Anxiety- Exam 2 Flashcards
Define akathisia
the feeling of not being able to sit still, constantly feeling the urge to move
aka the inability to remain still
What are some defining characteristics of fear?
emotional reaction to a real, external threat perceived as painful, dangerous, or harmful
very specific stimulus and short duration
always gear towards the present
goal is to get away from the threat
What are some defining characteristics of anxiety?
apprehension, nervousness, or dread associated with an anticipated event or an unknown, vague stimulus
nonspecific stimulus
long duration
geared towards the future
the idea of something
When does anxiety become pathologic?
Present without an obvious or reasonable cause
Excessive and out-of-proportion to actual threat
Causes distress, functional impairment, and/or reduced quality of life
name 4 maladaptive congnitions that a person with anxiety might exhibit
Judgement biases
Attentive biases
Avoidant behaviors
Low self-confidence in problem solving skills
_____ are oriented toward identifying how thoughts influence behaviors and perception of outcomes
Cognitive-based therapies (CBT)
_____ exposing patients to anxiety-inducing stimuli in small doses that gradually become more intense
Desensitization
_____ patient observes other individuals who are around anxiety-inducing stimuli
modeling
______ patient is exposed to stimulus that causes anxiety at its worst and made to use relaxation techniques to get through the experience
flooding
Which exposure therapy technique is quicker in the short term but is prone to spontaneous relapses?
flooding
What is the short term/prn therapy for anxiety?
Benzodiazepines (BZDs)
Hydroxyzine
What is the first line treatment for anxiety? second line?
SSRIs, SNRIs
Second-Line - Buspirone, TCAs, BZDs, antipsychotics
_____ MOA enhances the effect of GABA at the GABA receptor
Benzodiazepines
Name some uses of Benzodiazepines
anxiety, panic, insomnia, ETOH withdrawal, agitation, seizures, procedural sedation
Benzos in high doses can cause ____ and _____
amnesia and dissociation
What are the SE of benzos? What are the 2 major ones? A patient is at risk for ____ and _____
*drowsiness, *dizziness, decreased motor coordination, decreased libido, disinhibition, rebound anxiety, amnesia, suicidal ideation
dependence and withdrawal
What are the DDI of benzos? What are the 2 major ones?
*ETOH, *opioids, and other CNS depressants, anticonvulsants, antidepressants, antifungals
What are the CI of benzos?
*pregnancy, BZD allergy, myasthenia gravis, narrow-angle glaucoma
Risk for respiratory depression - COPD, sleep apnea, myasthenia gravis
_____ and _____ are short acting benzos. Which one is IV only? What is the onset?
Midazolam: IV only: 3-5 minutes
Triazolam
What is the indication for Triazolam? What is the onset?
insomnia
15-30 minutes
What are the intermediate acting benzos?
alprazolam
temazepam
oxazepam
lorazepam
clonazepam
_____ has a high abuse potential and possible rebound anxiety. What is the onset? 1/2 life?
alprazolam
15-30 minutes
11-16 hours
What is alprazolam indicated for?
panic, anxiety
What is temazepam indicated for? What is the onset? 1/2 life? Will it show up on a UDS?
insomnia
30-60 minutes
8-15 hours
minimally active metabolite
______ and _____ have no active metabolite
oxazepam and lorazepam
What is oxazepam indicated for? onset? 1/2 life?
insomnia and alcohol withdrawal
60-120 minutes
5-15 hours
What is lorazepam indicated for? onset? 1/2 life?
Anxiety, Seizures, Agitation, ETOH withdrawal, Insomnia, Procedural sedation
30-60 minutes
10-14 hours
What is clonazepam indicated for? onset? 1/2 life?
Panic, Anxiety, Seizures, Tremor
RLS, Insomnia
30-60 minutes
18-39 hours
Of the intermediate acting benzos, _____ has the longest 1/2 life.
