Anxiety DisordersAnxiety Disorders

Panic AttackPanic Attack Brief episode where pt. feel intense dread

accompanied by a variety of physical and other symptoms that begin suddenly and peak rapidly (usually 10 minutes)

Physical/mental sensations– Chest pain, chills or hot flashes, choking

sensation, derealization/depersonalization, dizziness, fear of losing control, tachycardia, numbness, sweating, shortness of breath, trembling.

Panic DisorderPanic Disorder Repeated Panic Attacks Worry/dread at having additional attacks With/without Agoraphobia

Posttraumatic StressPosttraumatic StressDisorderDisorder

• Symptoms following exposure to extreme trauma present for at least one month.

• Experiencing or witnessing an event that involves actual or threatened death or serious injury to self or another

• Elicits a reaction of intense fear, helplessness, or horror

• After trauma there is persistent reexperiencing of the trauma, persistent avoidance of stimuli associated with trauma, and persistent symptoms of increased arousal

Acute Distress DisorderAcute Distress Disorder• Similar to PTSD, except Sx must have

onset within 4 weeks of the trauma and must last for at least 2 days but no longer than 4 weeks

• 3 or more dissociative Sxs (e.g.. sense of numbing or emotional detachment, derealization, dissociative amnesia)

• Must exhibit persistent reexperiencing of the trauma.

• Marked avoidance of stimuli that cause recollection the trauma

• Sxs of marked anxiety or increased arousal.

PhobiaPhobia Specific Phobia-patients fear specific

objects or situation, such as animals, storms, heights, blood, airplanes, being closed in or any situation that may lead to vomiting, choking or developing an illness.

Social Phobia-These patient imagine themselves embarrassed when they speak, write, or eat in public, use a public urinal; during exposure-immediate panic attacks.

Generalized Anxiety Generalized Anxiety DisorderDisorder

• Excessive anxiety and worry about multiple events or activities.

• The anxiety and worry are relatively constant for at least 6 months, and the person finds them difficult to control.

• Must entail 3 of following: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance

• Disproportionate to feared events or their potential impact

• Worrier or GAD? Measures-State Trait Inventory; How else?

Substance-InducedSubstance-InducedAnxiety DisorderAnxiety Disorder

• The development of anxiety, OC Sxs, or panic attacks are present within one month of Substance Intoxication or Withdrawal or are due to medication use.

• Associated with caffeine, cannabis, cocaine, hallucinogen, inhalant, and PCP intoxication and withdrawal from alcohol, cocaine, or a sedative, hypnotic or anxiolytic

• Medications and toxins (e.g. gasoline, paint, insecticides, and CO can produce anxiety symptoms.)

Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder

• Characterized by recurrent obsessions or compulsions that are severe enough to cause significant distress, to be time-consuming (take more than one hour per day), or to markedly interfere with the person’s usual routine, occupational or academic functioning, social activities and relationships.

• Person must be aware, at some time during the course of the disorder, that his/her obsessions and compulsions are excessive or unreasonable

Biology & AnxietyBiology & Anxiety

Peripheral Nervous System– Somatic

Sensory Systems Skeletal Motor System

– Autonomic Sympathetic-arousal & energy expenditure Parasympathetic-conservation of energy

ANS & Anxiety DisordersANS & Anxiety Disorders

Although primarily involuntary, it has been found to be brought under voluntary control

Pts. With Anxiety D/O’s demonstrate delayed response to repeated stimuli and excessive response to moderate stimuli

Predisposition or Learning?????

Anxiety D/O EpidemiologyAnxiety D/O Epidemiology Lifetime %Lifetime % 12-Month %12-Month %

Panic (M/F%) 2/5 Agoroph. W/O 3.5/7 Social Phobia 11/15 Simple Phobia 7/16 Gen. ADO 4/7 OCD 2/3 Any Phobia 10/18 Any ADO 19/31

1.3 vs. 3.2

1.7 vs. 3.8

6.6 vs. 9.1

4.4 vs. 13.2

2.0 vs. 4.3

1.4 vs. 1.9

6.2 vs. 12.8

11.8 vs. 22.6

NeurotransmittersNeurotransmitters

Norepinephrine, Serotonin & GABA Act in brainstem (noradrenergic neurons);

limbic system(anticipatory anxiety) and prefrontal cortex

PFC associated with the possible generation of phobic avoidance

NorepinerhrineNorepinerhrine Pts. have poorly regulated noradrenergic

systems leading to occasional energy bursts Stimulation leads to fear response Beta-adrenergic agonists (Isuprel) or

Alpha2-adrenergic antagonist (Yohimbine) lead to severe panic attacks

Alpha2-adrenergic agonist (Clonidine/Catapres) & B-ATN (Propanolol/Inderal) reduce anxiety

SerotoninSerotonin

Many SE type receptors-more selective Clomipramine (Anafranil)-OCD Buspirone (Buspar) 5HT agonist with

projections from brainstem, cortex, limbic system and hypothalamus

GABA (Aminobutyric Acid)GABA (Aminobutyric Acid)

Most common inhibitory NT in CNS Benzodiazepines increase the activity of

GABA at the receptor Low potency most treatment for GAD High potency GABA’s (e.g. Xanex) have

been effective in treatment of PDO

Anxiolytic MedicationsAnxiolytic MedicationsWhat to Rx?What to Rx?

SSRIs: Paroxetine (Paxil)– other alternatives?

Benzodiazepines– Alprazolam (Xanex) Lorazepam (Ativan) &

Clonzaepam (Klonopin)

– Advantages and disadvantages?

Tricyclics: Clomipramine & Imipramine (Tofranil)– Alternatives, advantages & disadvantages

Psychotherapy and ADOsPsychotherapy and ADOs

Controversies? In vivo exposure with response prevention

(flooding) –Agoraphobia SDT or Participant modeling-Specific

Phobias (observation/graded participation) CBT, PMR, Social skills training &

Assertiveness Training Medication vs. Psychotherapy?

Realistic Anxiety?Realistic Anxiety?