Anxiety Flashcards
what are physical manifestations of anxiety?
- symapthetic: diaphoresis, mydriasis, tachycardia, tremor
- GI/GU symptoms (diarrhea, more urine)
- hyperventilation –> dizziness and syncope, parasthesia
- numbness and tingling in extremities and around the mouth
what are psychological manifestations of anxiety?
restlessness, irritability, trouble concentrating, worry
what is the time frame of anxiety?
disorder depdendent
what are organic (medical) causes for anxiety?
- caffeine
- substance abuse (cocaine, amphetamines)
- withdrawal (alcohol, benzos, opiates)
- hyperthyroidism
- arrhythmia
- B12 deficiency
- hypoglycemia
- pheochromocytoma
what are often seen in ED setting presenting as anxiety?
acute MI, PE, COPD, asthma
-regardless of setting, must take history about medical and psych components, perform physical, and send labs as needed to rule out medical causes
what are psychiatric disorders associated with anxiety?
- depression
- schizophrenia
- eating disorders
- personality disorders
- substance dependence
how do you diagnose anxiety?
symptoms must:
- be persistent (>6 mo, shorter in children)
- interfere with normal functioning (work, job, marriage)
- cause significant distress
otherwise, we declare normal anxiety and fear responses as pathological
what are psychosocial factors of anxiety?
- traumatic events or extreme stressors (PTSD, panic attack) may help create anxiety disorder (Freudian Signal Anxiety)
- maladaptive coping skills/personality traits make people vulnerable to increase stress levels (GAD, phobias)
what are biologic factors of anxiety?
- greater prevalence in populations of family members with anxiety disorders
- -genetics may play role (30% as opposed to 50% schizophrenia, 7-80% ADHD/bipolar)
- gender bias (disorder dependent) in that women > men (equal in OCD)
what are neurobiological factors of anxiety?
- decreased serotonin and GABA activity
- increased NE and glutamate activity
what is diagnostic criteria for general anxiety disorder?
- excessive anxiety/worry occurring more days than not for >6 mo, regarding >1 event/activity
- difficult to control worry
- associated with >3 of following:
- restlessness
- easily fatigued
- difficulty concentrating
- irritability
- muscle tension
- sleep disturbance
what is the occurrence of GAD?
- 3-5% in general population
- women > men
- 50% begin prior to adulthood
- parents may be GAD
- may self-medicate with alcohol
prognosis of GAD?
without treatment, tends to worsen over time (especially if stressful)
explain the treatment for all anxiety, and how they work?
- therapy (cognitive behavioral therapy or psychodynamic)
- medication
- antidepressants (SSRI, SNRI) increase SR or NE, or both (downregulate/desensitize receptors)
- Buspirone (slow-acting 5HT1a receptor agonist that initially lowers 5-HT activity, then increases output)
- -only used for GAD
- benzodiazepine (fast-acting GABA-A receptor positive allosteric modulator allows more Cl- channels to open)
- -second line due to risk of addiction, falls, and apnea
- beta-blockers (off-label use; for symtomatic relief of performance anxiety from sympathetic system - NOT GAD)
- combinations
what is the diagnostic criteria for 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
what are symptoms associated with panic disorder?
> 4 of the following physical and psychological components
- palpitations, pounding heart, accelerated HR
- sweating
- shaking/trembling
- sensation of SOB or smothering
- choking feeling
- chest pain/discomfort
- nausea
- dizziness, lightheadedness, or fainting
- chills/heat
- paresthesias
- derealization (out of body experience)
- fear of losing control
- fear of dying
what is agoraphobia?
- fear/anxiety of >2 of the following, for >6 mo:
- using public transportation
- being in open/enclosed spaces
- standing in line or a crowd
- being outside the home alone - fear of not being able to escape situation
- situation almost always produces fear/anxiety, to the point of avoiding it - fear/anxiety out of proportion to actual danger
- causes significant impairment, with no other explanations
occurrence and prognosis of panic disorder
- 5 to 3.5% prevalence in general population, women > men
- chronic and recurring
- increased risk of depression and suicide
what is treatment of panic disorder?
- therapy
- cognitive behavioral therapy via systemic desensitization or flooding
- psychodynamic therapy - medication
- emergency treatment: fast acting benzos
- long term 1st line: SSRI/SNRI
- intermediate or long-term 2nd line: benzos (addiction potential) - combination treatment
what are diagnostic criteria for phobia?
- > 6 mo of marked fear/anxiety about a specific object/situation
- object/situation almost always provokes fear/anxiety
- actively avoids object/situation
- fear/anxiety is out of proportion to actual danger - no other explanation for symptoms
what is coulrophobia?
fear of clowns
what is ophidiophobia?
fear of snakes
what is aerophobia?
fear of airplanes
what is aerophidiophobia?
fear of snakes on a plane
what is peladophobia?
fear of bald people
what is iatrophobia?
fear of going to the doctor or of doctors
how do you diagnose social anxiety disorder?
- social phobia for > 6 mo that 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 situation
- fear/anxiety is out of proportion to actual threat
what is performance anxiety?
subset of social anxiety disorder (social phobia) restricted to public speaking or performing, and doesn’t generalize to other social aspects of life
what is the occurrence and co-morbidities for phobia?
up to 5% of men, 10% of women
- if social phobia, women > men is questionable
- co-morbidities with other anxiety disorders and depression
what is treatment for specific phobias?
- therapy (first line): flooding, systemic desensitization (CBT)
- psychodynamics for signal anxiety - medication: sedatives depending
what is treatment for social anxiety disorder?
