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Anxiety Disorders - 8/4/05

1. Fear – appropriate, rational reaction to a known, external threat or danger.

Anxiety – same emotional response as fear, but the source of danger is not known, not recognized, or inadequate to account for symptoms. Anxiety does not have to be pathological. Anxiety is normal when it’s situation-related (testing, first date, etc.) Only when it is free-floating and interferes with pleasure, occupation, etc. is it considered pathological.

- more common in females

- comorbidities are common

- largest single group of psychiatric disorders

2. Anxiety may be due to hyperactivity of central adrenergic system (esp. locus ceruleus), producing excess norepinephrine and decreased serotonin and GABA.

Infusion of lactate or breathing of CO2 can induce panic in some.

Other possible biological causes are substance abuse (i.e. caffeine overuse) and subsequent withdrawal, hyperthyroidism, hypoglycemia, vestibular nerve disease, hypertension, cardiac arrhythmia, anemia, pulmonary disease, pheochromocytoma and carcinoid.

Anxiety is perceived to have a genetic basis. Heritable traits of (1) harm-avoidance, (2) low novelty seeking, and (3) high reward dependence can be seen in those suffering from anxiety. Also, those who have experienced separation anxiety in childhood are at a high risk.

3. Anxiety can also be seen as a breakdown of defensive structure of the psyche:

1) failure of repression (inability to keep a conflict unconscious)

2) mobilization of defenses such as regression, projection, conversion, displacement, which in turn leads to development of symptoms like phobias, obsessions, and compulsions, which lead to anxiety (primary gain)

3) patients may benefit from interpersonal and social consequences, such as relief of responsibility, expression of concern from others, financial rewards, etc. (secondary gain.)

Anxiety can be ego-syntonic (coming from oneself) or ego-alien (coming from the outside).

Anxiety can arise from modeling (children learn and adopt the anxieties of their parents).

4. Five clinical forms of anxiety disorders

1) Panic Disorders – sudden and unexpected attacks (palpitations, sweating, shaking, shortness of breath, numbness of the extremities, tingling, chills, hot flashes, upset stomach, sensations of choking, nausea, dizziness, depersonalization, derealization, fears of losing control, doing something stupid, or dying) of up to 30 minutes

- often accompanied by agoraphobia (fear of enclosed spaces or of leaving home.)

- anticipatory anxiety (fearful of having another attack) could be part of it.

- depression and substance abuse

- hyperventilation syndrome leads to alkalosis

- mitral valve prolapse in half the patients suffering from panic disorder; causal connection to panic is unclear

2) Phobias – irrational fear of certain things; most common mental problem

- agoraphobia (fear situations in which escape is difficult). Treatment includes exposure.

- Social phobia - can be generalized (most social situations) or circumscribed (certain specific events.)

- Specific phobia – fear of a specific object or event (heights, Kool-Aid man costumes, etc.)

3) OCD – recurrent intrusive feeling, thoughts and images that lead to anxiety, which is relieved by doing repetitive actions (compulsions)

- equal in both women and men (unlike other anxiety disorders)

- serotonin deficiency likely

- compulsive acts fall into 4 kinds: counting, checking, cleaning, and hoarding (magical harm-preventing quality)

- can be accompanied by Major Depressive Disorder (MDD) or Obsessive Compulsive Spectrum (eating disorders, Tourette’s syndrome, trichotillomania, Sydenham’s chorea, somatoform disorders)

- medications: SSRIs, clomipramine; surgery: cingulatomy and topectomy.

- The video from class said that if you are “absolutely pubescent about cars”, “lusting for a car”, or undergoing “automotive puberty”, you might have a problem. But probably not.

4) Generalized Anxiety Disorder – 6 mos or more; chronic worriers, poor sleepers, etc.

- GI complications

- Not related to specific situations or persons

- History of separation anxiety in childhood

- Medications: benzodiazepines like lorazepam (Ativan), clonazepam (Klonopin) and alprazolam); also SSRIs. Buspirone (BuSpar) is particularlyu useful for treating GAD.

5) Post-traumatic Stress Disorders – after a catastrophic event, affecting the the patient or patient’s close relatives.

- symptoms can last for more than 1 month or for years.

5. Treatment for anxiety falls into 3 categories:

1) Anti-anxiety agents – benzodiazepines, beta-blockers and anti-epileptics.

2) Antidepressants – SSRIs, monoamine oxidase inhibitors (MAOIs) (esp. for social phobias), tricyclics

3) Psychotherapy– systematic desensitization with reciprocal inhibition and cognitive therapy, behavioral therapies and support groups.

- analytically-oriented (sources of conflict are explored)

- cognitive behavioral therapy (systematized, looking at situation differently, breathing retraining, etc.)

- systematic desensitization gradual exposure to the fearful stimulation (vs. full exposure as a treatment)

- biofeedback

- hypnosis

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