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Behavioral dynamics > anxiety and stress disorders > Flashcards

anxiety and stress disorders Flashcards

1
Q

what is normal fear?

A

emotional reaction to a real, external threat perceived as painful, dangerous, or harmful
- Focused on a specific stimulus
- Relatively short duration
- Geared towards the present
- Goal → get away from or eliminate the threat

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2
Q

what is anxiety

A

apprehension, nervousness, or dread associated with an anticipated event or an unknown, vague stimulus
* Broadly aimed at a nonspecific stimulus
* Relatively long duration
* Geared towards the future
* Goal - use caution to avoid possible negative future outcomes

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3
Q

When is anxiety pathologic?

A
  1. Present without an obvious or reasonable cause
  2. Excessive and out-of-proportion to actual threat
  3. Causes distress, functional impairment, and/or reduced quality of life
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4
Q

Individuals with anxiety disorders have been shown to often have maladaptive cognition, including:

A

1. Judgement biases
- Interpreting situations in a threatening manner
- Overestimating the likelihood of negative events
2. Attentive biases
- Overreacting to threatening stimuli
3. Avoidant behaviors
- Excessive preparation
- Checking behaviors
- Procrastination
4. Low self-confidence in problem solving skills

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5
Q

____ are oriented toward identifying how thoughts influence behaviors and perception of outcomes

A

Cognitive-based therapies

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6
Q

what is Cognitive Restructuring

A
  1. Identifying negative thoughts
  2. Challenging negative thoughts
  3. Replacing negative thoughts with realistic thoughts
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7
Q

3 stress managements

A
  1. Time management techniques
    - To-do lists, schedules, organization
  2. Relaxation techniques
    - Yoga, meditation, exercise, deep breathing, biofeedback, muscle relaxation
  3. Social support systems
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8
Q

3 exposure therapies

A
  1. Desensitization - exposing patients in small doses that gradually become more intense
    - taught relaxation techniques
  2. Modeling - patient observes other individuals who are around stimuli
  3. Flooding - exposed to stimulus that causes anxiety at its worst and made to use relaxation techniques to get through the experience
    - Quicker than systematic desensitization
    - May have spontaneous relapses
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9
Q

short term medications for anxiety disorders

A
  1. Benzodiazepines (BZDs)
  2. Hydroxyzine

Short-Term/PRN Therapy

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10
Q

what are the long-term medications

A
  1. First-Line - SSRIs, SNRIs
  2. Second-Line - Buspirone, TCAs, BZDs, antipsychotics
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11
Q

what medication enhances the effect of GABA at the GABA receptor

A

Benzodiazepines

benzos, BZDs

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12
Q

uses for benzos

A
  1. anxiety
  2. panic
  3. insomnia
  4. ETOH withdrawal
  5. agitation
  6. seizures
  7. procedural sedation
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13
Q

SE of benzos

A
  1. drowsiness, dizziness
  2. decreased motor coordination
  3. decreased libido
  4. disinhibition
  5. rebound anxiety
  6. amnesia
  7. suicidal ideation
    8. Risk for dependence and withdrawal
  8. Rare - respiratory depression, paradoxical effects
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14
Q

DDI of benzos

A

ETOH, opioids, and other CNS depressants, anticonvulsants, antidepressants, antifungals

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15
Q

CI for benzos

A
  • pregnancy, BZD allergy, myasthenia gravis, narrow-angle glaucoma
  • Risk for respiratory depression - COPD, sleep apnea, myasthenia gravis
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16
Q

which benzo has a high abuse potential, commonly for panics

A

Alprazolam (Xanax)
intermediate acting

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17
Q

which medication is commonly used for Procedural Sedation

A

Midazolam (Versed)

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18
Q

which drug is commonly used for insomnia

short acting

A

Triazolam (Halcion)

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19
Q

which drug is commonly used for insomnia

intermediate-acting

A

Temazepam (Restoril)

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20
Q

which drug is commonly use for alc withdrawal and anxiety

long-acting

A

chlordiazepoxide (librium)

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21
Q

which drug is commonly used for insomnia

long acting

A

flurazepam (dalmane)

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22
Q

how can you avoid dependency on benzos

A
  1. Use PRN only
  2. limited time use (1-4 weeks)
  3. Cautioning of potential for dependency,
    tolerance and addiction
  4. Avoiding use in pts with substance
    abuse (current or history of)
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23
Q

how can you avoid withdrawal from benzos

A
  1. 10-25% dose reduction per 1-2 weeks
  2. Slower taper if s/s of withdrawal - Anxiety, dysphoria, tremor, seizures
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24
Q

which medication acts as a Histamine (H1) receptor antagonist
Anxiolytic, muscle relaxant, antihistamine, antiemetic, sedating
May be helpful for insomnia due to anxiety

