Anxiety Flashcards
A 25 year old medical student did not study for an upcoming exam. The morning of the exam, she feels nervous, uneasy, scared and has multiple somatic symptoms such as diarrhea, tremor, and palpitations.
tell her to study; this is normal
A 45 year old female presents to an ER with complaints of shortness of breath, chest discomfort and sensation of impending doom. She feels very scared and is certain she is dying. She undergoes a cardiac catheterization which is unremarkable.
most cardiac catheterization comes back clean; panic attacks
A 32 year old middle manager at a large hardware supply company is up for promotion this year. He dreads going to the annual holiday party and finds it extremely hard to socialize with other managers at monthly company retreats. His wife brings him to see his PCP because she notices he is markedly increasing his alcohol intake.
get this treated; it’s affecting his life
A 33 year old Hispanic woman who works for a large insurance company comes in for her annual exam. She tells you that she “worries about everything.” She describes being this way as long as she can remember. She is distressed by her worries and tends to have trouble being promoted at work and cannot maintain a relationship secondary to her constant “nervousness.”
dysthymia
A 31 year old female presents to see her PCP with complaints of “feeling like I will faint and having palpitations and sweats” every time she needs to speak to a large crowd . Her job requires that she present to a variety of groups but she is planning on quitting her job because of these uncomfortable feelings. She is a single mother of 2 young boys and receives no child support.
important to treat this to improve this patient’s life and keep her in her job, etc.
Anxiety
Excessive worry Associated physical symptoms Avoidant behavior Unknown internal source (scared of party, don't know why) vs. known external source (bear outside tent) Sense of dread Heightened apprehension
Manifestations of Anxiety
Physical symptoms
Affective symptoms
Cognitive symptoms
Behavioral symptoms
Anxiety Disorders
Normal vs. Pathological Anxiety
Psychologic and physiologic component
Anxiety Disorders are the most common class of mental disorders present in the general population
Affecting 40 million adults in the US in a given year
Only 1/3 suffering receive treatment
Cost $42 billion a year direct/indirect costs. ¾ of cost associated with indirect cost of lost or reduced productivity
Patients with anxiety disorder 5 times more likely to access medical care
Causes of Anxiety
Psychological Theories
Psychoanalytic Theories
– Freud: anxiety is a signal to the ego that an unacceptable drive is pressing for conscious representation
Behavioral Theories
– Anxiety is a conditioned response to a specific environmental stimuli
Biological Theories
- Neurotransmitters
- – Norepinephrine, Serotonin, GABA
Anxiety Disorder Sub-Types
Panic Disorder Agorophbia Generalized Anxiety Specific Phobias Social Anxiety Disorder (Social Phobia) Separation Anxiety Disorder Selective Mutism Anxiety Disorder Due to a General Medical Condition Substance Induced Anxiety Disorder Anxiety Disorder NOS -- Post Traumatic Stress Disorder (not DSM V) -- Obsessive Compulsive Disorder (not DSM V)
Panic Disorder
Recurrent, unexpected panic attacks
Followed by a least one month of:
- Persistent concern about having more attacks
- Worry about the implications of the attacks
- A significant change in behavior related to the attacks
Panic Attack
- A discrete period of intense fear or discomfort associated with multiple physical manifestations developing abruptly and reaching a peak within 10 min
Symptoms of Panic Attack
Palpitations Sweating Tremor Shortness of Breath Chest pain and discomfort Nausea Dizziness Fear of losing control Fear of dying
Agoraphobia
Anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having an unexpected panic attack
Panic Disorder epidemiology
Prevalence: 2% of the population
Sex: 1:2 Male to Female ratio
Usual onset early adulthood
Attacks usually last a few minutes
Associated symptoms of agoraphobia, depression, substance abuse
Higher rate of suicide
Marital tension, conflict at work, financial difficulties, higher rate of accessing medical care
Differential Diagnosis for Panic Disorder
Medical Disorders
- Cardiovascular diseases
- Pulmonary diseases
- Neurological diseases
- Endocrine diseases
- Drug intoxications
- Drug withdrawal
Mental disorders
- Malingering
- Hypochondriasis
- Phobias
- Post traumatic Stress Disorder
Panic Treatment
Pharmacotherapy
- Tricyclics
- SSRIs
- Benzodiazepines (works fast)
Cognitive Behavioral Therapy
- Address patient’s false beliefs about panic attack
- Relaxation techniques, gaining sense of control
Family Therapy
Insight oriented psychodynamic psychotherapy
- Help patient understand the unconscious meaning of the anxiety
Phobias
Phobia: irrational fear resulting in a conscious avoidance of the feared object, activity or situation
The single most common mental disorders in the US
10-25% of population are afflicted
Increased risk for other psychiatric complications including depression and substance abuse
Specific: Fear or avoidance of objects or situations other than agoraphobia or social phobia
- Commonly involves animals, insects, injury or procedures, heights, darkness
Phobias- social
Fear of humiliation or embarrassment in either general or specific social situations
