Anxiety Disorders

Question 1

• A vague uneasy feeling of discomfort or dread accompanied by an autonomic response; the source is often non-specific or unknown to the individual.
• Affects cognition and often produces distortions of perception

Answer 1

Anxiety Disorders

Question 2

Prevalence of Different Anxiety Disorders

Answer 2

• Phobias: 8-10%
• General anxiety disorder: 3-8%
• OCD, panic: 2-3%
• Social phobia- 2-13%
• PTSD- 1-9%

-40% of patients with primary anxiety disorders also have DSM-V dx of depressive disorder

Question 3

Anxiety Disorder Etiology Theories

Answer 3

1) Psychodynamic
2) Cognitive-Behavioral Theory
3) Cognitive
4) Biological

Question 4

Etiology theory of anxiety disorder based on fear. The was Freud’s original hypothesis

Answer 4

Psychodynamic Theory

Question 5

Etiology theory of anxiety disorder that occurs as an environment give cues associated with anxiety-producing advents. Piaget’s theory

Answer 5

Cognitive Behavioral Theory

Question 6

Etiology theory of anxiety disorder characterized by distorted beliefs about self, world, and future. Beck’s theory

Answer 6

Cognitive Theory

Question 7

Etiology theory of anxiety disorder characterized by fight or flight

Answer 7

Biological Theory

Question 8

2 Major Components of Anxiety Disorders

Answer 8

1) Awareness of physiological sensations (palpitations, sweating)
2) Awareness of being nervous or frightened

Question 9

Mental status exam findings for patients with anxiety disorders

Answer 9

A/O/3
Mood: normal or depressed
Affect: normal
Suicidal ideation possible
Cognition, insight, judgment are intact

Question 10

Always ask about use of these 4 things when a patient presents with Anxiety Disorder

Answer 10

• Caffeine,
• OTC meds (ASA w/ caffeine, pseudofed, ephedrine)
• Herbals
• Street drugs (PCP, amphetamines, cannabis, cocaine)

Question 11

Treatment for Anxiety Disorders

Answer 11

1) Benzodiazepines
2) SSRIs
3) Tricyclics (not first line)
4) Monoamine Oxidase Inhibitors (not first line)

Question 12

Examples of Benzodiazepines

Answer 12

Valium [diazepam],

Xanax [alprazolam] , Klonopin [clonazepam], Ativan [lorazepam]

Question 13

Examples of SSRIs

Answer 13

lexa [citalopram], 
Lexapro [escitalopram], 
Paxil [paroxetine], 
Zoloft [sertraline], 
Effexor [venlafaxine]

Question 14

Most Common Anxiety Disorder

Answer 14

Phobias

(8-10 percent of general population)

-More specific phobias than social phobias

Question 15

Patients with Phobias often have the DDx of …

Answer 15

Schizophrenia

Schizophrenic patients do NOT have insight into the irrational nature of their phobia

Question 16

Characteristics of Specific Phobias

Answer 16

• 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 & to the sociocultural context
• The fear, anxiety, or avoidance is persistent, typically for 6 months or more.
• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The disturbance is not better explained by the symptoms of another mental disorder

Question 17

Characteristics of Social Phobias

Answer 17

• Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others, being observed, and/or performing in front of others
• The individual fears that he/she will act in a way or show anxiety symptoms 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 for 6 months or more.
• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
• If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Question 18

Social Phobia Treatment

Answer 18

1) Therapy is most important.
- CBT is 1st choice
- Social skills training
- Relaxation training
- Group therapy

2) Medication
- SSRI
- Benzo

Question 19

Diagnostic Criteria for Generalized Anxiety Disorder (GAD)

Answer 19

1) Persistent fear, worry, or tension in the absence of panic attacks for at least 6 months
2) Person finds it difficult to control the worry
3) Need 3 or more of the following:

• Restlessness OR feeling on edge
• easily fatigued
• difficulty concentrating or mind going blank
• Irritability
• muscle tension
• sleep disturbance (falling or staying asleep)

4) Anxiety, worry cause significant distress/impairment in social, occupational, or other important areas
5) Disturbance not due to substance abuse or general medical condition
6) Disturbance is not explained better by another mental disorder.

