Terms in this set (42)
Fun facts for Panic Disorders
Women 2-3x more likely
Higher in American indians
Typical onset is 25yo
Panic Disorders Etiology
1.Noradrenergic dysregulation involving both peripheral and central nervous systems.
2.Other neurotransmitters implicated: serotonin and GABA.
3. MRI studies implicate pathology in the temporal lobes (hippocampus, amygdala).
4. Genetic factors: strong heritability findings in first degree relatives and twin studies.
5. Classical conditioning
Clinical presentation of Panic Disorders:
Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
*Note: The abrupt surge can occur from a calm state or an anxious state.
-Palpitations, pounding heart, or accelerated heart rate.
-Trembling or shaking.
-Sensations of shortness of breath or smothering.
-Feelings of choking.
-Chest pain or discomfort.
-Nausea or abdominal distress.
-Feeling dizzy, unsteady, light-headed, or faint.
-Chills or heat sensations.
-Paresthesias (numbness or tingling sensations).
-Derealization (feelings of unreality) or depersonalization (being detached from oneself).
-Fear of losing control or "going crazy."
-Fear of dying.
Why is the world"small and shrinking" for those with panic disorders?
In the example of agoraphobia, the person who has a panic attack will then avoid whatever circumstance or environment they were in when the panic attack occurred.
Panic Disorder medical DDX:
-Endocrine disorders including hypo- and hyperthyroidism, hyperparathyroidism and pheochromocytoma (tumor of the adrenal gland - rare).
-Hypoglycemia due to insulinoma (pancreatic tumor - rare).
-Tumors in the nervous system
-Cardiac and pulmonary: arrhythmias, COPD, asthma.
Patient symptoms that indicate a medical disorder is present and not a panic disorder:
-Altered consciousness (panic disorder will have no altered conciousness)
-Loss of bladder control
-Late onset(anxiety disorders happen at all ages)
-Other physical signs consistent with the medical disorders listed on previous slide.
Mental disorders DDX for anxiety disorders and panic attacks:
-Post Traumatic Stress Disorder:can have traumatic re-experince of original traumatic event.
-Obsessive Compulsive Disorder
-Generalized Anxiety Disorder
-Separation Anxiety Disorder
Pharmacological treatment for anxiety disorders:
-All SSRIs: Paxil is the only FDA approved. Paroxetine is best tolerated.
-Bencodiazepines offer a rapid response. Alprazolam(Xanax), only FDA approved, High risk of drug dependency.
Other therapies that are effective in treating anxiety disorders:
Cognitive Therapy- Knowledge is power!
-Psycho-education, usually focused on autonomic nervous system ('adrenaline').
-Challenging irrational beliefs regarding danger, risk, the meaning of sx's & anticipatory anxiety (get back in the saddle and face your fears)-builds tolerance
Behavior Therapy - Exposure
-Hierarchy; can involve interoceptive and exteroceptive cues.(most exposures in humans need to be 10-12 minutes)
-Progressive muscle relaxation
Social Phobia (Social Anxiety: DSM-V) fun facts:
-Lifetime prevalence: 3-13%; 12 month prevalence rates are around 7% in US, lower in other parts of the world
-Females affected more than males, but in clinical samples, the rate is equal or higher for males.
-Higher rates in American Indians; and whites, lower in other parts of the world.
-Peak age of onset is in the teens, although there is a fairly large range.
Etiology for Social Phobias
-Classical conditioning: (Pavlov).
-Psychodynamic factors: Freud- As the sexual urges came to the fore, the anxiety served to signal the ego of the coming danger. The anxiety is displaced onto the phobic object, which is then avoided.
-Genetic: 1st degree relatives of a social phobic have a 2-6 times greater chance of having the disorder.
-Diathesis-Stress Model: Temperament dimension known as behavioral inhibition combined with a social stressor or trauma.
-Some evidence for dopaminergic dysfunction.
Social anxiety disorder defined:
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).
-Symptoms must cause impairments to life function.
Social Phobia/anxiety DDX
Normal shyness- not impairing
Agoraphobia- diff in social phob(always looking for escape)
Generalized Anxiety Disorder
Separation Anxiety Disorder
Selective Mutism- found in children usually
Autism Spectrum Disorder
Schizoid Personality Disorder: not interested in others
Avoidant Personality Disorder: on the outside looking in but fear of rejection is too strong.
Pharmacotherapy for Social phobia:
1st line: SSRIs
For performance-related social anxiety, beta-blockers such as atenolol (Tenormin) and propranolol (Inderal).
Psychotherapy for Social Phobia
Behavior therapy: systematic desensitization, **exposure therapy(quicker and more effective).
Cognitive therapy: Need to challenge the faulty thinking involved in the two main themes of worry - fear of being harshly or critically judged and fear of public humiliation.
Fun facts for Specific Phobias:
12 month prevalence rates (using community samples) are 7-9%.
Asian, African and Latin American countries rates are lower than *U.S. which is equal to Europe.(western europeans tend to have more guilt).
There is a spike in 13-17 y.o.s (16%)
Women to men - 2:1
***Median age of onset: 7-11 y.o., mean=10 y.o. --very young
Definition of Specific phobias:
-Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
-Note: In children, the fear or anxiety may be expressed by crying, tantrums, -freezing, or clinging.
-The phobic object or situation almost always provokes immediate fear or anxiety.
-The phobic object or situation is actively avoided or endured with intense fear or anxiety.
