Anxiety Disorders

Definitions:

Fear: the stimulus is real (presence of an angry lion)

Anxiety: anticipation of the fear = fear without stimulus (fear from the nothing)

Disorder: if the anxiety

Persist for more than 6 month

Interfere with functioning

Cause of significant distress

Types of anxiety:

Situational  (for example an exam)

Free floating (no cause can be find)

Classification od anxiety disorders:

1.      GAD (Generalized Anxiety Disorder)

2.      Panic Disorder (with or without agoraphobia)

3.      Specific & Social Phobias

4.      OCD (Obsessive Compulsive Disorders)

5.      PTSD (Post Traumatic Stress Disorder)

6.      ASD (Acute Stress Disorder)

Women are more likely to have:

3x Panic disorder

2x PTSD

GAD

Biology:

Decreased serotonin – raphe nuclei 

Decreased GABA activity

Decreased GABA-benzodiazepine receptor binding

Increased NE activity – locus ceruleus

Anatomy:

Temporal cortex

Frontal cortex

Caudate nucleus (OCD)

Differential diagnosis:

Organic diseases

1.      Substance abuse & withdrawal

2.      Hyperthyroidism

3.      Vitamine B12 deficiency

4.      Hypo-, hyperglycemia

5.      Pheochromocytoma

6.      Anemia

7.      Cardiovascular disorders

8.      COPD (Chronic Obstructive Pulmonary Disease)

Psychiatric disorders

1.      MDD

2.      Dysthymic disorder

3.      Schizophrenia

4.      hypochondriasis

GAD (Generalized Anxiety Disorder)

Symptoms:

Persistent anxiety

Hyper arousal

Excessive worry

Free floating type anxiety

3-5% of population affected

50% onset in childhood or adolescence

Chronic condition frequently with indefinite need for treatment

Phobias

Definition: unfounded and irrational fear of certain things and situations

Subtypes

Specific phobia            (simple phobia)

5% in men

10% in women

Social phobias (social anxiety disorder)

3% in population in both sexes

Dd:

Shyness

Delusional disorder

Paranoid PD

Avoidant PD

Schizoid PD

OCD

Recurrent unwanted intrusive

Feelings

Thoughts

Images (obsessions)

Anxiety escorting the above

Anxiety relieved by

repetitive actions (compulsions)

Obsessive thinking itself

Compulsive rituals

Insight to irrationality

Higher occurrence of OCD in relatives of Tourette syndrome

Differential diagnosis:

Epilepsy

Tourette

Obsessive – compulsive PD (extreme cleanness)

Demographics

Starts in early adulthood

2-3% of population

No sex difference

1/3 fails to improve at all

Panic disorder

Subtypes: with or without agoraphobia

Clinically:        Episodic panic attacks

Anticipatory anxiety between attacks

Lifetime prevalence 1.5 – 3.5%

Mean onset: 25 y

Chronic – recurrent course

Increased risk of depression & suicide

Genetic factors + social precipitating factor

Diagnostic Tests:

Sodium lactate

CO2 inhalation

Stress Disorders

Criteria: Exposed to life threatening potentially fatal events

(War, volcanic eruption, earthquake, rape, accident, terror attack, mock or real execution etc.)

ASD: symptoms are lasting onlynfor 2 day – 1 month

PTSD: symptoms lasting for more than 1 month (usually years)

Symptoms:

Flashback: re-experiencing the event again and again with movie like clearness, this is present against all mental effort of the patient

Hyperarousal

Hypervigiliance

Anxiety

Increased startle

Impaired sleep

Emotional numbing and Inability for emotional involvements, relationships

Survivor’s guilt

Avoidance behavior and Social withdrawal

Lifetime prevalence:

1 – 14%

3 - 58 % in survivors

Risk factors

Female

Prior psychiatric history

1/3 rules:

1/3 comorbidity for major depressive disorder

1/3 recovers within 3 month

1/3 sick after 10 years

PTSD duration is longer if in the history is

Substance or drug abuse

Childhood trauma

Adjustment disorders

Milder than ASD & PTSD and not met the criteria of those disorders

Follows non life threatening stressor

Divorce

Bankruptcy

Emotional symptoms

Anxiety

Depression

Conduct problems

Social impairment (work, school)

Pharmacotherapy of Anxiety disorders:

Anti-anxiety drugs:

Benzodiazepines

Fast acting: (hours)

Clonazepam (Klonipin)

Alprazolam (Xanax)

Diazepam (Valium)

Intermediate:

Lorazepam (Ativan)

Long acting: (more than 24 hours)

clonazepam

Buspirone

Low abuse potential

Slowly developing effect (2 weeks) (because diazepam, and any anti anxiety drug has strong addictive and abuse potential, it is recommended to start treatment with diazepam and buspirone together, and after 2 -3 weeks weaning off the benzodiazepine drug)

Beta blockers

Propranolol (Inderal)

Atenolol (Tenormin)

Less sedation

Before public speech

Maintenance therapy needed in most cases, but especially long treatment in GAD

Antidepressants

            Types: 

MAO inhibitors

Heterocyclics

Clomipramine (Imipramin, Anafranil)

