Anxiety Disorders Master Class PDF

Anxiety Disorders Master Class David Montero MD, Psychotherapist  Objectives 1. Identify the etiology, psychopathology, clinical features, diagnosis, and treatment of: Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Panic Disorder, Agoraphobia...

Anxiety Disorders Master Class David Montero MD, Psychotherapist  Objectives 1. Identify the etiology, psychopathology, clinical features, diagnosis, and treatment of: Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Panic Disorder, Agoraphobia, Social Anxiety Disorder, Generalized Anxiety Disorder, Substance/Medication Induced Anxiety, and Anxiety Disorder Due to Another Medical Condition.  Anxiety Disorders Anxiety disorders comprise a group of conditions characterized by idiopathic anxiety, often accompanied by psychological and physical symptoms. While anxiety is a common feature in various psychiatric disorders, primary anxiety disorders are distinct in that they do not typically involve neurocognitive deficits, depressive or manic symptoms, or psychosis. The anxiety disorders differ from one another in the types of objects or situations that induce fear, anxiety, or avoidance behavior, and the associated cognition. Thus, while anxiety disorders tend to be highly comorbid with each other, they can be differentiated by close examination of the types of situations that are feared or avoided and the content of the associated thoughts or beliefs. Unlike transient fear or anxiety, which is often stress-induced and short-lived, anxiety disorders typically last for six months or more. However, this duration criterion is flexible and may vary, especially in children. It's worth noting that trauma-related disorders, stressor-related disorders, and obsessive-compulsive disorders may also exhibit significant anxiety but are classified separately from anxiety disorders. Anxiety Disorders Individuals with anxiety disorders often overestimate the danger in situations they fear or avoid. Clinicians should assess whether the fear or anxiety is excessive considering cultural factors. Many anxiety disorders start in childhood and can persist without treatment. They are more common in girls, with a ratio of approximately 2:1. Most common psychiatric disorders in women of all ages. Diagnosis of an anxiety disorder requires that symptoms are not due to substances, medical conditions, or other mental disorders.  Learning Theory in Anxiety Disorders Etiology of Anxiety (Learning Theory) According to learning theory an anxiety disorder develops when environmental cues become associated with anxiety-producing events during development. In Generalized Anxiety Disorder worry and fear become conditioned and are repeated in order to avoid intermittent negative reinforcement. Hence the periodic successful avoidance of a negative outcome reinforces the behavior. For example, an individual's fear (and subsequent avoidance) of air travel would be enhanced by reading about occasional air disasters.  Flight or Fight Response Anxiety disorders are distinguished from normal fear or anxiety by their excessive nature or persistence beyond developmentally appropriate periods. Anxiety can be seen as an inappropriate activation of the stress response system, known as "fight-or-flight." When someone experiences a stressful event, the eyes or ears (or both) send the information to the amygdala (an area of the brain that contributes to emotional processing), which sends a distress signal to the hypothalamus. When the amygdala signals distress, the hypothalamus activates the sympathetic system. This leads to the release of epinephrine from the adrenal glands. Epinephrine causes rapid physiological changes, including increased heart rate, blood pressure, and breathing rate, along with heightened senses and the release of energy sources into the bloodstream. This response occurs so rapidly that people often react before fully processing the danger. If the threat persists, the hypothalamus activates the HPA axis. This involves the release of hormones like CRH, ACTH, and cortisol, which sustain the body's alertness and energy levels. Once the threat subsides, cortisol levels drop, and the parasympathetic system helps calm the body down reducing the “flight or fight response”. However, in a patient with a dysregulated response such as an anxiety disorder the parasympathetic system will not be able to damp the stress response. Pathobiology - Neurotransmitters Neurotransmitters involved in anxiety development include: Increased activity of Adrenaline Increased activity of noradrenaline Decreased activity of serotonin Decreased activity of gamma- aminobutyric acid (GABA).  