Anxiety and Stress-related Disorders Flashcards
What is the most common mental disorder in the US?
Anxiety and stress disorders
What often is most common comorbid with?
depression - underlying
eating disorders
bipolar disorder
substance abuse
What gender is anxiety more prevalent in a lifetime?
women 30% to men 19%
- cultural underreported
What percentage of people with anxiety receive tx?
36.9%
What is the recovery rate of anxiety?
low
What is the recurrence rates of anxiety?
high
Anxiety interferes with
personal
academic
occupational
social functioning
Stress can go both ways, what are the ways?
High eustress
Low distress
Eustress
good stress
- motivation
- exciting anticipation
Stress distress
negative
- cause emotional, physical, or psychological problems
What are the different types of stress?
psychosocial
psychological
physical
spiritual
Psychosocial stress
in their appearance or lost opportubity
- break up no acceptance
- low self-esteem
Psychological stress
- new baby
- intense emotion
- can be positive intense
Spiritual stress
crisis of faith
- difficulty connecting with faith
- what is my purpose and why am i here
Stress can contribute to
worsening s/s of a mental health condition
If a patient has schizophrenia and anxiety, then
hallucinations and delusions will excel
If a patient has bipolar disorder and anxiety, then
triggers both mania and depression
- paranoia and anger with self-harm
Healthy coping defense mechanisms for anxiety
Altruism
Sublimation
Humor
Suppression (short term)
Intermediate defense mechanisms for anxiety
Repression
Displacement
Reaction formation,
Somatization
Undoing
Rationalization
primitive(immature) defense mechanisms of anxiety
Passive aggression
Acting out behaviors
Dissociation
Devaluation
Idealization
Splitting
Projection
Altruism
stress goes to motivation of other welfare
- do nice things for others
Sublimation
takes stress and puts it into something socially acceptable
- working out
- long-term permanent conversion
Managing Stress: relaxation/calm techniques
reframing/de-catastrophizing = realistic
- “You will look forward to the end of it”
sleep
physical exercise
reduce caffeine
Physiology of Anxiety and Stress
Originates in amygdala
- alerts hypothalamus
- engages SNS
- physiological s/s
Physiology of thoughts about anxiety
the limbic system sends neural messages to cerebral cortex
What neurotransmitters affect anxiety disorders?
Serotonin
Norepinephrine
GABA
With anxiety, serotonin is
decreased
What is the reason for giving SSRIs to anxiety patients?
decreased serotonin levels
With anxiety, norepinephrine is
increased
What is the reason for giving noradrenergic drugs to anxiety patients?
norepinephrine is increased
Norepinephrine medications for anxiety
propanolol
clonidine
What is the reason for giving Benzodiazepines to anxiety patients?
GABA altered
- benzo receptors sensitivity diminished
What is given for acute anxiety?
Benzodiazepines
Short-term effects of Epinephrine and Norepinephrine
Elevated heart & resp rate
Elevated FFAs, glucose, &triglycerides
Increased platelet aggregation
Increased kidney clearance
Increased blood to skeletal muscles
Increased muscular tension
primitive help to run away from the bear
Long-term effects of Epinephrine and Norepinephrine
High resting heart rate
Heart disease
Platelet aggregation
Reactive high BP
Hypercholesteremia & hyperlipidemia
Renal/hepatic problems
Glucose intolerance
Chronic muscle tension
Hyperventilation
Digestive problems
Chronic anxiety/anger
Short-term effects of Cortisol
Decreased fluid loss
Increase glucose/gluconeogenesis
Less inflammation
Less brain norepinephrine
Long-term effects of Cortisol
Immune system compromise
Atherosclerosis
Depression
Insulin insensitivity
Obesity
Hyperlipidemia
Protein breakdown in blood,bones (osteoporosis), muscle (heart) immunoglobulins
Chronic Stress results in
HTN
Heart disease/stokes
Diabetes
CA
Ulcers/Chronic GI problems
Atherosclerosis
Arthritis
Autoimmune diseases/allergies/eczema
Kidney and liver diseases
Chronic GI problems
HA
PTSD dx criteria
Exposure to actual or threatened death, injury, or sexual violence
Presence of intrusion symptoms
Avoidance of associated stimuli (external reminders)
Negative alt in cognitions/mood
Altered arousal & reactivity
Symptoms lasting longer than one month
Often presents with suicidal ideation & depression
NOT attributed to the physiological effects of a substance
What type of exposure can cause PTSD?
