# Anxiety Disorders

## General Anxiety Disorder

Generalized anxiety disorder is persistent hyper-arousal and worrying (about even minor matters) that causes significant distress or impairment and occurs more often than not for **>6 months**.

Patients with **generalized anxiety disorder** will be described in a question stem with some of the following key phrases/terms:

* "High-strung"
* "Always stressed"
* "Constantly worrying"

In a question stem, patients with **generalized anxiety disorder** will have a long list of things that they worry about. Look out for a patient who simultaneously incessantly worries about:

* Grades
* Relationship with their spouse or friends
* Money
* The health of their parents, friends, or pets
* Their future
* World events

Associated symptoms of generalized anxiety disorder include **restlessness, difficulty concentrating, and irritability.**

As with other psychiatric conditions, it is important to rule out organic causes of anxiety. These include:

* **Hyperthyroidism**
* **Atrial fibrillation**
* **Pheochromocytoma**
* **Amphetamines and sympathomimetics**

### Treatment

First-line treatments for generalized anxiety disorder include:

* **Cognitive behavioral therapy**
* **SSRIs**
* **SNRIs**

**Buspirone** is uniquely indicated for use in generalized anxiety disorder. However, buspirone is **not first line;** SSRI's are a better treatment choice.

## OCD

### Overview

Obsessive-compulsive disorder (OCD) is characterized by either **obsessions** or **compulsions** (or both) that cause **anxiety**.

Obsessions are non-suppressible, recurrent, and persistent thoughts that cause marked anxiety. The "buzzword" in a question stem is **"intrusive thoughts"**. The patient realizes the thoughts are products of his or her own mind. One example of an obsession is persistent thoughts of contamination/germs.

Obsessions **do not need to be logically related** to compulsions. For example, a man may have intrusive thoughts of killing his friend which are relieved by tapping his hands on a desk.

Compulsions are **repetitive behaviors in response to an obsession**; **they reduce distress**. For example, a patient may feel a compulsion to wash his/her hands to decrease the anxiety related to obsessive thoughts about cleanliness.

Contrary to obsessive-compulsive personality disorder, obsessive-compulsive disorder is **ego-dystonic**, meaning that *the afflicted recognize the obsessions/compulsions are excessive or unreasonable*.

### Imaging

Neuroanatomical changes include **orbitofrontal cortex abnormalities**.,

### Association

Psychiatric pathologies that are co-morbid with OCD are the following, from most common to least:

* **Other anxiety disorders** (e.g panic disorder, social anxiety disorder, generalized anxiety disorder, specific phobia)
* **Mood disorders**, most commonly major depressive disorder
* **OCD-related disorders**&#x20;

There is an increased incidence of obsessive-compulsive disorder patients with first-degree relatives who have **Tourette's disorder.**

### Treatment

The 1st line treatment of OCD is **SSRI's.** The 2nd line treatment of OCD is **clomipramine** (a TCA).

**Cognitive behavioral therapy (CBT)** incorporating **exposure and response prevention** (putting the patient in situations that provoke obsessional thoughts and achieving absence of compulsive behaviors) has been *shown to be more effective* than treatment with an SSRI, but is not appropriate for all patients.

For example, a therapist would guide this patient to practice leaving home after checking the stove and door once (exposure) and then prevent her from checking repeatedly (response prevention). Initially, anxiety increases, but with prolonged and repetitive exposure, habituation occurs and the anxiety subsides.

## OCD Related

The four obsessive compulsive-related disorders are the following:

* Hoarding disorder
* Excoriation (skin-picking) disorder
* Trichotillomania (hair-pulling) disorder
* Body dysmorphic disorder

They display an increased incidence of comorbid **OCD** and the **other disorders within the same group** **of four.** In other words, development of trichotillomania bears an increased risk of hoarding, body dysmorphic, and excoriation disorders, while these three also have an association with the development of trichotillomania.

