Disorders
Sean Anxiety M. Blitzstein, M.D.
Learning Objectives
Be able to recognize pathological anxiety and understand how it is different from normal anxiety Be able to describe the physiologic mechanisms which occur during anxiety and/or fear states Be able to state the diagnostic criteria for the anxiety disorders as listed in the DSM-IV Be able to list at least 5 medical conditions, medications, and/or substances that can mimic anxiety disorders
Domains of anxiety
Physical Affective Cognitive Behavioral
Physical domain
Anorexia Butterflies in stomach Chest pain/tightness Diaphoresis Dry mouth Dyspnea Faintness Flushing Hyperventilation Light-headedness Muscle tension Nausea Pallor Palpitations Paresthesias Sexual dysfunction
Physical domain (continued)
Headache Shortness of breath Stomach pain Tachycardia Tremulousness Urinary frequency Vomiting
Affective domain
Ranges from edginess and unease to terror and panic.
Cognitive domain
Worry Apprehension Thoughts concerned with emotional or bodily danger
Behavioral domain
Anxiety triggers many different responses concerned with diminishing or avoiding the distress.
Pathological vs. Normal Anxiety
Autonomous Greater intensity Longer duration Behavior of individual significantly affected
Origin of anxiety
Protective response Common underlying neurophysiology for both normal/protective anxiety/fear and pathological anxiety 2 categories of fear/anxiety
Acute fear state
Response to life-threatening danger Terror, helplessness, sense of impending disaster/doom Urgency to flee or seek safety Sympathetic/Nor-adrenergic activation Located in locus ceruleus Corresponds to panic attacks
Regulation of locus ceruleus
Alpha-noradrenergic auto receptors Serotonin receptors GABA-benzodiazepine receptors Opiate receptors
Alert state
Heightened sense of vigilance to possible threats Less intense levels of inhibition, physical distress and behavioral impairment GABA mechanism Limbic structures: hippocampus/amygdala Corresponds to generalized/anticipatory anxiety
DSM-IV Anxiety Disorders
Panic D/O With and Without Agoraphobia Agoraphobia Without History of Panic D/O Specific Phobia Social Phobia OCD Posttraumatic Stress D/O Acute Stress D/O Generalized Anxiety D/O Anxiety D/O Due to a General Medical Condition Substance-Induced Anxiety D/O Anxiety D/O, NOS
Case #1
Mr. A witnessed a friend die in a MVA six weeks ago and c/o frequent nightmares of the accident, poor sleep, fears of driving, anxiety around highways, anhedonia and decreased affection towards his girlfriend. His girlfriend also notes that he has been very irritable and startles easily since the accident.
Posttraumatic Stress Disorder
Exposure to a traumatic event Response involving intense fear, helplessness or horror Re-experiencing of the traumatic event Avoidance of stimuli/psychological numbing Increased arousal Symptoms greater than 1 month
Case #2
Mrs. B c/o a long h/o episodes of anxiety, SOB, racing heart, sweating, CP, and fears that she is having a MI and will die. These last 30 minutes and are unexpected. c/o She anxiety while in malls and traveling alone to new places for fear of having another attack. Despite a negative medical w/u, she still worries about having a MI during an attack.
Panic Disorder With Agoraphobia
Recurrent unexpected panic attacks: anxiety associated with at least four physical and/or cognitive symptoms At least 1 month of worry about having additional attacks or the consequences of an attack (losing control, having a heart attack, going crazy). Agoraphobia
Agoraphobia
Anxiety in situations where escape might be difficult (or embarrassing) or help might not be available in the event of having a panic attack or panic-like symptoms Situations are avoided or endured with marked distress
Case #3
Ms. D has a chief c/o worrying about everything for the last year. She also c/o frequent headaches, fatigue and insomnia secondary to the anxiety. These symptoms have worsened to the point where she has been distracted and making mistakes at work.
Generalized Anxiety Disorder
Excessive anxiety and worry about a number of events or activities Difficulty controlling the worry At least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance Symptoms last greater than 6 months
Case #4
Dr. E has a history since childhood of fears of speaking in front of others. He worries that he will perform poorly and be humiliated, and so he has avoided giving talks to other medical professionals. He feels that this has significantly interfered with his ability to progress further in his academic career.
Social Phobia
Marked, persistent fear of social or performance situations where a person is exposed to unfamiliar people or possible scrutiny by others. The individual fears acting in an embarrassing or humiliating way. Person recognizes...