Anxiety disorders, OCD, and trauma/stressor related disorders Flashcards
Level 3, now pathologic level of anxiety physiologic s/sx
-ANS triggered
- fight/flight
-pupils dilated
-VS inc
- diaphoresis
- muscle rigid
-hearing dec
- pain threshold inc
- urinary freq
-diarrhea
Level 3, now pathologic level of anxiety psychological s/sx
-perceptual field greatly narrowed
-diff with problem solving
-distorted perception of time
- selective inattention
- dissociative sensations
- automatic behavior
Level 4, pathologic level of anxiety physiologic s/sx
inc on severe sx, now at panic
-pale
- hypotensive
-poor hand/eye
-muscle pains
-marked dec hearing
-dizzy
-SOB
Level 4, pathologic level of anxiety psychological s/sx
-scattered perceptions
-unable to attend to environmental stimuli
- illogical thinking
- poss hallucinations/delusions
latino cultural anxiety
ataques de nervios
disruptions in family bonds
- trembling, crying, screaming
asian cultural anxiety
ex: khyal (wind) among cambodians
common sx neck sore/tinnitus
1st line tx for children and adolescents with anxiety disorders
psychotherapy
role of the PMHNP in assessing anxiety
separate normal vs pathological
- intervene to lower level
-improve overall function
Anxiety related disorders
panic
agoraphobia
specific phobia
social
selective mutism
GAD
Obsessive/compulsive related disorders
OCD
BDD
Hoarding
trichotillomania
excoriation
SUD
OCRD
Trauma/stressor related disorders
Reactive attachment
disinhibited social engagement
PTSD
acute stress
DID
Dissociative amnesia
depersonalization or derealization
GAD time for dx
6+mo
more days than not
impair function
psychodynamic theory of anxiety
freud
initially in response to stimulation at birth and need to adapt to changed environment
subsequent anxiety from intrapsychic conflict
unconscious repression of sexual drive
Conflict b/t instinctual need of the ID and the superego (conscience)
-conflict is unconscious but perceive consciously
fear of punishment and doing wrong
unconscious use of defense mechanisms
- behavioral manifestations from pathological overuse of the defense mechanisms
Interpersonal theory of anxiety
Sullivan
Humans are goal directed to satisfaction/security
Needs met in interpersonal interactions
anxiety from unmet needs
- starts with mother as infant
- rejection/inferiority
sense of self based on perception of how others view you
neurobiological theory of anxiety
deficit in normal brain function
-mediated by limbic, midline brainstem, cortex sections
-predispose to abnormal stress response (ANS)
problems with HPA axis
-threat perceived THEN amygdyla signal hypothalmus to secrete CRH
–amygdyla also activates SNS to start fight/flight
–pituitary stim to release ACTH
-adrenal stim to release cortisol to restore homeostasis
anxiety disorder: amygdyla may not be able to shut off response or may not be enough cortisol
- deficit could result in low NT (GABA) and high NT (NE)
NTs that suppress HPA are 5HT and GABA
pathological levels of anxiety indicative of underlying disorder
- distressing and out of control of the person
- unlinked and not seen as caused by life events
-accompanied by somatic complaints - interferes with social, occupational, recreational and ADL
anxiety rating scale
Hamilton (HAM-A)
ZUNG
Yale-Brown
most rx for anxiety act directly or indirectly on
GABA system
1st line agent for chronic anxiety disorders
SSRI
act on 5ht system directly and indirect on GABA
why BZDs for anxiety
potentiate effect of GABA
rapid onset
poss to use PRN
why BZDs with longer half lives
less frequent dosing
less severe withdrawal
less rebound anxiety
more useful for continuous use and mod-sev sx
bridge to SSRI
BZDs with longer half lives
clonazepam-klonipin
diazepam- valium
BZDs with shorter half life
alprazolam-xanax
lorazepam-ativan
why short half life BZDs
less daytime sedation
less drug accumulation
quick onset of action
useful for tx of insomnia
TCAs for anxiety
effective but multiple receptors and so more AEs
this means noncompliance
non BZD anxiolytics for adults
Buspar- helpful adjunct (Not PRN)
Gabapentin- pain and craving tx too
propranolol– performance anxiety, usually adjunct
children other rx anxiety
clonidine
guanfacine
panic disorder
discrete episodes/attacks
sudden onset
intense apprehension
fearfulness
terror