A

Hydroxyzine

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25
Q

Vistaril

A

hydroxyzine

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26
Q

Atarax

A

hydroxyzine

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27
Q

SE of hydroxyzine

A

drowsiness, dizziness, dry mouth, rash, fatigue, respiratory depression

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28
Q

DDI of hydroxyzine

A

potassium, MAOIs, CNS depressants

29
Q

CI for hydroxyzine

A

allergy to med
1st trimester of pregnancy,
administration via SC, IV, or intra-arterial routes

30
Q

which medication acts as a 5HT-1a receptor agonist; also acts on dopamine receptors
More effective for **cognitive anxiety s/s **than somatic s/s

A

Buspirone (Buspar)

No abuse/dependence potential, no withdrawal

31
Q

Often used to augment SSRIs/SNRIs or in pregnant pts

A

Buspirone

32
Q

this medication may by more helpful for benzo-naive patients

A

Buspirone

Less anxiolytic effects than BZDs

33
Q

SE of buspirone

A
  1. dizziness, drowsiness, nausea, headache
  2. Concern over potential for Serotonin Syndrome
34
Q

DDI of buspirone

A

other psych meds, CNS depressants

35
Q

GAD is MC in who?

epidemiology

A

women (2x)
35+
comorbidities - MDD, substance abuse, other anxiety disorders, chronic unexplained pain

36
Q

criteria for GAD

A
  1. Excessive anxiety and worry (apprehensive expectation) more days than not
    - about multiple things
    - for at least 6 months
    - Patient finds it difficult to control
  2. Anxiety/worry associated with 3+ of the following:
    - Restlessness or feeling keyed up/on edge
    - Being easily fatigued
    - Difficulty concentrating
  3. Syndrome causes distress and/or functional impairment
  4. Syndrome is not due to substance abuse or medical condition
37
Q

presentation of GAD

A

persistent worry + hyperarousal
- More worry over minor matters
- Somatic s/s - muscle tension, headaches, neck and back pain

38
Q

screenings for GAD

A
  1. Generalized Anxiety Disorder-7 (GAD-7)
    - Initial screening for GAD
    - Monitor severity of s/s and response to tx
  2. Beck Anxiety Inventory
    - 21-question self-reported inventory of s/s
    - Can be used for GAD or other anxiety disorders
    - No overlap with depressive s/s
39
Q

tx for GAD

A
  1. First-Line - SSRI/SNRI, CBT, or both
    - BZDs - short-term for severe s/s
  2. second-line - TCAs, buspirone
    - BZDs have been used for long-term tx in some patients
    - Mirtazapine, 5HT modulators, Pregabalin (Lyrica), 2nd gen antipsychotics
  3. Adjunct - Relaxation techniques, acupuncture, exercise

Therapy continued for 6-12 months

40
Q

intense fear or discomfort with multiple accompanying symptoms

A

panic attacks

41
Q

anxiety about and/or avoidance of situations where help may not be available or leaving would be difficult if the patient were to develop incapacitating or embarrassing symptoms

A

Agoraphobia

Separate diagnosis in DSM-V

42
Q

criteria for panic attacks

A
  1. Abrupt surge of intense fear/discomfort that peaks within minutes
  2. Accompanied by 4+ of the following:
    * Palpitations, pounding heart, or accelerated heart rate
    * Sweating
    * Trembling or shaking
    * Sensations of shortness of breath, choking, or smothering
    * Chest pain or discomfort
    * Nausea or abdominal distress
    * Feeling dizzy, unsteady, lightheaded, or faint
    * Chills or heat sensations
    * Paresthesias
    * Derealization or depersonalization
    * Fear of losing control, dying, or “going crazy”
  3. Recurrent unexpected panic attacks
  4. 1+ attacks have been followed by 1+ months of one or both of the following:
    * Persistent concern or worry about additional panic attacks
    * or their consequences
    * Significant maladaptive change in behavior due to the attacks
  5. Syndrome is not due to substance or medical condition
  6. Syndrome is not better explained by other mental disorder
    * Panic attacks do not occur only in response to specific triggers
43
Q

which psych disorder places more emphasis on physical symptoms, hx of somatization

