Anxiety and Adjustment Disorders Flashcards
What is anxiety?
What are some autonomic symptoms of anxiety?
- The subjective experience of fear and its physical manifestations
- Autonomic symptoms
- Palpitations
- Perspiration
- Dizziness
- Mydriasis
- GI disturbances
- Urinary urgency & frequency
What is the etiology of anxiety disorders?
- Combination of genetic, environmental, biological and psychosocial factors
- Neurotransmitter disturbances
- Increased NE
- Decreased GABA & serotonin
Anxiety disorders
Women: ___%
Men: ___%
(High/Low) socioeconomic groups
- Women: 30% lifetime prevalence
- Men: 19% lifetime prevalence
- Higher socioeconomic groups
What are the 9 primary anxiety disorders?
- Panic disorder
- Agoraphobia
- Specific and social phobias
- Obsessive-compulsive disorder
- Posttraumatic stress disorder
- Acute stress disorder
- Generalized anxiety disorder
- Anxiety disorder secondary to general medical condition
- Substance-induced anxiety disorder
What at 8 medical causes of anxiety disorders?
- Hyperthyroidism
- Vitamin B12 deficiency
- Hypoxia
- Neurological disorders
- Epilepsy, brain tumors, MS
- Cardiovascular disease
- Anemia
- Pheochromocytoma
- Hypoglycemia
What are the 10 medication or substance-induced anxiety disorders?
- Caffeine intake and withdrawal
- Amphetamines
- Alcohol and sedative withdrawal
- Other illicit drug withdrawal
- Mercury or arsenic toxicity
- Organophosphate or benzene toxicity
- Penicillin
- Sulfonamides
- Sympathomimetics
- Antidepressants
How long do panic attacks last?
Are they provoked?
- Often peak in several minutes and subside within 25 minutes
- Rarely last >1 hour
- Attacks unexpected or provoked by triggers
- “Sudden rush of fear”
What is the DSM IV criteria for a panic attack?
Discrete period of intense fear and discomfort that is accompanied by at least 4 of the following:
- Palpitations
- Sweating
- Shaking
- Shortness of breath
- Choking sensation
- Chest pain
- Nausea
- Light-headedness
- Depersonalization (feeling detached from oneself)
- Fear of losing control or “going crazy”
- Fear of dying
- Numbness or tingling
- Chills or hot flushes
What is the DSM IV criteria for panic disorder?
- Spontaneous recurrent panic attacks with no obvious precipitant
- At least 1 of the attacks has been followed by a minimum of 1 month of the following:
- Persistent concern about having additional attacks
- Worry about the implications of the attack (“Am I out of control?”)
- A significant change in behavior related to the attacks (avoid situations that may provoke attacks)
How should panic disorder by specified?
with or without agoraphobia
How do panic attacks related to panic disorder present?
How often do they occur?
- 1st panic attack unexpected
- Physical symptoms
- Tachycardia, sweating, SOB
- Extreme fear w/o understanding the source
- May sense impending death or harm
- Attacks on average 2x/week
- 20-30 min long
- Common: anticipatory anxiety
What is the etiology of panic disorder?
- Biological, genetic & psychosocial factors
- Dysregulation of the autonomic nervous system, CNS & cerebral blood flow
- Increased NE
- Decreased serotonin & GABA
What are some examples of panic-inducing substances?
- Hyperventilation or its treatment (inhalation of CO2/breathing in & out of a paper bag)
- Caffeine
- Nicotine
Panic disorder
- Lifetime prevalence
- Female vs. Male
- Genetics
- Age of onset
- Lifetime prevalence: 2-5%
- 2-3x more common in females than males
- Strong genetic component
- 4-8x greater risk if 1st degree relative affected
- Onset: late teens to early thirties (avg 25)
What are 4 conditions frequently associated with both panic disorder & agoraphobia?
