Anxiety Disorders and Phobias

• Anxiety disorders and phobias are the topic of discussion.

Instruction Outcomes

• Describe the psychological and physiological states associated with anxiety, and define the term "sympathomimetic" in the context of anxiety responses.
• Diagnose Panic Disorder, Agoraphobia, Generalized Anxiety Disorder (GAD), Specific Phobias, Social Phobia, Obsessive-Compulsive Disorder (OCD), and OCD-related disorders using the DSM-5 criteria.
• Prescribe appropriate treatments from the main drug classes used for anxiety disorders, and explain the general mechanisms of action (MOA) of azaspirodecanediones and benzodiazepines.
• Evaluate the advantages and disadvantages of using anxiolytic benzodiazepines, considering efficacy, safety, and dependency risks.
• Differentiate among various psychotherapy techniques, including cognitive-behavioral therapy (CBT), classical conditioning, biofeedback, interoception, and desensitization, and apply them appropriately to manage anxiety disorders.
• Analyze the medical disorders and drug-related conditions associated with significant anxiety, identifying potential contributors to symptomatology.

Anxiety Disorder vs Normal Anxiety

• Disorder: when worry begins to preoccupy a person's thoughts to the point that psychosocial functioning is impeded.
• "Normal" anxiety concerns living life.
• "Normal" anxiety is commonly associated with other medical or psychiatric conditions.

State vs Trait Anxiety

• State Anxiety: Dependent on specific stressors that produce an increased state of awareness, vigilance, and appropriate fear to ensure safety.
• Trait Anxiety: A pervasive elevation of worry and concern based on a perception of threat, but usually not an actual threat.

Anxiety Disorders

• Anxiety disorders are the most common psychiatric disorder.
• 15% of the population has an anxiety disorder.
• Median age of onset is in the mid-20s, but it can start in childhood.
• Women are twice as likely or more to be affected by anxiety disorders than men.

Pathology of Anxiety

• Genetics account for about 50% correlation with anxiety.
• Chemical imbalances can cause anxiety.
• Trauma, both physical and emotional, can cause anxiety.
• Poor parenting can cause anxiety.
• The state of the world can cause anxiety.
• Neuroinflammation theory may cause anxiety.

DDX Anxiety Disorders: Cardiac

• Angina can cause anxiety.
• Arrhythmias, specifically supraventricular tachycardia, can cause anxiety.
• Congestive heart failure can cause anxiety.
• Infarction can cause anxiety.
• Mitral valve prolapse can cause anxiety.

DDX Anxiety Disorders: Endocrine

• Hyperthyroidism can cause anxiety.
• Premenstrual dysphoric disorder can cause anxiety.

DDX Anxiety Disorders: Neoplastic

• Carcinoid tumors, which secrete serotonin, histamine, tachykinins, kallikrein, and prostaglandins, can cause anxiety.
• Insulinoma can cause anxiety.
• Pheochromocytoma can cause anxiety, characterized by paroxysmal HTN, sweating, tachycardia and anxiety, plus anxiety attack symptoms which can be diagnosed using 24-hour urine samples for metanephrines and catecholamine.

DDX Anxiety Disorders: Pulmonary

• Asthma can cause anxiety.
• Embolism, thrombotic vs fat, can cause anxiety.
• COPD can cause anxiety.

DDX Anxiety Disorders: Medications/Drugs

• Alcohol, sedative, or nicotine withdrawal can cause anxiety.
• Antidepressants can cause anxiety.
• Caffeine can cause anxiety.
• Hallucinogens can cause anxiety.
• Psychostimulants (e.g., methylphenidate, amphetamine) can cause anxiety.
• Steroids (corticosteroids, anabolic steroids) can cause anxiety.
• Stimulant abuse (e.g., cocaine) can cause anxiety.
• Sympathomimetics (e.g., pseudoephedrine) can cause anxiety.
• Medications or drug use should be investigated.

Autonomic Nervous System

• The parasympathetic nervous system calms you down.
• The sympathetic nervous system stimulates you with epinephrine.

Screening for Anxiety

• The United States Preventive Services Task Force (USPSTF) now recommends screening for anxiety in all individuals aged ≥8 years old.