### Hoarding

*Hoarding disorder* is a persistent difficulty in parting with possessions, such that the accumulation of possessions begins to **clutter living areas** and the intended use of the possessions is compromised.

In contrast to other psychiatric disorders where hoarding may be a feature, hoarding disorder is characterized by **active/intentional accumulation of objects**, with **distress upon attempted discard**.

### Excoriation

*Excoriation (skin-picking) disorder* is characterized by significant amounts of time spent excoriating skin through picking, rubbing, biting, or other means. **Skin lesions** must be present for diagnosis.

### Trichotillomania

*Trichotillomania (hair-pulling disorder)* is marked by repetitive pulling of one’s hair. The key manifestation is **visible hair loss, often of differing lengths and appearances** (e.g. broken, kinked strands).

### Body dysmorphic

**Body dysmorphic disorder** is characterized by preoccupation with body parts that are perceived by the patient as unattractive or otherwise abnormal. The defects are often minimal or even entirely imagined.

Patients spend significant time to correct their perceived defect. Suspect body dysmorphic disorder in patients with an **extensive history of cosmetic procedures.**&#x20;

Responding to a patient with no insight requires tact. The most appropriate response would be to **acknowledge** the patient's **distress** and desire for surgery in order to establish a therapeutic alliance and also **educate** her about **nonsurgical treatment options**. Treatment includes medication (typically selective serotonin reuptake inhibitors) and cognitive-behavioral psychotherapy specifically tailored to BDD.

### Treatment

OCD-related disorders can be treated with **CBT** and **SSRI's**.

## PTSD

Post-traumatic stress disorder is a stress response to a generally catastrophic experience, which is **life threatening or otherwise traumatic**.

* Exposure to actual or threatened trauma
* Intrusive memories, nightmares, flashbacks with intense psychological/physiological reactions
* **Amnesia** for event, detachment, **avoidance of reminders**
* Negative mood
* Arousal with sleep disturbance, irritability, hypervigilance, exaggerated startle, impaired concentration

Post-traumatic stress disorder must last for **> 1 month** to be diagnosed. Until then, symptoms of PTSD can be diagnosed as **acute stress disorder**.

### Acute stress vs brief psychotic disorder

* acute stress: short PTSD
* brief psychotic: short schizophrenia

In patients with **post-traumatic stress disorder**, there is a high incidence of substance abuse and depression. Addictive drugs such as benzodiazepines should be avoided in these patients.

Neuroanatomical findings include **decreased hippocampal volume**.,

### Treatment

First-line treatments for PTSD include trauma-focused **cognitive-behavioral therapy** (preferred) with or without pharmacotherapy with either a:

* **SSRI** (e.g. paroxetine)
* **SNRI** (e.g. venlafaxine)

Relaxation training and desensitization psychotherapies also may play a role in treatment.

The α1 receptor blocker **prazosin** can be used to treat patients with PTSD-related nightmares. Prazosin is often used concurrently with first-line pharmacotherapy (e.g. SSRIs).

## Panic Disorder

### Symptoms

Panic disorder is characterized by recurrent periods of intense fear and discomfort peaking in 10 minutes. Symptoms include palpitations, shortness of breath, and a *fear of dying or losing control*. These panic attacks are **unexpected with no obvious cause**.

Patients with panic disorder experience *excessive worry* about their next attack. This anxiety can lead to behavioral changes (e.g. agoraphobia).

Panic disorder can frequently lead to **agoraphobia.** Patients with agoraphobia may be described as spending most of their time at home, or "worrying about going out", since their panic attacks began.

NOTE: As of DSM-V, panic disorder is no longer diagnosed with the modifiers of "with agoraphobia" or "without agoraphobia". Agoraphobia and panic disorder are now separate diagnoses.

### Pathogenesis

Are thought to be due to a dysfunction of the **locus ceruleus**. Discharge of norepinephrine from this neural structure causes the autonomic symptoms of panic attacks.