From a cognitive psychology standpoint, the development of many anxiety disorders, especially panic disorders, can be seen as the result of catastrophic misinterpretations of typical bodily sensations. In vulnerable individuals, a normal or slightly abnormal bodily sensation may trigger an exaggerated alarm response, leading to sympathetic and autonomic arousal. This heightened arousal then generates more somatic sensations (like rapid heartbeat or sweating), creating a feedback loop of anxious thoughts and physical symptoms, perpetuating the cycle of anxiety. Psychopathology  Clinical Features of Anxiety Many individuals experience somatic symptoms alongside psychological anxiety, regardless of whether the anxiety is normal or pathological. These somatic symptoms can resemble those of genuine physiological abnormalities in various organ systems. Neurological/Autonomic: Diaphoresis. Warm Flushes or Chills. Dizziness or fainting. Headache. Tingling in extremities and numbness around the mouth. Mydriasis. Gastrointestinal: Sensation of choking. Dyspepsia. Nausea. Diarrhea. Abdominal bloating or pain. Cardiorespiratory: Palpitations (Subjective experience of tachycardia) Chest Pain. Dyspnea or sensation of being smothered. Genitourinary: Urinary frequency or urgency.  Screening Diagnosing anxiety disorders involves considering both etiologic and syndromic perspectives. Etiologic Syndromic It's crucial to ascertain whether the anxiety disorder is primary Accurate diagnosis of anxiety disorders requires a thorough assessment (idiopathic), or secondary to factors like systemic or neurological involving a detailed history and mental status examination. conditions, drug intoxication, or withdrawal. This process is crucial for identifying specific anxiety patterns, and This assessment involves physical examinations and appropriate associated symptoms, and matching them with diagnostic criteria for laboratory tests, such as toxic drug screening, guided by the potential various anxiety disorders. diagnoses derived from the patient's history and mental status evaluation. Additionally, assessing for concurrent psychiatric conditions is essential as anxiety may coexist with other disorders or be overshadowed by them in terms of diagnostic priority. For example, generalized anxiety can occur alongside neurocognitive Primary Secondary disorders, depressive or bipolar disorders, and psychotic disorders like schizophrenia. Psychiatric Substances, Illness Medications Medical Illness  Always screen for organic causes! Organic causes of anxiety symptoms can stem from excessive caffeine intake, substance abuse, hyperthyroidism, vitamin B12 deficiency, hypoglycemia or hyperglycemia, cardiac arrhythmias, anemia, pulmonary diseases, and pheochromocytoma (adrenal medullary tumor). If anxiety's primary cause is organic, diagnoses like substance/medication-induced anxiety disorder or anxiety disorder due to another medical condition may be appropriate. Vitamin B12 plays a critical role in the production of dopamine and serotonin  Separation Anxiety Disorder Separation anxiety is a normal part of early development, indicating healthy attachment relationships, but separation anxiety disorder can begin in preschool and persist into adulthood. The main feature of separation anxiety disorder is an excessive fear or anxiety related to being separated from home or attachment figures. Individuals with separation anxiety disorder exhibit a range of symptoms, including distress when separation is imminent or occurring, concern for the well-being of attachment figures, aversion to going out alone, fear of solitude or being away from home, hesitation to sleep without a primary attachment figure nearby, and physical symptoms like headaches or abdominal discomfort when apart from loved ones. Adults with separation anxiety disorder may deliberately reorganize their work schedules and other activities because of their anxieties about possible separations from close attachment figures; (e.g., by texting or phoning them repeatedly throughout the day). These symptoms vary with age, with younger children avoiding school and older individuals grappling with transitions such as relocation or marriage, which may affect their work and social interactions. These symptoms must persist for at least 4 weeks in children and adolescents and typically 6 months or longer in adults, causing significant distress or impairment in various areas of life. Separation Anxiety Disorder Separation anxiety disorder often arises following life stressors such as loss (like the death of a loved one or pet), illness, changes in schools or neighborhoods, parental divorce, moving, immigration, or experiencing disasters involving separation from attachment figures. Childhood bullying can also increase the risk of developing this disorder. Additionally, a history of overprotective or intrusive parenting may contribute to separation anxiety disorder in both childhood and adulthood. The disorder's onset varies and often shows a fluctuating course over a person's lifetime, with periods of exacerbation and remission. While some adults with the disorder experience persistent anxiety about separation and avoidance of separation situations, most children with the disorder do not develop long- term impairing anxiety disorders.  