Trauma Responses

• Trauma responses can be Fight, Flight, Freeze or Fawn depending on the situation.
• Fight involves sympathetic nervous system activation: irritability, anger, aggression, moving toward. Often associated with Narcissism and Anti-social behavior.
• Flight involves sympathetic nervous system activation: anxiety & fear, panic, avoiding, chronic worry and perfectionism. Associated with phobias.
• Freeze involves dorsal vagal activation: stuckness, collapse, immobilization, spacing out, dissociation, depression and shame. Associated with dissociation.
• Fawn involves people-pleasing, avoiding conflict, prioritizing others needs over own, difficulty saying "no" and setting boundaries is hard. Associated with Co-dependent Victim.

Specific Anxiety Disorders

• Specific anxiety disorders are a subset of anxiety disorders, including Generalized Anxiety Disorders, Panic Attacks, Panic Disorder, Agoraphobia, Social Anxiety Disorder, Specific Social Phobias and other Repetitive Disorders.

Generalized Anxiety Disorders (GAD) Epidemiology

• Women are 2-3 times more likely to suffer from generalized anxiety disorder than men.
• GAD is common in the elderly population.

Generalized Anxiety Disorder (GAD) Diagnostic Criteria

• Excessive anxiety and worry (apprehensive expectation), occurring most days for at least 6 months, about events or activities (such as work or school performance).
• Difficulty controlling the worry.
• Has 3 or more symptoms including Anxious, nervous, or worried on most days, No control over the worry, Duration of 6 months, Irritability, Concentration impairment, Restlessness, Energy decreased, Sleep impairment and Tension in muscles..
• Note: Only one item is required in children.

Formal GAD Evaluation

• GAD 2: 2 question screen for generalized anxiety, if positive.
• GAD 7: 7 question screen with Likert scale.
• Using a cut-off of 8 the GAD-7 has a sensitivity of 92% and specificity of 76% for diagnosis of generalized anxiety disorder.
• Online resources are available for GAD Evaluation.

GAD Other Physical Symptoms

• Weight loss: work up.
• Headaches.
• Nausea.
• Numbness in hands and feet.
• Muscle aches.
• Difficulty swallowing: work up, also known as Globus hystericus.

Psychiatric Diagnoses which Preclude Anxiety Disorders

• Major depression.
• Developmental disorders (e.g., autism spectrum).
• Dissociative disorders.
• Personality disorders.
• Somatoform disorders.
• Schizophrenia (and other psychotic disorders).

Diagnoses Which Preclude Generalized Anxiety Disorder GAD

• Obsessions in obsessive-compulsive disorder.
• Separation anxiety disorder (children).
• Posttraumatic stress disorder (PTSD).
• Anxiety about gaining weight in anorexia nervosa.
• Body dysmorphic disorder.
• Illness anxiety disorder.
• Social anxiety disorder.
• Phobic objects or situations.

GAD Treatment

• Cognitive-behavioral therapy (CBT) is more effective in the long term than medication.

GAD Tx: CBT

• Goal: change negative thought patterns that lead to the patient's anxiety, replacing them with positive, more realistic ones.
• Include exposure strategies to allow the patient to gradually confront their anxieties and feel more comfortable in anxiety-provoking situations, and practice cognitive/ behavioral/ relaxation
• 1/3 of the patients respond substantially, while another third do not respond at all to treatment.

GAD Treatment: Address Specific Stressors

• Assertiveness training.
• Rehearsal.
• Financial planning.
• Relationship counseling.
• Exercise to release tension, improve fitness and enable management of tasks, including studying.
• Caffeine intake should be stopped or decreased.

GAD Medications

• SSRIs (escitalopram (Lexapro), Paroxitene (Paxil) are FDA approved, but other SSRIs can work).
• SNRIs (Venlafaxine (Effexor, Effexor XR) and Duloxetine (Cymbalta)).
• Tricyclic- off label(Imipramine (Tofranil)).
• Beta blockers- off label (Low dose Propranolol (Inderal), Also used for performance anxiety).