- Major depression (40-80%)
- Substance dependence (20-40%)
- Social & specific phobias
- Obsessive-compulsive disorder
Differential diagnosis for panic disorder
Medical
- Cardiac
- CHF, angina, MI
- Endocrine
- Thyrotoxicosis, pheochromocytoma, carcinoid syndrome
- Neuro
- Temporal lobe epilepsy, MS
- Pulmonary
- COPD
Differential diagnosis for panic disorder
Mental
- Depressive disorders
- Phobic disorders
- Obsessive-compulsive disorders
- Posttraumatic stress disorder
Differential diagnosis for panic disorder
Drug
- Amphetamine
- Caffeine
- Nicotine
- Cocaine
- Hallucinogen intoxication
- Alcohol or opiate withdrawal
What is the prognosis for patients with panic disorder?
- 10-20% continue to have significant symptoms that interfere with daily functioning
- 50% continue to have mild, infrequent symptoms
- 30-40% remain free of symptoms after treatment
What drugs are used to treat panic disorder?
When are they used?
How long are they used for?
-
Benzodiazepines
- Acute initial treatment of anxiety
- Dose should be tapered with SSRI intro
-
SSRIs
- Maintenance
- Paroxetine, sertraline
- 2-4 weeks to become effective
- Treatment for 8-12 months
- Relapse common
What are some alternatives to drugs for panic disorder?
- Relaxation training
- Biofeedback
- Cognitive therapy
- Insight-oriented psychotherapy
- Family therapy
Why start SSRIs at low dose and increase slowly?
- Activation side effects
- Anxiety symptoms that mimic those of panic
In agoraphobia patients, ___% have coexisting panic disorder.
50-75%
What is the DSM-IV criteria for agoraphobia?
- Anxiety about being in places or situations from which escape might be difficult, or in which help would not be readily available in the event of a panic attack
- The situations are either avoided, endured with severe distress, or faced only with the presence of a companion
- These symptoms cannot be better explained by another mental disorder
What are the typical fears of agoraphobia?
- Being outside the home alone
- Being on a bridge or in a crowd
- Riding in a car, bus or train
What is an example of the relationship between panic attacks and agoraphobia?
Clinical progression
- A person who has a panic attack while shopping in a large supermarket subsequently develops a fear of entering that supermarket.
- As the person experiences more panic attacks in different settings, he or she develops a progressive and more general fear of public spaces (agoraphobia)
How is agoraphobia treated?
- SSRIs are first-line treatment
- Behavioral therapy
- As coexisting panic disorder is treated, agoraphobia usually resolves
- When not associated with a panic disorder, agoraphobia is chronic and debilitating
phobia vs. specific phobia vs. social phobia
- Phobia - irrational fear that leads to avoidance of the feared object or situation
- Specific phobia - strong, exaggerated fear of a specific object or situation
- Social phobia - fear of social situations in which embarrassment can occur (social anxiety disorder)
What are some common specific phobias?
- Fear of animals
- Fear of heights
- Fear of blood or needles
- Fear of illness or injury
- Fear of death
- Fear of flying
What are some common social phobias?
- Speaking in public
- Eating in public
- Using public restrooms
What is the DSM-IV criteria for specific phobias?
- Persistent excessive fear brought on by a specific situation or object
- Exposure to the situation beings about an immediate anxiety response
- Patient recognizes that the fear is excessive
- The situation is avoided when possible or tolerated with intense anxiety
- If person is under age 18, duration must be at least 6 months
What is the DSM-IV criteria for social phobia?
- Same as specific phobia
- Except that the feared situation is related to social settings in which the patient might be embarrassed or humiliated in front of other people
What are the most common mental disorders in the United States?
Phobias
Phobias
- ___% of the population
- Specific vs. Social
- Age of onset
- 5-10% of the population (some report 25%)
- Specific >> Social
- Onset at early as 5 for blood, as old as 35 for situational fears
- Average age for social phobias: mid-teens
Men vs. Women for social & specific phobias
- Specific phobia
- Women 2x more than men
- Social phobia
- Women = men
How do genetics play a role in the etiology of phobias?
