Transcript DSM-IV

Anxiety Disorders
Panic Attack
Brief episode where pt. feel intense dread
accompanied by a variety of physical and
other symptoms that begin suddenly and
peak rapidly (usually 10 minutes)
 Physical/mental sensations

– Chest pain, chills or hot flashes, choking
sensation, derealization/depersonalization,
dizziness, fear of losing control, tachycardia,
numbness, sweating, shortness of breath,
trembling.
Panic Disorder
Repeated Panic Attacks
 Worry/dread at having additional attacks
 With/without Agoraphobia

Posttraumatic Stress
Disorder
• Symptoms following exposure to extreme
trauma present for at least one month.
• Experiencing or witnessing an event that
involves actual or threatened death or
serious injury to self or another
• Elicits a reaction of intense fear,
helplessness, or horror
• After trauma there is persistent
reexperiencing of the trauma, persistent
avoidance of stimuli associated with
trauma, and persistent symptoms of
increased arousal
Acute Distress Disorder
• Similar to PTSD, except Sx must have
onset within 4 weeks of the trauma and
must last for at least 2 days but no longer
than 4 weeks
• 3 or more dissociative Sxs (e.g.. sense of
numbing or emotional detachment,
derealization, dissociative amnesia)
• Must exhibit persistent reexperiencing of
the trauma.
• Marked avoidance of stimuli that cause
recollection the trauma
• Sxs of marked anxiety or increased
arousal.
Phobia
Specific Phobia-patients fear specific
objects or situation, such as animals, storms,
heights, blood, airplanes, being closed in or
any situation that may lead to vomiting,
choking or developing an illness.
 Social Phobia-These patient imagine
themselves embarrassed when they speak,
write, or eat in public, use a public urinal;
during exposure-immediate panic attacks.

Generalized Anxiety
Disorder
• Excessive anxiety and worry about
multiple events or activities.
• The anxiety and worry are relatively
constant for at least 6 months, and the
person finds them difficult to control.
• Must entail 3 of following: restlessness,
being easily fatigued, difficulty
concentrating, irritability, muscle tension,
and sleep disturbance
• Disproportionate to feared events or their
potential impact
• Worrier or GAD? Measures-State Trait
Inventory; How else?
Substance-Induced
Anxiety Disorder
• The development of anxiety, OC Sxs, or
panic attacks are present within one month
of Substance Intoxication or Withdrawal or
are due to medication use.
• Associated with caffeine, cannabis,
cocaine, hallucinogen, inhalant, and PCP
intoxication and withdrawal from alcohol,
cocaine, or a sedative, hypnotic or
anxiolytic
• Medications and toxins (e.g. gasoline,
paint, insecticides, and CO can produce
anxiety symptoms.)
Obsessive-Compulsive
Disorder
• Characterized by recurrent obsessions or
compulsions that are severe enough to
cause significant distress, to be timeconsuming (take more than one hour per
day), or to markedly interfere with the
person’s usual routine, occupational or
academic functioning, social activities and
relationships.
• Person must be aware, at some time during
the course of the disorder, that his/her
obsessions and compulsions are excessive
or unreasonable
Biology & Anxiety

Peripheral Nervous System
– Somatic
Sensory Systems
 Skeletal Motor System

– Autonomic
Sympathetic-arousal & energy expenditure
 Parasympathetic-conservation of energy

ANS & Anxiety Disorders
Although primarily involuntary, it has been
found to be brought under voluntary control
 Pts. With Anxiety D/O’s demonstrate
delayed response to repeated stimuli and
excessive response to moderate stimuli
 Predisposition or Learning?????

Anxiety D/O Epidemiology
Lifetime %








Panic (M/F%)
Agoroph. W/O
Social Phobia
Simple Phobia
Gen. ADO
OCD
Any Phobia
Any ADO
12-Month %
2/5
3.5/7
11/15
7/16
4/7
2/3
10/18
19/31
1.3 vs.
1.7 vs.
6.6 vs.
4.4 vs.
2.0 vs.
1.4 vs.
6.2 vs.
11.8 vs.
3.2
3.8
9.1
13.2
4.3
1.9
12.8
22.6
Neurotransmitters
Norepinephrine, Serotonin & GABA
 Act in brainstem (noradrenergic neurons);
limbic system(anticipatory anxiety) and
prefrontal cortex
 PFC associated with the possible generation
of phobic avoidance

Norepinerhrine
Pts. have poorly regulated noradrenergic
systems leading to occasional energy bursts
 Stimulation leads to fear response
 Beta-adrenergic agonists (Isuprel) or
Alpha2-adrenergic antagonist (Yohimbine)
lead to severe panic attacks
 Alpha2-adrenergic agonist
(Clonidine/Catapres) & B-ATN
(Propanolol/Inderal) reduce anxiety

Serotonin
Many SE type receptors-more selective
 Clomipramine (Anafranil)-OCD
 Buspirone (Buspar) 5HT agonist with
projections from brainstem, cortex, limbic
system and hypothalamus

GABA (Aminobutyric Acid)
Most common inhibitory NT in CNS
 Benzodiazepines increase the activity of
GABA at the receptor
 Low potency most treatment for GAD
 High potency GABA’s (e.g. Xanex) have
been effective in treatment of PDO

Anxiolytic Medications
What to Rx?

SSRIs: Paroxetine (Paxil)
– other alternatives?

Benzodiazepines
– Alprazolam (Xanex) Lorazepam (Ativan) &
Clonzaepam (Klonopin)
– Advantages and disadvantages?

Tricyclics: Clomipramine & Imipramine (Tofranil)
– Alternatives, advantages & disadvantages
Psychotherapy and ADOs
Controversies?
 In vivo exposure with response prevention
(flooding) –Agoraphobia
 SDT or Participant modeling-Specific
Phobias (observation/graded participation)
 CBT, PMR, Social skills training &
Assertiveness Training
 Medication vs. Psychotherapy?

Realistic Anxiety?