Anxiety - MH Flashcards
Definition of Anxiety
- Subjective sense of disease, dread, or foreboding
- Can indicate a primary psychiatric or secondary medical condition
- What is the thing you are most afraid of or dread the most?
- How does it make you feel to confront that thing?
Anxiety Disorder
Primary Anxiety
- Generalized Anxiety Disorder
- Panic Disorder
- Obsessive-Compulsive Disorder
- Post-Traumatic Stress Disorder
- Social Phobia
Secondary Anxiety
- Medication/Illicit drug use
- Medication withdrawal
- Cardiopulmonary disease
- Endocrine disease
- Neurological disease
- Other: inner ear disease, Chronic Fatigue Syndrome, Acute hyperventilation syndrome, Wilson’s disease, Acute intermittnet porphyria
Primary Anxiety: Generalized Anxiety Disorder
Etiology
- Life stressors
- Trauma – physical or emotional
- Genetic factors
- Pathophysiology: Hyperarousal state, Hyperactive brain circuitry -> Hypervigilance
Epidemiology
- Most common anxiety disorder
- 20-40 yo women
- 90% handled by primary care providers
Generalized Anxiety Disorder H&P
-Excessive worry > 6 mos causing impairment AND
3 out of 6 symptoms:
-Muscle tension, Sleep disturbance, Fatigue, Restlessness or sense of feeling on edge, Irritability, Poor concentration
- Involves two or more life circumstances
- Family history of same
- History of trauma, stressors, substance abuse
- Common co-morbidities: depression, EtOH abuse, etc
- Patient may overuse health care resources
- Physical: Generally normal, Signs of hyperarousal/hypervigilance
GAD - Tx
CBT
- Replace negative thoughts with positive
- Relaxation
- Breathing retraining – arousal reduction
- Self-hypnosis
- Good for children, pregnancy, avoid rx
- Can combine CBT with medications
Anxiety medications
SSRIs
-Paroxetine 10 mg PO qam, increase by 10 mg weekly until desired dose
-Escitalopram 10 mg PO qam, can increase to 20 mg
-Citalopram 20 mg PO qam, can increase to 40 mg
SNRIs
- Venlafaxine 37.5-75 mg qd, increase by 75 mg weekly, Must taper slowly
- Duloxetine 30 mg PO qd, increase by 30 mg weekly
- Buspirone: Non-addictive, less sedation than BZDs
- Buspar 7.5 mg bid
Benzodiazepines
- SHORT TERM – 4-6 weeks, then taper
- Use after 4 week trial of above meds
- Not for patients with addiction history
- Alprazolam 0.25 – 0.5 mg PO tid prn
Primary Anxiety: Panic Disorder
Etiology
-Genetic, environmental, psychological factors, No one cause found
Epidemiology
-20-25 yo women
History and Physical
-Panic attacks – out of the blue
-Peak within 10 minutes
Four of the following symptoms
-Psychologic: sense of foreboding, fear of losing controlefeeling detached
-Neurologic: Dizzy/light-headed, paresthesias, trembling/shaking
-Cardiopulmonary: chest pain, palpitations, diaphoresis, SOB, chocking, chills/hot flushes
-GI: nausea
-Worry about the feelings experienced during the attacks
-Avoidance of situations/triggers for the attacks (agoraphobia)
Panic disorder - Tx
CBT is mainstay
- Identify triggers and prodromal symptoms, reassurance
- Relaxation, distraction, controlled breathing, exposure therapy
Medication
- SSRI: Paroxetine, Sertraline 25 mg PO qd, increase by 25 mg weekly
- BZDs: Clonazepam 0.25 mg PO bid prn, Alprazolam
Follow-up
- Treatment should be for 1 year
- Recurrence is 30-90%
- Be aware of high levels of medical service usage
Diagnostic Criteria for Panic Attack:4 or more of the following develop abruptly and reach a peak within 10 minutes
- Palpitations, pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensation of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Derealization (feeling of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or going crazy
- Fear of dying
- Paresthesias (numbness or tingling sensation)
- Chills or hot flashes
Primary Anxiety: Obsessive Compulsive Disorder
Etiology
- Serotonin mediated
- Definite genetic factor – family, twins
Epidemiology