Clonazepam (Klonopin)
What are the long acting benzos?
diazepam
chlordiazepoxide
flurazepam
What is the indication of diazepam? onset? 1/2 life?
anxiety, seizures, agitation, alcohol withdrawal, muscle spasms, procedural sedation
30 minutes
**50-100 hours- longer acting
What is the indication of chlordiazepoxide? onset? 1/2 life?
**alcohol withdrawal in the inpt setting
60 minutes
30-100 hours
What is the indication for flurazepam? onset? 1/2 life?
insominia
120 minutes
40-114 hours (up to 160 hours in the elderly)
What are the prescribing cautions with benzos?
PRN only
limited time (1-4 weeks)
have a potential for dependence, tolerance and addiction
avoid use in patients with hx of substance abuse
What is the recommended tapering schedule?
10-25% dose reduction per 1-2 weeks
Slower taper if s/s of withdrawal
Anxiety, dysphoria, tremor, seizures
______ Histamine (H1) receptor antagonist
Anxiolytic, muscle relaxant, antihistamine, antiemetic, sedating
May be helpful in patients with insomnia due to anxiety
hydroxyzine
What are the SE of hydroxyzine?
drowsiness, dizziness, dry mouth, rash, fatigue, respiratory depression
What are the DDI of hydroxyzine?
oral potassium, MAOIs, CNS depressants
Can you give hydroxyzine through an IV? Is it safe in pregnancy?
NO, only approved via PO
DO NOT GIVE in the the first trimester
______ 5HT1a receptor agonist; also acts on dopamine receptors
More effective for cognitive anxiety s/s than somatic s/s
Less anxiolytic effects than BZDs
Buspirone
_____ is often used increase SSRIs/SNRIs or in pregnant patients
Buspirone
What are the SE of buspirone?
dizziness, drowsiness, nausea, headache
**Concern over potential for Serotonin Syndrome
What is the DSM criteria for Generalized Anxiety Disorder?
Excessive anxiety and worry (apprehensive expectation) more days than not
Anxiety/worry is about multiple things
Anxiety/worry is present for at least 6 months
Patient finds it difficult to control anxiety/worry
______Plus at least 3 of the following things_____
Irritability
Muscle tension
Sleep disturbances
Restlessness or feeling keyed up/on edge
Being easily fatigued
Difficulty concentrating
+must cause distress or functional impairment
+not due to substance abuse or medical condition
_____ is a syndrome of persistent worry coupled with symptoms of hyperarousal, worry over minor matters, often coupled to somatic s/s
Generalized anxiety disorder
______ Initial screening for GAD, used to monitor severity of s/s and response to tx
GAD-7
______ 21-question self-reported inventory of s/s
Can be used for GAD or other anxiety disorders
No overlap with depressive s/s
Beck Anxiety inventory
What is first line treatment for GAD? 2nd line?
How long do you need to continue therapy?
1st- SSRI/SNRI, CBT, or both
2nd- TCAs, buspirone, other meds
6-12 months
_____ intense fear or discomfort with multiple accompanying symptoms
panic attacks
______ recurrent episodes of panic attacks
panic disorder
______ anxiety about and/or avoidance of situations where help may not be available or leaving would be difficult if the patient were to develop incapacitating or embarrassing symptoms (e.g. panic attacks, incontinence)
agoraphobia
_____ is a separate dx from GAD or panic disorder. Have have similar s/s
Agoraphobia
**What is the DSM dx for panic attack?
Abrupt surge of intense fear/discomfort that peaks within minutes
plus 4+ of the following:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath, choking, or smothering
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Chills or heat sensations
Paresthesias
Derealization¹ or depersonalization²
Fear of losing control, dying, or “going crazy”
** What is the DSM for panic disorder?
Recurrent unexpected panic attacks
1+ attacks have been followed by 1+ months of one or both of the following:
——-Persistent concern or worry about additional panic attacks
or their consequences
———Significant maladaptive change in behavior due to the attacks
+must cause distress or functional impairment
+not due to substance abuse or medical condition
T/F: Panic attacks only occur in response to a specific trigger
FALSE! Panic attacks DO NOT occur only in response to specific triggers
What is the 1st line treatment for panic disorders? 2nd?
