Anxiety d/os, trauma and stress-related d/os Flashcards
What are the major mediators of sx of anxiety d/os?
Norepinephrine
Serotonin
Dopamine
GABA
Etiology of GAD
Psychoanalytic, behavioral, and existential theories
Increased sympathetic tone
Slow adaptation to repeated stimuli
Excessive response to moderate stimuli
Excessive ans sustained cortisol secretion
Corticotropin-releasing hormone
Low NPY
Low galanin
Genetics
Increased activity in the septohippocampal pathway
DSM-5 criteria for panic d/o
Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following sx occur:
-Palpitations, pounding heart, or accelerated heart rate
-Sweating
-Trembling or shaking
-Sensations of SOB or smothering
-Feelings of choking
-CP or discomfort
-Nausea or abdominal distress
-Feeling dizzy, unsteady, light-headed or faint
-Chills or heat sensations
-Paresthesias
-Derealization or depersonalization
-Fear of losing control or going crazy
-Fear of dying
At least one of the attacks has been followed by 1 mo or more of one or both of the following:
-Persistent concern or worry about additional panic attacks or their consequences
-A significant maladaptive change in behavior related to the attacks
Etiology of panic d/o
Autonomic imbalance
Decreased GABA
Allelic polymorphism of the COMT gene
Increased adenosine receptor function
Increased cortisol
Diminished benzodiazepine receptor function
Disturbances in serotonin, serotonin transporter and promoter genes, NE, dopamine, cholecystokinine and interleukin 1-beta
Chronic hyperventilation and carbon dioxide receptor hypersensitivity
Genetics
Etiology of panic d/o- other theories
Serotonergic model Catecholamine model Locus coeruleus model Lactate model Neuroanatomic model involving amygdala, hypothalamus, and brainstem centers Cognitive theory
Workup for panic d/o
Serum electrolytes to exclude hypokalemia and acidosis
Serum glucose to exclude hypoglycemia
Cardiac enzymes in pts suspected of acute coronary syndromes
Serum hemoglobin in pts with near syncope
TSH in pts suspected of hyperthyroidism
Urine tox screen for amphetamines, cannabis, cocaine and phencyclidine
D-dimer assay to exclude pulm embolism
Tx for panic d/o
CBT, with or without pharmacotherapy is tx of choice
Other psychological tx modalities
Educate pt regarding the importance of longer-term pharm management with SSRIs
Only provide benzos in very limited quantities to emphasize the emergency aspect of them
ED management of panic d/o
Pts with CP, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or Fowler position
Educate the pt that their sx are neither from a serious medical condition nor from a psychotic d/o
Pts may require frequent reassurance and explanation
What are second line meds for panic d/o after SSRIs?
TCAs, such as imipramine or clomipramine may be considered for the management of panic disorder if an SSRI is not suitable or if there is no improvement after a 12-wk course of SSRI tx
What is a good med choice in panic d/o for pts with complicated medical regimens or for those who are concerned with drug interactions?
Citalopram and escitalopram
What is suggested for use in panic d/o with co-occurring depression?
Fluoxetine
What is usually prescribed in panic d/o to help improve with sleep?
Paroxetine, mirtazapine, and TCAs
Paroxetine is category D
DDx of panic d/o: cardiovascular dz
Anemia Angina CHF Hyperactive beta-adrenergic state HTN Mitral valve prolapse MI Paradoxical atrial tachycardia
DDx of panic d/o- pulm dz
Asthma
Hyperventilation
Pulmonary embolus
DDx of panic d/o- neurological dz
Cerebrovascular dz Epilepsy Huntington's dz Infection Meniere's dz Migraine Multiple sclerosis TIA Tumor Wilson's dz
DDx of panic d/o- endocrine diseases
Addison's Carcinoid syndrome Cushing's syndrome DM Hyperthyroidism Hypoglycemia Hypoparathyroidism Menopausal d/os Pheochromocytoma PMS
DDx of panic d/o- drug intoxications
Amphetamine Amyl nitrite Anticholinergics Cocaine Hallucinogens Marijuana Nicotine Theophylline
DDx of panic d/o- drug withdrawal
Alcohol
Antihypertensives
Opiates and opioids
Sedative-hypnotics
DDx of panic d/o- other conditions
Anaphylaxis B12 deficiency Electrolyte disturbances Heavy metal poisoning Systemic infections SLE Temporal arteritis Uremia
Duration of pharmacotherapy for panic d/o
8-12 mos
Acrophobia
Fear of heights
Agoraphobia
Fear of open places
Ailurophobia
Fear of cats
Hydrophobia
Fear of water
Claustrophobia
Fear of closed spaces
cynophobia
Fear of dogs
Mysophobia
Fear of dirt and germs
Pyrophobia
Fear of fire
Xenophobia
Fear of strangers
Zoophobia
Fear of animals
Theories of phobias
Classic conditioning
Operant conditioning
Learning theory
Psychodynamic theories of displacement, projection, and avoidance
Counterphobic attitudes
In specific phobia, the pairing of a specific object or situation with the emotions of fear and panic
Genetic factors
DSM-5 criteria for specific phobia
Marked fear or anxiety about a specific object or situation
The phobic object or situation almost always provokes immediate fear or anxiety
The phobic object or situation is actively avoided or endured with intense fear or anxiety
The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
The fear, anxiety, or avoidance causes is persistent, typically lasting for 6 mos or more
Tx of specific phobia
