Anxiety 1 & 2 Flashcards
When a patient presents with anxiety-like symptoms, what 3 broad categories are on your DDx?
Organic (medical) Causes, Heart/Lung Causes, Psychiatric Disorders
Intoxication with what 3 substances that can result in anxiety-like Syx?
Caffeine, cocaine, amphetamines
Withdrawals from what 3 drugs can show anxiety-like symptoms?
Alcohol, benzodiazepines, opiates
What 4 heart/lung problems commonly present in the ED with anxiety-like Syx?
Acute MI, PE, COPD, Asthma exacerbation
Describe the requirements for anxiety Dx
- Persistent (> 6 months) (shorter duration for children
- **Interfere ** with normal function
- Cause Significant Distress
3 Psychosocial events that can lead to anxiety
Traumatic event, extreme stressors, maladaptive coping skills
What percentage does genetics play in anxiety disorders?
30%
What is the general neurobiologic trend that contributes to anxiety disorders?
Decreased serotonin and decreased GABA activity. Also there is increased NE and in certain parts of the brain, Glutamate increase
What is the diagnostic criterion for General Anxiety Disorder (GAD)?
- Excessive anxiety/worry, occurring more days than not for > 6 m; > 1 event/activity
- Difficult to control worry
- Associated with > 3 of following Syx
- Restlessness
- Easily fatigued
- Difficulty concentrating
- Irritability
- Muscle Tension
- Sleep Disturbance
- Cause significant impairment
- No other explanation for Syx
What percentage of population have GAD?
3-5%
Which gender is affected more in GAD?
Women
What Tx is frequently used to treat CAD?
Cognitive Behavioral Therapy
What medications are commonly used to treat CAD?
SSRIs, SNRIs, Buspirone (5HT1aR agonist), Benzos
What type of anxiety are Beta Blockers used to treat? What’s the shortcoming of these drugs?
Performance/social anxiety; Only treat the Syx
What are the Dx criteria for a Panic Attack?
An abrupt surge of intense fear or discomfort, peaks within minutes that is unexpected with > 4 of the following:
- Palpitations
- Sweating
- Shaking/trembling
- Sensation of SOB
- Choking feeling
- Chest pain/discomfort
- Nausea
- Dizziness
- Chills/heat
- Paresthesias
- Derealization
- Fear of Losing Control
- Fear of Dying
What are the criteria for a Panic Disorder?
- Recurrent unexpected panic attacks
- > 1 attack followed by > 1 month of _>_1 of the following:
- Concern about additional panic attacks or consequences
- Significant maladaptive change in behavior related to attacks
No other explanation for Syx
What is the Dx criteria for Agoraphobia?
A. Fear/Anxiety about > 2 of the following:
- Using public transportation
- Being in open spaces
- Being in enclosed spaces
- Standing in line or in a crowd
- Being outside the home alone
B. Fear of not being able to escape situation
C. Situation almost always produces fear/anxiety
D. Avoids situations
E. Fear/anxiety out of proportion to actual danger
F. > 6 months
G. Causes significant impairment
H. No other explanation for Syx
In what gender are panic disorders more prevalent?
Female
What are the two therapies recommended for panic disorders?
CBT with systemic desensitization/flooding or Psychodynamic Tx
What meds are used in an acute panic attack? Chronic?
Benzos; SSRIs/SNRIs/Intermediate or Long Acting Benzos
Why is benzo use limited for panic disorder Tx?
Potential for addiction
What are the Dx criteria for a specific phobia?
- > 6 months
- Causes significant impairment
- Marked fear/anxiety of a thing/situation
- Thing/situation almost always provokes fear
- Actively avoids object/situation
- Fear/anxiety out of proportion of actual danger
- No other explanation for Syx
Dx criteria for Social Phobia
- > 6 months
- Causes significant impairment
- Marked fear/anxiety when exposed to social situation with possible scrutiny by others
- Fear of acting in ways that will be negatively scrutinized
- Social situation provokes fear
- Avoids social situations
- Fear/anxiety out of proportion to actual threat
- No other explanation of Syx
NOTE: Fear is restricted to public speaking/performing ONLY
What is first line Tx for specific phobias?
