Anxiety Disorders

  • Panic disorder: 2%-3% women, 0.5%-1.5% men
  • Onset in mid 20s
  • ? Genetic influences, twin studies, family studies
  • Chronic and lifelong, 50-70% improve over time (somewhat)
  • Increased risk for PUD, HTN and higher death rates than expected
  • Common complications: depression and alcohol abuse
  • Must r/o medical and psychiatric disorders
  • Treatment: SRIs (TCAs, MAOIs), avoid caffeine; CBT (distraction, breathing techniques)

 Panic disorder

  •  
    • With agoraphobia
    • Without agora phobia
  • Agoraphobia
  • Social phobia
  • Specific phobia
  • OCD
  • GAD
  • PTSD
  • Acute stress disorder
  • Anxiety disorder due to a general medical condition
  • Substance-induced anxiety disorder
  • Anxiety disorder not otherwise specified

 Panic Attacks (4/13)

  • Palpitations
  • Sweating/Diaphoresis
  • Trembling/Shaking
  • SOB/Smothering
  • Choking feeling
  • Chest pain
  • Nausea
  • Dizzy/Unsteady/Lightheaded/Faint
  • Derealization/Depersonalization
  • Fear of losing control/going crazy
  • Fear of dying
  • Paresthesias
  • Chills or hot flushes

Anxiety Differential:

  • MV prolapse
  • Hyperthyroid
  • Medication withdrawal
  • Pheochromocytoma (panic attack)

Panic Disorder w/o agoraphobia

  • Recurrent unexpected panic attacks
  • At least one of the attacks has been followed by 1 month of one of the following
    • Persistent concern about having additional attacks
    • Worry about the implications of the attack or its consequences
    • A significant change in behavior related to the attacks
  • Absence of agoraphobia
  • Not due to substances or GMC and not better accounted for by another mental disorder


Agoraphobia (w/ panic disorder or w/o) – Women > Men

  • Anxiety about being in places or situations from which escape may be difficult or in which help may not be available in the event of having an unexpected or situationally predisposed PA
  • Situations are avoided or else are endured with marked distress or with anxiety about having a PA or require the presence of a companion.
  • Anxiety or phobic avoidance not better accounted for by another mental disorder

Generalized Anxiety Disorder

  • 4%-7% general population
  • Women, African Americans, younger than 30 years old
  • Chronic course w/ fluctuations
  • R/O caffeine intoxication, stimulant abuse, alcohol withdrawal, sedative-hypnotic withdrawal
  • Treatment: psychotherapy, Buspirone (10-40mg/d), Velafaxine, Benzodiazepines
  • Excessive anxiety and worry occurring more days than not for 6 months, about a number of events or activities
  • Difficulty controlling worry
  • Anxiety and worry associated with at least 3:
    • Restlessness, feeling keyed up/on edge
    • Being easily fatigued
    • Difficulty concentrating, mind going blank
    • Irritability
    • Muscle tension
    • Sleep disturbance
  • Focus of anxiety and worry is not confined to features of Axis I disorder (panic attacks, public, contaminated, far from home, weight gain, physical complaints, serious illness, PTSD)
  • Cause clinically significant distress or impairment
  • Not due to a substance or GMC

 Phobic disorders

  • Agoraphobia
  • Social phobia – 3-5% general populations, men = women, begins in adolescence
  • Specific phobia – more than 1/3 at some point, women, begin in childhood
  • ? Genetic component, learning component (traumatic events)
  • Treatment: SRIs, MAOIs, Benzodiazepines; behavioural therapy (desensitization and flooding)

Post Traumatic Stress Disorder

  • Treatment: SRIs, Bezodiazepines; CBT; Group and family therapy

Criteria from DSM IV:

  • The person has been exposed to a traumatic event in which both of the following were present:
    • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
    • The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
  • The traumatic even is persistently re-experienced in one (or more) of the following ways:
    • Recurrent and intrusive distressing recollections of the event, including images, thoughts, and/or perceptions. Note: In young children, repetitive play may occur in which these or other aspects of the trauma are expressed.
    • Recurrent distressing dreams of the event. Note: In young children, there may be frightening dreams without recognizable content
    • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and/or dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur
    • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
    • Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
    • Efforts to avoid thoughts, feelings, and/or conversations associated with the trauma
    • Efforts to avoid activities, places, and/or people that arouse recollections of the trauma.
    • Inability to recall an important aspect of the trauma
    • Markedly diminished interest or participation in significant activities
    • Feeling of detachment or estrangement from others
    • Restricted range of affect (e.g., inability to have loving feelings)
    • Sense of a foreshortened future ( e.g., does not expect to have a career, marriage, children, or a normal life span)
  • Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
    • Difficulty falling or staying asleep
    • Irritability or outbursts of anger
    • Difficulty concentrating H
    • Hypervigilance
    • Exaggerated startle response
  • Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one (1) month
  • The disturbance causes clinically significant distress and/or impairment in social, occupational, and/or other important areas of functioning.

Acute                  Duration of symptoms is less than three (3) months
Chronic               Duration of symptoms is more than three (3) months
Delayed Onset    Onset of symptoms is at least six (6) months after the incident

Acute Stress Disorder

  • PTSD last longer than 1 month

 Criteria from DSM IV:

  • The person has been exposed to a traumatic event in which both of the following were present:
    • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
    • The person’s response involved intense fear, helplessness, or horror
  • Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
    • A subjective sense of numbing, detachment, or absence of emotional responsivenessA reduction in awareness of his or her surroundings (e.g., “being in a daze”)
    • Derealizatio
    • Depersonalization
    • Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).
  • The patient persistently re-experienced the traumatic event in at least one or more of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
  • Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
  • There are marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
  • Clinically significant distress or impairment
  • The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
  • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting mental disorder.

Obsessive-Compulsive Disorder

  • 2-3% of general population
  • Begins in late teens or early 20s
  • Men = Women
  • Treatment: Behavior therapy; Clomipramine, SRIs

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