MOOD & ANXIETY DISORDERS (Major depressive disorder (MDD) (With mixed…
MOOD & ANXIETY DISORDERS
Obsessive compulsive disorder (OCD)
Genetic studies are "contaminated" by experience and environmental factors!
Prevalence of 1-2% but not particularly easy to treat
Mood disorders, other anxiety disorders, tic disorders (20% of people with OCD have tics), eating disorders, psychotic disorders, personality disorders.
Comorbid depression is typically secondary to the OCD
Treating OCD can reduce PD as well
Clinical course: unremitting and chronic. Phasic with period of complete remission. Episodic with incomplete remission.
Repetitive behaviors or mental acts performed in response to obsessions. Aimed at reducing distress or preventing dreaded event (e.g. contracting disease). Cardinal feature: neutralizing.
Special words, images, numbers recreated mentally to neutralize anxiety. Special prayers repeated in a set manner. Mental counting, list-making, reviewing.
Unwanted thoughts, images, or impulses that cause marked anxiety/distress. Attempts to ignore, suppress or neutralize. Not simply excessive worries about real-life problems (GAD). Recognized as the product of one's mind.
Psychotic episode lasts two or more weeks past mood episode subsiding
Social anxiety disorder (social phobia)
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.
Core features include fear of scrutiny from others and fear of embarrassment. This can be performance based or interactional in nature.
Experience overwhelming amounts of anticipatory anxiety. Develop hypersensitivity to criticism or rejection. Engage in elaborate avoidance behaviors.
Generalized anxiety disorder
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.
Chronic hyperarousal leads to elevated sympathetic output, which in turn increases the
of sensory input, causing individuals to be more somatically preoccupied and to experience discomfort differently. Hyperarousal regardless of context.
Social phobia (social anxiety disorder), AUD, Panic, MDD, Cluster C traits
Course of illness
Onset in teens (on average), often chronic, full symptom remission is uncommon
Lifetime prevalence 3-4%, female to male ratio 2:1, commonly encountered by PCPs
A note on GAD vs. normal anxiety
Normal anxiety: Worries are
and can be put off until later. Worries are
, limited to few circumstances, and self-limiting. Physical symptoms are
GAD: Worries are difficult to control and
with functioning. Worries are
, pronounced, distressing, of long duration, and occur without precipitation,
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.
Persistent, excessive worry about a variety of routine events or occurrences. Symptoms must have persisted for
more than 6 months
and must be present on more days than not.
Must have 3 of 6 physical symptoms
Easy fatigue (hyperarousal and constant cortisol)
Results in avoidance of phobic stimulus, resulting in a vicious cycle.
Exposure therapy is most effective.
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.
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.
Medications alone are as effective as CBT alone. CBT effects are thought to last longer. Combination treatment is most effective.
Course of illness
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).
Half as prevalent as GAD, women remain more vulnerable than men.
A note on normal panic versus panic disorder
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.
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."
Disorder of false alarms and it just triggers. A panic attack is an intense flood of anxiety in response to an immediate threat, accompanied by a surge of sympathetic output, mind and body go into "overdrive."
Signs & symptoms
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.
Chest tightening, trembling, hyperventilation, flushing, palpitations, diaphoresis, GI upset, dizziness, derealization, sense of dread.
Persistent worry about having a panic attack (lasting greater than
Learned pattern of "false alarm" attacks.
Major depressive episode (MDE)
Major depressive disorder (MDD)
With mixed features
With psychotic features
Distinct period of abnormally elated or irritable mood at least seven days for first episode.
At least three of:
Poor judgment/risky behaviors
Increased goal-directed activity or agitation
Flight of ideas or racing thoughts
Decreased need for sleep
Not attributable to a general medical illness or a drug/medication effect
Impairment in occupational and/or social functioning
Treatment options; pharmacotherapy (SSRIs, SNRIs, TCAs; GABA, other agents) & psychotherapy.