anxiety and stress disorders Flashcards
what is normal fear?
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
what is anxiety
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
When is anxiety pathologic?
- Present without an obvious or reasonable cause
- Excessive and out-of-proportion to actual threat
- Causes distress, functional impairment, and/or reduced quality of life
Individuals with anxiety disorders have been shown to often have maladaptive cognition, including:
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
____ are oriented toward identifying how thoughts influence behaviors and perception of outcomes
Cognitive-based therapies
what is Cognitive Restructuring
- Identifying negative thoughts
- Challenging negative thoughts
- Replacing negative thoughts with realistic thoughts
3 stress managements
- Time management techniques
- To-do lists, schedules, organization - Relaxation techniques
- Yoga, meditation, exercise, deep breathing, biofeedback, muscle relaxation - Social support systems
3 exposure therapies
-
Desensitization - exposing patients in small doses that gradually become more intense
- taught relaxation techniques - Modeling - patient observes other individuals who are around stimuli
-
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
short term medications for anxiety disorders
- Benzodiazepines (BZDs)
- Hydroxyzine
Short-Term/PRN Therapy
what are the long-term medications
- First-Line - SSRIs, SNRIs
- Second-Line - Buspirone, TCAs, BZDs, antipsychotics
what medication enhances the effect of GABA at the GABA receptor
Benzodiazepines
benzos, BZDs
uses for benzos
- anxiety
- panic
- insomnia
- ETOH withdrawal
- agitation
- seizures
- procedural sedation
SE of benzos
- drowsiness, dizziness
- decreased motor coordination
- decreased libido
- disinhibition
- rebound anxiety
- amnesia
- suicidal ideation
8. Risk for dependence and withdrawal - Rare - respiratory depression, paradoxical effects
DDI of benzos
ETOH, opioids, and other CNS depressants, anticonvulsants, antidepressants, antifungals
CI for benzos
- pregnancy, BZD allergy, myasthenia gravis, narrow-angle glaucoma
- Risk for respiratory depression - COPD, sleep apnea, myasthenia gravis
which benzo has a high abuse potential, commonly for panics
Alprazolam (Xanax)
intermediate acting
which medication is commonly used for Procedural Sedation
Midazolam (Versed)
which drug is commonly used for insomnia
short acting
Triazolam (Halcion)
which drug is commonly used for insomnia
intermediate-acting
Temazepam (Restoril)
which drug is commonly use for alc withdrawal and anxiety
long-acting
chlordiazepoxide (librium)
which drug is commonly used for insomnia
long acting
flurazepam (dalmane)
how can you avoid dependency on benzos
- Use PRN only
- limited time use (1-4 weeks)
- Cautioning of potential for dependency,
tolerance and addiction - Avoiding use in pts with substance
abuse (current or history of)
how can you avoid withdrawal from benzos
- 10-25% dose reduction per 1-2 weeks
- Slower taper if s/s of withdrawal - Anxiety, dysphoria, tremor, seizures
which medication acts as a Histamine (H1) receptor antagonist
Anxiolytic, muscle relaxant, antihistamine, antiemetic, sedating
May be helpful for insomnia due to anxiety
Hydroxyzine
Vistaril
hydroxyzine
Atarax
hydroxyzine
SE of hydroxyzine
drowsiness, dizziness, dry mouth, rash, fatigue, respiratory depression
DDI of hydroxyzine
potassium, MAOIs, CNS depressants
CI for hydroxyzine
allergy to med
1st trimester of pregnancy,
administration via SC, IV, or intra-arterial routes
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
Buspirone (Buspar)
No abuse/dependence potential, no withdrawal
Often used to augment SSRIs/SNRIs or in pregnant pts
Buspirone
this medication may by more helpful for benzo-naive patients
Buspirone
Less anxiolytic effects than BZDs
SE of buspirone
- dizziness, drowsiness, nausea, headache
- Concern over potential for Serotonin Syndrome
DDI of buspirone
other psych meds, CNS depressants
GAD is MC in who?
