Anxiety Disorders

Agoraphobia

• Duration:
  • MUST LAST 6+ MONTHS
• Criteria:
  • A): Marked fear or anxiety about TWO OR MORE SITUATIONS:
    • 1. Using public transportation
    • 2. Being in open spaces
    • 3. Being in enclosed places
    • 4. Standing in line or being in a crowd
    • 5. Being outside of the home alone
  • B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like sxs or other incapacitating/embarrassing sxs
  • C. The situations almost always provoke fear/anxiety
  • D. Situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety
  • E. The fear/anxiety is out of proportion to the actual danger posed
  • F. Lasts 6+ months
  • G. The fear/anxiety/avoidance causes clinically significant distress or impairment
  • H. If another medical condition is present (e.g., IBS, Parkinson’s), the fear/anxiety/avoidance is unrelated or excessive
  • I. The fear/anxiety/avoidance are not better explained by another psych dx
• Rule out:
  • 1. Specific phobia, situational type
    
  • 2. Separation anxiety dx
    
  • 3. Social anxiety dx
    
  • 4. Panic dx
    
  • 5. Acute stress dx or PTSD
    
  • 6. MDD
    
  • 7. Other medical conditions
• Prevalence:
  • US 12 month: 1.7%
• Risk Factors:
  • Behavioral inhibition
    
  • Neurotic disposition
    
  • Anxiety sensitivity
    
  • Negative events in childhood
    
  • Heritability – 61%
• Treatment:
  • Psychological treatment
    • coached to gradually tackle leaving home, then driving a couple of miles from home, then sitting in a movie theatre for 5 minutes, and then staying for the full duration of a movie in a crowded theatre
    • Enhanced By:
      • involving the person’s partner. partners learn to foster exposure rather than avoidance

Generalized Anxiety

• Duration:
  • must be present for 6+ months
• Criteria:
  • A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for 6+ months, about a number of events or activities
  • B. The individual finds it difficult to control the worry
  • C. The anxiety and worry are associated with 3+ sxs:
    • 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/stomach problems
    • 6. Sleep disturbance
  • D. Causes clinically significant distress or impairment
  • E. Not attributable to physiological effects of a substance or another medical condition
  • F. Not better explained by another psych dx
• Rule out:
  • 1. Anxiety dx due to another medical condition
    
  • 2. Substance/medication-induced anxiety dx
    
  • 3. Social anxiety dx
    
  • 4. OCD
    
  • 5. PTSD or Adjustment Disorder
    
  • 6. Depressive, bipolar, or psychotic dxs
• Prevalence:
  • US 12 month: 0.9% in adolescents; 2.9% in adults
    
  • Prevalence peaks in middle age, declines later in life
• Risk Factors:
  • Behavioral inhibition
    
  • Negative affectivity
    
  • Harm avoidance
    
  • Childhood adversities
    
  • Parental overprotection
    
  • 1/3 of risk for GAD comes from genetic factors
• Treatment:
  • -CBT
    • very effective treatment for most anxiety disorders (70-80% improvement rates) and is the first-line treatment for anxiety disorders
      
    • strategies to help people tolerate uncertainty
      
    • asking people to worry only during scheduled times
      
    • asking people to question whether worry works by keeping a diary of the outcomes of worrying
  • Psychological Treatment:
    • relaxation training to promote calmness
    • e.g. relaxing muscle groups one by one or generating calming mental images.
    • typically learn to relax rapidly with practice
  • -Medication
    • Best: (SSRIs typically) combined w/ CBT 
      • may be indicated for more pervasive and impairing anxiety disorders (particularly OCD)
    • First Line: SSRIs and SNRIs
      • SSRI (esitalopram, Paroxetine) or SNRI (venlafaxine).
      • due to fewer side effects. some do still experience side effects, however, including gastrointestinal distress, restlessness, insomnia, headache, and diminished sexual functioning
    • antidepressants > benzos
      • SE: jitteriness/ weight gain/ elevated heart-rate/ high blood pressure
    • 3rd Line: Benzodiazepines after nonresponse to SSRI and SNRI. Also consider combination of CBT and Pharmoctherapy.
      • may experience severe withdrawal symptoms when they try to stop using benzodiazepines. they’re very addictive
      • takes 2 to 3 weeks.
        