Behavior therapy: models Systemic desensitization Imaginal flooding Virtual therapy Exposure therapy Insight-oriented psychotherapy
Neurochemical factors in social anxiety disorder
Adrenergic theory: pts with performance phobias may release more NE or epi, both centrally and peripherally
Dopaminergic dysfunction
DSM-5 criteria for social anxiety disorder
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others
The individual fears that he or she will act in a way or show anxiety sx that will be negatively evaluated
The social situations almost always provoke fear or anxiety
The social situations are avoided or endured with intense fear or anxiety
The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
The fear, anxiety, or avoidance is persistent, typically lasting 6 mos or more
Workup for social anxiety disorder
Basic labs to screen for comorbid conditions such as anemia, low ferritin levels, and hypothyroidism
DDx considerations for social anxiety d/o
Appropriate fear and normal shyness Agoraphobia Panic d/o Avoidant personality d/o Major depressive d/o Schizoid personality d/o
Pharmacotherapy for the tx of social anxiety d/o
SSRIs BZDs Venlafaxine Buspirone Severe cases- irreversible MAOIs SAD associated with performance situations: Beta-adrenergic receptor antagonists Short or immediate-acting BZD
Psychotherapy for social anxiety d/o
Cognitive retraining
Desensitization
Rehearsal during sessions
Homework assignments
Research and hypotheses with GAD- biological factors
GABA and serotonin neurotransmitter systems
Occipital, basal ganglia, limbic system, and frontal cortex
NE, glutamate, cholecystokinin systems
Genetic studies
EEG abnormalities in sleep
Psychosoical factors in GAD
CBT theory- pts with GAD respond to incorrectly and inaccurately perceived dangers. The inaccuracy is generated by selective attention to negative details in the environment, by distortions in information processing, and by an overly negative view of the person’s own ability to cope
Psychoanalytic school- anxiety is a symptom of unresolved, unconscious conflicts
DSM-5 criteria for GAD
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 mos, about a number of events or activities
The individual finds it difficult to control the worry
The anxiety and worry are associated with three or more of the following six sx, with at least some sx having been present for more days than not for the past 6 mos:
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Workup for GAD
CBC CMP Thyroid function UA Urine drug screen When CNS d/o suspected: EEG, LP, or CT When cardiac d/o suspected: EKG To r/o infection: RPR, LP, or HIV test ABG to exclude hypoxemia or metabolic acidosis
Tx of GAD
CBT Short-term BZD use Buspirone Venlafaxine Sertraline, citalopram or paroxetine- better SSRI choices for high anxiety
Psychological theories of PTSD
Psychodynamic- the trauma has reactivated a previously quiescent, yet unresolved psychological conflict
Cognitive-behavioral: Affected persons cannot process or rationalize the trauma that precipitated the disorder
Two phases:
Classic conditioning
Instrumental learning
Biological factors of PTSD
Altered function in the noradrenergic system
Opioid system hyperregulation
Hyperregulation of the HPA axis- low plasma and urinary free cortisol, blunted ACTH
Structural changes in the amygdala
DSM-5 criteria for PTSD: exposure
Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
Directly experiencing the traumatic event(s)
Witnessing, in person, the event(s) as it occurred to others
Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend,the event(s) must have been violent or accidental.
Experiencing repeated or extreme exposure to averse details of the traumatic event(s)
DSM-5 criteria of PTSD: intrusion sx
Presence of one or more of the following intrusion sx associated with the traumatic event(s), beginning after the traumatic event(s) occurred: Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
DSM-5 criteria of PTSD: persistent avoidance
Persistent avoidance of stimuli associated with the traumatic event(s) beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
DSM-5 criteria for PTSD: negative alterations in cognitions and mood
Negative alterations in cognition and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:
Inability to remember an important aspect of the traumatic event(s)
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
Persistent, distorted cognitions about the cause or consequences of traumatic event(s) that lead to the individual 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
DSM-5 criteria for PTSD: marked alterations in arousal and reactivity
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:
Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance
DSM-5 criteria for PTSD: duration
Duration is more than 1 mo
Self-report scales for PTSD
Distressing Events Questionnaire PTSD checklist for DSM-5 Screen for Posttraumatic Stress Sx Trauma Symptom Checklist-40 Trauma Symptom Inventory
Pharmacotherapy for PTSD
SSRIs first line Buspirone Imipramine and amitriptyline MAOIs Trazodone Anticonvulsants Clonidine and propranolol
Psychotherapy for PTSD
Exposure therapy Teaching pt stress management methods Behavior therapy Cognitive therapy Hypnosis EMDR
