress Disorder (PTSD) Comorbidities

• Depression

• Bipolar disorder

• Anxiety disorder

• Substance abuse

• Conduct disorder

• Physical illness (endocrine, autoimmune, pulmonary, etc.)

• In children specifically:

  • Separation anxiety

  • Oppositional defiant disorder

  • Major cognitive disorder

Post-Traumatic Stress Disorder (PTSD) Pathogenesis - Psychological Models

• Psychoanalytic model: Trauma brings quiescent but unresolved psychological conflict to light; subject experiences state of repression, denial, and immobility

• Cognitive-behavioral model: Subject unable to rationalize trauma; continuously relives it; implements avoidance behaviors to factors reactivating memory

  • Phase 1: Trauma (unconditioned stimulus) produces fear elicited by specific stimuli (physical or mental: sights, sounds, smells) causing conditioning

  • Phase 2: Repetition of conditioned stimulus evokes fear response even without original unconditioned stimulus; subject avoids both unconditioned and conditioned stimuli; secondary advantage (protection, compassion, care by others) should not be underestimated

Post-Traumatic Stress Disorder (PTSD) Pathogenesis - Biological Basis

• Noradrenergic system

• Dopaminergic system

• GABAergic system

• Endogenous opioids: Low concentration of plasma β-endorphins; analgesic response to opioid antagonists (e.g., naltrexone) observed in veterans with PTSD

• Hypothalamic-pituitary-adrenal (HPA) axis:

  • Low levels of plasma and urinary cortisol

  • Increased glucocorticoid receptors in lymphocytes

  • Poor ACTH response after CRF stimulation

  • Cortisol hypersuppression may predict who will develop disorder given exposure to same traumatic events

  • Hyperactivation of axis differs from other mental disorders

• Autonomic nervous system:

  • Increase in sympathetic tone leads to: increased heart rate, blood pressure, tremors, sweating, palpitations, sleep disturbance (fragmentation and increased sleep latency)

  • Desensitization of α₂- and β-adrenergic receptors via chronic downregulation

  • Increased concentrations of urinary catecholamines observed in laboratory tests

Post-Traumatic Stress Disorder (PTSD) Risk Factors for Development

• Physical or sexual abuse

• Female gender

• Youthful age

• Repeated exposure to traumatic events

• Objective severity or degree of direct exposure

• Personality disorder

• Ethnic minority status, low socioeconomic status, poor psychosocial resources

• Widowed, separated, or divorced status

• Personal or family history of psychiatric illness

• Recent excessive use of alcohol

Post-Traumatic Stress Disorder (PTSD) - Diagnostic Criteria #1

Exposure

• Direct or indirect exposure to actual or threatened death, serious injury, or sexual violence

Post-Traumatic Stress Disorder (PTSD) - Diagnostic Criteria #2

Intrusion Symptoms (At least one required)
(a) Recurrence of memories related to traumatic event on involuntary basis and perceived as intrusive

(b) Recurrent nightmares related to traumatic event

(c) Experience of dissociative reactions where patient feels as if traumatic event was recurring

(d) Psychological suffering as result of exposure to factors symbolizing and recalling traumatic event

(e) Marked physiological reactions as result of exposure to factors symbolizing and recalling traumatic event

Post-Traumatic Stress Disorder (PTSD) - Diagnostic Criteria #3

Avoidance

• Avoidance of distressing feelings, thoughts, or memories associated with traumatic event AND/OR

• Avoidance of external reminders that arouse distressing feelings, thoughts, or memories associated with traumatic event

Post-Traumatic Stress Disorder (PTSD) - Diagnostic Criteria #4

Negative Changes in Cognitions and Mood (At least two required)

• (a) Lack of ability to recall relevant aspects of traumatic event

• (b) Persistence of exaggerated negative beliefs and expectations about oneself, others, and world

• (c) Persistent, distorted thoughts about cause or consequences of traumatic event leading to self-blame or blaming others