Selective Mutism Selective mutism is characterized by a reluctance or refusal to speak in social situations, even though the individual is capable of speech. Children with this disorder typically do not initiate speech or respond verbally when addressed by others in social interactions. They may speak at home but remain silent in public, including in front of extended family or close friends. This behavior is often accompanied by high social anxiety. Selective Mutism The onset of selective mutism is usually before age 5, though it may not be noticed until school entry due to increased social demands. While many children may outgrow this condition, the long- term course remains unclear, and social anxiety symptoms often persist. This disorder can result in social and academic impairment, with affected individuals experiencing isolation and difficulties in school settings as teachers struggle to assess their skills, impacting tasks like reading aloud in class. However, in some cases, selective mutism may serve as a coping mechanism to reduce anxiety in social situations.  Specific Phobia Phobias are characterized by an intense and persistent fear of Women are more commonly affected than men across a specific environmental stimulus. specific phobia subtypes. 2:1. Exposure to this stimulus consistently triggers a pathological Traumatic events, panic attacks, or media exposure can anxiety response, leading individuals to either avoid the trigger specific phobia development, though many stimulus whenever possible (avoidance behavior) or endure it individuals cannot pinpoint the exact cause. with significant distress. Onset typically occurs in early childhood, with most cases Phobias are further categorized based on the type of stimulus emerging before age 10. that elicits the phobic response  Specific Phobia Specific phobia is characterized by persistent fear, anxiety, or avoidance lasting at least six months, leading to significant distress or impairment in various areas of life. People with specific phobia often experience heightened physiological arousal when exposed to their phobic object or situation. While the physiological response varies, it commonly involves sympathetic nervous system arousal, or a vasovagal fainting response, depending on the phobia subtype. Abnormal brain activity in regions like the amygdala, anterior cingulate cortex, thalamus, and insula is associated with specific phobia. Situational phobias tend to onset later than other types, and childhood phobias may fluctuate over time but often persist into adulthood without remission for most individuals.  Panic Attack (Specifier) Many anxiety disorders feature sudden, intense episodes of The typical age of onset for panic attacks in the United States is symptoms termed panic attacks. around 22-23 years among adults. During a panic attack, the individual experiences a rapid These symptoms include physical sensations like palpitations onset of anxiety, fear-driven thoughts, and physical and sweating, along with cognitive aspects such as fear of symptoms within a few minutes (known as 'crescendo onset’). losing control or dying. The onset of a panic attack can occur from either a calm or anxious state and is distinguished by its These acute symptoms typically subside swiftly, often within an rapid escalation and discrete nature. hour or less. To diagnose a panic attack, 4 out of 13 physical and cognitive There are two types of panic attacks: expected and unexpected. symptoms must be present. Expected Panic Attack: Identifiable Triggers Unexpected Panic Attack: Occurs seemingly without cause.  Panic Disorder Panic disorder is characterized by recurrent panic attacks, which can occur unexpectedly or in response to known triggers. Patients with panic disorder often experience anticipatory anxiety, worrying about future panic attacks or their consequences, such as embarrassment in public. They may also exhibit avoidance behaviors, avoiding situations or triggers that could lead to panic attacks. Interestingly, for many patients, the anticipatory anxiety and avoidance behaviors can be more debilitating than the panic attacks themselves.  