- therapy: CBT, asseriveness training, group therapy
- medication: first line SSRI, then MAOi
- beta-blockers are first line for performance-only variant, as it will stop the physical symptoms to prevent downhill spiral
what is the definition of OCD?
criterion A: presence of obsessions and compulsions
criterion B: obsessions and compulsions must be either:
-time consuming (>1hr/day) or
-cause clinically significant distress
what is an obsession?
- recurrent/persistent thoughts, urges, and/or images
- intrusive and unwated
- -sometimes called ego dystonic
- -cause person anxiety and distress
- patient tries to ignore or suppress them, or try to neurtalize with thought or action
- -undoing ego defense mechanism
what is a compulsion?
- repetitive behavior or activity that patient performs in response to obsession or as a set of rules that must be strictly adhered to
- typically undoes or reduces anxiety (typically an obsession)
- stopping compulsion often dramatically increases anxiety
what is the occurrence of OCD?
- lifetime prevalence = 2-3%
- men and women equally affected
- 50-70% have onset after a stressful event
- mean onset for men is 19 yo, women is 22 yo
what is the prognosis of OCD?
- long, but variable course
- 20-30% have significant improvement
- 40-50% have moderate improvement
- 20-40% remain ill, or wosen
- hardest anxiety to treat
what are comorbidities with OCD?
1/3 have MDD, and up to 2/3 of Tourette’s patients have OCD
-suicide risk is high
what is treatment for OCD? what definitely doesn’t work?
- psychotherapy
- CBT (as effective as Rx, with longer-lasting effects)
- -ERP (exposure and response prevention0 is specific for OCD
- supportive and dynamic psychotherapy - pharmacotherapy (best results when combined with psychotherapy)
- 1st line: SSRIs, higher dosage and duration than MDD
- 2nd line: TCA (clomipramine approved for OCD)
- 3rd line: antipsychotics, other antidepressants
- benzos DON’T WORK
what are the different diagnoses for OCD?
- Tourette’s disorder (vocal and/or motor tics)
- temporal lobe epilepsy (both may have repetitive motor movements, which may look like compulsion)
- OC personality disorder
- unlike OCD patients, they do not have insight into behavior; they are rigid, moralistic, work-a-holics, list-oriented, but don’t have repetitive discrete behaviors to undo anxiety
what is the most common thing that can cause PTSD?
death of a loved one
what is the most likely thing to cause PTSD?
assault
what is the likelihood of getting PTSD after a car crash?
15%
what are the greatest variables associated with PTSD?
- proximity
- harm by another human
- severity repetition
what are the criteria for PTSD via DSM-V?
- exposure to an actual or threatened traumatic event
- death, serious injury, sexual violence - 1+ intrusion symptom associated with event
- reliving event via distressing memories, dreams/nightmares, or dissociative reactions - avoidance of stimuli associated with traumatic events
- negative changes in cognition and mood associated with event (2+)
- alterations in arousal/reactivity
how long to symptoms need to present for it to be PTSD?
> 1 month
- must cause distress/impairment
- must not be result of substance or other medical condition
what are the modes of exposure in PTSD?
exposure to death, serious injury, or sexual violence must have occured via:
- directly experiencing event
- witnessing events that occur to others
- learning that a family member/friend experienced an event
- directly experiencing repeated/extreme exposure to horrific details of an event
what does “intrusion symptom” mean for PTSD?
1+ for PTSD definition: reliving of events
- distressing memories, dreams/nightmares, or dissociative reactions (flashbacks)
- -during falshbacks, they are unaware of surroundings
- psycholocial distress from exposure to internal or external cues that symbolize/resemble an aspect of the traumatic event(s)
- distinct psycholocial reactions to exposure to external cues
how do people avoid stimuli associated with PTSD?
avoid:
- memories/thoughts/feelings about or associated with the event
- external reminders (people/places/situations) that may arouse memories, thoughts, or feelings
- interpersonal connectivity (estrangement, lack of commitment, unwilling to settle down, reclusiveness
what are negative changes in cognition/ood related to PTSD
2+ of the following:
- inability to remember an important part of the event due to dissociative amnesia or repression
- persistent, exaggerated beliefs/expectations of oneself, others, or the world (paranoid stance)
- distortion of thoughts/memories of the event, causing individual to blame themselves/others
- persistently negative emotional setate (depression, irritability)
- decreased interest in participating in daily activities
- feeling of detachment from others
- inability to experience positive emotions
what are alterations in arousal/activity in PTSD?
- irritable behavior/angry outbursts expressed as verbal or physical aggression towards other people/objects
- reckless/self-destructive behavior
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbances
what is acute stress disorder (ASD)
PTSD, except for 3 days to 1 month after exposure (as opposed to >1 mo)
-best time to treat is early, to decrease risk of full PTSD onset
occurrence of PTSD and ASD?
PTSD: 8%
ASD: 5-15%
women > men
prognosis of PTSD and ASD?
variable
-better if: rapid onset of symptoms, good pre-morbid functioning, no other psychiatric co-morbidities
untreated
- 30% recover completely, 60% continue having mild/moderate symptoms, and 10% have worsening symptoms
- by 1 year, 50% will have recovered
co-morbidities with PTSD/ASD?
- depressive disorders
- substance-related disorders
- other anxiety disorders
- bipolar disorders
- personality disorders (esp. borderline personality disorder)
treatment for PTSD/ASD?
psychotherapy
- follow model of crisis intervention
- -initial support, grounding, validation of feelings
- -relive event VS seal over and move on
- –CBT, eye-movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy, support groups, family therapy
pharmacotherapy
- 1st line: SSRIs
- 2nd line: TCAs, atypical antipsychotics
- 3rd line: MAOi, trazodone, anticonvulsants, clonidine, propanolol
what is a very effective nightmare treatment?
prazosin (a1 inhibitor)