- direct experience
- witnessing in person
- occurs to close family members or friends and actual or threatened death violent or accidental
- experience repeat or extreme exposure to aversive details of the events (first responders, police)
does not apply to media, TV, movies, or pictures unless work-related
Presence of 1+ intrusion s/s with traumatic events
-recurrent and involuntary memories
-dissociative reactions (flashbacks)
-intense or prolonged distress with exposure to internal or external cues
- physiological reactions that symbolize or resemble trauma
What are negative alterations in cognition and mood with PTSD?
dissociative amnesia (not head injury, alcohol, or drugs)
negative beliefs (I am bad, no one can be trusted, completely dangerous, permanently ruined)
constant negative emotional state
diminished interest in interest or activities
detachment or estrangement
unable to experience positive emotions
PTSD alteration arousal and reactivity
irritable and angry outbursts (no provocation)
- verbal/physical with people or objects
reckless or self-destructive behaviors
hypervigilance
exaggerated startle response
concentration problems
difficulty sleeping, staying asleep, or restless sleeping
PTSD with dissociative s/s
PTSD s/s and depersonalization and derealization
- NOT attributed to substance (blackouts, intoxication, complex partial seizures)
Depersonalization
persistent experience of detachment (like outside observer)
- dream, sense of unreality of self/body/time moving slowly
Derealization
persistent unreality of surroundings
- feels dreamlike, distant, distorted
S/S of PTSD (mnemonic)
Traumatic event
Re-experience the trauma
Avoiding things associated with trauma
Unable to focus
Month (1)
Arousal increase (hypervigilance, startle response)
PTSD Tx
Cognitive behavioral therapy
Prolonged exposure therapy
EMDR: Eye movement & reprocessing
Adaptive disclosure
Meds: SSRIs
Meds: Others to treat target symptoms (such as psychosis) - Antipsychotic, low dose olanzapine
prazosin for nightmares
Acute Stress Disorder Dx criteria
Exposure to actual or threatened death, injury, or sexual violence - medical emergency, car wreck
Negative mood
Dissociative & avoidance behaviors
Arousal Symptoms
Intrusion Symptoms
Hypervigilance
Longer than 3 days but Resolution of symptoms within 1 month
Tx of acute stress disorder
May resolve without treatment
- support and coping
Meds: Benzos prn for severe symptoms
Dissociative Identity Disorder formerly known as
multiple personality disorder
Dissociative amnesia
unable to recall info about self
Dissociative amnesia with fugue
amnesia for identity involve travel or wandering
Depersonalization
experience unreality or detachment from mind/self/body
Derealization
experience unreality or detachment from surroundings
Trauma-informed care high ACE scores
increased risk for physical and psychiatric disorders and adverse childhood experiences
for dissociative disorders = TIC recognizes the impact of trauma on
health
how trauma impacts behavior seeking treatment
awareness that service systems have potential to retraumatize victims
Anxiety order
Normal (good)
Acute (with loss/change of someone)
Pathological (absent of a threat and cause loss of functioning)
Different Anxiety Disorders
Generalized Anxiety Disorder (GAD)
OCD
Phobic Disorders (Agoraphobia, Social Anxiety, specific phobics)
Panic Disorders (w/ or w/o agoraphobia)
Neurobiological theory for anxiety disorders
Lower levels of serotonin-serotonin dysfunction
Increased levels of norepinephrine-alterations in the noradrenergic system
Altered GABA-Alterations in the benzodiazepine receptors
genetics theory for anxiety disorders
40% hereditary
behavioral theory for anxiety disorders
learned response
cognitive theory for anxiety disorders
cognitive distortion in thinking
cultural considerations for anxiety disorders
Sociocultural variations (transition mental to physical)
- tinnitus, neck soreness, HA, uncontrollable screaming or crying (not counted)
Somatic symptoms and cognitive symptoms vary between cultures
Mild anxiety s/s (green)
Heightened awareness
Still able to work, learn, & solve problems
slight psychomotor agitation - slight restless, pacing, tapping foot
Mild anxiety interventions
Reframing that this is a positive thing
Allow ventilation
Activity to release energy
Identify triggers
Focus on communication
Monitor level of anxiety
NO MEDS
Moderate anxiety s/s (yellow)
Narrowed perceptual field
Selective inattention
Less able to problem-solve
HR & RR up
Somatic complaints - tinnitus, HA
What level of anxiety will cause VS changes?