Panic Disorder These individuals may anticipate severe outcomes from minor physical symptoms or medication side effects, leading to intolerance of such effects. They may also exhibit excessive drug use to manage panic attacks or extreme behaviors aimed at controlling symptoms, such as severe dietary restrictions. The disorder typically starts in early adulthood, with a median onset age in the mid-20s in the United States and early 30s globally. If untreated, panic disorder tends to have a chronic course with fluctuations in symptom severity. Women are at a higher risk for developing panic disorder, and relapse rates are also higher among women, indicating a more unstable illness course in females. Agoraphobia Agoraphobia is characterized by intense fear or anxiety triggered by exposure to various situations where escape might be challenging such as using public transportation, being in open or enclosed spaces, standing in lines or crowds, or being outside the home alone. Individuals with agoraphobia often anticipate something terrible happening and fear being unable to receive help during panic-like symptoms or other embarrassing symptoms like vomiting or falling. This fear can arise in anticipation or actual exposure to agoraphobic situations and may lead to full- or limited- symptom panic attacks. Individuals actively avoid these situations or require companionship to endure them, often using safety behaviors to cope.  Agoraphobia Their fear, anxiety, or avoidance must be disproportionate to actual danger and cause significant distress or impairment, persisting for at least 6 months. Agoraphobia affects women twice as often as men and typically emerges in late adolescence or early adulthood. Its course is often chronic, with consistent clinical features across the lifespan but varying triggers and cognitions. In severe cases, agoraphobia can lead to complete homeboundness and reliance on others for basic needs. Social Anxiety Disorder Social anxiety disorder is characterized by an intense fear or anxiety in social situations where scrutiny by others is anticipated. The fear revolves around being negatively evaluated, judged as anxious or inadequate, or causing offense or rejection. This fear can lead to avoidance behaviors or enduring social situations with intense anxiety. Symptoms may manifest differently with age, such as crying or tantrums in children, and excessive concern for others' opinions or physical symptoms like blushing or sweating in adults.  Social Anxiety Disorder Diagnosis considers the duration of symptoms, interference with daily life, and distress caused, typically lasting for 6 months or more. Individuals with social anxiety disorder may exhibit shy or withdrawn behaviors, avoid social interactions or assertiveness, and self-medicate with substances like alcohol. Onset typically occurs in adolescence, with triggers ranging from childhood shyness to stressful or humiliating experiences. While adolescents may fear dating, older adults may worry about sensory decline or medical conditions affecting social functioning. Detection in older adults can be challenging due to somatic symptoms or changes in social roles, and remission rates vary widely. Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry about various events or activities, often unrelated to immediate threats. 6 months or longer. This worry is disproportionate to the actual likelihood or impact of the anticipated event and is challenging to control, interfering with daily tasks. In adults, worries can encompass routine life circumstances, job responsibilities, health, finances, family well-being, or minor issues. Symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and disturbed sleep. Somatic symptoms like sweating or nausea may also be present. Key distinctions from nonpathological anxiety include the excessive and pervasive nature of worries, interference with functioning, longer duration, and occurrence without specific triggers.  GAD often starts in adulthood, with symptoms persisting across the lifespan, although severity may vary with age. Generalized Anxiety Disorder Children with GAD tend to worry about their competence or performance quality, while the elderly may worry about health or safety issues related to physical decline. Excessive worrying in GAD impacts daily efficiency, and associated symptoms contribute to impairment. GAD is associated with significant disability, reduced work performance, increased medical resource use, and heightened risk for coronary problems.  Substance/Medication- Induced Anxiety Disorder Substance/medication-induced anxiety disorder is characterized by prominent symptoms of panic or anxiety that are attributed to the effects of a substance, medication, or toxin exposure. These symptoms must arise during or shortly after substance intoxication or withdrawal, or after exposure to or withdrawal from a medication capable of producing such symptoms. The onset of anxiety symptoms should align with substance use or withdrawal, with improvement upon discontinuation of the substance or medication. If anxiety persists beyond a month post-intoxication or withdrawal, other causes should be considered.  