Anxiety Flashcards
What is anxiety?
Fear – Response specific object or situation that threatens impending injury, death or harm
unpleasant emotional state in which the distress may not be directly attached to feared object or event
Disorder – Out of proportion to the threat
most common psychiatric disorders
Future focus
unpleasant state that may be ameliorated by avoidance behaviors that may be powerfully reinforced Worry Tension Panic Hypervigilance Heightened Startle Response Rumination Avoidance Sleeplessness
What is panic?
a discrete episode of unexpected terror accompanied by a variety of physical symptoms
not a codable disorder
here and now
Why are these important to recognize and treat?
Diagnostic difficulties
Evaluation complicated by medical conditions
Symptoms of illness may mimic, asthma, angina, thyroid disorders
Side effects of medications, Albuterol, Corticosteroids, decongestants
Substance use (caffeine, cocaine) or withdrawal (alcohol, sedatives) may complicate diagnosis
How do anxiety disorders differ from normal fear and stress?
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Be able to describe basic symptoms, presentations and diagnostic criteria related to:Separation Anxiety Disorder
Developmentally inappropriate and excessive anxiety concerning attachment figures
Extreme worry and fear when separating from home or primary care giver
Fear that something bad may happen to themselves or care givers
School refusal or refusal to participate in activities
Physical complaints at time of separating
Lasts 4 weeks in children or 6 months in adults
Be able to describe basic symptoms, presentations and diagnostic criteria related to: Phobia
Marked fear about a specific object or situation
6 months or more
Examples: Spiders,
behavioral therapy (systematic desensitization)
respond to certain medications
7-9% (common)
Social Anxiety Disorder
What is ‘avoidance” and how does it relate to anxiety?
Marked fear about one or more social situations
6 months or more
Individuals fear that they will act in a way to be negatively evaluated by others
out of proportion to the actual threat
Avoidance is common
7% (common)
Generalized Anxiety Disorder
Excessive anxiety and worry occurring more days than not for at least 6 months
difficulty controlling the worry
Three or more of the following: Restlessness Easily fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance Focus of anxiety not confined to features of another axis I disorder
Panic Disorder
Recurrent unexpected panic attacks One month or more of the following: Concern about additional attacks Worry about implication of the attacks Change in Behavior related to attacks Attacks not better accounted for by features of another axis I disorder (e.g. PTSD) With or without avoidance (agorophobia) 2-3% with onset usually in adolescence
What is agoraphobia?
fear or anxiety of 2 or more of the following
Using public transit
open spaces
enclosed spaces
line or being in a crowd
outside the home alone
Fear of having marked anxiety or panic like symptoms
Fear is out of proportion and last 6 months or longer
Causes distress, social or occupational impairment
associated with avoidance behavior
What is the role of trauma in the diagnosis of PTSD?
Post-Traumatic Stress Disorder Complex Trauma C-PTSD Developmental Trauma Disorder Areas of controversy in psychiatry Not recognized in DSMIV or DSM5 Differential: Personality disorders, substance use disorder versus trauma Overlap with Social Justice theories
What is the role of trauma in the diagnosis of PTSD?
Complex Trauma Developmental Trauma Disorder controversy Not recognized in DSMIV or DSM5 Differential: Personality disorders, substance use disorder versus trauma Overlap with Social Justice theories
Understand co-occurrence of anxiety disorders and/or depressive disorders. Frequency?
70% of social anxiety
disorder patients have
depression**
50% to 65% of panic disorder patients have depression†
67% of OCD patients have depression*
49% of social anxiety disorder patients have panic disorder**
11% of social anxiety disorder patients have OCD**
What are the pros and cons regarding the use of benzodiazepines?
Pros Generally quite effective Don’t cause: weight gain anticholinergic side effects sexual dysfunction diabetes or elevate cholesterol EPS or Tardive dyskinesia Cost pennies.
Cons abused or misused diverted impair motor function impair cognition Short term? Long term? Synergistic effects with other substances May contribute to clinic chaos
What are problems associated with benzodiazepines in the treatment of sleep and anxiety? Red flags?
Antidepressants:Buproprion (Wellbutrin)
exacerbate anxiety symptoms or insomnia
No current indication for treatment of anxiety
Red flags for concern: Lost prescriptions Multiple prescribers Running out early Dose escalation Evidence of measurable impairment Combination with other substances
What are the pros and cons regarding treatment of anxiety with the following medication classes? Antidepressants
Pros
Less likely to cause sexual dysfunction
Very effective for depression and long-term management of anxiety disorders.
cons Less well tolerated . exacerbate anxiety symptoms or insomnia No current indication for treatment of anxiety weight gain problematic. Risk of overdosage
What are the pros and cons regarding treatment of anxiety with the following medication classes?
Buspirone
Generally safe and well tolerated
questionable in a community population
questionable in a population previously exposed to benzodiazepines.
No efficacy in panic
What are the pros and cons regarding treatment of anxiety with the following medication classes? Antihistamines
Frequently used for anxiety over many decades
Generally safe and well tolerated
Cognitive impairment in elderly or frail
What are the pros and cons regarding treatment of anxiety with the following medication classes?
Beta Blockers
Frequently used for anxiety over many decades
safe and well tolerated
Generally seen as a blocker of physiological symptoms of anxiety as opposed to true anxiolytics
block “self fulfilling” nature of anxiety and panic
What are common components of “Sleep Hygiene?
Sleep Hygiene (sleep diet)
Regular Schedule
Bed for sleep and sex only
No more than 15 minutes in bed without sleep
Limit late caffeine, exercise or emotional activity
Effective sleep aid in top drawer Sleep Promotion Sedative (benzodiazepines, benzo like agents) Antidepressants Trazadone Mirtazapine (Remeron) TCAs Antihistamines (benadryl) Valerian, Melatonin, Camomile, Te de Siete Azahares
Tapering Benzodiazepines
> 2-4 weeks for receptor dependence
Withdrawal more severe with shorter acting BZDs Taper 10-25% dose every 1-2 weeks (slower if needed) Consider switch to longer-acting for easier tapering
What are the pros and cons regarding treatment of anxiety with the following medication classes?
Less well tolerated across a wide dosage range.
Less likely to cause sexual dysfunction
weight gain problematic.
Risk of overdosage
Very effective for depression and long-term management of anxiety disorders.
Antidepressants:Selective Serotonin Re-uptake Inhibitors (SSRI)
All tolerated across a wide dosage range
All may cause sexual dysfunction or weight gain
Very effective for depression and long-term management of anxiety disorders
May take weeks to be effective
May require higher doses than for depression treatment (especially OCD)
Watch out for paradoxical agitation
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