often associated with sense of impending doom
Panic disorder diagnostic criteria
discrete episodes
sudden onset, peaking within 10 min of onset of 4+ of:
Paresthesias
Chills or hot flushing
Fear of losing control or of going crazy
Fear of dying
SOB or smothering sensation
Palpitations/pounding/ Inc HR
Chest pain, tightness, or discomfort
Sweating
Trembling/Shaking
Nausea or Abdominal distress
Panic Disorder common results post 1st attack
After 1st attack: persistent concern over having another/worry about consequences of 1st/significant behavior change r/t 1st
R/t high somatic sensations, often sensitive to new somatic experiences or perceptions
intolerant of or concerned with common AE
ashamed of failure to control emo, over concern about dying
Panic Disorder dual dx
2/3 major depression 1st
1/3 panic disorder 1st
Panic Disorder differential dx
Hyperthyroid
hyperparathyroid
pheochromocytosis
vestibular dysfunction
Sz
Cardiac like SVT
CNS stimulants
Alt anx like PTSD/phobias
Consider general med dx if panic sx are atypical like vertigo, LOC, incont, HA, slurred speech, amnesic pattern post attack
Note panic is sudden onset, discrete, self limiting, paroxysmal
Panic disorder rx
SSRI
BZO for short term or bridge to SSRI
Buspar as adjunct to SSRI
Agoraphobia dx criteria
agoraphobia anxiety r/t fear of developing panic like sx
never met criteria for panic disorder
avoidant behavior as a result of agoraphobia anxiety
Agoraphobia rx
SSRI
BZO short term
BB off label for discrete episodes of social anxiety
specific phobias adults vs children
adults this exists in conscious recognition that the fear is excessive or unreasonable
children insight increases with age
specific phobia risk factors
past trauma
observe another trauma
excessive info transmission
genetic loading
Blood/injection/injury type is most familial
1st deg relative
Specific phobias history assessment
content: varies with culture, ethnic/age
Dx only with significant functional impairment (full avoidance school r/t spider etc)
Exposure to specific provokes onset of clinically significant levels of anxiety
- may fit criteria for cued panic attack
-directly r/t proximity or degree of escape
-children manifest as cry/freeze/tantrum/excess cling
avoidant behavior is distressful with implications
5 subtypes specific phobia
situational- most common (driving, spaces, tunnel etc), bimodal peak (child/mid 20s)
natural environment- cued by objects natural (storm/lightning/water/heights etc), onset usually child
blood injection injury- seeing or receiving, strong vasovagal
animal- cued by animals, onset usually childhood
other- range of stimuli (choking/vomit/specific illness) , children: loud sounds or costumed characters
-note 1 class means more likely for another within that class
specific phobias rx
SSRI
TCA
short term BZO
length of time for social anxiety (phobia)
6+ mo
social anxiety (phobia) onset age
mid teens, often following stressful or humiliating experience and tends to remit with age
social anxiety (phobia) DDX assist
awareness that people with it do not feel better or experience decreased anxiety when accompanied by a trusted companion
social anxiety (phobia) common descriptive features
Hypersensitivity to criticism
negative self evaluation
Sensitivity to rejection
Low self-esteem
Inferiority feelings
Lack of assertiveness
may have anticipatory anxiety
distress/impaired function–poss association with SI
GAD description
excess worry
apprehension
anxiety about events/activities
more days than not for 6+ mo
hard to control
no clear link to life event/stressors
interfere with ADL
nature and focus of worry shifts
pattern of waxing/waning of sx
sx worsen as life events stress
children with GAD
Common but important to assess normal versus pathological
Manifested in excessive worry over competence or quality of performance
Common over punctuality, or catastrophes like earthquakes
Often accompanied by overly conforming behavior, perfectionist, excessive seeking of approval, need frequent reassurance
separation anxiety disorder
Abnormal after four described as excessive distress, when faced with separation from a major attachment figure
obsessive compulsive disorder
Presence of anxiety provoking obsessions OR compulsions
that function to reduce the persons, subjective anxiety level
