ANXIETY DISORDERS

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ANXIETY DISORDERS
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Anxiety disorders classification

• Panic disorder with/without agoraphobia
• Agoraphobia
• Simple or specific phobia
• Social phobia
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Acute stress disorder
• Generalized anxiety disorder
• Anxiety disorder due to a general medical
  condition
• Substance induced anxiety disorder
• Anxiety disorder NOS

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Anxiety disorder due to a GMC

• Prominent anxiety, panic attacks or obsessions or
  compulsions predominate the clinical picture
• There is evidence that the disturbance is
  consequence of a GMC
• Not better accounted for another condition
• Does not occur exclusively in the course of a
  delirium
• Disorder causes significant impairment in social,
  occupational, or other areas of functioning
• Same for drug induced anxiety disorder

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Mixed anxiety depressive disorder

• Persistent dysphoric mood lasting for at least a
  month
• Dysphoric mood accompanied by at least one month
  of symptoms (four or more) such as
• Fatigue, low energy, irritability, worry,
  tearful, hypervigilance, anticipating the worst,
  hoplesness, worthlesness.
• Symptoms cause significant distress
• Not due to substances or medical conditions
• Criteria not met, historically or currently by
  mood disorders or any other disease.

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Panic attacks

• Recurrent and unexpected panic attacks
• At least one of the attacks has been followed for
  one month of persistent worry about recurring
  attacks and worry about the meaning of the
  attacks
• Significant change in behaviour related to the
  attacks
• With or without agoraphibia

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Specific phobia

• Marked and persistent fear, excessive and
  unreasonable, cued by the presence or
  anticipation of a specific object or situation
• Exposure to the phobic stimuli produces and
  immediate anxious response
• Person recognizes that the fear is exaggerated
• Phobic object or situation is avoided or endured
  with anxiety
• Interferes significantly with functioning
• Younger individuals (18 yo) had it for at least 6
  months

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Social phobia

• Marked and persistent fear of one or more social
  situations in which the person is exposed to
  unfamiliar situations or is object of scrutiny
• Exposure invariably causes anxiety
• Person understands fear as unreasonable or
  excessive
• Feared situations are avoided or confronted with
  anxiety
• The fear or anxiety interferes with the
  individuals functioning
• If younger than 18 duration is at least 6 months
• Not due to substance or GMC

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Obsessive compulsive disorder

• Obsessions
• Recurrent and persistent thoughts, impulses or
  images experienced as intrusive and inappropriate
  and cause anxiety or distress
• They are not excessive worries about real life
  problems
• The person attempts to ignore, or neutralize them
• The person recognizes they are the product of
  his/her mind

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Obsessive compulsive disorder

• Compulsions
• Repetitive behaviours that the person feels
  driven to perform in response to an obsessive
  thought and following strict rules
• Aimed at decreasing or reducing discomfort or at
  avoiding a dreaded event or situation they are
  not connected with the origin of the discomfort
  and are not realistic but and they are excessive

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Obsessive compulsive disorder

• The person recognizes Os and Cs as excessive and
  unreasonable
• Os and Cs cause marked distress, are time
  consuming and interfere with regular activities
• If comorbid, Os or Cs are not restricted to the
  thoughts related to the comorbid disease

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Post traumatic stress disorder

• Exposure to a traumatic event (life threatening
  or causing serious injury and response involved
  intense fear, helplessness or horror)
• Traumatic event is reexperienced as
• Images, thoughts, perceptions
• Dreams
• Reliving the experience, illusions,
  hallucinations, flash-backs while awakening or
  intoxicated
• Intense psychological distress when confronted or
  exposed to cues that symbolize or resemble the
  event
• Physiological reponses associated with the
  distress above

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Post traumatic stress disorder

• Avoidance of stimuli associated with traumatic
  event
• Avoid thoughts, feelings, conversations,
  activities, places, people, etc
• Forgets important aspects of the traumatic event
• Diminished interest and participation in
  activities
• Detachment or estrangement
• Restricted affect
• Foreshortened future

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Post traumatic stress disorder

• Increased arousal
• Insomnia
• Irritability or anger
• Difficulty concentrating
• Hyper vigilance
• Startling
• Symptoms last for more than a month
• Symptoms cause severe functional impairment

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Generalized anxiety

• Excessive worries about a number of events more
  often than not
• Difficulties controlling the worry
• Worries manifested as
• Restlessness or on edge
• Fatigue
• High distractibility or absent minded
• Irritability
• Muscle tension
• Sleep disturbance
• No specific focus of anxiety
• Causes functional impairment and is not caused by
  other psychopathologies

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Neuropsychophysiology

• Panic attacks induced by lactic acid and
  yohimbine (a2 adrenergic autoreceptors)
• PTSD patients excrete high levels of NE in urine.
  They also respond with increased blood pressure
  and heart rate when exposed with associated
  stimuli
• PTSD response elicited by yohimbine and blunted
  by propranolol and clonidine
• PTSD and panic attacks are frequently comorbid

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Neuropsychophysiology

• GAD responds to benzodiazepines
• GABAergic agents open Cl channels that
  hyperpolarize the cell
• Naturally occurring inverse agonists may mediate
  anxiety states
• High concentration of GABA receptors in limbic
  system ie. Amygdala
• Good response to SSRIs

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Neuropsychophysiology

• OCD disturbance in the basal ganglia
• Associated to Tourettes Sx, postencephalic
  parkinsonism, Sydenham chorea, bilateral necrosis
  of globus pallidus and Huntingtons disease
• Head of caudate nucleus and connections with
  orbitofrontal cortex are hyperactive.
• They are GABAergic and inhibitory to the globus
  pallidus-thalamus-orbitofrontal cortex pathway.
• Failure causes reverberating firing
• Responds to SSRIs
• 5HT found in ventral medial aspects of head of
  caudate and nucleus accumbens which receive input
  from orbitofrontal cortex and cingulate cortex

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Genetic studies

• Family studies suggest resemblance
• Twin studies findings not confirmed by population
  based studies
• Large female twin study showed heritability
• Panic disorder risk amongst 1st degree relatives
  25 while 2 for general population
• Twin studies of panic disorder concordances were
  31 and 10 for MZ and DZ
• GAD 20 risk for 1st degree relatives while 5
  for general population

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Genetic studies

• Phobias 31 risk 1st degree relatives vs 11
  in controls
• Social phobias twin study concordances 24 and 15
  for MZ and DZ respectively
• OCD genetic influence is confusing
• Candidate gene 5HT transporter association with
  OCD
• PTSD present more often in individuals with
  families showing high propensity to anxiety

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