• (d) Persistent negative emotional state

• (e) Markedly diminished interest in several activities

• (f) Feelings of detachment or estrangement from others

• (g) Persistent incapability of experiencing positive emotions

Post-Traumatic Stress Disorder (PTSD) - Diagnostic Criteria #5

Alterations in Arousal and Reactivity (At least two required)

• (a) Irritability

• (b) Reckless or self-destructive behavior

• (c) Hypervigilance

• (d) Incremented startle response

• (e) Difficulty in concentrating

• (f) Difficulty in sleeping

Post-Traumatic Stress Disorder (PTSD) - Diagnostic Criteria #6

Duration

• Symptoms last more than 1 month

Post-Traumatic Stress Disorder (PTSD) Clinical Presentation

• Intrusive symptoms: Flashbacks

• Avoidance: Avoidance of anything reminiscent of stressor

• Psychogenic amnesia: Can't remember important aspects of stressor

• Hyperarousal: Heightened arousal state

• Suicidal ideation

Post-Traumatic Stress Disorder (PTSD) Treatment: Pharmacotherapy

• First-line: SSRIs & SNRIs

• Alternative medications:

  • Tricyclic antidepressants

  • MAOIs

  • Mood stabilizers

  • Trazodone (helps with both sleep and depression)

  • Hypnotics and sedatives for sleep (caution: can produce vivid nightmares)

  • Alpha blockers for nightmares

  • Antipsychotics

Post-Traumatic Stress Disorder (PTSD) Treatment: Psychotherapy

• Cognitive Behavioral Therapy:

  • Exposure: Repeatedly exposing patient to traumatic thought, memory, or feeling

• Eye Movement Desensitization and Reprocessing (EMDR):

  • Structured psychotherapy approach to alleviate distress associated with traumatic memories

  • Therapist has patient focus on specific memory, thought, or feeling while engaging in bilateral stimulation (e.g., following therapist's hands or light with eyes)

Trauma-Informed Care Definition

• Framework that acknowledges effects of trauma on people and aims to help restore sense of safety and self-worth

• Based on idea that traumatic experiences can be terrifying and overwhelming

• Care teams need to understand patient's past and present life situation to provide effective care

Trauma-Informed Care Core Concepts

• Safety (physical and emotional)

• Trustworthiness

• Choice

• Collaboration

• Empowerment

Stress vs. Anxiety

• Stress: adaptive response to a threat; generally temporary; useful for motivation

• Anxiety: the reaction to stress; may occur without identifiable trigger; can be disproportionate; may persist beyond trigger removal; interferes with daily functioning

• Shared element: many interventions are helpful with both stress and anxiety

Yerkes-Dodson curve

• Relates intensity of anxiety with efficiency of performance

• Depicts continuum between physiological (adaptive) and pathological (maladaptive) anxiety

• Normal anxiety level required for satisfactory performance

• Phase 1: increased anxiety improves performance up to optimal level

• Phase 2: continued anxiety increase leads to decreased physical and cognitive performance, progressing to dysfunctional state

General Epidemiology of Anxiety Disorders

Prevalence Data (U.S. Adults, 2019)

• Approximately 15.6% had any anxiety disorder in past year

• Higher in females (19%) than males (11.9%)

• Estimated 31-34% experience any anxiety disorder at some point in lifetime

• Among those with any anxiety disorder:

  • 10.8% had serious impairment (interfering with individual’s ability to function in daily life)

  • 13.5% had moderate impairment

Generalized Anxiety Disorder (GAD) Epidemiology

• Affects approximately 4-7% of population

• Higher rates in women (2x more than men), African-Americans, and ages less than 30

• Can occur at any age; typically begins in early 20s

• Chronic condition; may develop panic disorder later

• 50-90% co-occur with Major Depressive Episode, other anxiety disorders (panic disorder), or substance use disorders

