Anxiety Disorders and PTSD Flashcards
Panic attack
- A panic attack is characterized by the abrupt onset of intense fear or discomfort.
- The terror is experienced as a feeling of impending doom, with a fear of dying, “going crazy,” or losing control
- Physical symptoms such as trembling, sweating, and shortness of breath commonly occur
- Panic attacks may be expected or unexpected (ie, with or without triggers)
Triad of panic disorder
- Acute panic attacks
- Anticipatory anxiety (fear of having another panic attack)
- Avoidance (avoiding situations for fear they may cause a panic attack)
Panic disorder epidemiology and natural history
- More common in females
- Usually onsets between adolescence - early 30’s
- Episodic outbreaks with several years of remission in between – may wax and wane over years as well
- Often accompanied by MDD
- Risk factor for suicide
Common trigger for panic attacks
The realization that you are stuck in a physical location or situation.
Once this occurs, the very realization that it would bad to have a panic attack at that moment causes anticipatory anxiety, which then triggers a panic attack.
For this reason flying, long bus trips, or being generally stuck commonly cause panic attacks.
This aspect makes this particular trigger similar to agoraphobia.
Agoraphobia
Persons with agoraphobia have intense fear or anxiety in two or more places or situations from which escape might be difficult or in which help might not be available, in which the anxiety is out of proportion to the actual threat of the situation orthe sociocultural context
Approximately half of patients with agoraphobia also have ___.
Approximately half of patients with agoraphobia also have panic disorder.
Social anxiety disorder
Persistent fear of social interactions, being observed, or performance situations, due to concerns about embarrassment or humiliation
During the feared situation, or in the anticipation of it, symptoms may include fear of negative social evaluation, blushing, sweating, tachycardia, trembling, and a desire to escape.
Onset generally mid-teens, characterized by chronic course, may be complicated by depression or substance use.
Specific phobias
- Specific phobia is characterized by intense fear or anxiety and avoidance of a specific object or situation
- Blood, injection, and injury phobias are uniquely related to a vasovagal physiological response, which includes similar somatic symptoms but is accompanied by a decrease in heart rate and blood pressure, often resulting in fainting
Generalized anxiety disorder
- Persons with generalized anxiety disorder experience frequent, excessive anxiety and worry and autonomic nervous system hyperarousal, which causes significant distress and/or impairment in functioning
- Symptoms include restlessness, fatigue, irritability, muscle tension, and impaired sleep and concentration
- “Constant anxiety” without discrete episodes of panic, or obsessions or compulsions
- Multiple domains of anxiety
- Chronic course with waxing and waning, often appearing in 20’s
- May be comorbid with MDD
Anxiety Disorder Due to Another Medical Condition
- Forthis psychiatric diagnosis,the physical illness must be evidenced by history, physical examination, and laboratory findings; precede the onset of the anxiety or panic symptoms; and be commonly known to precede the type of anxiety experienced
- Can also coexist with a more general anxiety disorder
- Some medical diagnoses that precede anxiety and panic symptoms include various respiratory illnesses, cardiovascular disorders, and endocrine disease.
Substance- or medication-induced anxiety disorders may be induced by . . .
. . . use OR withdrawal
Anxiety from stimulant intoxication
- Cocaine, amphetamines, caffeine, or diet pills may induce
- “Anxiogenic”
- Amount and route of administration both relevant
- Autonomic nervous system arousal may be evidenced by tachycardia, hypertension, mydriasis, and diaphoresis
Cocaine and marijuana both caused. . .
