Anxiety disorders; Trauma- and Stress-Related Disorders

Question 1

generalized anxiety disorder

Answer 1

• onset before 20yo
• hx childhood fears, social inhib, F 2x > M
• all anxiogenic agents work on GABA-A receptor/chloride ion channel complex
• sxs: chronic, excessive anxiety, worry about job performance, health, marital relatinships, social life (duration >/=6 mo, usually lifetime)
  
  • 3 out of 6 sxs: restlessness, irritability, muscle tension, easily fatigued, dec concentration, disturbed sleep (insomn, restless sleep)
  • not attributable to physiologic effects of a substance
• dx: clinical dx, CBC< CMP, TSH, UA, EKG, urine or serum tox
• tx: SSRI/SNRI (1st line), CBT, buspirone (second line adjunct or monotherapy, TID dosing), pregabalin (Off-label), short acting benzos (adjunct or monotx), mirtazapine, antipsychotics (quetiapine), long acting benzos
  
  • Time to onset = 4-6 weeks
  • if no response to first SSRI/SNRI, taper and start different one
  • if robust response, continue for at least 12 mos
• screening: GAD7

Question 2

panic disorder

Answer 2

• genetic predisp, altered autonomic responsivity, social learning
• onset: usually late adolescence or early adulthood, F 2x > M
• sxs: intense fear/discomfort
  
  • requires at least 1 month of concern about attacks or their consequences, change in behavior related to attacks (avoidance of exercise or unfamiliar situation), recurrent (at least 2) unexpected panic attacks
• signs: palps, CP, SOB, N, abd pain, sweating, shaking, trembling, chills, dizziness, fear of dying, losing control or going crazy, paresthesias, GI distress, depersonalization, derealization, feelings of unreality
• dx: clinical, CBC, TSH, CMP, EKG (ro other causes), echo, cogonary angiogram = normal, PFTs
• tx: antidepressants (SSRI, SNRI, MAOIs), CBT
• complications: anticipatory anxiety (pt tries to predict attacks coming on) nezos useful in early course
• prognosis: higher likelihood of suicide attmenpts
• health maintenance: panic disorder severity scale (GOLD STANDARD for monitoring)
• comorbidities: major depression, OCD, agoraphobia, GAD, social anxiety disorder, PTSD

Question 3

Post traumatic stress disorder

Answer 3

• RF: past psychiatric hx and personality characteristics of high neuroticism and extroversion, excessive release of NE in response to stress and inc noradrenergic activity
• sxs: exposure to actual or threatened death, serious injury, or sexual violence
  
  • the following occur for more than 1 month: (PAIN) 1+ Persistent avoidance of associated stim, 2+ Alterations in arousal and reactivity and feelings of isolation from close friends and fam, 1+ Intrusion/re-experiencing sxs, 2+ Negative alterations in cognitions/mood
• dx: clinical dx
• tx: SSRI (sertraline and paroxetine), trauma focused CBT, exposure tx, eye mvmt desens and reprocessing

Question 4

Phobic disorders

Answer 4

• sxs: marked and persistent fear of objects or situations - exposure causes immediate anxiety, excessive fear of possible scrutiny, humiliation, or embarassment (exposure provokes anxiety, situation avoided, recognized as unreasonable), panic attacks triggered by stim, pts experience anxiety ONLY in specific situation
• dx: clinical dx
• tx: combo of meds and tx → anxiolytic antidepressants, benzos

Question 5

Specific phobia

Answer 5

• fear of particular object or situation that leads to avoidance
• RF: first-deg relatives
• five main specifiers: anima, natural enviro (heights, storms, water), blood-injection, situation (airplane, elevators, enclosed spaces), other (situations that may lead to choking or vomiting, loud sounds, etc.)
• sxs: marked fear or anxiety about object or situation, phobic object or situation almost always provokes immediate fear or anxiety, phobic object or situation actively avoided or endure with fear or anxiety, fear or anxiety out of proportion to actual danger, fear anxiety or avoidance is persistent typically lasting 6mo or more, causes clinically significant distress, disturbance not better explained by sxs of another disorder
• dx: fear excessive and out of proportion, cannot be alleviated with rational explan, out of voluntary control, leads to situational avoidance, maladaptive and persistent, not age or stage-specific
• tx: CPT (first line), benzos, SSRI