Substance/Medication- Induced Anxiety Disorder The diagnosis of substance/medication-induced anxiety disorder is distinguished from substance intoxication or withdrawal when anxiety symptoms are predominant and severe enough to require independent clinical attention. Various substances and medications, including alcohol, caffeine, cannabis, opioids, sedatives, and certain medications like antidepressants and antipsychotics, can induce anxiety symptoms. Laboratory tests, such as urine toxicology, can aid in assessing substance intoxication as part of diagnosing substance/medication-induced anxiety disorder. Anxiety Disorder Due to Another Medical Condition Anxiety disorder due to another medical condition involves clinically significant anxiety attributed to the physiological effects of a specific medical condition. Symptoms can include anxiety or panic attacks, and this attribution must be supported by evidence from history, physical examination, or lab findings. It's crucial to rule out other mental disorders like adjustment disorder and ensure the anxiety is not merely a symptom of delirium. Factors like temporal association with the medical condition, atypical features for an independent anxiety disorder, and known physiological mechanisms causing anxiety help confirm the diagnosis. Medical conditions like endocrine disorders, cardiovascular issues, respiratory illnesses, metabolic disturbances, and neurological problems can manifest with anxiety symptoms. The course of anxiety disorder due to another medical condition typically mirrors that of the underlying illness. It's distinct from primary anxiety disorders arising independently of chronic medical conditions, especially relevant in older adults with comorbidities. Confirming the associated medical condition through lab tests or medical assessments is essential for accurate diagnosis.  Treatment Cognitive-behavioral psychotherapy is useful in treating various anxiety disorders. Given its efficacy, CBT is often recommended as a first-line treatment for most outpatients with anxiety disorders. The behavioral aspect of CBT employs learning theory principles to eliminate unhelpful behaviors and reinforce adaptive ones. Meanwhile, the cognitive component focuses on identifying and correcting dysfunctional thought patterns (automatic thoughts) that contribute to or trigger pathological anxiety responses. CBT can be used as a standalone therapy, especially for specific phobias, or combined with medication for conditions like panic disorder and social phobia. It can be administered individually or in group settings to address reinforcing behaviors.  Treatment While anxiolytic drugs like benzodiazepines can provide short-term relief for acute anxiety symptoms, they are not recommended for long-term use due to concerns about efficacy and side effects such as abuse potential, neurocognitive impairment, and risk of falls. Antidepressant medications, particularly SSRIs like sertraline and paroxetine, are preferred for most anxiety disorders due to their effectiveness and better long-term safety profile. While β-adrenergic blockers can be used for acute sympathetic symptoms of anxiety, they are not recommended for prolonged use in panic disorder or phobias as they do not address all symptoms and may not be effective in the long term. Cognitive behavioral therapies should be combined with pharmacotherapy for more severe or treatment-resistant anxiety disorders. Prognosis In general, individuals with persistent anxiety disorders typically experience a chronic course with fluctuating symptoms. Maintenance therapies are often necessary for patients with chronic anxiety disorders, although the evidence supporting specific long-term treatments is not as strong as it is for depressive, bipolar, and psychotic disorders.  References Goldman, L., & Cooney, K. A. (2024). Psychiatric disorders in the medical practice. In Goldman Cecil Internal Medicine (27th ed., pp. 2342-2343). Elsevier. American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed., Text Revision, pp. 215-261). American Psychiatric Association. Fadem, B. (2020).Anxiety Disorders. In Boards Review Series: Behavioral Sciences 8th Edition (pp. 132-133). Wolters Kluwer. Shelton R.C. (2019). Anxiety disorders. Ebert M.H., & Leckman J.F., & Petrakis I.L.(Eds.), Current Diagnosis & Treatment: Psychiatry, 3e. McGraw-Hill Education. https://bibliodig.uag.mx:2091/content.aspx?bookid=2509&sectionid=200804771