a. When fear is greater than warranted

b. when fear occurs in inappropriate situations

(panic attack from riding the subway, having to use a public restroom)

Neurobiologic Basis of Fear and Anxiety

Name 4 areas in the brain, and describe their roles in generation and/or control of an individual's fear

Name 4 substances which my trigger Panic Attacks in pations w/ Panic Disorder or family history

1. Locus Coeruleus:  hyperactivity of noradrenergic neurons from LC to amygdala implicated in the pathophys of most stress induced fear circuitry disorders, especially PTSD

2. Amygdala - 'The Heart and Soul' of the Fear System, responsible for fear processing and learning

3. Hippocampus - processes environmental contextual cues --> might have deficits in this ability in anxiety disorder

4. Medial Prefrontal Cortex - responsible for extinction of conditioned fear responses

Biochemical Triggers:  Sodium Lactate, CO2, CCK, and Yohimbine

How does the ANS play into Anxiety?

What 3 NT systems are involved in Anxiety Disorders?

Excessive ANS reaction, increaseing sympathetic tone (increased fight or flight = fear/anxiety)

GABA:  decreased GABA levels/function results in CNS hyperactivity, inappropriate/excessive autonomic reaction

Seratonin system abnormalities also implicated

Stress and the HPA Axis

Stress has been assoc. w/ an increase in what substance?  What is the normal role of this substance in the body, and how is it related to anxiety?

Stress assoc w/ CRF (cortisol releasing factor)

It normally plays a role in the stress response, but is assoc w/ Serotonin and DA chances, other neuroendocrine abnormalities in patiens w/ anxiety

1. Unresolved Conflict

2. Loss

3. Unresolved childhood fears 

4. Unconcious forbidden desires or impulses

1. Learned (parents display anxiety)

2. Catastrophic Thinking (faulty and distorted view of cause and effect)

3. Avoidant - see the world as a place where many things must be avoided

1. Psychological/Cognitive: 

worry, dread, doom, doubt

Decreased conc., distortions, hypervigilance

2. Physiologic - Autonomic arousal, hypersensitive fight or flight response 

What is a Panic Attack?

What pathway (eg. cholinergic, GABAergic, etc) produces physical symptoms?

How long do they typically last?

Panic attack = discrete period of intense fear 'out of the blue' --- but may later become 'cued'

Panic attacks are a central feature of Panic disorder (along w/ cognitions, somatic symptoms, and developing a 'fear of fear' - phobic avoidance)

Paroxysmal - means it builds rapidly to a peak

Adrenergic pathway responsible for physical symptoms

Usually lasts 10-20 mins, more than that and its not a panic attack

1. Caffeine

2. Stimulants like Cocaine

3. Alcohol (Hypnotics Withdrawl)

4. Medications (herbal or prescribed)

5. Club drugs like ecstacy

6. Medical illnesses

- Neuro/endocrine/Cardiac disorders

- Could be due to toxic exposuere

Epidemiology of Panic Disorders

Lifetime prevalence?

Up to 1 in 4 patients being seen in what specialty have a panic disorder?

Typical age of onset?

Male: Female ratio?

Any hereditary basis to panic disorders?

Lifetime prevalence 1.5-4%

Cardiology Practices

Onset around age 15-25

Twice as many females affected than males

Does tend to run in families, Panic patients likely inherit a susceptibility to an unusually sensitive fear network/noradrenergic system

Co-Morbidity w/ Panic Disorder

Name 5 co-morbid conditions

1. Increased utilization of medical services

2. Job/Social Impairment

3. Depression

4. Suicide 

5. Alcohol and Benzodiazepine Abuse

1. Experience a somatic sensation (Chest pain)

2. Catastrophic misinterpretation

3. Causes increased physical symptoms

4. Fear/Anxiety (feed forward mech)

5. Development into a full-blown panic attack

Social Phobia (aka SAD):

What is it?

NT pathway?

Age of onset?

Typically acute or chronic?

Do they recognize their fear as excessive?

Rx?

Defined as intense anxiety about scrutiny by others (fear driven by embarrassment/humiliation)

Adrenergic symptoms (including blushing response)

Onset in teens, its chronic

Patients recognize their fear is excessive

Can treat w/ SSRI's

50% don't finish high school

20% can't work

50% are single, separated, or divorced

HIGHLY comorbid w/ alcohol abuse (see an alcoholic in clinic? Must examine them for social anxiety)

Generalized Anxiety Disorder (GAD)

What is it?

5 associated symptoms?

Pattern of uncontrollable anxiety/Chronic worry unrelated to a specific person/situation/event; causes extreme distress, interferes w/ functioning

Symptoms: (for greater than 6 months)

Fatigue

Insomnia

Muscle tension

Impaired conc.

Irritability

(pumping out monoamines all the time, generally will seem on edge but also tired)

GAD Epidemiology:

Prevalence

Male:Female ratio; any possible reason for this?

More common in young/middle age/older people?

Age of onset?

How many can fully remit, w/ and w/o treatment?

2% point prevalence, 5% lifetime

More females affected, and could be assoc w/ menopause

More common in older age group 55-85

Many patients say they've been anxious all their lives, can't remember a time they didnt worry

Rarely remit fully, period.

1. Depression

2. Alcohol abuse/dependence

3. Other Anxiety Disorders

OCD

List 4 common Obsessions, and 5 common Compulsions

Four factor symptom structure for OCD?

Obsessions:

Contamination

Doubt

Agressive/Sexual thoughts

Symmetry

Compulsion

Washing

Checking

Confessing

Rituals

Counting

1. Symmetry factor

2. Forbidden thoughts factor

3. Cleaning factor

4. Hoarding factor

Prevalence and Course of OCD

Lifetime prev?

M/F ratio? Differences in onset?

Lifetime prev 1-2% (but they know its crazy, sothey're secretive; its under reported)

Male = Female in adults (the exception of the panic disorders, normally girls just be buggin); early onset more common in boys

OCD

Dysregulation of what NT implicated?

Brain pathway implicated?

Concordance in MZ twins?

What infection could potentially trigger OCD in kids?

Serotonin dysregulation

Caudate - Basal Ganglia - Frontal lobe pathway implicated (hyperactivity)

50-85% concordance, very high = very heritable illness

post strep onset in some children

1. Criminal Victimization (rape, domestic violence, robbery)

2. Car accident

3. childhood abuse

4. natural disasters

5. unexpected death of relative/friend

6. War/Terrorism

1. Re-experiencing: intrustive thoughts/nightmares/flashbacks

2. Avoidance: avoids relationships and things that remind of the event

3. Emotional Numbing

4. Hyerarousal:  startle, trouble concentrating, insomnia

**1 and 4 are excitatory

PTSD Epidemiology

Prevalence

Male vs. Female ratio?

1 year 3%, lifetime 8%

2:1 Women to Men

Why?

Increased exposure to traumatic events (rape, mugging)

Increased risk of PTSD once exposed

PTSD Course and Treatment

What % of patients recover after 1 year?  What % remains chronic?

Treatment options:

Pharmacotherapy?

Psychotherapy?

50% recover after 1 year; 30% are chronic

Pharmacotherapy to treat specific symptoms (anxiety, insomnia, depression)

Psychotherapy options:

CBT

Group and family 

Prevention: could give a beta blocker to patient in acute phase immediately following the event