anxiety and adjustment disorders

Question 1

anxiety NTs

Answer 1

• increase NE
• decreased GABA
• decreased 5HT

Question 2

medical causes of anxiety

Answer 2

• hyperthyroidism
• B12 deficiency
• hypoxia
• neurological d/os
• CV disease
• anemia
• pheo
• hypoglycemia

Question 3

mx/substances causing anxiety

Answer 3

• caffeine
• theophylline
• amphetamines
• alcohol/sedative w/drawal
• mercury/arsenic toxicity
• organophosphate or benzene toxicity
• PCN
• sulfonamides
• sympathomimetics
• antidepressants

Question 4

panic attacks

Answer 4

• peak w/in 10 min, last < 25 min
• at least 4 of: palpitations, sweating, shaking, SOB, choking sensation, chest pain, nausea/abdominal distress, light-headedness, depersonalization/derealization, fear of losing control, fear of dying, numbness/tingling, chills, hot flushes
• 1st attack often follows pd of stress/physical exertion
• assoc with medical conditions: MVP, asthma, PE, angina, anaphylaxis

Question 5

panic d/o: diagnosis

Answer 5

• spontaneous recurrent panic attacks
• avg 2x per week, but range to only few times per year
• at least 1 attack followed by minimum 1 mo of: persistent concern about another attack, worry about implications of attack, change in behavior related to attack
• specify whether WITH or W/O agoraphobia

Question 6

pt with chest pain and nl angiogram

Answer 6

• 40% may have panic disorder

Question 7

panic d/o: pathophys

Answer 7

• biological, genetic, psychosocial
• dysregulation of ANS, CNS, cerebral blood flow
• increased NE, decreased 5HT and GABA
• may be induced by caffeine, nicotine, hyperventilation

Question 8

panic d/o: epidemiology

Answer 8

• 2-5% lifetime prevalence
• females 2-3x more than males
• 4-8x risk if first degree relative affected
• onset late teens to early 30s

Question 9

panic d/o: prognosis

Answer 9

• variable course, often chronic
• relapses common with d/c of mx
• 10-20% have significant sx interfering with fn
• 50%: mild, infrequent sx
• 30-40%: free of sx after d/c

Question 10

panic d/o: tx

Answer 10

• SSRIs are best long-term tx; esp paroxetine and sertraline
• start at low dose and increase slowly
• BZOs effective immediately, only short-term tx
• tx for at least 8-12 mos
• relaxation, biofeedback, cognitive tx, psychotherapy

Question 11

agoraphobia

Answer 11

• anxiety –> avoidance
• often develops 2ary to panic attacks
• dx alone or as panic d/o with agoraphobia (50-75% of panic d/o have agoraphobia)
• usually resolves with tx of coexistent panic d/o
• chronic and debilitating if not assoc with panic d/o

Question 12

specific phobia diagnosis

Answer 12

• persistent excessive fear by specific situation/object
• exposure to situation bringing about immediate anxiety response
• patient recognizes that fear is excessive
• situation avoided when possible
• if under age 18, must be at least 6 mos duration

Question 13

social phobia

Answer 13

• same criteria as specific phobia

- situation related to social settings

Question 14

phobias: epidemiology

Answer 14

• most common mental d/os in US
• 5-10% of population
• specific phobia more common than social phobia
• women 2x than men
• social phobia equal in men and women
• substance d/os often comorbid
• 1/3 have assoc major depression

Question 15

phobias: tx

Answer 15

• specific phobias: pharmacotherapy not found effective; behavior therapy (systemic desensitization) effective + short BZO/betaB course as necessary
• social phobia: paroxetine, betaBs (performance anxiety) + cognitive/behavioral therapy adjuncts

Question 16

OCD: diagnosis

Answer 16

EITHER obsessions or compulsions (75% have both)

• recurrent intrusive thoughts that increase anxiety; relieved by compulsions
• ego-dystonic
• obsessions: recurrent/persistent cause anxiety, attempt to suppress, pt realizes they are products of own mind
• compulsions: repetitive behaviors in response to obsession, aimed at reducing distress

Question 17

OCD: epidem

Answer 17

• 2-3% lifetime prevalence
• onset early adulthood
• men = women
• assoc with MDD, eating do, anxiety do, OCPD
• higher rate in pts with 1st degree relatives with Tourette

Question 18

OCD: pathophys

Answer 18

• abnl serotonin regulation
• genetics
• assoc with head injury, epilepsy, basal ganglia, dos, postpartum conditions
• 60% of pts: triggered by stresful life event

Question 19

OCD: prognosis

Answer 19

• 30% pts show significant improvement with tx
• 40-50% moderate improvement
• 20-40%: same or worse

Question 20

OCD: tx

Answer 20

• SSRIs are 1st line, may require high dose
• TCAs: CLOMIPRAMINE
• behavioral therapy + pharmacotherapy best bet - exposure and response prevention
• ECT or surgery in severe refractory cases

Question 21

PTSD: diagnosis

Answer 21

• presence of traumatic experience
• persistent avoidance
• hyperarousal or increased psychological/physiological tension
• reexperiencing traumatic event
• MORE THAN 1 MONTH
• high incidence of assoc substance abuse and depression: AVOID BZOs for tx

Question 22

PTSD: prognosis

Answer 22

• 50% symptom free after 3 mos tx

Question 23

PTSD: tx

Answer 23

• SSRIs, TCAs (imipramine, doxepin), MAOIs
• anticonvulsants (for flashbacks/nightmares)
• therapy, relaxation, support groups

Question 24

acute stress do: diagnosis

Answer 24

• patients experience major traumatic event but experience sx for < 1 mo and w/in 1 mo of trauma
• similar sx and tx to PTSD

Question 25

GAD: diagnosis

Answer 25

• persistent, excessive hyperarousal and anxiety about daily events
• AT LEAST 6 MONTHS
• assoc with 3+ of: restlessness, fatigue, difficulty concentrating, irritability, mm tension, sleep disturbance

Question 26

GAD: epidemiology

Answer 26

• 45% lifetime prevalence
• women 2x as men
• onset before age 20
• 50-90% have coexisting mental d/o, esp MDD, phobia, panic do

Question 27

GAD: prognosis

Answer 27

• chronic, lifelong, fluctuating in 50%

- other 50% completely recover with several years of therapy

Question 28

GAD: tx

Answer 28

• SSRIs, buspirone, venlafaxine

- BZOs for acute episodes byt should be TAPERED WHEN POSSILBE