      • Remember that BZN are not effective for depressive symptoms and may contribute to depression.
    • Refractory GAD:
      • Quetiapine 150mg.

Obsessive Compulsive Disorders

• Criteria:
  • Obsessions – repetitive thoughts, images, impulses
    
  • Compulsions – repetitive activities, mental acts.
    
  • Time-Consuming – the hallmark of diagnosis is having things that you feel you are compelled to do which takes up over an hour per day.
• Goal:
  • reduction in frequency and severity of compulsive acts.
• Rating Scale:
  • Yale-Brown Obsessive-Compulsive Scale (Y-BOC)
    
  • For children, use CY-BOC.
• Treatment:
  • First line: CBT or SSRI
  • Non-Pharm:
    • CBT, Deep Brain Stimulation (surgically implanted), Surgery (radiofrequency waves destroy small amount of brain tissue in the corticostriatal circuit).
  • Pharm:
    • SSRIs (fluoxetine, fluvoxamine, paroxetine, and sertraline.
      
    • Higher doses produce a higher response rate and symptoms
  • Acute OCD:
    • Consider clomipramine and all SSRI.
      
    • Psychological: exposure therapy, CBT, or cognitive therapy.
  • First-line for Children and Adolescents:
    • CBT and SSRI.

Panic Attacks

• Criteria:
  • Note: Panic attacks ≠ Panic Disorder
  • Full-symptom panic attacks: 4+ sxs (see Panic Disorder)
  • Limited-symptom attacks: < 4
  • DSM IV:
    • a discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes:
    • 1) palpitations,
    • 2) sweating
    • 3) trembling/shaking
    • 4) sensations of shortness of breath
    • 5) feeling of choking
    • 6)chest pain/discomfort
    • 7) nausea/abdominal distress
    • 8) feeling dizzy, unsteady, lightheaded, or faint
    • 9) derealization (feelings of unreality) or depersonalization (being detached from oneself)
    • 10) fear of losing control or going crazy
    • 11) fear of dying
    • 12) paresthesias (numbness or tightening sensation)
    • 13) chills or hot flashes
• Types of Panic Attacks:
  • 1. Unexpected (uncued) – comes out of the blue
  • 2. Situationally predisposed – situations will sometimes cause an attack, but not always
  • 3. Situationally bound – person only has panic attack if in that situation
• Rule out:
  • 1. Other paroxysmal episodes (e.g., “anger attacks”)
    
  • 2. Anxiety dx due to another medical condition
    
  • 3. Substance/medication-induced anxiety dx
    
  • 4. Panic dx
• Prevalence:
  • US 12 month: 11.2% in adults
    
• Risk Factors:
  • Negative affectivity and anxiety sensitivity
    
  • History of limited-symptom attacks
    
  • Childhood physical/sexual abuse
    
  • Smoking

Panic Disorder

• Duration:
  • Must BE PRESENT FOR MORE THAN A MONTH
• Criteria:
  • A.Recurrent unexpected panic attacks – an abrupt surge of intense fear or discomfort that reaches a peak within minutes and during which 4+ sxs occur: NOTE: 3-5 panic attacks in one month
    • 1. Palpitations, pounding heart, increased heart rate
    • 2. Sweating
    • 3. Trembling/shaking
    • 4. Shortness of breath or smothering feeling
    • 5. Feelings of choking
    • 6. Chest pain or discomfort
    • 7. Nausea/abdominal distress
    • 8. Feeling dizzy, unsteady, lightheaded, etc
    • 9. Chills or heat sensations
    • 10. Paresthesias (numbness/tingling)
    • 11. Derealization or depersonalization
    • 12. Fear of losing control or “going crazy”
    • 13. Fear of dying
  • B): At least one of the attacks has been followed by ONE OR MORE MONTHS OF ONE OR MORE SXS:
    • 1. Persistent concern or worry about additional panic attacks or their consequences
    • 2. A significant maladaptive change in behavior related to the attacks
  • C): Disturbance not attributable to the physiological effects of a substance or another medical condtion
  • D): Disturbance not better explained by AMC
• Rule out:
  • 1. Other anxiety dx (esp social phobia, specific phobia, separation anxiety dx)
    