Question 20

GAD Treatment

Answer 20

1) Psychotherapy
2) Anxiolytic
- Benzodiazepines +SSRI
- Buspirone (BuSpar)
- Venlafaxine (Effexor)

Question 21

is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes

Answer 21

Panic Attack

Question 22

During a panic attack, 4 or more of these symptoms occur..

Answer 22

1) Palpitations, pounding heart, or tachycardia
2) Sweating
3) Trembling or shaking
4) Sensation of shortness of breath or smothering
5) Feelings of choking
6) Chest pain or discomfort
7) Nausea or abdominal distress
8) Feeling dizzy, unsteady, light-headed, or faint
9) Chills OR heat sensations
10) Paresthesias (numbness or tingling)
11) Derealization (feeling of unreality) OR depersonalization (being detached from one-self)
12) Fear of losing control or “going crazy”
13) Fear of dying.

Question 23

In panic disorder, a panic attack is followed by at least 1 month of one or both of the following:

Answer 23

1) Persistent concern or worry about additional panic attacks or their consequences
2) A significant maladaptive change in behavior related to the attacks

Question 24

Panic Disorder Treatment

also Agoraphobia treatment

Answer 24

~start with double medication treatment – an SSRI, like sertraline (Zoloft) PLUS a short-acting benzodiazepine, like alprazolam (Xanax).

• Start low on SSRI and dose up
• Benzo used for rapid relief, short term only

Question 25

Agoraphobia is marked by fear or anxiety about 2 or more of these 5 situations

Answer 25

1) Using public transportation (e.g., cars, buses, trains, ships, planes)
2) Being in open spaces (e.g., parking lots, marketplaces, bridges)
3) Being in enclosed spaces (e.g., shops, theaters, cinemas)
4) Being in line or being in a crowd
5) Being outside the home by themselves

Question 26

Acute Stress Disorder is exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways

Answer 26

1)Directly experiencing the traumatic event(s)

2) Witnessing, in person, the events as it occurs to
others
3) Learning that the event(s) occurred to a close family
member or close friend

4) Experiencing repeated or extreme exposure to
aversive details of the traumatic event

Question 27

Intrusion Symptoms of Acute Stress Disorder

Answer 27

1) Recurrent, involuntary, and intrusive distressing memories of the event.
2) Recurrent distressing dreams in which the content and/or affect of the dream are related to the event.
3) Dissociative reaction (e.g. flashbacks) in which the individual feels or acts as if the event were recurring.
4) Intense or prolonged psychological distress or marked psychological reactions in response to internal or external cues that symbolize or resemble an aspect of the event(s).

Question 28

Negative mood symptoms of acute stress disorder:

Answer 28

Persistent inability to experience positive emotions (happiness, satisfaction, or loving feelings)

Question 29

Dissociative Symptoms of acute stress disorder

Answer 29

• An altered sense of the reality of one’s surroundings or oneself.
• Inability to remember an important aspect of the event(s) (dissociative amnesia)

Question 30

Avoidance Symptoms of acute stress disorder

Answer 30

• Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the event.
• Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the event(s).

Question 31

Arousal Symptoms of acute stress disorder

Answer 31

• Sleep disturbances (difficulty falling or staying asleep, restless sleep).
• Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
• Hypervigilance
• Problems with concentration
• Exaggerated startle response.

Question 32

Acute stress disorder is diagnosed by at least 9 of the symptoms from these 5 categories:

Answer 32

1) Intrusions
2) Negative Mood
3) Dissociative
4) Avoidance
5) Arousal

**The symptoms begin immediately after trauma and last 3 days to 1 month

Question 33

PTSD Diagnosis

Answer 33

Same as acute stress but MORE THAN 1 MONTH OF SYMPTOMS

Question 34

PTSD Treatment

Answer 34

First-line treatment should consist of “trauma-focused Cognitive-Behavioral Therapy”.
If there is a delay expected in treatment with the psychotherapy, then start and SSRI or SNRI, typically sertraline (Zoloft) or paroxetine (Paxil).
Animal therapy has been shown to help with many patients with PTSD.