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MOOD & ANXIETY DISORDERS (Major depressive disorder (MDD) (Melancholia…

- - - - Learned pattern of "false alarm" attacks.
      - Persistent worry about having a panic attack (lasting greater than one month).
    - - Chest tightening, trembling, hyperventilation, flushing, palpitations, diaphoresis, GI upset, dizziness, derealization, sense of dread.
      - One consequence of panic disorder can be agoraphobia (although this is also a stand alone disorder).
        
        Agoraphobia is an avoidance of situations where a panic attack might occur and/or escape would be difficult. Not all Panic Disorder patients develop agoraphobia. It is a coping strategy or managing the fear of having a panic attack, and at its most severe patients may not leave their home, or even a specific room. Short term it is effective, but long term only fuels the panic symptoms.
    - - Normal panic: if you accidentally walk into the street and a bus is heading at you, a panic response is natural and protective (the threat is real and this serves as a "true alarm." Having one or two "false alarm" attacks is not sufficient for a diagnosis without the fear of future attacks. Almost 40% of Americans have a "false alarm."
      - Panic disorder: occurs when "false alarm" attacks become a pattern. When panic occurs "out of the blue" without a clear threat or apparent danger, it is considered a "false alarm" attack.
    - - Half as prevalent as GAD, women remain more vulnerable than men.
    - - Chronic, relapses common though patients can recover quickly with good therapy. Patients with Panic Disorder are high utilizers of medical resources, particularly ER settings. Medical workups for possible organic causes are often repeated in excess to reassure patients (and doctors).
    - - Medications alone are as effective as CBT alone. CBT effects are thought to last longer. Combination treatment is most effective.
  - - - Defined as enduring and excessive fear of a specific object or situation. The fear must be out of proportion to any real danger. The patient is aware that the fear is illogical/irrational.
    - - Approximately 8% of adults have a diagnosable phobia. In women fear of animals is most common; in men fear of heights is most common. Onset typically occurs during childhood.
    - - Exposure therapy is most effective.
  - - - Muscle tension
      - Sleep disturbance
      - Irritability
      - Poor concentration
      - Easy fatigue (hyperarousal and constant cortisol)
      - Restlessness
    - - GAD: Worries are difficult to control and interfere with functioning. Worries are pervasive, pronounced, distressing, of long duration, and occur without precipitation, physical symptoms are present.
        
        Somatic manifestations: emotional states are closely tied to our enteric nervous system, bi-directional feedback exists and 95% of the body's serotonin is in our gut.
      - Normal anxiety: Worries are controllable and can be put off until later. Worries are situational, limited to few circumstances, and self-limiting. Physical symptoms are minimal or absent.
    - - Lifetime prevalence 3-4%, female to male ratio 2:1, commonly encountered by PCPs
    - - Onset in teens (on average), often chronic, full symptom remission is uncommon
    - - Social phobia (social anxiety disorder), AUD, Panic, MDD, Cluster C traits
    - - Chronic hyperarousal leads to elevated sympathetic output, which in turn increases the gain of sensory input, causing individuals to be more somatically preoccupied and to experience discomfort differently. Hyperarousal regardless of context.
    - - Medications alone are as effective as CBT alone. Combination treatment is most effective. Patients respond well to mindfulness medication practice. Trains the mind to rest in an awareness of the present moment. Effective in GAD because patients get "stuck" in the future.
  - - - Core features include fear of scrutiny from others and fear of embarrassment. This can be performance based or interactional in nature.
    - - Behavioral therapy can help. Model involves identifying patients' "safety behaviors." Safety behaviors are a barrier to learning new skills. Exposing patients to social situations without letter them use safety behaviors. No comparison studies exist.
- - - - Doubting obsesion
  - - - Checking compulsions
      - Mental compulsions
        
        Special words, images, numbers recreated mentally to neutralize anxiety. Special prayers repeated in a set manner. Mental counting, list-making, reviewing.