  • 2. Anxiety dx due to another medical condition
    
  • 3. Substance/medication-induced anxiety dx
    
  • 4. Other mental dxs with panic attacks as an associated feature
    
  • 5. OCD
    
  • 6. PTSD
• Prevalence:
  • US 12 month: 2-3% in adolescents/adults
• Risk Factors:
  • Negative affectivity and anxiety sensitivity
    
  • History of limited-symptom attacks
    
  • Childhood physical/sexual abuse
    
  • Some heritability
    
  • Respiratory disturbances (e.g., asthma)
• Tests:
  • Panic Disorder Severity Scale (PDSS)– just clinician-rated
    
  • Panic and Agoraphobia Scale (PAS)– it monitors treatment efficacy. It can be clinician or self-rated.
• Evidence-Based Treatment for Panic Disorder:
  • -Exposure to panic symptoms (physical sensations) that provoke anxious thoughts and avoidance
    ex) spinning in a chair, running up steps
  • -Anxiety-related to physical symptoms decreases through the process of habituation
  • -Over time, the individual learns that the feared consequences of physical symptoms will not happen
    • Ex) they won’t have a heart attack

Post Traumatic Stress Disorder (PTSD)

• Duration: 
  • 3 months after the trauma or there could be a delay of several months or even years
• Criteria:
  • a reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone, such as natural or manmade disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, or other crimes
  • Characteristics:
    
    • – Re-experiencing the traumatic event
    • – A sustained high level of anxiety or arousal
    • – A general numbing of responsiveness
    • – Intrusive recollections or nightmares
    • – Amnesia to certain aspects of the trauma
    • – Depression
    • – Survivor’s guilt
    • – Substance abuse
    • – Anger and aggression
    • – Relationship problems
• Treatment:
  • CBT (usually 12 sessions), Eye movement desensitization and reprocessing (EMDR-entails 8 stages), Exposure Therapy (confrontation with trauma cues to lessen triggers), Anxiety Management Techniques (involves exercises, relaxation techniques, etc)
  • First Line:
    • SSRI, SNRI (venlafaxine), Adrenergic blocker (prazosin for combat-related PTSD)
    • takes 6 to 12 weeks
    • assess efficacy in 12 weeks
    • should be on medication for 12 months
  • Acute PTSD:
    • Paroxetine, sertraline, venlafaxine
  • Non-pharm acute PTSD:
    • Trauma-focused CBT or EMDR.
  • Reduces symptoms but does not treat the emergence of PTSD:
    • Propanolol 160 mg/day.
  • Prevent PTSD in surgery patients:
    • IV hydrocortisone
  • Atypical antipsychotics:
    • Olanzapine
  • Children: Clonidine – anticholinergic

Social Anxiety Disorder

• Duration:
  • MUST BE PRESENT FOR 6 MONTHS
• Criteria:
  • A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others (e.g., social interactions, being observed, performing in front of others)
    -In kids, must occur in peer settings, not just around adults
  • B. Individual fears that they will act in a way or show sxs that will be negatively evaluated by others (e.g., will be humiliating/embarrassing, will lead to rejection or offend others)
  • C. Situations almost always provoke fear/anxiety
    -In kids, may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak )
  • D. Situations are avoided or endured with intense fear/anxiety
  • E. The fear/anxiety is out of proportion to the actual threat posed by social situation or sociocultural context
  • F. Last 6+ months
  • G. Causes clinically significant distress/impairment
  • H. Not attributable to physiological effects of a substance or another medical condition
  • I. Not better explained by sxs of another mental dx
  • J. If another medical condition in present (e.g., Parkinson’s, obesity, disfigurement, stuttering), the sxs are unrelated or are excessive
  • **Specify if:
    • 1. Performance only (restricted to speaking or performing in public)
• Rule out:
  • 1. Normative shyness
    