Generalized Anxiety Disorder (GAD) General Etiology and Pathophysiology

still not fully understood ***

Multifactorial: genetic, environmental, and biologic factors
Genetic Factors

Psychosocial Factors

Neurobiologic Factors

Generalized Anxiety Disorder (GAD) Genetic Factors

• First-degree relatives have 25% risk

• Not fully understood

Generalized Anxiety Disorder (GAD) Psychosocial Factors

• Conditioning

• Stress or trauma

• Chronic illness

• Substance abuse (some substances cause anxiety, some patients self medicate and the substances exacerbate their symptoms)

Generalized Anxiety Disorder (GAD) Neurobiologic Factors

• Functional imaging findings:

  • Hyperactivity of the amygdala

  • Decreased activity of the hippocampus

  • HPA axis hyperactivation leading to increased cortisol levels

• Neurotransmitter imbalances/abnormal functioning: Norepinephrine, Serotonin, Dopamine, GABA (low)

Generalized Anxiety Disorder (GAD) Psychosomatic Symptoms - Cardiovascular System

• Increased heart rate and output

• Increased blood volume and blood pressure

• Peripheral vasoconstriction

• Coronary dilation

• Positive cardiac inotropic effect

Generalized Anxiety Disorder (GAD) Psychosomatic Symptoms - Respiratory System

• Increased oxygen exchange

• Tachypnea

Generalized Anxiety Disorder (GAD) Psychosomatic Symptoms - Digestive System

• Xerostomia (dry mouth)

• Contractions of the esophagus

Generalized Anxiety Disorder (GAD) Psychosomatic Symptoms - Gastrointestinal System

• Increase in gastric acid secretion

• Changes in peristalsis

Generalized Anxiety Disorder (GAD) Psychosomatic Symptoms - Metabolic Effects of Catacholamines

• Activation of glycogenolysis and lipolysis

• Increase in free fatty acids, glucose, and lactate

• Increased blood levels of glucose, free fatty acids, cholesterol

Generalized Anxiety Disorder (GAD) Psychosomatic Symptoms - Musculoskeletal, Skin, Immune System

• Increased muscle tone

• Increased smooth muscle contractions

• Increased perspiration

• Decreased skin temperature

• Reduction of immune activity

Generalized Anxiety Disorder (GAD) Cognitive Symptoms

• Feeling nervous or on edge/tightrope

• Exaggerated alarm responses

• Difficulty concentrating

• Inability to relax

• Insomnia

• Irritability

• Apprehensive attitude (fearful of being in situations they would not be able to handle)

• Fear of being unable to deal with situations

***General feeling that everyone is out to get them

Generalized Anxiety Disorder (GAD) Diagnostic Criteria

• A. Excessive anxiety and worry occurring more days than not for at least 6 months

• B. Difficulty controlling the worry

• C. 3 (or more) of the following six symptoms (only one required in children):

  1. Restlessness or feeling keyed up or on edge

  2. Being easily fatigued

  3. Difficulty concentrating or mind going blank

  4. Irritability

  5. Muscle tension

  6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

• D. Symptoms cause clinically significant distress or impairment

• E. Not attributable to drugs, medications, other medical condition, or other mental disorder

Generalized Anxiety Disorder (GAD) Differential Diagnosis

(what might be causing these anxiety symptoms)

• Hyperthyroidism - can cause heart palpitations/weight loss/jittery/ on-edge/hyperactive/cardiac arrhythmias

• Paroxysmal supraventricular tachycardia

• Pheochromocytoma

• Hypoglycemic crisis

• Complex partial seizure

• Mitral prolapse

• Respiratory pathologies - ex. professor did a study where he semi-suffocated patients, high CO2 in the brain have increased feelings of anxiety

• Dizzy syndromes

• Anxiety disorder due to another medical condition

• Induced anxiety disorder

• Depression (50% of patients often have overlap; assess for both if one is present. Lots of drugs for anxiety will also cover depression)

• Phobias

• Conversion disorder

Generalized Anxiety Disorder (GAD) Screening Recommendations

• 70-90% of patients with anxiety present with somatic complaints

• Evaluation/exclusion of other causes:

  • Cardiac: EKG, cardiac enzymes

  • Metabolic panel: electrolyte abnormalities

  • Thyroid studies: rule out hyperthyroidism

  • Cortisol levels: rule out Cushing syndrome (buffalo hump, round belly

  • Screen for other medications, illicit substances, vitamins, herbs, caffeine, alcohol, nicotine

USPSTF Screening Tools

• GAD-7: 7 questions, rank 0 to 3 - Recommended for annual screening in adults 64 years and younger, including pregnant and postpartum persons

  • Scoring: 5 (mild), 10 (moderate), 15 (severe)

  • Cut-off of 10 yields sensitivity of 89% and specificity of 82%

  • screens for presence and severity of anxiety

• GAD-2: Modified tool using only first 2 questions

Generalized Anxiety Disorder (GAD) Non-Pharmacologic Treatment

• Can be as effective as medications

• Cognitive Behavioral Therapy (CBT): has best level of evidence (see a counselor/psychologist. duration varies by patient and severity, how motivated they are to attend and implement changes. Approximately 6-12 months)

• Education

• Self-monitoring

• Biofeedback/relaxation/breathing techniques

• Cognitive restructuring

• Exposure therapy

3 C’s of Cognitive Behavioral Therapy

1. Identify the thought that came before the emotion

2. Reflect on how accurate and useful the thought is

3. Change the thought to a more accurate or helpful one as needed

Generalized Anxiety Disorder (GAD) Pharmacotherapy

• First-line therapy: Antidepressants

  • Selective serotonin reuptake inhibitors (SSRIs)

  • Serotonin norepinephrine reuptake inhibitors (SNRIs)

  • Tricyclic antidepressants (TCAs)

  • Atypical antidepressants

• Combination therapy: Sometimes needed for severe/refractory disease

• Secondary options, when you have exhausted all other avenues

  • Benzodiazepines (may be addictive and lead to tolerance and dependence)

  • Beta-blockers

  • Anticonvulsants

• Duration: Treat 6-12 months (long-term acting treatment, follow up to wean dose down. Completely stopping the treatment can cause rebound)

Separation Anxiety Disorder Epidemiology

• Childhood prevalence: 12-month prevalence ~4% (divorced parents)

• Adult prevalence: 12-month prevalence 1-2% (divorce, separation from close friend)

• Course in childhood: Usually does not progress into adulthood (attachment typically to parent)

• Adult onset: Majority of adults develop symptoms in adulthood (attachment to spouse or friend)

Separation Anxiety Disorder DSM-5 Diagnostic Criteria

A. Clinical Presentation (at least 3 of following):

1. Recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures

2. Persistent and excessive worry about losing major attachment figures or possible harm to them (illness, injury, disasters, death)

3. Persistent and excessive worry about experiencing untoward event (getting lost, being kidnapped, having accident, becoming ill) that causes separation from major attachment figure

4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere due to fear of separation

5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or other settings

6. Persistent reluctance or refusal to sleep away from home or go to sleep without being near major attachment figure

7. Repeated nightmares involving theme of separation

8. Repeated complaints of physical symptoms (headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated

B. Duration:

• At least 4 weeks in children and adolescents

• Typically 6 months or more in adults

C. Functional Impact:

• Causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning

D. Exclusion:

• Not better explained by other condition

Separation Anxiety Disorder Treatment

• Medication: SSRIs, benzodiazepines (in combination with psychotherapy)

• Psychotherapy: Cognitive behavioral therapy, social skills training, graded exposure and relaxation training

• Family involvement: Individual psychotherapy and potentially family therapy (social skills training, graded exposure)

Specific Phobias Epidemiology

• Fairly common - Prevalence: ~7-12% of population

• Typical onset: Childhood, before age 12

• Gender: Women > men (2:1 ratio)

• Genetic factor: Run in families - hyperactive stress response, conditioning from analyzing parent reactions