- Fear of seeing blood may be associated with an inherited, exaggerated vasovagal response
- 1st degree relatives of patients w/ social phobias 3x more likely to develop the disorder
How do behaviors play a role in the etiology of phobias?
- Phobias may develop through association with traumatic events
- Ex: people who were in a car accident may develop a specific phobia for driving
How do neurochemical components play a role in the etiology of phobias?
- Overproduction of adrenergic NTs may contribute to anxiety symptoms
- Ex: performance anxiety is often successfully treated with beta blockers
What is the treatment for specific phobias?
- Pharmacological treatment NOT effective
- Systemic desensitization
- Supportive psychotherapy
- Short course of benzos or beta blockers may be used to control autonomic symptoms
What is systemic desensitization?
Gradually expose patient to feared object or situation while teaching relaxation and breathing techniques
What is the treatment for social phobias?
- SSRIs
- Paroxetine (Paxil)
- Beta blockers
- Cognitive & behavioral therapies
What is the definition of an obsession?
A recurrent or intrusive thought, feeling or idea
What is the definition of a compulsion?
A conscious repetitive behavior linked to an obsession that, when performed, functions to relieve anxiety caused by the obsession
What are the definitions of insight and ego-dystonic in the context of OCD?
- Insight
- Patients are generally aware of their problems and realize that their thoughts and behaviors are irrational
- Ego-dystonic
- Symptoms cause significant stress in their lives, patients with they could get rid of them
What is the DSM-IV criteria for Obsessive-compulsive disorder?
Either obsessions or compulsions as defined below:
-
Obsessions
- Recurrent & persistent intrusive thoughts or impulses that cause marked anxiety and are not simply excessive worries about real problems
- Person attempts to suppress the thoughts
- Person realizes thoughts are product of his or her own mind
-
Compulsions
- Repetitive behaviors that the person feels driven to perform in response to an obsession
- The behaviors are aimed at reducing distress, but there is no realistic link between the behavior and the distress
- The person is aware that the obsessions and compulsions are unreasonable and excessive
- The obsessions cause marked distress, are time consuming or significantly interfere w/ daily functioning
What are the 4 common patterns of obsessions & compulsions?
- Obsessions about contamination followed by excessive washing or compulsive avoidance of the feared contaminant
- Obsessions of doubt (forgetting to turn off the stove, lock the door) followed by repeated checking to avoid potential danger
- Obsessions about symmetry followed by compulsively slow performance of a task (eating, showering, etc)
- Intrusive thoughts with no compulsion. Thoughts are often sexual or violent.
OCD
- Lifetime prevalence: ___%
- Age of onset
- Men vs. Women
- Lifetime prevalence: 2-3%
- Onset in early adulthood
- Men = Women
- Rate higher if 1st degree relatives w/ Tourette’s
OCD is associated with…
- Major depressive disorder
- Eating disorders
- Other anxiety disorders
- OCD personality disorder
What are the 3 common etiologies of OCD?
-
Neurochemical
- Abnormal regulation of serotonin
-
Genetic
- Rates higher in 1st degree relatives and monozygotic twins than the general population
-
Psychosocial
- Onset triggered by a stressful life event in 60% of patients
OCD
___% show significant improvement w/o treatment
___% have moderate improvement
___% remain significantly impaired or experience worsening of symptoms
30% show significant improvement w/o treatment
40-50% have moderate improvement
20-40% remain significantly impaired or experience worsening of symptoms
What pharmacologic treatment is used for OCD?
- SSRIs are the first line of treatment
- Higher than normal doses may be required
- TCAs (clomipramine)
What behavioral treatments are used for OCD?
- Best outcomes achieved with behavioral therapy and drugs are used simultaneously
-
Exposure & response prevention (ERP)
- Prolonged exposure to the ritual-eliciting stimulus and prevention of receiving compulsion
- Relaxation techniques employed to help the patient manage the anxiety that occurs when the compulsion is prevented
What is considered “last resort” for treatment of OCD?