GAD Medications: Benzodiazepines

• FDA approved for anxiety, not GAD (Alprazolam (Xanax, Xanax XR), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Clorazepate (Tranxene), Diazepam (Valium) and Lorazepam (Ativan)).
• Benzodiazepines bind to gamma-aminobutyric acid type A receptors receptors and enhances GABA.
• They are effective and quick-acting as a depressant/ relaxant.
• They can be a short-term treatment, if at all.
• Their use long-term is not recommended because of 2º tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and withdrawal syndrome.

GAD Medications: Azaspirodecanedione

• FDA approved for anxiety, not GAD.
• Buspirone (Buspar).
• Not as effective as SSRIs or benzodiazepines.
• Serotonin 1A receptor partial agonist.
• Produces fewer motor, memory, or concentration impairment than benzodiazepines.
• No abuse potential, does not cause dependency or withdrawal, even after long periods of exposure.
• Mostly used as "add on" treatment.
• Fewer drug interactions.
• Avoid grapefruit juice.
• Requires at least 3 weeks to mitigate anxiety.
• Stimulates the locus coeruleus, which may be associated with a paradoxical increase in anxiety in some patients.

Panic Attacks

• ≥ 50% of patients with panic disorder have a family history.

Panic Attack DSM 5 TR Diagnostic Criteria

• Recurrent unexpected episodes that include 4 or more: Palpitations, Sweating, Shaking, SOB, Choking feeling, Chest pain, Nausea, Dizziness, Chills Oo heat sensations, Paresthesia, Derealization or depersonalization, Fear of going crazy, fear of dying, Uncontrollable fear and Hyperventilation.
• Symptoms reach maximum severity within 10 minutes but can peak within a few seconds.
• Symptoms usually last for less than 1 hour and most commonly diminish within 30 minutes.

Panic Disorder Diagnostic Criteria

• Recurring unexpected panic attacks.
• May include significant behavioral changes lasting at least a month.
• At least one of the attacks has been followed by 1 month (or more) of one or both of: Worry about additional panic attacks or Maladaptive behaviors to avoid having panic attacks

Agoraphobia

• Fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong.
• Fear of being trapped, helpless or embarrassed.

Agoraphobia DSM 5 TR Diagnostic Criteria

• A marked fear or anxiety in ≥ 2 of the following five situations: Using public transportation, Being in open spaces, Being in enclosed spaces (e.g., shops, theaters, cinemas), Standing in line or being in a crowd, Being outside the home alone.

Panic Disorder Treatment

• CBT is the treatment of choice.
• Biofeedback.
• Guided imagery and relaxation techniques.
• Supportive family and friends who understand the condition can help increase the rate of recovery.
• Support Groups for "terminal uniqueness".

Interoceptive (Inoculation) Exposure

• Symptom reproduction of anxiety attack for one minute.
• Intentional hyperventilation: creates lightheadedness, blurred vision, dizziness.
• Spinning in a chair: creates dizziness, disorientation.
• Straw breathing: creates dyspnea, airway constriction.
• Breath holding: creates sensation of being out of breath.
• Running in place: creates increased heart rate, respiration, perspiration.
• Body tensing: agoraphobia.

Panic Disorder Medication Treatment

• SSRIs are the first line pharmacological option.
• SNRIs such as venlafaxine (Effexor XR).
• Tricyclic antidepressants such as imipramine (off label).
• Benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin) have specific anti-panic effects.

Panic Disorder Prognosis

• Usually chronic, long-term prognosis is good.
• Treat as early as recognized.

Specific Phobia

• Unreasonable/ irrational fear of specific objects or situations.
• Actively avoid direct contact with the objects or situations.
• In severe cases, any mention, anticipation of, or depiction of them, can incite a panic attack.

Specific Phobias

Phobias Types

• Animal type: Fear of spiders(arachnophobia), fear of snakes(ophidiophobia).
• Natural environment type: Fear of heights(acrophobia), fear of lightning and thunderstorms(astraphobia), fear of aging(gerascophobia).
• Situational type: Fear of small confined spaces(claustrophobia) and being "afraid of the dark," (nyctophobia).
• Blood/injection/injury type: Fear of medical procedures including needles and injections (Trypanophobia)
• Other: Fear of the number 13 (triskaidekaphobia), and the fear of clowns (coulrophobia).