Etiology of Specific phobias
-Classical conditioning (although many pts. do not recall a specific causal event). This can include the occurrence of a panic attack in the presence of the phobic stimulus.
-Observational learning (seeing a negative reaction in another or being exposed to negative information about the object).
-Genetic: having a 1st degree relative with specific phobia increases one's risk. Blood-injection-injury type have high familial occurrence and a tendency to faint in presence of phobic stimulus.
Specific phobias mental DDX
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Normal childhood fear(a little fear is normal, but so much fear that it causes a panic attack is not normal)
Treatments for Specific Phobia:
Psychotherapy: Behavior Therapy: Exposure Therapy or Hypnosis
OCD fun facts
12 month prevalence rate: 1.2 % (similar internationally).
-Lifetime prevalence rate: 2-3%
-In adulthood, men and women show roughly equal rates.
-In adolescence, boys have higher rates.
-Mean age of onset: 20 y.o.
-25% of cases start by age 14.
*Males have earlier age of onset than females.
-Dysregulation in serotonergic system.
-PANDAS (link with streptococcal infection) Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
-Altered functioning in the neural pathways between the orbiofrontal cortex, caudate and thalamus.
-Genetics: rate of OCD among 1st degree relatives of a diagnosed pt. are 3-5 times higher than for a person without OCD. For childhood onset, the heritability is even higher. Twin studies support a genetic component.
OCD clinical presentation:
-No longer listed with the Anxiety Disorders. OCD is now grouped with body dysmorphic disorder, hoarding disorder, trichotillomania and excoriation disorder. This is based on the increasing evidence of these disorders relatedness to one another.
-Obsessions and/or compulsions which are time-consuming and impair functioning.
-Anxiety Disorders: Generalized Anxiety Disorder (worry), phobias
-The other related disorders (see slide 26)
-Tics and motor stereotypes
-SSRIs: all of those available in the U.S. are FDA approved for treatment of OCD. Among these fluvoxamine (Luvox) is very commonly used.
-SSRI tx may be augmented with mood stabilizers, BuSpar or atypical antipsychotics.
Behavior Therapy: Exposure plus response prevention (when compulsions are involved).
-Challenge intrusive thoughts
-Notice that feared consequence did not happen
PTSD Fun Facts
-Lifetime prevalence for PTSD around 8% in U.S., rates are lower internationally.
-In the U.S., Latinos, African Americans and American Indians have higher rates than whites, while Asian Americans have lower rates.
-Prevalence rates for women are double those for men.
Traumatic event is the cause, but not everyone exposed to an event will develop PTSD. Post traumatic event can result in abnormalities in noradrenergic and opioid systems and HPA axis.
-Childhood emotional problems by age 6
-Prior anxiety and mood disorders, PTSD, OCD
-Lower SES, childhood adversity
-Female gender, younger age at time of trauma
PTSD Clinical presentation:
Exposure to actual or threatened trauma
Intrusive re-experiencing of the event
Avoidance of stimuli associated with the event
Negative alterations in cognition and mood
Alterations in arousal and reactivity
Duration is more than 1 month
Anxiety disorders and OCD
Traumatic Brain Injury (headache, dizziness, sensitivity to light or sound, irritability, poor concentration)
-SSRIs are first-line tx. BuSpar is also used.
-Treatment should continue for 1 year.
-Trazodone and anticonvulsants can be helpful
Prolonged exposure (imaginal)
In vivo exposure
Acute Stress Disorder:
In U.S. and non-U.S. populations, Acute Stress Disorder is identified in less than 20% of cases following traumatic events that do not involve interpersonal assault. Higher rates (20-50%) are reported following assault, rape and witnessing a mass shooting.
Acute stress Disorder Etiology:
The same caveat as with PTSD applies here
Prior mental disorder
High levels of negative affect
Greater perceived severity of the trauma
Avoidant coping style
Prior elevated reactivity (acoustic startle response)
Acute Stress Disorder Clinical Presentation:
-Exposure to actual or threatened trauma
-Duration is 3 days to 1 month
Acute stress disorder DDX:
Traumatic Brain Injury
General Anxiety Disorder Fun Facts:
-12 month prevalence rates: 3-8%
-Females twice as likely as men to get GAD
-Rates among those of European descent are higher than non-European descent.
-Rates among those from developed countries are higher than from nondeveloped countries.
Brain imaging studies: lower metabolic rate in basal ganglia and white matter in GAD pts.
25% of 1st degree relatives of GAD patients are also affected.
Twin studies tend to support a genetic risk.
DSM V reports that 1/3 of the risk of GAD is genetic.
Risk factors: temperamental factors of behavioral inhibition, negative affectivity and harm avoidance.
GAD Clinical presentation:
Excessive anxiety and worry lasting for at least 6 months.
Difficulty controlling the worry
The anxiety and worry are associated with 3 or more of: restlessness, easily fatigued, poor concentration, irritability, muscle tension and sleep disturbance.
Substance/medication induced anxiety
Social anxiety disorder
Depression/other mood disorders/psychosis
SSRIs, especially Zoloft, Celexa and Paxil due to less activating effects.
Benzodiazepines can be prescribed as needed and at the same time as an SSRI. The benzo can then be tapered to avoid dependence.
BuSpar (more effective for the cognitive sx.s than the somatic sx.s)
Cognitive Behavioral Therapy to address the cognitive distortions
Relaxation strategies to address the somatic sxs.