Anxiety Disorders

1. Be able to differentiate diagnoses among the anxiety disorders and outline their specific treatments.

Anxiety Disorder due to Medical Condition
Anxiety disorders due to medical conditions can manifest as anxiety, panic attacks, obsessions or compulsions and are the direct result of a general medical condition. They are not an adjustment disorder with anxiety and not exclusive to course of delirium. However, these disorders can severely impair social and occupational aspects of a patient. e.g. 83% of patients awaiting heart transplant exhibit panic disorder symptoms.

Treatment usually entails the resolution of the underlying medical condition. Behavioral modification techniques, anxiolytic agents and serotonergic antidepressants are also helpful.

Substance-Induced Anxiety Disorder
Substance-induced anxiety disorders can manifest as anxiety, panic attacks, obsessions or compulsions. However, these symptoms are usually developed during or within 1 month of substance abuse of withdrawal.

Always ask about any medication changes including sympathomimetics such as amphetamines, cocaine, and caffine, and serotonergic drugs such as LSD, as well as prescription drugs.

Panic Disorder and Agoraphobia
Panic disorder is associated with abrupt onset of one of four symptoms: palpitations, sweating, trembling, shortness of breath, choking, chest pain, chills/hotflash, dizziness, derealization, depersonification, fear of losing control, fear of dying, and paresthesias. It is usually preceded by less than or equal to 1 month of worry and may occur with or without agoraphobia. Other associated symptoms of panic disorder are depressive symptoms, risk of suicide, and co-existing phobias or obsessive-compulsive disorder. Symptoms are usually exacerbated by use of caffeine or nicotine and substance dependence is present in up to 40% of patients.

Agoraphobia is characterized by avoidance of situations such as crowded stores or open public spaces. Individuals may refuse to leave the house or prefer to be accompanied wherever they go.

Pharmacotherapy of panic disorders include tricyclic antidepressants, SSRI, MAOI, and benzodiazepines. Buspirone is NOT effective in treating panic disorder. Cognative and behavioral therapies are also effective. Patients should be told that panic attacks are time limited (10 min average) and not life-threatening. Muscle relaxation and desensitization techniques are effective as well as respiratory training (breathing out “stress,” etc.)

Specific Phobias and Social Phobias

Phobias are common mental disorders involving irrational fear resulting in severe distress and conscious avoidance of feared object/situation. Specific phobias (animals, thunder/lightening, illness, injury, death) are more common than social phobias (public speaking, dating, etc.) Phobias have genetic factors and have adrenergic and dopaminergic theoretical models due to efficacy of beta-blockers and SSRIs.

Exposure therapy is effective for treatment of specific phobias and often includes relaxation and breathing control exercises. Social phobias can be treated by psychotherapy and pharmacotherapy with MAOIs, benzodiazepine, SSRIs, and beta-adrenergic receptor antagonists (beta blockers).

Post Traumatic Stress Disorder
Post traumatic stress disorder is often elicted after traumatic stress such as combat, natural catastrophe, assault, and rape. Patients often re-experience traumatic event through dreams and thoughts. They can engage in avoidance behaviors or become hypervigilant. Depression, anxiety and loss of concentration are common symptoms. Duration can have onset of 1 week to over 30 years after trauma. Recent head injury, epilepsy, and substance abuse must be ruled out.

Treatment of PTSD includes psychodyanimc therapy with reconstruction of trauma, abreaction, and catharsis. Behavior therapies such as exposure therapy and stress management as well as group or family therapy are also effective. Pharmacotherapy such as SSRI, TCA, MAOI, anticonvulsants, and beta blockers are also used.

Acute Stress Disorder
Similar to PTSD but with symptoms occurring within 4 weeks of trauma and symptoms lasting between 2 days to 4 weeks.

Generalized Anxiety Disorder
Generalized anxiety disorder is manifested by excessive anxiety and worry for over 6 months along with at least 3 of the following: restlessness, fatigue, decreased concentration, irritability, muscle tension, and sleep disturbance. GAD must cause significant stress or impairment. 50% of GAD patients have another mental disorder. GAD tends to be a chronic disorder.

Treatment may be psychosocial such as cognitive behavior therapy, relaxation therapy, or insight-oriented psychotherapy. Pharmacotherapy using SSRI is the front-line option. Benxodiazepines and antihistamines are also effective. Buspirone is also effective, but takes 2-3 weeks to work.