1st: CBT, SSRI, or combination
2nd: SNRIs or TCAs
What is a good first SSRI to try for panic disorders? Why?
paroxetine due to its sedating effects
What should you consider as an adjunct medication for panic disorders?
BZDs (short-term/PRN use)
What are the pros/cons of using alprazolam and clonazepam?
alprazolam: commonly used due to short time to onset, Risk of dependency, rebound anxiety
clonazepam: Less risk of rebound anxiety, fewer doses/day
What is the DSM criteria for agoraphobia?
Persistent (6+ months) of marked fear/anxiety about 2+ of the following:
Using public transportation
Being in open spaces (e.g., parking lots, marketplaces, bridges)
Being in enclosed places (e.g., shops, theaters, cinemas)
Standing in line or being in a crowd
Being outside of the home alone
Pt fears/avoids these situations due to fear that escape might be difficult or help might not be available in the event of developing incapacitating or embarrassing s/s:
Agoraphobic situations almost always provoke fear or anxiety
Agoraphobic situations are avoided, require presence of a companion, or are endured
with intense fear/anxiety
Fear/anxiety is out of proportion to the actual danger posed by situations and conditions
+must cause distress or functional impairment
+not due to substance abuse or medical condition
What is the treatment for agoraphobia?
same as panic disorder:
1st: CBT, SSRI, or combination
2nd: SNRIs or TCAs
What is the DSM criteria of social anxiety disorder?
Persistent (6+ months) of marked fear/anxiety about 1+ social situations in which the pt is exposed to possible scrutiny by others
Pt fears acting in a way or showing anxiety s/s that will be negatively evaluated
The social situations almost always provoke fear or anxiety
The social situations are avoided or endured with intense fear or anxiety
Fear/anxiety is out of proportion to the actual threat posed
+must cause distress or functional impairment
+not due to substance abuse or medical condition
Children with social anxiety disorder the anxiety must occur _____ and with adults
in front of their peers
How does social anxiety disorder manifest in children?
crying, tantrums, freezing, clinging, shrinking, failing to speak
_____ is a subtype of social anxiety disorder, that only happens in specific instances usually related to public speaking
performance only social anxiety disorder
What is the first line treatment for social anxiety disorder? How long do you need to continue treatment?
CBT, SSRI or SNRI, or both
May choose to augment with PRN BZD
6-12 months
What is the treatment for performance only social anxiety disorder?
Propranolol 20-60 mg, 30-60 min before performance
PRN BZD dosing 30-60 min before performance
Cannot use propanolol and pts who have _____ together
asthma
How do acute stress disorder and posttraumatic stress disorder differ?
acute stress occurs within the initial month after a trauma
PTSD lasts more than 1 month
What are some risk factors for acute stress and PTSD?
history of other psych disorder, female gender, severe trauma, avoidant coping mechanisms
What is the DSM criteria for acute stress disorder?
Exposure to actual or threatened death, serious injury, or sexual violation in 1+ of the following ways:
Directly experiencing traumatic event(s)
Witnessing, in person, event(s) as it occurred to others
Learning that event(s) occurred to close family/friend
—For actual or threatened death of a family member or friend, event(s) must have been violent or accidental
Experiencing repeated or extreme exposure to aversive details of traumatic event(s) (think EMS, psych providers, social workers)
9+ of the following symptoms from any category, beginning or worsening after event(s) occurred, lasting at least 3 days - 1 month after trauma:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
-2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s).
-3. Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
-4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- Persistent inability to experience positive emotions (eg, inability to experience happiness, satisfaction, or loving feelings).
- An altered sense of the reality of one’s surroundings or oneself (eg, seeing oneself from another’s perspective, being in a daze, time slowing).
-7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs)
- Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
-9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
- Sleep disturbance (eg, difficulty falling or staying asleep, restless sleep)
-11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects
-12. Hypervigilance
-13. Problems with concentration
-14. Exaggerated startle response
+must cause distress or functional impairment
+not due to substance abuse or medical condition
What is the treatment for acute stress disorder? What is adjunct therapy?