Flooding, systemic desensitization (CBT)
What is the Tx for Social Anxiety Disorder
CBT, Assertiveness Training, Group Tx
What medications do you use for Social Phobia Disorders? The performance variant?
SSRIs/SNRIs, MAOIs; Beta Blockers
What are the Dx criteria for OCD?
Criterion A: Presence of OBSESSIONS and COMPULSIONS
Criterion B: Obsessions and compulsions must be either:
- Time consuming (>1 hr/day)
- Cause clinically significant distress
- Are not substance induced
- Not better explained by another mental illness
What is an obsession?
Recurrent/persistent thoughts, urges, images that are intrusive** or **unwanted
When patients try to ignore/suppress intrusive thoughts OR they try to neutralize them with a thought or action, what defense mechanism are they utilizing?
UNDOING ego defense mechanism
What is a compulsion?
Repetitive behavior/activity that the patient performs in response to an obsession or as a set of rules that must be strictly adhered to
What is the prevalence of OCD between men and women?
Equal
What event preceeds onset of OCD in 50-70% of cases?
Stressful event
What conditions are associated with OCD?
Tourette’s Syndrome and suicide
What has greater efficacy in OCD Tx: Psychotherapy or Pharmacotherapy?
Psychotherapy! CBT
What is 1st line PharmTx for OCD? 2nd? 3rd? When does PharmTx work best? Do benzos work?
SSRIs; Clomipramine (TCA); Antipsychotics; With Psychotherapy; No!
What is the DDx for OCD?
Tourette’s, Temporal Lobe Epilepsy, Obsessive Compulsive Personality, OCD
What is the most common cause of PTSD?
Death of loved one
What is the most likely thing to cause PTSD?
Assault
If you get a fracture in a car crash, likelihood of PTSD?
15%
What four variables have the greatest association with PTSD?
Proximity, harm by human, severity, repetition
What is criterion A for PTSD?
- Exposure to actual or threatening traumatic event
- Syx for > 1 month
- Syx cause significant distress/impairment
- Syx must not be result of substance or other medical condition
What are 4 modes of exposure in PTSD?
- Directly experiencing
- Witnessing
- Learning that family member/friend experienced event
- Directly experiencing repeated/extreme exposure to horrific details of an event
What is Dx criterion B for PTSD?
> 1 Intrusion Symptom involved with reliving event:
- Distressing memory
- Distressing nightmare/dreams
- Dissociative reactions such as flashbacks
- Psychological distress from exposure to internal/external cues
- Distinct psychological reactions to exposure to external cues
What is Dx criterion C for PTSD?
Avoidance of stimuli associated with traumatic events - such as thoughts/feelings, people/places/situations, and interpersonal connectivity
What is Dx criterion D for PTSD?
Negative changes in cognition and mood associated with event (> 2 of following):
- Dissociated amnesia or repression
- Persistent exaggerated beliefs/expectations of oneself
- Distortion of thoughts/memories of event causing individual to blame themselves/others
- Persistent negative emotional state
- Decreased interest in daily activities
- Feeling of detachment from others
- Inability to experience positive emotions
What is the Dx criterion E for PTSD?
Alterations in arousal/reactivity (> 2 of the following):
- Irritable behavior/angry outbursts
- Reckless/self-destructive
- hypervigilance
- Exaggerated startle response
- Problems with concentration
- Sleep disturbances
What is acute stress disorder?
Precursor to PTSD
What is the difference between ASD and PTSD?
Criteria B-D (of PTSD) must persist for 3 days - 1 month after exposure
Okay, let’s simplify this. What are the 5 categories of symptoms that must be present following a traumatic experience for PTSD?
- Re-experiencing event
- Avoidance
- Dissociative Syx (amnesia)
- Negative mood
- Changes in arousal
Duration >1 month
What is the best psychoTx for PTSD?
CBT
What is the first line pharmTx for PTSD? 2nd line? 3rd line? What is used for nightmares?
SSRI; TCAs; MAOI; Prazosin (Alpha1 antagonist)
What factors contribute to a better prognosis of PTSD?
Rapid onset of Syx, good premorbid function, no other psychiatric comorbidities