SSRI

Paroxetine (Paxil)

Fluoxetine (Prosac)

Sertaline (Zoloft)

Recommended drugs in different groups of anxiety disorders:

GAD:

Buspirone

Doxepine

venlafaxine

OCD:

SSRI

Panic disorder:

SSRI

Social phobia

Paroxetine

Sertaline

Venlafaxine

PTSD:

Sertaline

Paroxetine

Olanzapine in combination

Carbamazepine ( addressing flashbacks, nightmares)

Valproic acid (addressing flashback, nightmares)

Psychotherapies:

Case Studies

v  A 20-year-old single woman presents to your office complaining of “episodes of complete terror.” She states that “totally out of nowhere” she became extremely anxious, experienced heart palpitations, felt short of breath, began sweating profusely, and believed that she was going to die. She reports that these episodes last approximately 10 minutes and that they have occurred several times over the last 3 months. She constantly worries that they will occur again.

1. What general medical condition should be considered in the differential diagnosis for this patient’s cluster of symptoms?

(A) hypothyroidism

(B) systemic lupus erythematosus (SLE)

(C) pheochromocytoma

(D) folate deficiency

(E) hypertension

2. Which of the following is the most likely diagnosis for this patient’s symptoms?

(A) generalized anxiety disorder (GAD)

(B) social phobia

(C) panic disorder

(D) obsessive-compulsive disorder (OCD)

(E) agoraphobia

1. (C) Hyperthyroidism, hyperparathyroidism, pheochromocytoma, cardiac arrhythmias, and substance abuse should all be considered in the differential diagnosis of panic disorder.

Pheochromocytomas can produce similar symptoms to panic disorder, such as flushing, sweating, trembling, and tachycardia. Cardiac arrhythmias should obviously be considered in a patient complaining of palpitations. Substance abuse with caffeine, cocaine, or amphetamines can cause symptoms similar to a panic attack as can withdrawal from alcohol, barbiturates, or benzodiazepines. Hypertension, folate deficiency, hypothyroidism, and lupus are not generally thought of as causing an anxiety-like syndrome.

2. (C) The most likely diagnosis in this case is panic disorder. This patient reports some classic symptoms of a panic attack, namely an intense fear in a very short amount of time, associated with palpitations, sweating, shortness of breath, and a feeling of being unable to breathe. The patient has also related past multiple episodes and that she spends a lot of time worrying she will have another episode. These symptoms fit criteria for a panic disorder and not GAD, social phobia, or OCD. Agoraphobia is the fear of crowded spaces.

v  A 29-year-old woman tells her doctor that about 3 weeks ago a child she was caring for ran into the street and was killed by a bus. Since then, she cannot get the image of the accident out of her mind. Even in sleep, she dreams about it. She used to take a bus to work but she now walks because she cannot bear to be near buses. In the past week, she has begun missing work because she is uncomfortable leaving her house. She feels guilty, believing the accident was her fault.

1. What is the most likely diagnosis?

(A) posttraumatic stress disorder (PTSD)

(B) acute stress disorder

(C) major depressive disorder (MDD)

(D) panic disorder with agoraphobia

(E) adjustment disorder

2. The patient decides against any medication and follows up with psychotherapy. A year later, although she is no longer having distressful symptoms relating to the accident, she complains she feels sad and tearful most of the time, is having trouble eating, has lost interest in gardening, and wakes up at 4 AM every morning, unable to get back to sleep. What ist he most likely diagnosis?

(A) PTSD

(B) Acute stress disorder

(C) MDD

(D) Panic disorder with agoraphobia

(E) Adjustment disorder

1. (B) Acute stress disorder is a reaction that causes clinically significant disruption or distress in a patient who witnesses or somehow participates in a traumatic event. The event must be quite horrible, invoking in the patient intense fear, and usually involving death or threatened death. The typical symptoms include hyperarousal states, dissociative states, and intrusive re-experiencing of the event (e.g., flashbacks and avoidance behaviors). PTSD is similar in most respects to acute distress disorder, but in PTSD the symptoms persist for at least 4 weeks following the trauma; a shorter duration suggests a diagnosis of acute distress disorder. The patient does not appear to be suffering from any of the typical criteria for MDD or adjustment disorder, except for guilt. Although she is suffering from agoraphobia, a symptom consistent with an acute stress reaction, there is no evidence of panic disorder.

2. (C) Although MDD, panic disorder with agoraphobia, and adjustment disorder are all in the differential diagnosis at the initial presentation and should be carefully considered,

MDD does not emerge as a clear diagnosis until this question’s additional information is presented. At this time, the principal symptoms of the acute stress disorder have remitted, and the classic symptoms of depression—feelings of sadness, loss of interest, a change in sleep habits, tearfulness, and change in appetite are apparent. These outweigh the earlier working diagnoses.

v  A 59-year-old woman with a long history of GAD tells her primary care doctor that in a crowded supermarket 2 days previously she felt dizzy, with associated heart palpitations, pressure on her chest, and frightening sense of doom. Shortly thereafter, she fell unconscious and woke up minutes later with a crowd around her. She felt somewhat better and rejected others’ advice that an ambulance be called. She quickly made her way home.