Trauma-oriented CBT with incorporated exposure therapy
2 weeks of benzos in pts with severe s/s such as agitation/insomnia
Why are antidepressants NOT first line therapy for acute stress disorder?
because they take 4-6 to start working
_____ is the MC trauma in women with PTSD
sexual assault
_____ increases the risk of PTSD correlated with severity of injury and presence of traumatic brain injury (TBI)
military combat
______ and _____ are 2-4x more common than in the general population
substance abuse and PTSD
up to ____ of TBI pts also have PTSD
60%
What is the first part of the DSM criteria for PTSD
What is the additional part of DSM to dx PTSD?
What is the treatment for PTSD?
Trauma-oriented CBT with exposure therapies
SSRIs or SNRIs if medication is needed
_______ can be used for add-on therapy for refractory cases of PTSD
Atypical antipsychotics
_____ is an 1-adrenergic blocker for insomnia associated with PTSD
Prazosin (Minipress)
_____ mental event - recurrent intrusive thoughts, images, or urges that typically cause anxiety or distress
obsessions
_____ behavioral event - repetitive acts that pt feels driven to perform, either due to an obsession or according to rules that he/she believes must be applied rigidly. Action is usually not ration or act is clearly excessive
compulsions
T/F: Many OCD patients recognize their thoughts and behaviors are abnormal and take avoidant actions to hide them
True
What populations are most common to have OCD? in children?
adult females
male children
What is the DSM criteria to dx OCD?
Obessions: Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted, and that in most pts cause marked anxiety or distress
Pt attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion)
Compulsions: Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
Compulsions are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. Not usually realistically connected and are clearly excessive.
**Must be time-consuming or cause distress/functional impairment
______ are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. Not usually realistically connected and are clearly excessive.
Compulsions
Degree of OCD insight: _____ Pt recognizes OCD beliefs are definitely or probably not true, or that they may or may not be true
Good or fair insight
Degree of OCD insight: ____ Pt thinks OCD beliefs are probably true
poor insight
Degree of OCD insight: ______ Pt is completely convinced that OCD beliefs are true
Absent insight/delusional beliefs
_____ behaviors and thoughts are focused on a specific fear-inducing stimulus
Phobic Disorder
______ individuals are focused mainly on their body’s perceived flaws; no sense of dread if they do not take actions to hide flaws
Body Dysmorphic Disorder
_______ similar obsessions and compulsions, but also have desire that other individuals should follow their OCD beliefs, and less distress caused by OCD beliefs
Obsessive-Compulsive Personality Disorder
_______ compulsive hair-pulling is done because it brings a sense of satisfaction, instead of done to avoid negative outcomes; no obsessive thoughts
Trichotillomania
What is first line therapy for OCD?
CBT with exposure therapy, SSRI, or combination
Psychotherapy preferred for OCD alone
Due to high rate of comorbid psych disorders - using SSRI is often beneficial
OCD pts often need ______ of SSRI therapy
higher maintenance doses
If an OCD patient has no response to SSRI, what should you do?
try another SSRI or SNRI
_____ intense, irrational fear of a particular object or situation
phobia
What is the DSM criteria for phobic disorder?
Persistent (6+ months) of marked fear/anxiety about a specific
object or situation
Phobic object/situation almost always causes immediate fear/anxiety
Phobic object/situation is actively avoided or endured with intense fear or anxiety
Fear/anxiety is out of proportion to the actual danger posed by object/situation
Fear/anxiety or avoidance causes distress or functional impairment
Syndrome is not better explained by another mental disorder
Give some distinguishing factors of phobias vs fear
Is excessive and out of proportion
Cannot be alleviated with rational explanation
Is out of voluntary control
Leads to situational avoidance
Is maladaptive and persistent over time
Is not age or stage-specific
What is the treatment for phobias?
CBT with exposure therapy
PRN benzos when the stimulus is infrequently encountered
2nd line SSRI, SNRI when the stimulus is frequently encountered