moderate
- start anxiolytics PRN
Moderate anxiety interventions
Reframing
Allow ventilation
Activity to release energy
Identify triggers
Focus on communication
Monitor level of anxiety
PRN anxiolytic
Severe anxiety s/s (orange)
Perceptual field very limited
Scattered attention,
Distorted perceptions
Diminished problem-solving ability
**Tunnel vision
Sense of impending doom
Somatic symptoms - Intense difficulty breathing, freeze, GI upset, Nausea **
Pt can still be redirectable and in control of their behavior
Severe anxiety interventions
Remain calm
Stay with patient and be calm and low pitched with simple sentences
PRN anxiolytics
Pt can still be redirectable and in control of their behavior - main difference
Panic level anxiety s/s (red)
Unable to focus on environment
Feeling of doom
Disorganized thinking
No problem solving
Emotional paralysis
Increased HR, Respirations
Irrational
Agitation = self harm and violence
Panic-level anxiety interventions
Stay with patient - guide them
Remain calm
Simple direct statements
Assure safety
- if violent last option is sedatives
PRN anxiolytic
Minimize environmental stimulation
- no groups
Panic Disorder Dx criteria
recurrent unexpected panic attacks w/o clear triggers
rapid onset from calm to anxious (peak at 10 minutes) 0 to 100 real quick
4+ s/s
followed by 1 month of fear of reoccurrence and maladaptive change in behavior
Panic Disorder s/s
Palpitations, pounding heart, or accelerated heart rate.
Sweating.
Trembling or shaking.
Sensations of shortness of breath or smothering.
Feelings of choking.
Chest pain or discomfort.
Nausea or abdominal distress.
Feeling dizzy, unsteady, light-headed, or faint.
Chills or heat sensations.
Paresthesias (numbness or tingling sensations).
Derealization (feelings of unreality) or depersonalization (being detached from oneself).
Fear of losing control or “going crazy.”
Fear of dying.
Panic Disorder is comorbid with
agoraphobia and depression
Panic Disorders are usually followed for a month of
persistent concern about additional panic attacks or consequences (losing control, heart attack, “going crazy”
behaviors to avoid exercise of unfamiliar situations
not explained by a cardiac or hyperthyroidism problem
Panic Disorder Tx
CBT (reframing)
1 - antidepressants (longer term)
2 - Benzo (short term)
Phobic Disorders Dx
fear or anxiety about an object or situation
- provokes immediate fear or anxiety
- actively avoids/endures with intense fear or anxiety
OUT OF PROPORTION to actual danger and sociocultural context
significant distress o impairment in social, work, or functioning
6+ months
not explained by another mental disorder
Agoraphobia
Fear of leaving the house
Using public transportation
Being in open spaces (eg, parking lot, marketplace)
Being in an enclosed place (eg, shop, theater)
Standing in line or being in a crowd
Being alone outside the home
Agoraphobia Dx consists of s/s for
Marked fear with 2+ s/s in 5 situations
6+ months
disproportionate to the risk of danger
distress or impairment
Social Anxiety Dx
6+ months of fear and anxiety of social situations where they will be scrutinized by others
The Social Anxiety must involve
A negative evaluation by others (eg, that patients will be humiliated, embarrassed, or rejected or will offend others).
What must be present for SAD?
The same social situations nearly always trigger fear or anxiety.
Patients actively avoid the situation.
Fear/anxiety/avoidance
Is out of proportion to the actual threat (taking into account sociocultural norms).
