Anxiety Disorders Panic Disorder: defined by DSM-5 criteria Table 9.

2-2
Recurrent unexpected panic attacks with 4 or more
Normal Anxiety symptoms
Adaptive response to given stimulus Panic Attack: a discrete, sudden episode of intense discomfort or fear.
Diffuse, unpleasant, vague sense of apprehension, accompanied by Feelings of impending doom
autonomic symptoms: HA, perspiration, palpitations, chest tightness Peaks within minutes
Anxiety is an alerting signal (impending danger, ability to deal with a Epidemiology
threat) Lifetime prevalence is 1-4%
Awareness of: W>M
Physiologic sensations (ie palpitations & sweating) Onset: young adulthood (average 25 yo)
Being nervous or frightened Etiology
Affects: Biologic
Thinking, perception, learning Genetic
Produces: Psychosocial
Confusion, distortions of perception of time, place, person DSM-5 Criteria
and meaning A. Recurrent unexpected panic attacks with 4 of the following symptoms:
Can be a symptom or a disorder 1. Palpitations 8. Dizziness/faint
Fear vs anxiety: 2. Sweating 9. Chills/heat sensations
Fear: sudden response to known, external, definite threat 3. Trembling 10. Paresthesias
Anxiety: insidious response to unknown, internal, vague threat 4. SOB 11. Derealization or depersonalization
5. Choking 12. Fear of losing control
Stress & Anxiety 6. Chest pain/discomfort 13. Fear of dying
Response to stress depends on ego 7. Nausea/Abd distress
External: pressures of outside world produce interpersonal conflicts
Internal: pressures of persons impulses and conscience produce B. At least 1 attack followed by 1 of the following:
intrapsychic or intrapersonal conflicts 1. Persistent concern about future attacks
2. Significant maladaptive behavioral change panic attack
Pathologic Anxiety C. The disturbance is not attributable to substance use or medical condition
MC in Women D. The disturbance is not better explained by other mental disorder
Up to 25% may meet criteria
Decreased in higher socioeconomic status Associated Symptoms
Contributing Factors: Depressive Sx present
Biology Depression + panic disorder
Autonomic nervous stimulation Higher risk of suicide
Neurotransmitters (NE, ST, GABA) Other phobias can coexist with panic disorder
Genetic Factors Agoraphobia
Predisposing genetic factors Obsessive-compulsive disorder
Nearly half of all patients have one affected Other specific phobias
relative DDX
Medical conditions can mimic symptoms
Substance use
Asthma
Angina
Cardiac arrhythmias
Comorbid psychiatric disorders
Depression
Prognosis
Chronic disorder
However 30-40% of patients are symptom free at long-term f/u
50% have mild symptoms
10-20% continue to have significant symptoms