A

Somatization Disorder

44
Q

psych disorder where other psych symptoms/occurrences are more predominant

A

Anxiety Disorders, Depressive Disorders

45
Q

tx for panic disorder

A
  1. First-Line - CBT, SSRI, or combination
    - Paroxetine - sedating effects, can help calm patients
  2. Second-Line - SNRIs; TCAs
  3. Adjunct - BZDs (short-term/PRN use)
    - Alprazolam - FDA approved, treats panic disorder, MC for short time to onset - Risk of dependency, rebound anxiety
    - Clonazepam - FDA-approved for panic disorder -Less risk of rebound anxiety, fewer doses/day
    - Lorazepam and diazepam
46
Q

criteria for agoraphobia

A
  1. Persistent (6+ months) of marked fear/anxiety about 2+ of the following:
    * Using public transportation
    * Being in open spaces (e.g., parking lots, marketplaces, bridges)
    * Being in enclosed places (e.g., shops, theaters, cinemas)
    * Standing in line or being in a crowd
    * Being outside of the home alone
  2. Pt fears/avoids these situations due to fear that escape might be difficult or help might not be available in the event of developing incapacitating or embarrassing s/s
  3. Syndrome causes distress or functional impairment
  4. Syndrome is not better explained by another mental disorder
47
Q

Tx for agoraphobia

A

SSRI, CBT, or both
Current guidelines are to treat as one would for panic disorder

48
Q

criteria for social anxiety disorder

A
  1. Persistent (6+ months) of marked fear/anxiety about 1+ social situations in which the pt is exposed to possible scrutiny by others
  2. Pt fears acting in a way or showing anxiety s/s that will be negatively evaluated
  3. The social situations almost always provoke fear or anxiety
    * In children - crying, tantrums, freezing, clinging, shrinking, failing to speak
  4. The social situations are avoided or endured with intense fear or anxiety
  5. Fear/anxiety is out of proportion to the actual threat posed
  6. Fear/anxiety or avoidance causes distress or functional impairment
  7. Not due to substance use, medical condition, or another psych disorder
49
Q

what is the subtype for social anxiety disorder

A

If only related to performance and not general social interaction, may use modifier “performance-only” (versus “generalized”)

50
Q

tx for social anxiety disorder

A
  1. Generalized Social Anxiety Disorder
    * First-Line - CBT, SSRI or SNRI, or both
    * May choose to augment with PRN BZD
    * Continue tx for at least 6-12 months
  2. Performance-Only Social Anxiety Disorder
    * PRN BZD - 30-60 min before performance
    * PRN beta-blocker - Propranolol 20-60 mg, 30-60 min before performance
  3. May augment with relaxation techniques
51
Q

how does acute stress disorder differ from PTSD

A

in timing of onset and duration

52
Q

criteria of acute stress disorder

A
  1. Exposure to actual or threatened death, serious injury, or sexual violation in 1+ of the following ways:
    * Directly experiencing traumatic event(s)
    * Witnessing, in person, event(s) as it occurred to others
    * Learning that event(s) occurred to close family/friend
    * Experiencing repeated or extreme exposure to aversive details of traumatic event(s)
  2. 9+ of the following symptoms from any category, beginning or worsening after event(s) occurred, lasting at least 3 days - 1 month after trauma:
    * Intrusion symptoms - Dissociative reactions
    * Negative mood
    * Dissociative symptoms
    * Avoidance symptoms
    * Arousal symptoms
53
Q

tx for acute stress disorder

A
  1. Goal - lessen stress response and reduce or prevent progression to PTSD
  2. First-Line - Trauma-oriented CBT with incorporated exposure therapy
    * Adjunct - short-term (~2 weeks) use of BZDs in patients with severe s/s such as agitation or insomnia
    * May need suicide interventions and inpatient treatment
    * Antidepressants - often limited due to time to onset of efficacy
54
Q

depressive disorders, anxiety disorders, and substance abuse are how much more common than in the general population that experience PTSD

A

2-4x more common

  • Substance abuse - to self-medicate
  • Somatization disorder - 90x MC in PTSD
  • TBI - 60% of TBI pts also have PTSD
55
Q

