Anxiety Disorders Flashcards
Influence of gender on developing an anxiety disorder
Female more likely (3:2 or 2:1 to men)
3 complications/comorbidities associated with anxiety disorders
- Suicide
- Alcohol and drug abuse
- Cardiovascular morbidity and mortality
Define Fear
- Emotional response to real or perceived imminent threat
- Threat is external and definite
- Warns against body damage, pain, etc.
- Associated with surges of autonomic arousal (flight or flight)
Define Anxiety
- Anticipation of future threat
- Threat is internal, vague, unknown
- Associated with muscle tension, vigilance, and avoidance of behaviors
Anxiety pathophysiology
- Genetic vulnerability
- Stress
- Situational
- Traumatic life events
- Vague, undefined causes
Mediators of
- peripheral stress
- central stress
- Peripheral: SNS
- CNS: serotonin, norepinephrine, GABA
Physical manifestations of anxiety (11)
- Restlessness, pacing
- Syncope, dizziness, lightheadedness
- Tachycardia, palpations
- Tingling in extremities
- Tremors
- GI: Upset stomach, “butterflies”, nausea, diarrhea
- Urinary frequency, hesitancy, urgency
- Hyperhydrosis
- Hyperreflexia
- Hypertension
- Pupillary mydriasis
Two anxiety assessment tools
- GAD-7
- OASIS (overall anxiety severity and impairment scale)
* *always assess for suicide intentions
Toxic conditions that can cause anxiety (9)
- Alcohol use/withdrawal
- Illicit drug use/withdrawal
- Caffeine use/withdrawal
- Sympathomimetic agents (pseudoephedrine or phenylephrine)
- Vasopressor agents (dopamine)
- Penicillin
- Sulfa drugs
- Heavy metals
- Other chemicals: phosphorus, organophosphates, carbon disulfide, etc.
Neuro med conditions associated with anxiety
- Cerebral trauma
- neoplasms
- CVA
- SAH
- encephalitis
- Huntingtons Dz
- epilepsy
Cardiac med conditions associated with anxiety
- MI
- arrythmias
- anemia
Endocrine med conditions associated with anxiety
- *Hyperthyroidism
- pituitary dysfunction
- parathyroid disease
- adrenal dysfunction
- pheochromocytoma
- hypoglycemia
Inflammatory med conditions associated with anxiety
- Lupus
- RA
- polyarteritis nodosa
- temporal arteritis
Deficiencies associated with anxiety
- B12
- B3 (pellagra)
Other psych conditions associated with anxiety
- depression
- mania
- schizophrenia
- malingering
- PTSD
Misc med conditions associated with anxiety
- systemic malignancies
- PMS
- febrile illnesses
- chronic infections
- mononucleosis
- uremia
Lab assessment when have low index anxiety is dt medical disorder
CBC CMP Thyroid (graves disease) UA urine drug screen r/o infections
Lab assessment when have mod to high index anxiety is dt medical disorder
- r/o CNS disorder – EEG, lumbar puncture, brain CT
- r/o cardiac – EKG, treadmill stress test
- r/o infection
DMS 5 criteria
- separation anxiety
- Developmentally inappropriate and excessive fear/anxiety concerning separation from people attached to
- Must have three of the following
- Excessive stress when anticipating separation
- Persistent, excessive worry about losing/harm to attachment figure
- Persistent, excessive worry about future event that separates one from attachment figure
- Persistent reluctance/refusal to go out (school, work, etc.) bc of fear of separation
- Persistent reluctance about being alone or without attachment figures at home or elsewhere
- Persistent reluctance/refusal to sleep away from home or go to sleep without being near attachment figure
- Repeated nightmares involving theme or separation
- Repeated complaints of physical sx when separation is anticipated
DMS-5 time criteria for separation anxiety
Fear/anxiety/avoidance lasts
- at least 4 weeks in children and adolescents
- 6 months or more in adults
DSM 5 criteria
- specific phobia
Marked fear or anxiety about a specific object or situation
- Object/situation provokes immediate fear or anxiety
- Object/situation is actively avoided/endured with intense fear/anxiety
- Fear/anxiety is out of proportion to the danger posed
- Causes clinically significant distress in school, work, etc.
