Anxiety Disorders

Anxiety Disorders

Anxiety Disorders: Prevalence, general informationAnxiety disorders - most prevalent disorders of childhood and adulthood (Prevalence of 1 -25% - Gelfland, 2002)To be a disorder, it must interfere with daily functioning.Most prevalent:Obsessive compulsive disorder (OCD)Generalized anxiety disorder (GAD)Social Phobias and Panic Disorders

Anxiety Disorders

About Anxiety DisordersPhysical AspectStress: generally a physiological state associated with anxiety - heightened arousal with physical symptomsPsychological AspectAnxiety: a feeling of anticipation (negative) or worry in a particular context - no specific target is necessaryFear: often used interchangeably - usually used in reference to a specific target

Axiogenic: anxiety producingAxiolytic: anxiety reducing

Anxiety Disorders

The Stress ResponseHypothalamic-Pituitary-Adrenal (HPA) AxisHypothalamus releases of corticotropin releasing hormone (CRH)Pituitary gland releases (adreno)corticotropin hormoneCortisol (and other adrenal hormones) released from adrenal glands Increasing energy, awareness in response to a threatIncrease heart rate, sweating, heavier breathing, increase in muscle tension, etc.Preparation of fight or flight

Anxiety Disorders

Anxiety Disorders

The Stress ResponseThe hypothalamus is a the centre of the stress response via the sympathetic nervous system.However, projections from the amygdala and prefrontal areas to the hypothalamus influence how threatening situations are interpreted and, hence, regulatedStructures involved in establishing classical and operant learning

Anxiety Disorders

The Stress ResponseCRH receptors found throughout the brain: Prefrontal, cingulate, amygdala, nucleus accumbens, locus coereliusOf course, epinephrine and norepinephrine also act in similar areas.

Anxiety Disorders

Development and Maintenance of FearTwo Factor TheoryFears develop by classical conditioning: A neutral event is associated with a fearful eventFear elicited by neutral event2. Fear is maintained by operant conditioningAvoidance of fear inducing situation (negative reinforcement)

Anxiety Disorders

Neuropathology: Learning Anxiety Producing BehavioursThe amygdala and pre-frontal areas play an important role in learning of fear-based behavioursAmygdala: contextual learning and (re-)consolidation.2. Frontal lobe: extinction memory.Both areas implicated in processing incoming conditioned stimulus information.Anxiety producing behaviours associated with increased hippocampal and reduced frontal activation.

Anxiety Disorders

Neuropathology: Learning Anxiety Producing BehavioursNeurotransmitter SystemsGlutamate (NMDA receptor)NMDA receptor is ionotropic: slow, long lasting depolarization.Present in amygdala and prefrontal areasAlso a number of brainstem areas associated with stress response (locus coeruleus, ventral tegmental area, periadaqueductal grey matter)

Anxiety Disorders

Neuropathology: Learning Anxiety Producing BehavioursNeurotransmitter SystemsGABA (A-receptor subtype)Implied through the effects of GABAA agonist benzodiazapineSedative used in the treatment of anxiety and insomniaLarge occipital reductions in GABA concentrationsReceptor disruption through other modulator steroids

Anxiety Disorders

Neuropathology: Learning Anxiety Producing BehavioursNeurotransmitter Systems3. Norepinephrine Locus coeruleus: Arousal, vigilanceLimbic and frontal cortex: elaboration, adaptive responses to stressLong term potentiation in medial PFCSustained stress producing reduction in number of NE 2 receptors

Anxiety Disorders

Neuropathology: Learning Anxiety Producing BehavioursNeurotransmitter Systems4. Corticotropin Releasing HormoneMediation of response to stressIn amygdala: occurrence of fear related behavioursIn cortex: reduction reward expectationMemory systems may be particularly sensitive to the effects of CRH in early life.

Anxiety Disorders

Obsessive-Compulsive Disorder: DSM-IV CriteriaA.1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

2. the thoughts, impulses, or images are not simply excessive worries about real-life problems

Anxiety Disorders

OCD: DSM-IV Criteria3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (compulsion)

4.the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Anxiety Disorders

OCD: DSM-IV CriteriaCompulsions 1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) person feels driven to perform in response to an obsessionaccording to rules that must be applied rigidly2. behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation;not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

Anxiety Disorders

OCD: DSM-IV CriteriaB. At some point, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the persons normal routine, occupational (or academic) functioning, or usual social activities or relationships.

Anxiety Disorders

OCD: DSM-IV CriteriaD. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g, preoccupation with food in the presence of an Eating Disorder; preoccupation with drugs in the presence of a Substance Use Disorder.

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Anxiety Disorders

More informationObsessions are very difficult to repress despite their unpleasant nature.Obsessions and compulsions can occur independently.Common compulsions include washing, checking behaviours, order, and symmetry.

Anxiety Disorders

Generalized Anxiety Disorder: DSM-IV A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).B. The person finds it difficult to control the worry.

Anxiety Disorders

GAD: DSM-IV CriteriaC. The anxiety and worry are associated with three (or more) of the following six symptoms :muscle tensionbeing easily fatiguedIrritabilitysleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)restlessness or feeling keyed up or on edgedifficulty concentrating or mind going blank

Anxiety Disorders

GAD: DSM-IV CriteriaD. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in a Panic Disorder), being embarrassed in public (as in Social Phobia).

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Anxiety Disorders

GAD: DSM-IV Criteria

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Anxiety Disorders

Social PhobiaFear is centred on some aspect of the social situation.Children fear a teacher, being called on in class, or even entering the classroom.Adults may fear public speaking, social interaction, or initiation of conversationsSymptoms are similar to fear response associated with all phobias.

Anxiety Disorders

Social Phobia: DSM-IVA. Marked and persistent fear of one or more social and performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

Anxiety Disorders

Social Phobia: DSM-IVB. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or predisposed Panic Attack.Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

C. The person recognizes that the fear is excessive or unreasonable.Note: In children, this feature may be absent

Anxiety Disorders

Social Phobia: DSM-IVD. The feared social or performance situation are avoided or else are endured with intense anxiety or distress

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months

Anxiety Disorders

Social Phobia: DSM-IVG. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it. Usually refers to realistic fears

Anxiety Disorders

Panic DisorderWhen panic attacks due to anxiety and fear occur regularly, may have panic disorderSudden feelings of terror that occur suddenly and without warningSymptoms vary but may include:Chest pain.Heart palpitationsShortness of breath.Dizziness.Abdominal distress

Anxiety Disorders

Some EtiologyBegins in young adulthood--may or may not be linked to a particular traumatic experienceEvidence that heightened fear response begins in early childhood Related to neurological syndromes, like epilepsy, Tourettes, lesions (encephalitis, TBI)Some patients have damage or dysfunction of basal ganglia, cingulate gyrus, prefrontal cortex (Giedd et al., 1995; Robinson et al., 1995)Difficulty with extinction

Anxiety Disorders

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