• Nature: Irrational fears of specific objects, places, situations, or activities with associated avoidance behaviors that negatively affect quality of life

***Person’s reaction is excessive and inappropriate

Specific Phobias Clinical Characteristics

• Fear of objects that could cause harm (snakes, heights, flying, blood) with excessive and inappropriate reactions

• Person's reaction disproportionate to actual danger

Specific Phobias DSM-5 Diagnostic Criteria

A. Fear or Anxiety:

• Marked fear or anxiety about specific object or situation (e.g., flying, heights, animals, receiving injection, seeing blood)

• Note: In children, may be expressed by crying, tantrums, freezing, or clinging

B. Provocation:

• Phobic object or situation almost always provokes immediate fear or anxiety

C. Avoidance/Endurance:

• Phobic object or situation actively avoided or endured with intense fear or anxiety

D. Disproportionality:

• Fear or anxiety out of proportion to actual danger posed by specific object or situation and to sociocultural context

E. Persistence:

• Typically lasting for 6 months or more

F. Functional Impact:

• Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

G. Exclusion:

• Not better explained by another condition

Specify type: Animal, natural environment, blood-injection-injury, situational, or other

Specific Phobias Treatment

Behavioral Interventions (Most Effective)

Cognitive Behavioral Therapy:

• Systematic desensitization: Patient gradually exposed to feared situations, beginning with least-feared situation

  • ex. draw a bird, look at a photograph of a bird, went outside to look at bird in real life

• Flooding: Patient enters situations associated with anxiety until anxiety subsides (e.g., eating in restaurants)

  • ex. throwing them in until they can tolerate fear

• Requirement: Patient must be willing to confront feared situations

Pharmacologic Interventions

• Generally ineffective for phobias

• May use anxiolytics or beta-blockers for acute symptoms

  • ex. short-acting benzodiazepine for fear of heights in order to ride an airplane

***Most patients do not seek treatment (avoidance of trigger maintains disorder)

Social Anxiety Disorder Epidemiology

aka: Social Phobia - Fear of humiliation or embarrassment in social situations

• Prevalence: ~13%

• Gender: Women = Men

• Typical presentation: Before age 25, usually in adolescence

• Precipitating factors: No identifiable precipitating factor

• Comorbidity: Frequently co-occurs with other psychiatric disorders (schizo - zero interest in socializing or avoidant personality disorders - insecure about the relationship) and/or substance abuse

  • both not fearful of the situation

• Neurobiological factor: Dopaminergic pathways may play a role

Social Anxiety Disorder DSM-5 Diagnostic Criteria

A. Fear/Anxiety: Marked fear or anxiety about one or more social situations where individual is exposed to possible scrutiny by others

• Note: In children, anxiety must occur in peer settings, not just during interactions with adults

B. Fear of Negative Evaluation: Individual fears acting in a way or showing anxiety symptoms that will be negatively evaluated (humiliating, embarrassing, leading to rejection, or offending others)

C. Provocation: Social situations almost always provoke fear or anxiety

• Note: In children, fear/anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations

D. Avoidance: Social situations are avoided or endured with intense fear or anxiety

E. Disproportionality: Fear or anxiety is out of proportion to actual threat posed by social situation and to sociocultural context

F. Persistence: Fear, anxiety, or avoidance is persistent, typically lasting 6 months or more

G. Functional Impairment: Fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

H-J. Exclusion: Not caused by illicit substance or other medical or psychiatric condition

Specifier: If performance only—fear is restricted to speaking or performing in public

Social Anxiety Disorder Treatment Approaches

• Most Effective: Combination of CBT and medications

• Pharmacotherapy Options:

  • First-line: Fluoxetine, Paroxetine, Sertraline, long-acting Venlafaxine

  • Other SSRIs

  • MAOIs

  • Benzodiazepines (provide temporary relief but have long-term risks)

  • Tricyclic antidepressants (probably less effective)