Electroconvulsive therapy (ECT)
Surgery (cingulotomy)
What is the DSM-IV criteria for PTSD?
- Having experienced or witnessed a traumatic event (war, rape, natural disaster). The event was potentially harmful or fatal, and the initial reaction was fear or horror
- Persistent reexperiencing of the event (dreams, flashbacks, recurrent recollections)
- Avoidance of stimuli associated with the trauma (avoiding location or difficulty recalling details)
- Numbing of responsiveness (limited range of affect, feelings of detachment or estrangement from others, etc)
- Persistent symptoms of increased arousal (difficulty sleeping, outbursts of anger, exaggerated startle response, difficulty concentrating)
- Symptoms must be present for at least 1 month
What are the comorbidities and prognosis of PTSD?
- High incidence of associated substance abuse and depression
- 1/2 patients remain symptom free after 3 months of treatment
How is PTSD treated?
- Pharmacological
- TCAs - imipramine & doxepin
- SSRIs, MAOIs
- Anticonvulsants (for flashbacks & nightmares)
- Other
- Psychotherapy
- Relaxation training
- Support groups, family therapy
What is the DSM-IV criteria for acute stress disorder?
- Reserved for patients who experience a major traumatic event but have anxiety symptoms for only a short duration
- Symptoms must occur w/i 1 month of the trauma
- Last for a maximum of 1 month
- Symptoms similar to PTSD
PTSD vs. Acute Stress Disorder
-
PTSD
- Event occurred at any time in the past
- Symptoms last >1 month
-
Acute Stress Disorder
- Event occurred <1 month ago
- Symptoms last <1 month
- Both are treated the same
What is the DSM-IV criteria for generalized anxiety disorder?
- Excessive anxiety & worry about daily events and activities for at least 6 months
- It is difficult to control the worry
- Must be associated with at least 3 of the following:
- Restlessness
- Fatigue
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
Generalized Anxiety Disorder
- Lifetime prevalence: ___%
- Women vs. Men
- Age of onset
- Lifetime prevalence: 45%
- GAD is very common in the general population
- Women 2x more likely to have GAD than men
- Onset usually before age 20
- Many patients report lifetime of “feeling anxious”
What is the clinical presentation of a patient with GAD?
- Most patients do not initially seek psychiatric help
- Most seek out a specialist because of their somatic complaints that accompany this disorder, such as muscle tension or fatigue
GAD
- Etiology
- Comorbidities
- Prognosis
- Biological & psychosocial
- 50-90% have a coexisting mental disorder
- Major depression
- Social or specific phobia
- Panic disorder
- Chronic, with lifelong fluctuating symptoms in 50% of patients; the other half fully recover w/i several years of therapy
How is GAD treated?
- Pharm
- Buspirone
- Benzodiazepines (clonazepam, diazepam)
- Taper ASAP due to risk of dependence
- SSRIs
- Venlafaxine (extended release)
- Other
- Behavioral therapy
- Psychotherapy
What is the DSM-IV criteria for adjustment disorders?
- Development of emotional or behavioral symptoms w/i 3 mo after a stressful life event. These symptoms produce either:
- Severe distress in excess of what would be expected after such an event
- Significant impairment in daily functioning
- The symptoms are not those of bereavement
- Symptoms resolve w/i 6 mo after stressor has terminated
What are the subtypes of adjustment disorders?
Coded based on predominance of either depressed mood, anxiety, disturbance of conduct (such as aggression) or combinations of the above
Adjustment disorders
- Prevalence
- Females vs. Males
- Age of onset
- Very common
- Females 2x more than males
- Most frequently diagnosed in adolescents
What is the etiology and prognosis of adjustment disorders?
- Triggered by psychosocial factors
- May be chronic if stressor is recurrent
- Symptoms resolve w/i 6 mo of cessation of stressor (by definition)