  • 2. Agoraphobia
    
  • 3. Panic dx
    
  • 4. GAD
    
  • 5. Separation anxiety dx
    
  • 6. Specific phobias
    
  • 7. Selective mutism
    
  • 8. MDD
    
  • 9. Body dysmorphic dx
    
  • 10. Delusional dx
    
  • 11. Autism
    
  • 12. Personality dxs
    
  • 13. Other mental dxs
    
  • 14. Other medical conditions
    
  • 15. Oppositional defiant dx
• Prevalence:
  • US 12 month: 7%
    
  • Prevalence rates decrease with age
• Risk Factors:
  • Behavioral inhibition and fear of negative evaluation
    
  • Childhood maltreatment/adversity
    
  • Heritable: 2-6x greater chance of developing in first-degree relatives
• Assess Response:
  • Liebowitz Social Anxiety Scale or Social Phobia Inventory (SPI).
    
  • Remission is </= 30 on LSA scale.
• Treatment:
  • First line: 
    • Adults: CBT, SSRIs (escitalopram, Fluvoxamine, Paroxetine, Sertraline) or SNRI (venlafaxine) for 12 weeks
    • Women: Mirtazapine.
      • improve QOL and anxiety and also effective for insomnia
      • It takes 10 weeks for therapy to onset.
    • Children: Nonpharmacological treatment. Common comorbidity is substance abuse.
  • Resistant SAD:
    • Clonazepam, atypical antipsychotics (quetiapine), Phenelzine (MAOI)
  • AVOID in SAD:
    • Atenolol or Buspirone (monotherapy)
  • Psychological and pharm tx: 
    • Do not combine therapy. Conduct CBT after the patient responds to pharmacological therapy.
  • CBT beneficial over medication in SAD:
    • Patients with specific phobias

Specific Phobia

• Duration:
  • -MUST LAST MORE THAN 6 MONTHS
• Criteria:
  • A): Marked fear or anxiety about a specific object or situation
  • B): The phobic object or situation almost always provokes immediate fear or anxiety
  • C): The phobic object or situation is actively avoided or endured with intense fear/anxiety
  • D): Fear/anxiety is out of proportion to the actual danger posed by the object/situation
  • E): Fear/anxiety/avoidance is persistent, typically lasting 6+ months
  • F): Causes clinically significant distress or impairment
  • G): Not better explained by symptoms of another mental dx
• Types:
  
  • 1) Animal
  • 2) Natural environment (heights, storms, water, etc)
  • 3) Blood-injection-injury (BII) (needles, invasive procedures, etc)
  • 4) Situational (airplanes, elevators, enclosed places)
    • Public Speaking – Most common nonclinical fear; 20% of the population
• Rule out:
  • 1) Agoraphobia
    
  • 2) Social anxiety Dx
    
  • 3) Separation anxiety dx
    
  • 4) Panic dx
    
  • 5) OCD
    
  • 6) Trauma and stressor-related dxs
    
  • 7) Eating dxs
    
  • 8) Schizophrenia/psychotic dxs
• Prevalence Rates:
  • US 12 month: 7-9%
    
  • Similar in Europe, lower in Asia, Africa, and Latin America
    
  • Kids – 5%
    
  • Adolescents – 16%
    
  • Adults – 3-5%
• Risk Factors:
  • Negative effect/behavioral inhibition
    
  • Parental overprotectiveness, parental loss/separation, physical/sexual abuse
    
  • Limited evidence of heritability, except in BII phobia
• Treatment:
  • 1. psychodynamic
  • 2. social skills training
  • 3. behavioral therapies
  • CBT
    • Cognitive Restructuring:
      • 1. Identifying Automatic Thought
      • 2. Recognizing Logical fallacies (HELPFUL vs. HURTFUL distinction) and
      • 3. Directly Challenging Thoughts
    • Behavioral-Exposure:
      • Systematic, graduated exposure to feared situations; In-session or in-vivo
      • 1. Short-Circuits AVOIDANCE
      • 2. Allows practice of behavioral skills
      • 3. Opportunity to empirically test dysfunctional beliefs
  • CBT group therapy:
    • Small groups (< 6) individuals can be treated together with similar manualized, CBT “Talk” Therapy 
    • Maybe even more effective.