Anxiety Disorders

Question 1

Generalized Anxiety Disorder

Answer 1

Uncontrollable excessive anxiety or worry about multiple activities or events that leads to significant impairment or distress. Clinical onset usually in early 20s. Male-to-female is 1 to 2.

Question 2

History and physical for GAD

Answer 2

Presents with anxiety on most days (6 or more months) and with 3 or more somatic symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, disturbed sleep)

Question 3

Tx for GAD

Answer 3

A) Short term therapy

1) Benzo may help for immediate symptom relief
2) Taper benzos as soon as long term treatment is established (SSRI) in view of high risk of tolerance and dependence
3) Do not stop benzos abruptly as patients may develop potentially lethal withdrawal symptoms similar to those of alcohol withdrawal

B) Long term therapy

1) Lifestyle changes
2) Psychotherapy
3) Medications: SSRI (1st line), venlafaxine, buspirone (Just like SSRI, dont use buspirone with MAOIs)

PATIENT EDUCATION IS ESSENTIAL

Question 4

SSRIs as an anxiolytic

Answer 4

Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram

Indications: First line treatment for GAD, OCD and PTSD

Side effects: Nausea, GI upset, somnolence, sexual dysfunction, agitation

Question 5

Buspirone

Answer 5

Can use as anxiolytic

Indications: GAD, OCD, PTSD

Side effects: Seizures with chronic use. No tolerance, dependence or withdrawal. HA. nausea. Dizziness.

Question 6

B- blockers as anxiolytics

Answer 6

Indications: Performance anxiety, PTSD

Side effects: Bradycardia, hypotension

Question 7

Benzos

Answer 7

Can be used as anxiolytics

Indications: Anxiety, insomnia, alcohol withdrawal, muscle spasm, night terrors, sleepwalking

Side effects: Reduced sleep duration; risk of abuse, tolerance and dependence; disinhibition in young or old patients; confusion. Respiratory depression.

Question 8

Flumazenil

Answer 8

Competitive antagonist at GABA receptor

Indication: Antidote to benzo intox

Side effects: Resedation; nausea, dizziness, vomiting, and pain at injection site

Question 9

Specifically when do you use flumazenil?

Answer 9

ONLY when either:

1) The OD is acute

AND

2) You are certain that there is no chronic dependence.

It can cause seizures in benzo-dependent patients. It causes acute withdrawal, which can be tremor or seizures similar to DT

Question 10

When do you use Lorazepam?

Answer 10

It’s used often in emergency situations bc it can be given IM

Question 11

When do you use Clonazepam?

Answer 11

It can be used if addiction is a concern given its longer half-life

Question 12

When do you use Chlordiazepoxide, oxazepam, lorazepam?

Answer 12

Used often in treatment of alcohol withdrawal. Lorazepam and oxazepam are the drugs of choice in patients with liver problems.

Question 13

When do you use alprazolam?

Answer 13

Used often in panic attacks and panic disorder

Question 14

When do you use flurazepam, temazepam, triazolam?

Answer 14

They are approved as hypnotics but are rarely used.

Question 15

OCD

Answer 15

Characterized by obsessions and/or compulsions that lead to significant distress and dysfunction in social or personal areas. Usually presents in later adolescence or early adulthood. Prevalence equal in men and women. Often chronic and hard to treat.

Many often present to nonpsychiatrist (may consult derm with a skin complaint secondary to overwashing hands)

Question 16

History and physical for OCD

Answer 16

1) Obsessions: Persistent, unwanted and intrusive ideas, thoughts, impulses, or images that lead to marked anxiety or distress (fear of contamination, fear of harm to oneself or to loved ones)
2) Compulsions: Repeated mental acts or behaviors that neutralize anxiety from from obsessions (hand washing, elaborate rituals for ordinary tasks, counting, excessive checking)
3) Patients recognize these behaviors as excessive and irrational products of their own minds (vs OCPD)
4) Patients wish they could get rid of the obsessions and/or compulsions

Question 17

Treatment of OCD

Answer 17

1) Pharm (SSRI***)
2) CBT using exposure and desensitization
3) Patient education!!!

TIP: If all answer choices are TCAs, pick clomipramine*

Question 18

OCD vs OCPD

Answer 18

1) OCD - characterized by obsessions and/or compulsions

Patients recognize* the obsessions/compulsions and want to be rid of them (ego dystonic)

2) OCPD - patients are excessively conscientious and inflexible.

