BMS150 wk 6 lec 2

Fear and Anxiety Disorders

• Fear is considered "pathologic" when:
  • It is out of proportion to the risk or severity of the threat
  • The response lasts beyond the duration of the threat
  • The response becomes generalized to other situations (similar or dissimilar)
  • Social or occupational functioning is impaired
• Wide range of anxiety disorders:
  • 17% of adults report a lifetime history of one of the major anxiety disorders

Anxiety Disorders

• "True" anxiety disorders:
  • Panic disorder
  • Agoraphobia
  • Specific phobia
  • Generalized anxiety disorder
• "Anxiety-like" disorders (no longer strictly considered as part of the anxiety disorder spectrum):
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder

Panic Disorder

• A type of anxiety disorder
  • 1-2% prevalence
• Characterized by recurrent panic attacks
  • The panic can't be due to a particular phobia or another anxiety-related disorder
  • The panic symptoms cannot be due to an underlying medical disorder
• To be diagnosed with panic disorder, need to have periods in between attacks where:
  • The patient fears another attack
  • The patient does maladaptive things to avoid another attack
  • Need at least 1 month history of avoidance or fear of another panic attack

Panic Attacks - Features

• Four or more of the following:
  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, light-headed, or faint
  • Chills or heat sensations
  • Paresthesias (numbness or tingling sensations)
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or "going crazy"
  • Fear of dying

Generalized Anxiety Disorder

• GAD - generalized worry that occurs more days than not that is disproportionate to the severity of the event that is feared
  • Common, prevalence is 3-8%
  • Can be difficult to treat
  • Often anxiety reduces with age
• Diagnostic criteria:
  • Excessive anxiety for more days than not for 6 months
  • Individual has difficulty controlling the anxiety
  • Is accompanied by typical symptoms

Generalized Anxiety Disorder - Symptoms

• 3 of 6 of the following must be present for diagnosis:
  • Restlessness or feeling "keyed up" or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance
• As with all psychiatric diagnoses, the anxiety, worry, or physical symptoms must:
  • Cause clinically significant distress
  • Impairment in social, occupational, or other important areas of function

Agoraphobia

• In general, unreasonable fear of being out-of-doors or being in a crowd or being in a place where they can't escape from or may suffer embarrassment
  • The anxiety and its symptoms are typically present almost all of the time… even when the patient is somewhere comfortable to them
  • Avoidance is prominent
• Very common disease, but again has a good prognosis if well-treated
  • Rough estimate – about 1% of the population

Agoraphobia - Symptoms

• Examples of situations that cause worry or fear in agoraphobia:
  • Using public transportation
  • Being in open spaces… or enclosed spaces
  • Standing in line, being in a crowd, or being in other social situations
  • Being outside of the home
• These situations should almost always provoke fear or anxiety
  • Usually the patient fears that he/she cannot escape from the situation/environment or that they will experience a panic attack or other embarrassing symptom
• The fear or anxiety needs to be present for > 6 months and needs to cause significant distress or impairment in social or occupational function

Specific Phobias

• Fears of specific objects or situations that go beyond the true threat of the stimulus and cause avoidance and functional impairment
  • Surprisingly common – 12-16%
• Diagnostic criteria:
  • Exposure to stimulus provokes an immediate fear/anxiety response; may present as a panic attack
  • Phobic object/situation is actively avoided or endured with intense anxiety
  • Fear/anxiety out of proportion to actual danger/sociocultural context
  • Person recognizes fear as excessive or unreasonable
  • Significant distress or impact on daily routine, occupational/social functioning and/or marked distress
  • Must be present > 6 months

Social Anxiety Disorder

• Marked and persistent (>6 mo) fear of social or performance situations in which:
  • One is exposed to unfamiliar people or to possible scrutiny by others
  • One is afraid that fearing he/she will act in a way that may be humiliating or embarrassing
• Diagnostic criteria:
  • Exposure to actual death, threatened death, physical or sexual violence, serious injury
  • Could have witnessed or received the violent act
  • Can occur in people that are repetitively exposed to disturbing or violent events

Post-Traumatic Stress Disorder

• When does it happen?
  • Exposure to actual death, threatened death, physical or sexual violence, serious injury
  • Could have witnessed or received the violent act
  • Can occur in people that are repetitively exposed to disturbing or violent events
• Neurological pathways involved:
  • Amygdala
  • Hippocampus
  • Prefrontal cortex
  • Raphe nucleus
  • Noradrenergic, serotonergic, and dopaminergic pathways

Neurotransmitters and Pathways

• Noradrenergic pathway:
  • Neurotransmitter: Noradrenaline (also known as norepinephrine)
  • Origin: Locus coeruleus in the brainstem
  • Function: Plays a key role in regulating mood, attention, arousal, and stress response
  • Clinical significance: Dysregulation of noradrenergic pathways is implicated in various psychiatric disorders
• Serotonergic pathway:
  • Neurotransmitter: Serotonin (also known as 5-hydroxytryptamine or 5-HT)
  • Origin: Raphe nuclei in the brainstem
  • Function: Regulates mood, emotion, appetite, sleep, and various cognitive functions
  • Clinical significance: Imbalances in serotonin levels are associated with mood disorders, anxiety disorders, and other conditions
• Dopaminergic pathway:
  • Neurotransmitter: Dopamine
  • Origin: Dopaminergic neurons have several nuclei in the brain, including the substantia nigra and the ventral tegmental area (VTA)
  • Function: Involved in motivation, pleasure, reward, and movement

Eating Disorders

• Basics of eating disorders - anorexia nervosa and bulimia nervosa:
  • F:M ratio ~ 10:1
  • Lifetime prevalence of around 1% in the female population for anorexia and 2-4% for bulimia
  • Higher risk:
    • Display "perfectionist" traits
    • Have a past history of sexual abuse
    • Feel that they lack control in other dimensions of their lives
    • Expectations (i.e. athletic) regarding weight

Anorexia Diagnostic Criteria

• A. Intake and weight:
  • Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health
  • Significantly low weight !a weight that is less than minimally normal
• B. Fear or behaviour:
  • Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight
• C. Perception:
  • Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
• Note: Criteria A tends to be based on BMI criteria
  • Wrestlers, gymnasts, dancers (athletes) can have a lot of muscle mass but still have disordered eating habits

Learn about the characteristics of pathologic fear and the different types of anxiety disorders, including panic disorder, agoraphobia, and specific phobia.