Panic Disorder Definition

• Recurrent, unexpected panic (or anxiety) attacks that are distressing and cause persistent worry or behavioral changes

• May be caused by adverse event, but often no precipitating stressors before onset

• Typically chronic with waxing and waning symptoms

Panic Disorder DSM-5 Diagnostic Criteria

A. Recurrent Unexpected Panic Attacks: Abrupt surge of intense fear or discomfort reaching peak within minutes

• Note: Abrupt surge can occur from calm state or anxious state

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath or smothering

• Feelings of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, light-headed, or faint

• Chills or heat sensations

• Paresthesias (numbness or tingling sensations)

• Derealization (feelings of unreality) or depersonalization (being detached from oneself)

• Fear of losing control or "going crazy"

• Fear of dying

B. Post-Attack Symptoms (1 month or more following at least one attack):

1. Persistent concern or worry about additional panic attacks or their consequences (losing control, having heart attack, "going crazy")

2. Significant maladaptive change in behavior related to attacks (avoidance of exercise, unfamiliar situations)

C-D. Exclusion: Not better explained by substance use or another medical/psychiatric condition

An abrupt surge of intense fear or discomfort reaching peak within minutes, with four or more of the following symptoms:

Panic Disorder Epidemiology

• Prevalence: 1-4% of population

• Genetic factors: 20% among first-degree relatives

• Lifetime risk: 5% in women, 2% in men

• Age of onset: Mid-20s (8 in 10 before age 30)

• Theoretical basis: Conditioned response vs. biologic basis unclear

• Neurobiological mechanisms:

  • Increased catecholamine levels in CNS (stress response)

  • Abnormality in locus coeruleus (brain stem area regulating alertness)

  • Carbon dioxide (CO₂) hypersensitivity

  • Abnormalities in lactate metabolism or γγ-aminobutyric acid (GABA) neurotransmitter system

Panic Disorder Treatments

• Combined Approach: CBT + Pharmacotherapy

• First-line Medications: SSRIs, 70-80% effective, safe, and well-tolerated

  • Fluoxetine

  • Paroxetine

  • Sertraline

• Alternative Medications:

  • Serotonin-norepinephrine reuptake inhibitor (SNRI): Venlafaxine (long-acting)

  • TCAs

  • MAOIs

  • Benzodiazepines

  • Beta-blocking drugs (note side effects)

• Duration: Continue medications for at least 1 year; relapse is common - most people take medication lifelong

Agoraphobia Definition

"Agoraphobia translates literally from Greek as 'fear of the marketplace'"
Anxiety related to being in embarrassing places or situations or from which it would be difficult to escape or in which help may not be available in event of panic attack

Agoraphobia Triggers and Impact

• Common Triggers:

  • Leaving home alone

  • Crowded or closed places (stadiums, shopping malls, cinemas, means of transport, queuing in traffic, tunnels)

  • Wide-open spaces (freeways, bridges, wide streets, squares)

• Consequence: Avoidance of triggers severely limits patient's autonomy and quality of life

• Comorbidity: May co-occur with panic disorder; treatments are similar (exposure therapy + medications)

Agoraphobia DSM-5 Diagnostic Criteria

A. Fear/Anxiety About Two or More Situations:

1. Using public transportation (automobiles, buses, trains, ships, planes)

2. Being in open spaces (parking lots, marketplaces, bridges)

3. Being in enclosed places (shops, theaters, cinemas)

4. Standing in line or being in a crowd

5. Being outside of home alone

B. Avoidance Motivation: Avoidance of situations because of thoughts that escape might be difficult or help might not be available in event of panic-like symptoms or other incapacitating/embarrassing symptoms (e.g., fear of falling in elderly; fear of incontinence)

C. Provocation: Agoraphobic situations almost always provoke fear or anxiety

D. Response: Agoraphobic situations are actively avoided, require presence of companion, or are endured with intense fear or anxiety

E. Disproportionality: Fear or anxiety is out of proportion to actual danger posed by situations and to sociocultural context