Patients do not recognize their behavior as problematic (ego syntonic)

Question 19

What disorder often coexists with OCD?

Answer 19

Tourettes

Question 20

Panic Disorder

Answer 20

Characterized by recurrent, unexpected panic attacks. 2 to 3 times more common in women. Agoraphobia (fear of places where escape may be difficult/fear of being alone in a public place) is present in 30-50% of cases. The average onset is 25, but can happen at any age.

Question 21

History and exam for panic disorder

Answer 21

1) Panic attacks are defined as discrete periods of intense fear or discomfort in which at least 4 of the following symptoms (autonomic symptoms) develop abruptly and peak within 10 minutes:
a) tachypnea
b) chest pain
c) palpitations
d) diaphoresis
e) nausea
f) trembling
g) dizziness
h) fear of dying or “going crazy”
i) depersonalization
j) hot flashes
k) chills
l) parasthesias

2) Perioral and or acral parasthesias, when present are fairly specific to panic attacks, which produce hyperventilaton and low O2 saturation
3) Patients present with 1 or more months of concern about having additional attacks or significant behavior change as a result of the attacks -avoiding situations that may precipitate attacks

Usually last less than 30minutes and may be accompanied by agoraphobia

Make sure you determine if patient has PD with or without agoraphobia so you can address the agoraphobia in treatment plan

Question 22

Treatment of PD

Answer 22

1) Short term: Benzos (clonazepam) may be used for immediate relief, but long term use should be avoided in light of potential for addiction and tolerance. Taper benzos as soon as long term treatment is started (SSRI)
2) Long term - CBT. SSRIs are first line. Start with benzos and SSRI and taper off the benzo. Use CBT WITH meds not alone.

Alprazolam (Xanax) is a med sometimes used for PD, but patients can go into minor withdrawal within a day due to short half life

Question 23

Phobias

Answer 23

1) Social phobia/anxiety - characterized by marked fear provoked by SOCIAL or PERFORMANCE situations in which embarassment may occur. It may be specific (public speaking, urinating in public) or general (social interaction) and often begins in adolescence.
2) Specific phobia - anxiety is provoked by exposure to a feared object or situation. Most cases begin in childhood

Question 24

History and physical for phobias

Answer 24

Presents with excessive or unreasonable fear and/or avoidance of an object or situation that is persistent and leads to significant distress or impairment in function. Patients KNOW fear is excessive.

Question 25

Treatment of phobias

Answer 25

1) Specific phobias - CBT involving desensitization through incremental exposure to the feared object or situation along with relaxation techniques. Other options include supportive, family, and insight-oriented psychotherapy
2) Social phobias - CBT, SSRIs, low dose benzos, or B blockers (for performance anxiety) may be used.

Beta blockers such as atenolol or propranolol are used only for performance anxiety such as stage fright. They are given 30-60 minutes before the performance.

Question 26

PTSD

Answer 26

Follows exposure to an extreme, life threatening traumatic event (assault, combat, witnessing a violent crime) that evoked intense fear, helplessness or horror

top causes in men are rape (#1) and combat (#2).

Top causes in women are childhood abuse (#1) and rape (#2)

Question 27

History and physical for PTSD

Answer 27

1) Characterized by the following:
a) Reexperiencing of event (nightmares)
b) Avoidance of stimuli associated with the trauma
c) numbed responsiveness (detachment, anhedonia)
d) Increased arousal (hypervigilance, exaggerated startle) that leads to significant distress or impairment in functioning

2) Symptoms for at least 1 month
3) Survivor guilt, irritability, poor concentration, amnesia, personality change, sleep disturbance, substance abuse, depression, and suicidality may be present

Question 28

Tx for PTSD

Answer 28

1) Short term - To target anxiety; includes B blockers and alpha agonists (clonidine)

2) Long term
a) Meds: SSRIs are first line; buspirone, TCAs and MAOIs may be helpful. Benzos are also used by incidence of substance abuse among PTSD patients is high so use caution

b) psychotherapy and support groups

In ANY patient with history of substance abuse, avoid benzos

Summary of tx for PTSD: Paroxetine and sertraline. Prazosin is used to reduced incidence of nightmares. Psychotherapy for coping mechanisms and relaxation techniques/hypnosis.