. . . increased risk for panic attacks and psychiatric conditions even when not intoxicated
Alcohol withdrawal
- Two distinct types that may cause anxiety:
-
“Classic” alcohol withdrawal:
- Often seen in hospitals
- Alcoholics who either stop or sharply reduce their alcohol intake for several hours to one day
- Occurs 1 day to 1 week after last drink
- Jitteriness, nervousness, mild tremor, and a mild increase in the heart rate and blood pressure. Panic attacks may also occur
- Thiamine deficiency may also produce delirium
-
Nocturnal withdrawal syndrome:
- Also characterized by anxiety but involves a milder, less prolonged process, occurs in nonalcoholics, and is not a function of addiction
- Initially alcohol inhibits REM, but once it is metabolized there is a rebound increase in REM
- This rebound effect results in insomnia, anxiety, and a sense of unease, symptoms that the individual may try to relieve by drinking more alcohol
Withdrawal from Benzodiazepines and Barbiturates
- The shorter-acting benzodiazepines tend to produce a more rapid onset of symptoms and a more intense withdrawal syndrome, characterized by jitteriness, a sense of unease, insomnia, mild tremulousness, and increased pulse and blood pressure (“Rebound anxiety”)
- As with alcohol, there is a concomitant rebound increase in REM during sleep (“Rebound insomnia”)
- Patients withdrawing abruptly from the prolonged use of high dosages of short-acting barbiturates become anxious, tremulous, nauseated, and weak within approximately 24 hours of taking the last dose
The longer acting the drug, the ____ the withdrawal.
The longer acting the drug, the slower the onset of the withdrawal.
Withdrawal from Opioids
Anxiety syndromes are also caused by withdrawal from opioids, such as morphine, heroin (which is converted to morphine in vivo), methadone, fentanyl, meperidine, and codeine.
Acute heroin withdrawal causes marked anxiety that begins 8–12 hours after the last dose istaken. During this phase, the addict has intense cravings for the drug
The withdrawalsyndrome peaks at 48–72 hours after the last dose, with piloerection, yawning, sneezing, nausea, vomiting, and diarrhea.
Obsessive-Compulsive Disorder
- Obsessions are intrusive, recurrent, and persistent thoughts, urges, or images experienced that an individual tries to ignore or suppress
- An obsession such as “I may have forgotten to lock my door” commonly leads to compulsions or repetitive behaviors that the individual feels driven to perform in response to the obsession
- Insight varies. Many OCD patients recognize that their OCD fixation is irrational, while some are convinced their OCD beliefs are true.
- Onset often gradual, but can be acute
- Course tends to be chronic waxing/waning
Posttraumatic stress disorder
- A psychophysiological syndrome that follows exposure to a traumatic event such as threatened or actual death, sexual violence, or serious injury
- Four cardinal features of PTSD:
- Reexperiencing of trauma
- Avoidance
- Persistent negative alteration in cognition and mood
- Alteration in arousal and activity
- May involve dissociative symptoms (depersonalization, derealization)
- Predictors for positive outcome: solid social supportsystem, good psychiatric and medical health before the trauma occurred, and a rapid onset of symptoms
Acute stress disorder
- Occurs after experiencing or being exposed to a traumatic event directly or indirectly
- Has specific signs and symptoms resembling those of PTSD (e.g., intrusion, negative mood, avoidance, arousal, dissociation), although they occur more rapidly after the trauma and are shorter in duration
- Specifically, a patient must experience at least nine symptoms within the following five categories beginning after trauma and persisting for 3 days to 1 month:
- Intrusive symptoms
- Negative mood
- Dissociative symptoms
- Avoidance symptoms
- Arousal symptoms
Anxiety disorder comparrison table
Depersonalization/derealization disorder
- Characterized by repeated episodes of depersonalization/derealization/dissociative experiences
- Depersonalization is a dissociative phenomenon in which a person feels somewhat removed from his or her body.
- Derealization is a dissociative state in which a person experiences his or her surroundings as strange or unreal
Dissociative amnesia
- Disorder in which past events that are usually of a traumatic nature are forgotten
- Dissociative fugue may accompany dissociative amnesia and is characterized by apparently purposeful travel or bewildered wandering that is associated with amnesia
Adjustment Disorder
Buspirone
5-HT1A receptor partial agonist, used to treat GAD
No sexual side effects, in contrast to SSRIs
Note that buspirone is different from buproprion! Buproprion (welbutrin) is used to treat depression and nicotine addiction.
Efficacy, indications, off-label uses, and side effects of hypnotics
Efficacy, indications, off-label uses, and side effects of benzodiazepines
Diagnostic criteria for PTSD