Obsessive-Compulsive Disorder
OCD is characterized by obsessions which are unwanted, persistent thoughts or impulses/images which are perceived as intrusive or senseless. Patients will make attempts to ignore, suppress, or neutralize obsessions that they recognize are a product of their mind. Additionally, OCD has compulsions which are repetitive or mental acts in response to obsessions aimed at reducing distress or preventing dreaded event. Patients will recognize these compulsions as excessive or unreasonable. Obsessions and compulsions will cause distress, are time consuming, and significantly interfere with occupation, lifestyle, relationships, etc.

Treatments include SSRI pharmacotherapy, supportive psychotherapy with individual or family, and behavior therapies such as exposure and response prevention. In extreme cases, stereotactic cingulotomy severing the cingulated gyrus fibers connecting the limbic system to prefrontal cortex may be considered.

2. Name the major neurotransmitters associated with anxiety.

Stress can result in dysregulationof hypothalamic-pituitary-adrenal axis and abnormal information processing. Important neurotransmitters for anxiety include glutamate, GABA, serotonin, dopamine, and norepinephrine.

3. Present the organic differential diagnosis for panic disorder.

The hallmark of panic disorder is the unexpected nature of panic attacks with no clear indication of eliciting event.

4. List predisposing factors for the development of post-traumatic stress disorder.

Predisposing factors to PTSD include childhood trauma, borderline/paranoid/dependent/antisocial personality traits, inadequate support system, genetic vulnerability, recent stressful life changes, external locus of control, recent excessive EtOH intake, and alexithymia (difficulty verbalizing fears). The very young or elderly tend to have the worse prognosis.

5. Understand the behavioral theories of anxiety.

Anxiety is a conditioned response to specific environmental stimuli and can be evolutionally adaptive. These condition responses can be developed by classical conditioning and generalization. Social learning theory suggests that some anxiety responses are learned through imitation of responses from others such as one’s parents. Cognitive theory suggests that anxiety is due to the patient overestimating the degree of danger and underestimating his or her ability to cope.

6. Differentiate obsessive compulsive disorder from obsessive compulsive personality disorder.

Obsessive compulsive disorder (OCD) is characterized by obessions and compulsions that are thoughts or behaviors that are recurrent or intrusive and perceived to be irrational and time-consuming by the patient. Patients try to resist their compulsions which may result in marked anxiety. Obsessions and compulsions often involve themes.

Obsessive compulsive personality disorder (OCPD) is not characterized by obsessions or compulsions. Patient has a preoccupation with perfection, orderliness, and control and does not perceive preoccupations as irrational until they begin to affect close relationships. Patient may defend traits as being justifiable or efficient/productive and performs behaviors automatically without resistance. Behaviors do not elicit anxiety.

7. Outline the psychoanalytic, neuropathologic, and biochemical hypotheses of obsessive compulsive disorder.

Psychoanalytic hypothesis believes that OCD is the result of conflicts in the Oedipal stage of development, leading to regression to the anal stage. The anal stage is characterized by ambivalence and magical thinking. The psychoanalytic defenses may include:
Undoing – compulsive act preformed to undo consequences patient irrationally anticipates from frightening obsessional thought
Isolation – protecting patient from anxiety-provoking affects
Reaction-formation – behavior and conscious attitude opposite of underlying impulse
Intellectualization – controlling affects and impulses by thinking about them instead of experiencing them.

Neuropathologic theory suggests abnormalities in the frontal lobes, caudate nucleus, and interconnections between these systems and limbic structures. For example, abnormality in the basal ganglia may have effects on filtering out unnecessary information. Also, stereotactic cingulotomy (cutting of cingulated gyrus fibers connecting limbic system to prefrontal cortex) can be an effective treatment in severe cases.

Animal studies appear to show OCD related to a 5-HT abnormality. SSRI have been shown to be effective medications for treatment of OCD.

8. Give and example of how exposure and response prevention might be applied to treat a person with a hand washing compulsion.

The idea of exposure therapy is to have patient think of their fearful experience (such as dirtiness on hands) and expose them to their fearful experience and gradually wean them off their response (to wash their hands).

A patient with hand washing compulsion might be asked to make a list of their fearful experience and rank them in order of fearfulness. For example, the list may start with having the patient touch the bathroom floor (which would elicit hand washing response) and be asked to not wash their hands for 1 minute. During this time, the therapist would engage in relaxation, breathing control, etc. to try to mediate the patient’s anxiety over delaying their response.

The next step may be to ask the patient to repeat the step but wait 5 minutes before washing their hands, gradually increasing the time from responding with hand washing. Eventually, the goal is to be able to prevent the response entirely. It is important to make sure that the patient masters a previous step before moving on to the next step.