Commonly involving public speaking, urinating in public restrooms, stage fright
phobia Etiology
The pairing of a specific object or situation with the emotions of fear and panic
Genetic factors: specific phobias tend to run in families. Blood, injection, injury high family tendency
Neurochemical factors: patients with performance phobias may release more norepinephrine or epinephrine
Genetic factors: First degree relatives of patients with social phobias are about 3 x more likely to be affected
phobia Clinical Features
Severe anxiety when patient exposed to a specific situation or object or when anticipates such exposure
Panic attacks can occur
Patients avoid the phobic stimulus
Co-morbid substance abuse and depression
Impact on social, occupational, marital relationships
Phobia Treatment
Specific Phobias
- Exposure therapy (behavioral therapy)
- Insight oriented psychotherapy
- Pharmacotherapy (Benzodiazepines, SSRIs)
Social Phobias
- Psychotherapy (behavioral, cognitive, insight oriented)
- Pharmacotherapy (Beta-Blockers, SSRIs, Benzodiazepines, Buspirone)
Obsessive Compulsive Disorder
Lifetime prevalence: 2-3% of population
4th most common psychiatric disorder
Men = Women
Mean age of onset 20 years old
2/3 of cases onset before age of 25 years old
Can occur in childhood; has been seen in 2 year olds
Single more affected than married (? Result of disorder)
Caucasian > African American (access to healthcare)
Etiology of OCD
Biological Factors
- Neurotransmitters
- Dysregulation of serotonin
- Brain imaging studies
- – Increased activity in frontal lobes, basal ganglia, and cingulum; treatment reverses this activity
- – Decreased size of caudates bilaterally
- Genetics
- Non specific EEG abnormalities
Psychological Factors
Learned theory
- Person discovers that a certain action reduces anxiety
- Personality traits
OCD dx
Obsession: A recurrent and intrusive thought, feeling, idea, or sensation
Compulsion: A conscious, standardized, recurrent thought or behavior, such as counting, checking, or avoiding
Obsessions increase a patient’s anxiety
Compulsions decrease a patient’s anxiety
If resist compulsion, anxiety increases
A patient realizes the irrationality of the obsessions
Either obsession or compulsion. Over 75% have both
OCD Clinical Features
Most common pattern compulsion: Obsession of contamination, compulsion of washing, avoiding
Next most common pattern: Doubt, followed by a compulsion of checking
Others:
- Intrusive obsessional thoughts without a compulsion such as a sexual or aggressive act without
- Need for symmetry or precision
Treatment of OCD
Pharmacotherapy
- Clomipramine
- SSRIs
- Lithium
- Benzodiazepines
Psychotherapy
- Behavioral therapy (exposure, response and flooding)
- Family therapy
Other
- ECT
- Psychosurgery (cingulotomy)
Post Traumatic Stress Disorder
Experience an emotional stress of potentially life threatening magnitude that would be traumatic for almost anyone
Re-experiencing of the trauma through dreams and waking thoughts
Persistent avoidance of reminders of the trauma
Numbing of responsiveness to such reminders
Persistent hyperarousal
Symptoms greater than a month
PTSD Epidemiology
Lifetime prevalence estimated to be 1-3% of population
In high risk groups, prevalence rates range from 5-75%
Most prevalent in young adults due to the nature of the precipitating situation
Men usually combat related
Women usually related to assault
Higher rates in single, divorced, widowed, socially withdrawn
PTSD Etiology
The stressor is the prime causative factor
Predisposing vulnerability include presence of childhood trauma, personality disorders, poor social support, genetic vulnerability to psychiatric illness, recent stressful life change, recent excessive alcohol use
PTSD Course
Delay can be as short as a week to as long as 30 years
Symptoms fluctuate over time
Good prognosis predicted by a rapid onset of symptoms, short duration of symptoms, good premorbid functioning, strong support, absence of other psychiatric, medical, or substance disorder
Very young and very old have harder time with trauma
PTSD Treatment
Pharmacotherapy
- SSRIs
- Mood stabilizers
- Hypnotics
- Anxiolytics
- Antipsychotics
Psychotherapy
- Supportive
- Cognitive
- Group
- Family
Generalized Anxiety Disorder
An excessive and pervasive worry accompanied by a variety of somatic symptoms, that cause significant impairment in social or occupational functioning or marked distress
A person finds it difficult to control the anxiety
Not due to the direct physiological affects of a substance
GAD Epidemiology
Prevalence ranges from 3-8 %
Frequently co-exists with another psychiatric disorder
Estimated that 50% of GAD patients have another mental disorder
Ratio 3:2 Women to Men
Age of onset ? “I’ve been anxious as long as I can remember”
Usually first seek treatment in 20’s
GAD Clinical Features
Anxiety, motor tension, autonomic hyperactivity
Shakiness, restlessness, and headaches
Shortness of breath, excessive sweating, palpitations, GI symptoms
Easy startle, irritability
Usually seek out primary care physicians with somatic complaints
Chronic condition, usually life long
Frequently co morbid depression, panic disorder, substance abuse
GAD Treatment
Pharmacotherapy
- Benzodiazepines
- Buspirone
- Mood stabilizers
- Antipsychotics
- SSRIs
Psychotherapy
- Cognitive behavioral
- Insight oriented
- Supportive
