Anxiety Disorders

A 62-year-old Chinese female, referred here as patient X, was admitted for recurrent episodes of
uncontrollable screaming and shaking of all four limbs. These episodes began 4 days before
admission, occurring two to three times daily. Each episode was abrupt in onset, lasting several
minutes to an hour. Onset was characterized by an uncomfortable coldness in the chest
spreading outwards to both arms and legs, transforming into a tingling sensation followed by
involuntary tremors. Patient X described a lack of control, oscillating between laughing and crying
whilst shouting incomprehensibly and flailing her limbs against her surroundings. She
experienced fatigue and diaphoresis with no loss of consciousness nor amnesia during these
episodes. She had persistent concerns over future episodes, which she described as unbearable.
In the emergency department, patient X suffered an episode and was given intramuscular
haloperidol 5 mg with cessation of the episode within minutes. She was able to sit up and
apologize, before cooperating with further investigations. After 10 min, she suffered another
episode and was given intravenous midazolam 1 mg with the resolution of symptoms within
minutes.

BMS: to receptors on the surface of the adrenal

1. HPA axis cortices, leading to a series of intracellular
The stress response begins in the brain. events that result in the adrenal glands
When someone confronts an oncoming car secreting glucocorticoids like the hormone
or other danger, the eyes or ears (or both) cortisol.
send the information to the amygdala, an
area of the brain that contributes to Cortisol has a number of effects on the
emotional processing. The amygdala body that are thought to be carried out in
interprets the images and sounds. When it order to help the body deal with a stressor
perceives danger, it instantly sends a distress that lasts longer than a few minutes. For
signal to the hypothalamus. example, it increases blood pressure and
cardiac output, providing more blood to
The hypothalamus responds to signals like your skeletal muscles in case the stressor
elevated norepinephrine levels by secreting you're dealing with involves some sort of
corticotropin-releasing hormone into the physical exertion (like running for your life).
bloodstream. Corticotropin-releasing It acts to increase circulating levels of
hormone (also known as corticotropin glucose in your blood as well. As glucose is a
releasing factor or CRH or CRF for short) crucial energy source for your cells, this also
itself increases the activity of the provides your body with extra energy to
sympathetic nervous system, perpetuating deal with the stressor.
effects like elevated heart rate. CRH,
however, also tells the pituitary gland to Negative Feedback
secrete a substance called Once the stress response has been initiated,
adrenocorticotropic hormone (ACTH). The and cortisol enters the circulation, cortisol
pituitary gland releases ACTH into the itself is able to act on the hypothalamus and
bloodstream, and the hormone travels down pituitary and inhibit production of CRH and
to the adrenal cortex, which is a term for the ACTH. This is called a negative feedback
outer layer of the adrenal glands. ACTH binds loop; the active hormone (cortisol) can shut
off its own production. Negative feedback is Amygdala
possible because neurons in the ● Heart of the limbic system, responsible for
hypothalamus and pituitary express all emotions.
glucocorticoid receptors that are activated ● Fear is its most distinct emotion.
by cortisol. Septal Area
● The septal area is a "pleasure center" in
2. limbic system the brain.
THE LIMBIC SYSTEM
● Subserves basic survival functions that Hippocampus
include feeding behavior, "fight-or-flight" ● Responsible for the formation of new
responses, aggression, and the expressions memories and making
of emotion and of the autonomic, them long-term.
behavioral, and endocrine aspects of the ● Also responsible for topographical
sexual response. memory.
● Sometimes called the “emotional brain” Process of taking memory:
because it plays a primary role in a range of ○ Encoding
emotions, including pain, pleasure, docility, ○ Storage
affection, and anger. ○ Retrieving
○ It is also involved in olfaction (smell) and
memory. 3. Thalamus
● Also called the old lobe and is responsible - sensory relay center
for making connections with the frontal
lobe. 4. Autonomic Nervous System
Autonomic motor neurons regulate visceral
IMPORTANT STRUCTURES activities by either increasing (exciting) or
Cingulate Gyrus decreasing (inhibiting) ongoing activities in
● Located in the medial side of the brain next their effector tissues (cardiac muscle,
to the corpus smooth muscle, and glands).
callosum.
● Responsible for pain and emotions Unlike somatic output (motor), the output
brought about by memory; also responsible part of the ANS has two divisions: the
for avoiding something painful. sympathetic division and the
parasympathetic division. Most organs have
Parahippocampal dual innervation; that is, they receive
● Gray matter cortical that is responsible for impulses from both sympathetic and
memory encoding and retrieval. parasympathetic neurons. In some organs,
● In charge of short term memory, spatial nerve impulses from one division of the ANS
recognition, and directions. stimulate the organ to increase its activity
(excitation), and impulses from the other
Uncus division decrease the organ’s activity
● The relay center of olfaction. (inhibition).
● Responsible for smell and its relation to
memory. The sympathetic division is often called the
fight-or-flight division. Sympathetic activities
result in increased alertness and metabolic
activities in order to prepare the body for an
emergency situation. Responses to such
situations, which may occur during physical
activity or emotional stress, include a rapid
heart rate, faster breathing rate, dilation of
the pupils, dry mouth, sweaty but cool skin,
dilation of blood vessels to organs involved
in combating stress (such as the heart and
skeletal muscles), constriction of blood
vessels to organs not involved in combating
stress (for example, the gastrointestinal tract
and kidneys), and release of glucose from
the liver.

The parasympathetic division is often

referred to as the rest- and-digest division
because its activities conserve and restore
body energy during times of rest or digesting
a meal; the majority of its output is directed
to the smooth muscle and glandular tissue of
the gastrointestinal and respiratory tracts.
The parasympathetic division conserves
energy and replenishes nutrient stores.
Although both the sympathetic and
parasympathetic divisions are concerned
with maintaining homeostasis, they do so in
dramatically different ways.