criteria for PTSD

A
  1. Exposure to actual or threatened death, serious injury, or sexual violation in 1+ of the following ways:
    * Directly experiencing traumatic event(s)
    * Witnessing, in person, event(s) as it occurred to others
    * Learning that event(s) occurred to close family/friend
    * Experiencing repeated or extreme exposure to aversive details of traumatic event(s)
  2. 1+ intrusion symptoms associated with the trauma, beginning after trauma, lasting 1+ month:
    * Recurrent, involuntary, and intrusive distressing memories of trauma
    * Recurrent distressing dreams related to the trauma
    * Dissociative reactions in which the individual feels or acts as if the trauma were recurring (e.g., flashbacks)
    * Psychological distress and/or physiological reactions to cues (internal or external) that symbolize or resemble the trauma
  3. Alterations in arousal/reactivity associated with trauma, beginning or worsening after trauma, lasting 1+ months, as evidenced by 2+ of the following:
    - Irritable behavior and angry outbursts
    - Reckless or self-destructive behavior
    - Hypervigilance
    - Exaggerated startle response
    - Problems with concentration
    - Sleep disturbance
  4. Persistent avoidance of stimuli associated with trauma, beginning after trauma and lasting 1+ months, as evidenced by one or both of:
    - Efforts to avoid distressing memories, thoughts, or feelings about the trauma
    - Efforts to avoid external reminders that arouse memories, thoughts, or feelings about the trauma
  5. Negative changes in cognition/mood, associated with trauma, beginning or worsening after trauma, lasting 1+ months, as evidenced by 2+ of:
    - Inability to remember an important aspect of the trauma
    - Exaggerated negative beliefs about oneself, others, or the world
    - Distorted thoughts about the cause or consequences of the trauma that lead the pt to blame himself/herself or others
    - Persistent negative emotional state
    - Markedly diminished interest or participation in significant activities
    - Feelings of detachment or estrangement from others
    - Persistent inability to experience positive emotions
56
Q

tx for PTSD

A
  1. First-Line -Trauma-oriented CBT with exposure therapies
    * Psychotherapy or combination often preferred over pharmacotherapy alone…but not always easy to implement
  2. Medications - SSRIs or SNRIs
    * Atypical antipsychotics - refractory cases
    * Prazosin (Minipress) - α1-adrenergic blocker - insomnia
    * BZDs - severe agitation, hyperarousal
57
Q

Characterized by the presence of pathologic obsessions, compulsions, or both
Time-consuming and distressing
Cause functional impairment

A

Obsessive compulsive disorder
Most patients suffer from both obsessions and compulsions
Many patients recognize their thoughts and behaviors are abnormal and take avoidant actions to hide them

58
Q

recurrent intrusive unwanted thoughts, images, or urges that typically cause anxiety or distress

A

Obsessions - mental event

59
Q

repetitive acts that pt feels driven to perform, either due to an obsession or according to rules that he/she believes must be applied rigidly

A

Compulsions - behavioral event

Not rationally connected or act is clearly excessive

60
Q

what are the MC obsessions/compulsions

A
  1. Cleaning - fears of contamination; cleaning rituals
  2. Symmetry - symmetry obsessions; repeating, ordering, and counting compulsions
  3. Forbidden or taboo thoughts - Aggressive, sexual, and religious obsessions; related compulsions
  4. Harm - thoughts about harm befalling oneself or others; checking and precautionary compulsions
61
Q

degrees of insight into illness (OCD)

A
  1. Good or fair insight - recognizes OCD beliefs are definitely or probably not true, or that they may or may not be true
  2. Poor insight - thinks OCD beliefs are probably true
  3. Absent insight/delusional beliefs - completely convinced that OCD beliefs are true
62
Q

tx for OCD

A
  1. First-Line - CBT with exposure therapy, SSRI, or combination
    * Psychotherapy preferred for OCD alone
    * Due to high rate of comorbid psych disorders - using SSRI is often beneficial
  2. often need higher maintenance doses of SSRI therapy
  3. If no response to SSRI - may try other SSRI or SNRI
63
Q

intense, irrational fear of a particular object or situation
May be triggered by:
Anticipation of stimulus
Actual exposure to stimulus
Non-stimulus reminders

A

phobia

64
Q

criteria for phobia

A
  1. Persistent (6+ months) of marked fear/anxiety about a specific
    object or situation
  2. Phobic object/situation almost always causes immediate fear/anxiety
  3. Phobic object/situation is actively avoided or endured with intense fear or anxiety
  4. Fear/anxiety is out of proportionto the actual danger posed by object/situation
  5. Fear/anxiety or avoidance causes distress or functional impairment
  6. Syndrome is not better explained by another mental disorder
65
Q

tx for phobia

A
  1. First-Line - CBT with exposure therapy
  2. Second-Line: Infrequently Encountered Stimulus - PRN treatment with BZD
  3. Second-Line: Frequently Encountered Stimulus - SSRI, SNRI
66
Q

which intermediate-acting benzo is indicated for Insomnia, ETOH withdrawal

A

Oxazepam (Serax)

67
Q

which intermediate-acting benzo is indicated for Anxiety, Seizures, Agitation, ETOH withdrawal, Insomnia, Procedural sedation

A

Lorazepam (Ativan)

68
Q

which intermediate-acting benzo is indicated for Panic, Anxiety, Seizures, Tremor, RLS, Insomnia

A

Clonazepam (Klonopin)

69
Q

which LA benzo is indicated for anxiety, seizures, agitation, EtOH withdrawal, muscle spasms, procedural sedation

A

diazepam (valium)

Behavioral dynamics (19 decks)

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