Social Phobias

• Social Anxiety Disorder: Fear of scrutiny by others lasting 6 months or more, including fear of having a conversation, meeting unfamiliar people, being observed (e.g., eating or drinking) or performing in front of others (e.g., giving a concert).
• Specific Social Phobias: anxiety occurring only in one specific situation, such as a fear of public speaking.

Treatment of Phobias

• Exposure therapy.
• Inoculation Therapy including Relaxation, self-soothing talk, breathing/ Rehearsing, role-playing, visualization with exposure/ Diversion techniques.
• Desensitization.
• CBT.
• SSRIs.
• Beta-blocker: propranolol for performance anxiety.

Obsessive Compulsive Disorder (OCD)

• 4th most common diagnosed-nearly as common as asthma and DM.
• In the United States, one in 50 adults has OCD.
• Different from obsessive-compulsive personality disorder (OCPD), autism spectrum disorder or some other condition: someone who is meticulous, perfectionistic. absorbed in a cause, or otherwise fixated on something or someone is NOT OCD.

OCD Etiology

• Genetics account for 10-20% (Possible Tourette syndrome gene associations).
• Head trauma.
• Poor correlation with psychological trauma.
• Abnormal brain "circuitry".
• Nero autoimmune diseases.
• Up to 43% increase in autoimmune disorders in patients with OCD.

Red Flag Symptoms For Potential Autoimmune Obsessive-compulsive Disorder

• Subacute onset of OCD (< 3 months).
• Treatment resistance despite guideline-based therapy.
• Atypical age of onset (early childhood or later adulthood).
• Atypical presentation of OCD (e.g., combination with severe hypersomnia or loss of function due to disproportionate cognitive deficits).
• Accompanying neurological signs such as Movement disorder (catatonia, choreiform movements, dyskinesia, etc.) or Focal neurological deficits
• New seizures
• New headache
• Autonomic dysfunction (e.g., hyperthermia, tachycardia, fluctuating blood pressure)
• Adverse response to antipsychotics (especially if malignant neuroleptic syndrome is suspected)
• Temporal association* of OCD onset with infections (such as Group A streptococcal infection).
• Comorbid autoimmune diseases (such as multiple sclerosis or systemic lupus erythematosus).
• Comorbid malignancies (such as ovarian teratoma).
• Suspicious alterations in diagnostic investigations.

Two Types of OCD Thoughts

• Pathologic doubt, e.g., dread and uncertainty.
• Incompletion, or "not-just-right" perceptions.

Intrusive Thoughts

• Inappropriate, obsessive thoughts at inappropriate times, usually falling into common categories such as Aggressive, Sexual, Blasphemous religious or Fear of harm.

OCD Compulsions

• Compelling behavior to alleviate the fearful obsession.
• Highly secretive 2nd to embarrassment.

Other Diagnoses with OCD Like Symptoms

• Anorexia nervosa.
• Bulimia nervosa.
• Tourette syndrome.
• Autism spectrum disorder/ "Asperger syndrome".
• Compulsive skin picking
• Body dysmorphic disorder
• Trichotillomania
• Obsessive-compulsive personality disorder.

OCD Relationships: Dysfunctional Facilitation

• "Co dependency".
• The facilitator may perform rituals or permit the patient to control the environment or common time.
• Allows behavior without normal constraints.
• Gives into pleading, nagging, demanding, or threats.

OCD Relationships: Adversarial

• Antagonistic-defensive dyad.
• The antagonistic partner of "patient" acts in a caustic, demeaning manner and does not understand or accept the illness.
• Symptoms are viewed as willful antagonism.
• The patient reacts with hostility and defensiveness that aggravates the partner.
• Instability, loss of self-esteem, and stress exacerbate patient's OCD and leads to further antagonism.