Neuroanatomical findings include **decreased amygdala volume**.,

Even more so than for other psychiatric disorders, it is extremely important in panic disorder to **rule out underlying organic causes**:

* **pheochromocytoma**
* **asthma**
* **arrythmia**
* **hyperthyroidism**
* **PE**
* Substance use: Substance/medication-induced anxiety disorder is diagnosed when panic symptoms are due directly to **intoxication (eg, cocaine, amphetamines) or withdrawal (eg, alcohol, benzodiazepines)** or after **exposure to a medication (eg, albuterol, levothyroxine)**.  Overmedication with levothyroxine or albuterol could precipitate panic. &#x20;

### Management

The first step in management of a patient stabilized after a panic attack may be to **order routine lab studies.**

The 1st line treatment of panic disorder is **SSRIs**. Nonpharmacological treatments such as cognitive-behavioral therapy (CBT) and biofeedback may also be helpful.

The best choice for *immediate relief of symptoms* in panic disorder is **benzodiazepines.**

## Social Phobia

Social phobia (also called social anxiety disorder) is a **fear of social situations in which embarrassment can occur**. These social settings need not be high-stress settings (such as a business meeting), and may be as casual as a birthday party.

### Vs panic disorder

Anxiety disorders can present with panic attacks without meeting the criteria for panic disorder. *Social phobia complicated by panic attacks* may closely resemble *panic disorder complicated by agoraphobia*. The primary difference between the two is the patient's **anticipation of panic attacks in social phobia.** Social phobia patients in a social setting may experience their phobia increasing to a point of panic leading to an attack; this is in contrast to a patient with panic disorder, whose attacks are random and unanticipated.

In summary:

* Panic disorder: Fear of unanticipated, unpredictable panic attacks leads to agoraphobia
* Social phobia: Phobia causes climactic, anticipated panic attacks

Performance anxiety is a subtype of **social phobia**. This means that "social phobia" may be the correct answer in a diagnosis of performance anxiety!

### Treatment

The 1st line treatment of social phobia is cognitive-behavioral therapy (**CBT**). Selective serotonin reuptake inhibitors (**SSRIs**) are first-line pharmacotherapy.

Two 1st line treatments of performance anxiety are **beta blockers** (esp. **propranolol**) and **benzodiazepines** (use cautiously in patients with substance abuse). CBT and SSRIs may be used as adjuncts.

*Note that while performance anxiety is a type of social phobia, their treatments are quite different!*

## Specific Phobia

Specific phobia is an anxiety disorder characterized by **unreasonable and excessive** fear of a specific object or situation that interferes with normal routine and causes avoidance behavior.

Many patients with a specific phobia can live relatively normal lives and may not seek treatment. The most commonly diagnosed cases of specific phobia involve **phobias that cause functional or lifestyle impairments** and are **intrusive to everyday life** (e.g. fear of driving, fear of vomiting).

As with most other anxiety disorders, patients with specific phobias have higher rates of **other anxiety disorders, mood disorders** and **substance abuse.**

Patients with a specific phobia **demonstrate insight** by recognizing their phobias as excessive fear; unfortunately, the exposure still provokes an anxiety response, which forces patients to avoid triggers.

Experiencing or witnessing a traumatic event in the phobic situation can **precipitate or worsen a phobia**.

### Treatment

First-line treatment for a specific phobia is **cognitive behavioral therapy** with **exposure therapy**.

Examples of exposure therapy for specific phobia include:

* *Systematic desensitization:* **Repeated, gradually increasing exposures to a feared stimulus.** Generally slower, although more effective.
* *Flooding:* **Sudden confrontation with the patient's full fear.** Generally faster, although less effective.

Second-line (pharmacologic) treatments for specific phobias include **benzodiazepines** (e.g. lorazepam) for patients that infrequently encounter the phobic stimulus or **selective serotonin reuptake inhibitors** for patients that frequently encounter the phobic stimulus.

These treatments are used when CBT is not available or if the stimulus is encountered relatively infrequently (flying for vacation, for example).