recognize that they are excessive or unreasonable
cause marked distress/time consuming/interfere with normal day
recognize as product of own mind
attempt to suppress/ignore to override (worse if resist)
avoid situations where content may be encountered (public restroom etc)
obsession
Recurrent and persistent thoughts, impulses, images that anxiety in distress
Intrusive and inappropriate
Ego dystonic: feels the content is alien to belief structure, and not common/usually experienced
compulsion
Repetitive behaviors or mental actions that you feel driven to perform in response to an obsession
OCD risk factors
Familial, higher with first degree
Higher with first- degree with Tourette’s
Good to consider PANDAS in kids with sudden onset
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
OCD common obsessions
Repeated thoughts about contamination/dirt/germs
Repeated doubts (left the oven on etc)
Need to have things in specific order and distress if not
Aggressive/horrific thought
May occur in pregnancy/postpartum and manifest as intrusive thoughts about the baby (highly ego-dystonic
Sexual imagery
NOT often real world (finance etc)
OCD common compulsions
Repetitive actions, usually behavioral a.k.a. rituals
-handwashing
-excess cleaning
-lights off, stove off, doors locked
-needing to place objects in a certain order
OCD common mental actions
counting
silently repeating words
praying
OCD rx tx
SSRI
- often need higher dose range for sc control
TCA
-clomipramine
2nd gen antipsychotic
- risperidone (off label) but data support adjunct with SSRI
OCD lifespan
CHILDREN
- common with prepubertal onset
-more boys
- most common washing/checking/ordering
- common comorbid with learning disorder, disruptive behavioral disorders, tourettes
-associated with PANDA
OLDER ADULTS
-more obsession than compulsion
-obsessions often about dying
-compulsions often washing/cleaning
PTSD
The reexperiencing of an extremely traumatic event
Accompanied by symptoms of increased arousal, and avoidance of stimuli from the trauma
Can be experienced directly or witnessed
There is a relationship between physical proximity and likelihood of symptom onset
PTSD, common witnessed trauma
observed/learning of death/significant injury (learning of would be family/close friend)
unexpected witnessing of common PTSD experienced traumas
PTSD subtypes
Three subtypes
- acute: <3 mo
-chronic: >3 mo
-Delayed onset: 6+ mo b/t event and onset
PTSD diagnostic criteria
sx 1+ mo
exposure to trauma
- experienced/witnessed/or confronted with an event involving death/threatened death/serious injury
AND
-response is intense fear, helplessness, or horror
The event is persistently re-experienced in one or more ways:
-recurrent/intrusive/distressing recollection
-flashbacks
-dissociative state lasting hours to days (rare)
-recurrent distressing dreams about the event
-acting/feeling like event is reocurring
-intense, psychological distress and exposure to cues
-physiological reactivity on exposure to cues
3+ avoidance sx
-persistent, avoidance of stimuli associated
-efforts to avoid talking about, or thinking about even
-avoidance of activities/places/people that arouse recollections of event
-inability to recall important aspects of event
-marked decreased interest/participation in activities
-feelings of detachment or estrangement from others
-restricted range of affect
-sense of foreboding/certain future/premature death/no expectation for success/happy
2+ increased arousal sx
-diff falling asleep
-irritability
-diff concentrating
-hypervigiliance
- exaggerated startle response
Sx cause impaired activities of daily function
sx usually within 3 mo of event
PTSD duration
highly variable
1/2 remit within 3 mo
common waxing/waning r/t internal and external cues that resemble trauma
PTSD rx tx
SSRI
TCA
BZO not recommended for PTSD
antipsych maybe during flashback episodes
alpha agonists
- prazosin
-maybe during tx for nightmares
-off label
PTSD non pharm tx
CBT
ERP
supportive group therapy
relaxation therapies
EMDR
PTSD children
Fear/horror occurs in disorganized or agitated behavior
Repetitive play behaviors show themes or aspects of trauma
Frightening dreams, but without recognize content are common
Young children may get from learning about trauma to parent or caregiver