OCD Healthier Interacting

• Talk openly about behaviors that impact household routines and time.
• Gradually reduce participation in the person's rituals and explain the reasons for doing this.
• Encourage the person with OCD to be a part of decision.
• Set realistic goals together and talk about ways to ensure that everyone will abide by the plan.
• If the person with OCD is in treatment, offer to attend a session with them.
• Try to maintain normal household routines, connections, and events whenever possible.
• Reinforce positive communication and behaviors (such as sharing, hugs and helping each other)

OCD Treatment, Exposure and Ritual Prevention

• Also known as "exposure and response prevention" or ERP.
• Gradually learning to tolerate the anxiety associated with not performing the ritual/ behavior.
• Most effective treatment for OCD (70% in one study.)
• Using ERP alone, one can become completely symptom-free.
• Must be highly motivated and consistent.

OCD Treatments: Cognitive Restructuring

• Uses thought replacing of one's irrational, counter-factual beliefs with more accurate and beneficial ones.
• Relaxation techniques.
• Family therapy.

OCD Medications

• SSRIs the drugs of choice (Fluvoxamine (Luvox) SSRI with special indication).
• Maximal benefit for OCD at 12 weeks.
• Most effective at higher range of dosing.
• If no improvement at 8 weeks, increase dose or change.
• 20% will improve with another SSRI.
• After a third SSRI failure, a trial of clomipramine (Clomipramine (Tofranil), but ↑ anticholinergic side effects).
• Medication can be lifelong.
• 50-60% will have response
• Therapy and medication are synergic.

OCD Neuro Stimulation

• Deep-brain stimulation (DBS) and vagus nerve stimulation (VNS) do not require destruction of brain tissue.
• Surgery is only if patient has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive-behavioral therapy with exposure and ritual/response prevention.

Other OCD Treatments

• Neurosurgical treatments (extreme, refractory cases only) such as Anterior cingulotomy, Limbic leukotomy, Anterior capsulotomy and Subcaudate tractotomy.
• Experimental treatments.
• Intravenous clomipramine
• Plasmapheresis (autoimmune-related OCD)*
• Immunoglobulin (autoimmune-related OCD)*
• Chronic penicillin (streptococcal autoimmune-related OCD)*
• *Special circumstances that might favor this treatment option.

Other Repetitive Disorders

• Not the same as OCD, but associated with them.
• Some behaviors bring some relief.
• Body dysmorphic disorder produces more anxiety.

Body Dysmorphic Disorder

• Preoccupation with one or more perceived defects/flaws in physical appearance that are not observable or appear slight to others.
• Performed repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance-seeking) or mental acts (comparing his or her appearance with that of others) in response to appearance concerns.
• Not better explained by an eating disorder.

Body Dysmorphic Disorder Specifiers

• With muscle dysmorphia: is preoccupied that their body build, or body area is too small or insufficiently muscular.
• Specify if: Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I look deformed"), With good, fair, poor insight, absent, delusional, Can be suicidal.

Body Dysmorphic Disorder Treatment

• CBT
• SSRIs

Hoarding Disorder

• Difficulty discarding or parting with possessions, regardless of their value.
• Perceived need to save the items and distress associated with discarding them.
• Substantially compromises use of the area.
• If living areas are uncluttered, it is only because of the interventions of family members, cleaners, authorities.
• Enjoys acquiring, distressed to let go.

Difference Between OCD and Hoarding

• With OCD, there are Obsessions with compensatory compulsions, Excessive acquisition is usually not present; but if present, items are acquired because of a specific obsession, Hoarding items is not pleasurable and Hoarded items are bizarre.
• With Hoarding, there is are needs for Buying and having for pleasure/ security. Hoarded items are seen as useful or pleasurable.

Hoarding Disorder Treatment

• Treatment: CBT, therapy

Trichotillomania

• Recurrent pulling out of one's hair, resulting in thinning/ alopecia.
• Repeated attempts to decrease or stop.
• Not related to cosmetics or body dysmorphic disorder.
• Can be any body area.
• Treatment: psychiatry, hypnosis, no approved medications.

Pathologic Excoriation (Skin Picking) Disorder

• Recurrent skin picking resulting in lesions.
• Repeated attempts to decrease/ stop.
• May use fingers, tweezers, biting, other instruments.
• May be triggered by feelings of anxiety or boredom.
• May be preceded by tension (either immediately before picking the skin or when attempting to resist the urge to pick).
• May lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked.
• Not related to body dysmorphic disorder.
• Treatment: No approved medications, Refer for hypnosis, psychiatry.