Causes significant distress or significantly impair social or occupational functioning
Specific Phobias Dx is the
fear of 1+ specific objects or situations
Acrophobia
fear of heights
Claustrophobia
fear of closed spaces
Arachnophobia
fear os spiders
Pteromechanophobia
fear of flying
Tx for Phobias
CBT
Assertiveness Training (agoraphobia)
systematic desentization
social skills training (Social Anxiety Disorder)
Meds: SSRIs, beta blockers, benzo
Benzo will help in the moment but not the overall disorder
GAD Dx
excessive worries/anxiety < 6 months
- Ask if they can’t control the worrying
- 3+ s/s
- R/o SUBSTANCE ABUSE OR OTHER DISORDERS
S/S of GAD
Restlessness or a keyed-up or on-edge feeling
Easily fatigability
Difficulty concentrating
Irritability
Muscle tension
Disturbed sleep
GAD Tx
CBT
Stress Mgmt
psychical activity
meds: SSRI, SNRI, buspirone
- teach that effectiveness will take a while
Benzo - acute
Anxiety r/t other medical conditions
COPD
Parkinson’s
Metabolic disorders
Hyperthyroidism
OCD S/S
Presence of obsessions, compulsions, or both
Unable to ignore or suppress thoughts or actions
Obsessions & compulsions are time consuming; > 1 hour a day
1st degree relative has it as a childhood
Questions to ask OCD patients
do you do certain thinks repetitively
do you have intrusive thoughts you cant shut out
do you have to do things in a specific certain way
Obsessions in OCD
Recurrent & persistent thoughts, urges or images which are unwanted and intrusive causing distress to the individual
Compulsions of OCD
Repetitive behaviors that the individual is compelled to perform in response to related obsession
What is aimed to alleviate anxiety in OCD
compulsions
Obsession of contamination = compulsion of
washing and cleaning
Obsession of loss, fear of loss = compulsion of
acquiring, collect, save
Obsession of symmetry = compulsion of
order, arranging, and repeating (counting)
Obsession of causing harm = compulsion of
avoid contact
Tx of OCD
Exposure / Response Prevention - force delay between thoughts and compulsions
Medication: SSRIs
OCD-related disorders
Body dysmorphia
hoarding
trichotillomania
skin picking disorder
Trichotillomania
hair pulling out and bald spots
Assessment for Anxiety Disorder
Level of anxiety
Suicide risk
Use of coping/defense mechanisms
Standardized Scale Ratings for Anxiety
The Clinically Useful Anxiety Outcome Scale
Generalized Anxiety Disorder Screener
Hamilton Rating Scale for Anxiety
Priority for Anxiety pts
safety and therapeutic communication
Medications for Anxiety
Antidepressants - SSRI, SNRI
Anxiolytics - Benzo, buspirone, hydroxyzine, beat blockers
Interventions for Anxiety
communication
expression of feelings and thoughts
decrease environmental stimuli
limit stimulants
diversional activities and stress reduction techniques
milieu therapy
What are the first line antianxiety drugs?
SNRI SSRI
SSRI works
blocks reuptake of serotonin
SSRI example
Paroxetine = GAD
SNRI works with
blocks reuptake of serotonin and norepinephrine
SNRI example
Venlafaxine = mixed anxiety and depression, anxiety, and nerve pain
Noradrenergic drugs
Propanolol
Clonidine
Propanolol MOA
blocks adrenergic receptor activity
Clonidine MOA
stimulates adrenergic receptors
Propanolol use
short-term relief of social anxiety and performance anxiety
Clonidine used
anxiety disorders, panic attacks
Benzodiazepines MOA
Binds to benzodiazapine receptors, facilitates GABA, slows neural transmission
benzo example
Alprazolam – may be used short term to treat panic disorder and agoraphobia
Buspirone MOA
serotonin receptor partial agonist
Buspirone tx
worry associated with GAD
What drug is only FDA-approved for GAD?
Buspirone (Buspar)
Benzodiazepines
- onset
- sedating?
- dependence and withdrawal?
- change with age
- PRN
Rapid onset
Sedating
Dependence & withdrawal
Tolerance varies with increased age
May be used PRN
Buspirone (Buspar)
- onset
- sedating?
- dependence and withdrawal?
- change with age
- PRN
Delayed onset
Non-sedating
No dependence or withdrawal
No pharmacokinetic change with age
Not suitable for PRN use
Hydroxyzine pamoate (Vistaril)
- onset
- sedating?
- dependence and withdrawal?
- PRN
Rapid onset
Sedating
No dependence or withdrawal
May be used PRN