F. Persistence: Fear, anxiety, or avoidance is persistent, typically lasting 6 months or more

G. Functional Impairment: Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

H. Medical Exclusion: If another medical condition exists (inflammatory bowel disease, Parkinson's disease), fear/anxiety/avoidance is clearly excessive

I. Exclusion: Not better explained by other condition

Obsessive-Compulsive Disorder (OCD) Historical Classification Note

OCD was previously classified with anxiety disorders; now classified separately in the DSM-5

Obsessive-Compulsive Disorder (OCD) Definition

Obsessions: Definition and Characteristics

• Recurrent and persistent thoughts, urges, or images

• Experienced as intrusive and unwanted at some point during disturbance

• Cause marked anxiety or distress in most individuals

• Individual attempts to ignore, suppress, or neutralize with another thought or action

Compulsions: Definition and Characteristics

• Repetitive behaviors that individuals feel driven to perform in response to obsession or according to rigidly applied rules

• Aimed at preventing or reducing anxiety/distress or some dreaded event or situation

• Not connected in a realistic way with what they are designed to neutralize or prevent (incongruent compulsion)

Obsessive-Compulsive Disorder (OCD) Epidemiology

• Lifetime prevalence: 0.3-3% (mean 2%)

• Age of Onset: Typically begins in late teens or early 20s; generally gradual onset

• Gender Ratio: Women = Men (though earlier onset in men)

• Course of Illness: 85% chronic course, 10% deteriorating course, 2% episodic course

Obsessive-Compulsive Disorder (OCD) Etiopathogenesis

** Multifactoral Approach

Genetic Factors

• 12% overall risk if first-degree relative affected

• This represents 6x greater risk than general population

Neurobiological Abnormalities

• Increase in metabolic activity in some cortical regions (orbitofrontal cortex) and subcortical regions (caudate nucleus, dorsomedial thalamus)

• Neurotransmitter/receptor abnormalities: Serotonin, norepinephrine, dopamine abnormalities supported by response to drug therapy

• Occurs more often in various neurologic disorders: epilepsy, Huntington's chorea, birth trauma

• PANDAS Association: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections - tics, vocalizations, OCD compulsions. Resolve with treatment of strep (abx)

Behavioral Factors

• Conditioned responses (The OCD cycle)

Obsessive-Compulsive Disorder (OCD) Comorbidity Patterns

• Mood Disorders: Major depression and bipolar disorder co-occur in up to 60% of cases (can precede or be consequence of OCD)

• Anxiety Disorders: In particular panic disorder and phobias, co-occur in up to 70% of cases

• Tic Disorders: Tourette's syndrome; up to 50% of Tourette's sufferers also develop OCD

The OCD Cycle

1. obsessive thought

2. anxiety

3. compulsive behavior

4. temporary relief

REPEAT

Obsessive-Compulsive Disorder (OCD) DSM-5 Diagnostic Criteria

A. Core Features: Presence of obsessions, compulsions, or both

B. Functional Impairment: Obsessions or compulsions are:

• Time-consuming (taking more than 1 hour per day), OR

• Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C-D. Exclusion: Not attributable to substance or other medical/psychiatric disorder

Specifiers: Specify if with good, fair, or absent insight; delusional beliefs; tic-related

Obsessive-Compulsive Disorder (OCD)

• Combined Approach: Typically involves medication and behavioral/psychotherapy (exposure with response prevention)

• First-line Pharmacotherapy: SSRIs particularly effective, usually higher dosage is needed for OCD, along with longer duration

  • Fluoxetine

  • Fluvoxamine

  • Paroxetine

  • Sertraline

  • Note: Higher dosages of SSRIs needed compared with depression treatment

  • Response may be delayed: 4-6 weeks typically, average 12 weeks

  • Continue for 2 years

• Alternative Medication: Clomipramine (tricyclic antidepressant) is useful but limited by side effects

• Refractory Cases: Neurosurgical procedures (cingulotomy, deep brain stimulation)