DSM 5 criteria
- time for specific phobia
6+ months
DSM 5 criteria
- social phobia / social anxiety disorder
- Marked fear/anxiety about 1+ social situations that could involve possible scrutiny by others
- Social interactions: conversation, meeting with unfamiliar people
- Observation: eating or drinking
- Performing: giving a speech
- Fear will act in a way or show anxiety sx that are negatively evaluated (humiliated or embarrassed, leads to rejection by or offends others)
- Social situations
- Almost always provoke fear/anxiety
- Are avoided/endured with intense fear/anxiety
- Fear is out of proportion to actual threat
- Causes clinically sig distress or impairment
DSM 5 Social phobia timing
6+ months
DSM 5 panic disorder
- Recurrent panic attacks (periods of intense fear of abrupt onset, peaking in intensity within minutes)
- Attacks are spontaneous, not associated with specific situation or object
- 4 of the following:
- Palpations, pounding heart, tachycardia
- Sweating
- Trembling/shaking
- SOB
- Sensation of choking
- Chest pain, discomfort
- Nausea, GI distress
- Dizzy, unsteady, light-headed, faint
- Chills/heat sensation
- Paresthesias
- Derealization (feeling of unreality) or depersonalization (being detached from self)
- Fear of losing control or “going crazy”
- Fear of dying
- At least one attack was followed by 1+ months of:
- Persistent concern/worry about additional panic attack or their consequences
- Sig maladaptive change in behavior relating to attacks (to avoid another one)
DSM 5 Agoraphobia criteria
- Marked fear or anxiety about 2+ of:
- Using public transportation
- Being in open spaces (bridge, marketplace)
- Being in enclosed spaces (shops, theater, cinema)
- Standing in line, being a crowd
- Being outside of home alone
- Avoids these situations – thoughts that escape might be difficult, help might not be avail if panic-like sx develop
- Actively avoided
- Require presence of companion
- Endured with intense fear or anxiety
- Not sx of another disorder or medical condition
- Out of proportion to actual danger
- Can co-exist with panic disorder or be alone
DSM 5 time criteria for agoraphobia
6+ months
DSM 5 Criteria GAD
- Excessive anxiety/worry (apprehensive expectation) about a number of events of activities (work, school performance, etc.)
- Occurs more days than not for 6+ months
- Hard to control the worry
- Associated with 3+ of:
- Restlessness, feeling keyed up/on edge
- Easily fatigued
- Difficult concentration, mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (hard to fall/stay asleep, restless, unsatisfying sleep)
circumstances that might precede the development of a specific phobia
- Might follow a traumatic event (attacked by a dog), observation of others going through traumatic event (see someone drown), informational transmission (news about plane crash)
- Many are unable to recall specific reason for phobia
Age of onset for most phobias
before 10
Specific phobia treatment
- behavioral therapy
- medications
Behavioral therapy for specific phobias
- Exposure therapy (systemic desensitization, flooding with prolonged exposure)
- Hypnosis
- Relaxation techniques
- Family/supportive psychotherapy
Medication tx for specific phobias
anxiolytics in severe cases for temp relief as behavioral therapy is started
Ddx for social phobia
- Depression
- Schizophrenia
- Avoidant personality disorder
- Panic disorder with agoraphobia
comorbidities associated with social phobia
- Alcohol/drug dependence
- Depression
- Other anxiety disorders
- Personality disorders
2 Methods used in social phobia therapy
- Group therapy
- Socialization, support, learning to perform tasks/fn without anxiety/fear
- Recognize own and others’ excessive social critiquing - Systemic desensitization with psychotherapist
* * both use video feedback and fantasy situations
Drug therapy overview for social phobia
- SSRI, SNRI, MAOI
- BB for performance anxiety
- Benzodiazepines sparingly (dt risk of dependency)
Tx for panic disorder (3)
- Cognitive therapy
- Help reframe catastrophic thinking and expectations of panic
- Often paired with relaxation training - Behavioral therapy
- Desensitization to panic sx paired with relaxation training - Family and insight-oriented therapy often adjuncts
First line meds for panic disorder
- SSRI (paroxetine, fluoxetine, sertraline), - TCAs
- High potency benzodiazepines (clonazepam)
Ddx for GAD
- Caffeine/stimulants
- Alcohol/sedative withdrawal
- Psych disorders (OCD, panic disorder, phobias, depression, schizophrenia, anxious somatization, ADHD, atypical bipolar)
- Medical (Hyperthyroid, pheochromocytoma, carcinoid, pulmonary dz, CVD)
GAD meds
- SSRI, SNRI, Benzos (short term), Buspirone
- Others: TCA, BB, antihistamine, hydroxyzine