1. What is the most appropriate next step?

(A) short-acting benzodiazepines

(B) an SSRI

(C) cognitive-behavioral therapy

(D) electrocardiogram (ECG)

(E) reassurance that her condition is benign

2. What is the most likely diagnosis?

(A) Cardiovascular disease

(B) Panic attack

(C) GAD

(D) Acute stress disorder

(E) Anxiety disorder due to cardiovascular disease

1. (D) Benzodiazepines, SSRIs, and cognitivebehavioral therapy each have a place in treatment of the anxiety disorders. In this case, however, these should not be considered until an organic cause is ruled out.

2. (A) Regardless of a patient’s past psychiatric diagnosis, organic causes of physical signs and symptoms must always be ruled out. The anxiety disorders, although intensely distressing and uncomfortable to patients, rarely, if ever, result in unconsciousness. Many aspects of the patient’s story seem to be related to anxiety and could in fact occur during a panic attack, but this patient’s presentation is more consistent with ischemic heart disease and should prompt a cardiac workup.

v  A 26-year-old woman with no previous psychiatric history is referred to you by her primary care physician for evaluation of an episode of anxiety. She tells you that approximately 2 months ago she began having episodes lasting 10 or 15 minutes during which, she says, “I feel like I’m going to die.” During these episodes, her heart races, she feels as though she cannot catch her breath, she is dizzy and worried she may pass out, and has tingling and tremors in her hands. She is concerned because she is now having problems leaving her father’s house and getting married, because she is worried these episodes will occur and make it impossible for her how to acquire her new home with her husband. She cannot identify any triggers leading to the episodes. She is not on any medication and has no medical problems.

1. You diagnose her with which of the following?

(A) GAD

(B) Panic disorder with agoraphobia

(C) Separation anxiety disorder

(D) Social phobia

(E) Panic disorder without agoraphobia

2. You initiate treatment with which of the following?

(A) Sertraline

(B) Alprazolam

(C) Lithium

(D) Propranolol

(E) Tranylcypromine (Parnate)

1. (B) This patient is describing symptoms associated with panic disorder. This disorder occurs in late adolescence or the early twenties and is more common in women than men. People typically describe feelings of fear, dread, or intense discomfort associated with a variety of somatic symptoms, including tachycardia, chest pain, shortness of breath, tremulousness, diaphoresis, nausea, fear of dying, paresthesias, light headedness, and hot or cold flashes. The diagnosis of agoraphobia is made when fears of having an attack or being unable to leave a place where they are having an attack force patients to remain in familiar places. The medical workup for panic disorder includes CBC, electrolytes, fasting glucose, calcium, liver function tests, BUN, creatinine, urinalysis, toxicology screen, ECG, and thyroid function studies. A careful substance abuse and caffeine intake history should also be taken. Social phobia or social anxiety disorder occurs in the context of public appearances or performances. Individuals may experience anxiety and fear. These feelings cause great distress and may cause people to limit or avoid these settings. This disorder differs from panic disorder by having an identifiable trigger. Separation anxiety disorder is commonly diagnosed in young children when separated from their primary caregiver. GAD occurs in individuals experiencing continued anxiety and worry for periods greater than 6 months, occurring throughout the day. Unlike panic disorder, there do not seem to be discrete episodes.

2. (A) A variety of medications, including SSRIs (sertraline), TCAs, MAOIs (tranylcypromine), and benzodiazepines (alprazolam) have been used to treat panic disorder. Although all have shown some efficacy in the treatment of panic, SSRIs are usually the first agent of choice because they are generally well tolerated, with fewer side effects than TCAs or MAOIs, and lack the dependency potential of benzodiazepines. Common side effects include sexual dysfunction, gastrointestinal disturbances, and insomnia. Lithium is used in the treatment of bipolar disorder, and propranolol is used for social phobia.

v  A 47-year-old man comes to your office complaining, “I’m always worried.” He says that he worries about her job, his kids, and his wife. He is seeking help now because he has been having an increasingly difficult time concentrating at work and has been more irritable with people around him. His sleep has been “okay,” but he does not feel rested when he gets up in the morning. He has been more aware of these feelings over the last 2 years and they occur almost every day. He denies any discrete episodes of increased anxiety. You discuss which of the following diagnoses with the patient?

(A) GAD

(B) OCD

(C) Social phobia disorder

(D) Panic disorder

(E) Schizophrenia

 (A) Symptoms of excessive worry and anxiety occurring for over 6 months without discrete episodes are best characterized by the diagnosis of GAD. Other symptoms of GAD include sleep difficulties, irritability, and difficulty concentrating. Patients with GAD may also suffer from muscle tension, fatigue, and restlessness. Although this patient does admit to anxiety, it does not occur in episodic fashion or in response to public performances, as with panic disorder or social phobia. Similarly, although the symptoms of anxiety and worry are in excess of what would be expected, they do not reach the magnitude characteristic for OCD, nor are any compulsions elicited. There is no evidence of psychosis or a thought disorder in this patient.