Treatment:
SSRIs, benzodiazepines, MAOIs, tricyclic and tetracyclic drugs
CBT
Agoraphobia Specific Phobia
Anxiety related to places where escape may be difficult Strong, persisting fear of an object or situation
Disabling due to effects on school, work and social function Intense anxiety
Association with Panic Disorder but in DSM-5 own diagnosis Epidemiology: 5-10% of US population
Epidemiology Most common mental disorder in women, 2nd most common in
Life prevalence 2-6% men
Higher incidence in population over 65yo MC in women 2:1
Onset often follows a traumatic event Types:
Debate related to distinct nature of diagnosis form Panic Disorder Acrophobia- fear of heights
A. Marked fear or anxiety about > 2 of the following 5 situations Ailurophobia- fear of cats
1. Using public transportation Hydrophobia- fear of water
2. Being in open spaces Claustrophobia- fear of closed spaces
3. Being in enclosed places Cynophobia- fear of dogs
4. Standing in line or being in a crowd Mysophobia- fear of dirt/germs
5. Being outside of the home alone Pyrophobia- fear of fire
B. Fear due to escape may be difficult or help may not be available in event Xenophobia- fear of strangers
of a panic or other embarrassing symptoms Zoophobia- fear of animals
C. Agoraphobia situations almost always provoke fear or anxiety A. Marked fear/anxiety about object or situation
D. Agoraphobic situations are actively avoided, require a companion, or are B. Object/situation almost always provokes immediate fear/anxiety
endured with intense fear or anxiety C. Object/situation avoided or endured with intense fear
E. The fear or anxiety is out of proportion to actual danger D. Fear/anxiety is out of proportion to actual danger
F. Persistent typically last > 6 months E. Symptoms persistent > 6 months
G. Causes significant distress or impairment in social or occupational areas F. Impairment in social/work functioning
H. If another medical condition is present the fear is excessive G. Disturbance not otherwise explained by mental disorder
I. The fear anxiety or avoidance is not better explained by another mental Tx:
disorder Behavioral therapy
Insight-oriented therapy
DDX: Virtual therapy
Major Depressive Disorder Others:
Schizophrenia Hypnosis
Paranoid Personality Disorder Family therapy
Avoidance Personality Disorder Exposure therapy to desensitize and teach relaxation
Dependent Personality Disorder techniques
Course & Prognosis:
Without Co-Diagnosis of Panic Disorder poor prognosis Social Anxiety Disorder
Treat Panic Disorder gradual improvement of Agoraphobia over Fear of social situations including situations that involve scrutiny or
time contact with strangers
Fast resolution also behavioral therapy used Epidemiology
Depression & alcohol use complicate course Lifetime prevalence 3-13%
MC in Women
Tx: Onset: teens
Psychotherapy Etiology
Supportive psychotherapy Possible inherited trait??
Insight-Orientated Therapy Neurochemical factors
Behavior Therapy Genetic factors
Cognitive Therapy DSM-5 Criteria (Table 9.5-2):
Virtual Therapy A. Marked fear/anxiety about 1 social situations where pt may be
Pharmacotherapy exposed to scrutiny by others
Benzodiazepines B. Pt fears they will show anxiety that will be negatively evaluated by
SSRIs others
TCAs C. Social situations almost always evoke fear
D. Social situations area avoided/endured with anxiety
E. Anxiety out of proportion to actual threat
F. Symptoms 6 mos
G. Impairment in social/work functioning
H. Not attributable to substance or medical condition
I. Not explained by other mental disorder
J. If other medical condition present, this anxiety is clearly unrelated
Prognosis:
Typically chronic
If symptoms remit, pts tend to do well
Can be profoundly disruptive to pts life
Treatment:
Psychotherapy
Behavioral and cognitive
Pharmacotherapy
SSRI, benzo, venlafaxine, buspirone
Generalized Anxiety Disorder
Definition: excessive levels of anxiety and worry most of the time and
have great difficulty controlling their worry for at least 6 months
Worry is difficult to control
May be associated with somatic symptoms
Frequently associate with other psychiatric disorders
Phobias, panic disorder, depression
Epidemiology: common!
MC in Women 2:1
Lifetime prevalence is 5-8%
Onset late adolescence early adulthood
Etiology: unknown
Genetic
Biological: decreased GABA and alpha 2 receptors
Psychosocial: cognitive distortions cause patients to focus on negative
details and inaccurately perceive their ability to cope
Stressful life events increase the likelihood

DSM-5 Criteria (Table 9.6-2):

A. Excessive anxiety and worry 6months
B. Pt finds it difficult to control the worry
C. Anxiety associated with 3 of the following:
1. Restlessness/on edge
2. Easily fatigued
3. Difficulty concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbance
D. Impairment in social/work functioning
E. Not attributable to substance or medical condition
F. Not better explained by other psychological disorder

Tx:
Cognitive Behavioral Therapy (CBT)
Addresses cognitive distortions and behavioral approaches
address somatic symptoms
May be the TOC in some
Pharmacotherapy
Benzodiazepines
Buspirone
SNRIs
SSRIs