Anxiety Disorders

Question 1

Discuss the pathophysiology and presentation of anxiety disorders

Answer 1

Pathological
- when anxiety is autonomous, intense and exceeds patient tolerance, persistent >=6 months, impairs social functioning and results in avoidance or withdrawal
Presentation
- autonomic arousal
- terror
- loss of control
- avoidance

Question 2

List the most common anxiety disorders and risk factors

Answer 2

Most to least Common:
- specific phobia
- social phobia
- PTSD
- GAD
- panic disorder
- OCD
Risk
- family history
- personal history
- adverse childhood event
- comorbid psychiatric disability

Question 3

List the differential diagnosis for anxiety disorders

Answer 3

• Pheochromocytoma
• Hypethyrodisim
• Hyperparathyroidism
• Hypothyroidism
• Hypoglycemia or Hyperglycemia
• Anemia
• Cardiac arrhythmia
• Asthma
• Vestibular dysfunction

Question 4

Discuss medications and treatment for anxiety

Answer 4

1st Line long term
- SSRI Paroxetine
- SNRI: Venlafaxine (except OCD)
- follow up in 1-2 weeks
1st Line short term
- Benzodiazepine (except OCD): diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan)
2nd line
- TCA or MAOI
3rd Line
- Atypical antipsychotics
Psychosocial
- all get CBT

Question 5

Discuss the diagnostic criteria and treatment for specific phobia

Answer 5

• marked fear about specific object or situation >=6 months
• phobic object always provokes immediate fear or anxiety
• phobic object is actively avoided or endured with intense fear
• fear is out of proportion
• cause distress and impair functioning
• no other disorder
  Treatment
• CBT with exposure therapy best

Question 6

Discuss the diagnostic criteria and treatment for social phobia

Answer 6

• marked fear about social situation where exposed to scrutiny for >=6 months
• fear symptoms at thought of being negatively evaluated by others
• social situation always provokes fear
• social situation is avoided or endured with intense fear
• fear is out of proportion
• cause distress or impair functioning
• no other disorder
  Treatment
• CBT most effective

Question 7

Discuss the diagnostic criteria and treatment for generalized anxiety disorder

Answer 7

• excessive and uncontrollable anxiety and worry >=6 months about number of events
• anxiety and worry associated with >=3 symptoms
  - restlessness
  - easily fatigued
  - difficulty concentrating
  - irritability
  - muscle tension
  - sleep disturbance
• cause distress and impair functioning
• no other disorder
  Treatment
• CBT most effective

Question 8

Discuss the diagnostic criteria and treatment for panic disorder

Answer 8

• panic disorder is anticipatory anxiety in response to recurrent and unexpected panic attacks
• panic attacks are acute and last 10 minutes where anxiety attacks are slow and last hours
  Diagnosis
• > 1 panic attack of intense fear that peaks within minutes with >=4 of the following
  - derealization or depersonalization
  - fear of losing control
  - fear of dying
  - sweating
  - chills
  - paresthesia
  - trembling
  - lightheadedness
  - feeling of choking
  - shortness of breath
  - chest pain
  - palpitation
  - nausea
• panic attack following by >=1 month of >=1 of the following
  - persistent concern or worry about additional panic attacks
  - significant maladaptive change such as avoidance
• no other causes
  Treatment
• CBT

Question 9

List the differential for panic attacs

Answer 9

THE PANIC

• Thyrotoxicosis
• Hypoxia
• Endocrine
• Embolism
• Pheochromocytoma
• Arrthymia
• Anemia
• Neoplasm
• Intoxication
• Carcinoid

Question 10

Discuss the diagnostic criteria and treatment for agoraphobia

Answer 10

• marked fear or anxiety about >=2 of the following
  - using public transport
  - being in open spaces
  - being in enclosed spaces
  - standing in line or being in crowd
  - being outside of home alone
• patient fears these situations because escape is difficult or help might not be available
• situation always provokes fear
• situation is actively avoided
• anxiety is out of proportion
• persistant >=6 months
• cause distress and impair function
• clearly excessive
• no other disorder

Question 11

Discuss the differences with anxiety in the elderly

Answer 11

• anxiety is less common in the elderly and if elderly person presents with anxiety it is depression until proven otherwise
  Treatment
• 1st line is SSRI Escitalopram or Sertaline

Question 12

Discuss anxiety in pregnancy

Answer 12

• usually does not occur as hormones decrease anxiety
• perinatal have increased risk of OCD or GAD
  Risks to fetus
• neurodevelopmental disorder
• pre-term labour
• low birth weight
• low APGAR scores
  Treatment
• CBT is first line
• monotherapy of SSRI: fluoxetine or Sertraline (cannot use Paroxetine in 1st trimester)

Question 13

Differentiate between obsessions and compulsions

Answer 13

Obsessions
- recurrent and persistant anxiety-provoking thoughts, urges or images that are intrusive and unwanted
- commonly involve contamination, harm, somatic, religious or sexual
Compulsions
- repetitive behaviours or mental acts that individual feels driven to perform in response to obsession or rigidly applied rules
- done to decrease anxiety
- done excessively and not connected in realistic way with desired neutralizing event

Question 14

List the common comorbidities with OCD

Answer 14

Depression Body TAASTE

• Depression
• Body dysmorphic disorder
• trichotillomania (hair pulling)
• anxiety
• autism
• Schizophrenia
• Tourette’s
• Eating disorder

Question 15

List the diagnostic criteria and treatment for OCD

Answer 15

• presence of obsession and/or compulsions
• spend >=1 hour per day on obsession or compulsion or cause distress or impairement
• no other disorder
  Treatment
• CBT with exposure response prevention
• 1st line medication SSRI: fluoxetine and sertaline and require higher dosage
• possible neurosurgery if refractory