epidemiology
women (2x)
35+
comorbidities - MDD, substance abuse, other anxiety disorders, chronic unexplained pain
criteria for GAD
-
Excessive anxiety and worry (apprehensive expectation) more days than not
- about multiple things
- for at least 6 months
- Patient finds it difficult to control - Anxiety/worry associated with 3+ of the following:
- Restlessness or feeling keyed up/on edge
- Being easily fatigued
- Difficulty concentrating - Syndrome causes distress and/or functional impairment
- Syndrome is not due to substance abuse or medical condition
presentation of GAD
persistent worry + hyperarousal
- More worry over minor matters
- Somatic s/s - muscle tension, headaches, neck and back pain
screenings for GAD
-
Generalized Anxiety Disorder-7 (GAD-7)
- Initial screening for GAD
- Monitor severity of s/s and response to tx -
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
tx for GAD
- First-Line - SSRI/SNRI, CBT, or both
- BZDs - short-term for severe s/s - second-line - TCAs, buspirone
- BZDs have been used for long-term tx in some patients
- Mirtazapine, 5HT modulators, Pregabalin (Lyrica), 2nd gen antipsychotics - Adjunct - Relaxation techniques, acupuncture, exercise
Therapy continued for 6-12 months
intense fear or discomfort with multiple accompanying symptoms
panic attacks
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
Agoraphobia
Separate diagnosis in DSM-V
criteria for panic attacks
- Abrupt surge of intense fear/discomfort that peaks within minutes
- 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” - Recurrent unexpected panic attacks
-
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 - Syndrome is not due to substance or medical condition
- Syndrome is not better explained by other mental disorder
* Panic attacks do not occur only in response to specific triggers
which psych disorder places more emphasis on physical symptoms, hx of somatization
Somatization Disorder
psych disorder where other psych symptoms/occurrences are more predominant
Anxiety Disorders, Depressive Disorders
tx for panic disorder
-
First-Line - CBT, SSRI, or combination
- Paroxetine - sedating effects, can help calm patients - Second-Line - SNRIs; TCAs
-
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
criteria for agoraphobia
- 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 - 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
- Syndrome causes distress or functional impairment
- Syndrome is not better explained by another mental disorder
Tx for agoraphobia
SSRI, CBT, or both
Current guidelines are to treat as one would for panic disorder
criteria for social anxiety disorder
- Persistent (6+ months) of marked fear/anxiety about 1+ social situations in which the pt is exposed to possible scrutiny by others
- Pt fears acting in a way or showing anxiety s/s that will be negatively evaluated
- The social situations almost always provoke fear or anxiety
* In children - crying, tantrums, freezing, clinging, shrinking, failing to speak - The social situations are avoided or endured with intense fear or anxiety
- Fear/anxiety is out of proportion to the actual threat posed
- Fear/anxiety or avoidance causes distress or functional impairment
- Not due to substance use, medical condition, or another psych disorder
what is the subtype for social anxiety disorder
If only related to performance and not general social interaction, may use modifier “performance-only” (versus “generalized”)
tx for social anxiety disorder
-
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 -
Performance-Only Social Anxiety Disorder
* PRN BZD - 30-60 min before performance
* PRN beta-blocker - Propranolol 20-60 mg, 30-60 min before performance - May augment with relaxation techniques
how does acute stress disorder differ from PTSD
in timing of onset and duration
criteria of acute stress disorder
- 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) -
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
tx for acute stress disorder
- Goal - lessen stress response and reduce or prevent progression to PTSD
- 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
depressive disorders, anxiety disorders, and substance abuse are how much more common than in the general population that experience PTSD
2-4x more common
- Substance abuse - to self-medicate
- Somatization disorder - 90x MC in PTSD
- TBI - 60% of TBI pts also have PTSD
criteria for PTSD
- 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) -
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 -
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 - 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 - 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
tx for PTSD
- First-Line -Trauma-oriented CBT with exposure therapies
* Psychotherapy or combination often preferred over pharmacotherapy alone…but not always easy to implement - Medications - SSRIs or SNRIs
* Atypical antipsychotics - refractory cases
* Prazosin (Minipress) - α1-adrenergic blocker - insomnia
* BZDs - severe agitation, hyperarousal
Characterized by the presence of pathologic obsessions, compulsions, or both
Time-consuming and distressing
Cause functional impairment
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
recurrent intrusive unwanted thoughts, images, or urges that typically cause anxiety or distress
Obsessions - mental event
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
Compulsions - behavioral event
Not rationally connected or act is clearly excessive
what are the MC obsessions/compulsions
- Cleaning - fears of contamination; cleaning rituals
- Symmetry - symmetry obsessions; repeating, ordering, and counting compulsions
- Forbidden or taboo thoughts - Aggressive, sexual, and religious obsessions; related compulsions
- Harm - thoughts about harm befalling oneself or others; checking and precautionary compulsions
degrees of insight into illness (OCD)
- Good or fair insight - recognizes OCD beliefs are definitely or probably not true, or that they may or may not be true
- Poor insight - thinks OCD beliefs are probably true
- Absent insight/delusional beliefs - completely convinced that OCD beliefs are true
tx for OCD
- 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 - often need higher maintenance doses of SSRI therapy
- If no response to SSRI - may try other SSRI or SNRI
intense, irrational fear of a particular object or situation
May be triggered by:
Anticipation of stimulus
Actual exposure to stimulus
Non-stimulus reminders
phobia
criteria for phobia
- Persistent (6+ months) of marked fear/anxiety about a specific
object or situation - Phobic object/situation almost always causes immediate fear/anxiety
- Phobic object/situation is actively avoided or endured with intense fear or anxiety
- Fear/anxiety is out of proportionto the actual danger posed by object/situation
- Fear/anxiety or avoidance causes distress or functional impairment
- Syndrome is not better explained by another mental disorder
tx for phobia
- First-Line - CBT with exposure therapy
- Second-Line: Infrequently Encountered Stimulus - PRN treatment with BZD
- Second-Line: Frequently Encountered Stimulus - SSRI, SNRI
which intermediate-acting benzo is indicated for Insomnia, ETOH withdrawal
Oxazepam (Serax)
which intermediate-acting benzo is indicated for Anxiety, Seizures, Agitation, ETOH withdrawal, Insomnia, Procedural sedation
Lorazepam (Ativan)
which intermediate-acting benzo is indicated for Panic, Anxiety, Seizures, Tremor, RLS, Insomnia
Clonazepam (Klonopin)
which LA benzo is indicated for anxiety, seizures, agitation, EtOH withdrawal, muscle spasms, procedural sedation
diazepam (valium)
