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