- Late adolescent, early adulthood
- Equal in men and women
History
- Obsession – recurrent, persistant thoughts
- Not excessive worry about real problems
- Patient recognizes they are a product of the mind, makes attempts to ignore them
- Contamination, Pathologic doubt, somatic, symmetry, aggressive, sexual, religious
- Compulsion – repetitive activity or mental act
- Performed in response to or to try to neutralize obsession
- Not connected in an actual way to the obsession
- “If I don’t wash my hands 3 times every hour, my family will die”
Obsessive Compulsive Disorder - Tx
- Very difficult
- 40% fail initial treatment
- Was considered treatment resistant until about 20 yrs ago
CBT
-Exposure and response prevention, 13-20 weeks
Pharmacotherapy
- SSRI – high doses
- Fluoxetine 40-80 mg qd (can be used > 7yo)
- Fluvoxamine 200-300 mg qd
Follow-up
- Lifelong treatment generally needed
- 40-60% of patients do not respond to meds
Primary Anxiety: Post-Traumatic Stress Disorder
Etiology
- Traumatic triggers
- Natural disaster, fire, MVA, serious accident, toxic substance exposure, physical assault, sexual assault, war-related trauma, captivity, life-threatening illness/injury, severe suffering, sudden violent death of someone else or someone close, spontaneous abortion
Risk factors
-Severity of trauma, genetic predisposition, history of previous trauma or chance that it will happen again, previous psych hx, family psych hx, limited support systems
Epidemiology
- Military personnel, police officers, emergency personnel
- Inner-city dwellers
- Refugees
- Abuse victims – prostitution, transient/homeless, domestic violence
PTSD - H&P
Spectrum of stress
- Acute stress reaction (normal reaction)
- Acute stress disorder – 2 days to 4 weeks
- PTSD > 4 weeks/1 month
History
-Diagnosis requires experiencing 3 types of symptoms to the point that it impairs function
-Re-experiencing: Recurrent, intrusive thoughts, “flashbacks”
Distress/physiologic reaction to above thoughts
-Avoidance: Any reminders of trauma: people, situations/circumstances, Will not discuss the event, Emotional numbing, detachment, flat affect, amnesia of event
-Hyperarousal: Insomnia, angry outbursts, trouble concentrating, hyper-vigilance, exaggerated startle response
Post-Traumatic Stress Disorder -Tx
Wait
-If not severe and <3 mos out, can consider watchful waiting
Therapy
- Trauma-focused psychotherapy – CBT
- Group therapy
Medication
- Dependant on primary symptoms
- Paroxetine 20 mg PO qd, max of 60 mg/d
- Sertraline 25 mg PO qd x 1 wk, incr to 50-200 mg PO qd
- Dissociative flashbacks: Propranolol 10-20 mg PO qid prn
- Nightmares: BZD (Alprazolam) qhs prn
Follow-up
- Consider family effects
- Can be considerable burden for caregivers
- Self-help and support groups
- Assess and treat substance abuse if needed
- Avg duration of symptoms: With treatment = 36 mos, Without treatment = 64 mos
Primary Anxiety: Social Anxiety Disorder
Etiology
-Heightened autonomic arousal to social cues
Epidemiology
-Common – 13% of people will experience it in their lifetime, 11-19 yo most common
History
- Marked and persistent fear of social situations
- Fear of being scrutinized by others
- Fear that actions will cause embarrassment or humiliation
- Exposure to situation results in anxiety +/- panic attack
- Fear is recognized as unreasonable or excessive
- Social/performance situations are avoided
- Phobia causes impaired functioning and/or distress
- Not 2/2 another medical condition
- If patient is < 18 yo, symptoms have been present > 6 mos
Social Anxiety Disorder
Physical
-Anxiety, Nervousness, Embarrassment, Avoiding eye contact
Screening (taken from epocrates “Social Anxiety Disorder”)
- The following brief screening questions during the clinical interview can assist in the recognition of social anxiety cues, symptoms, and behaviors:
- Do you feel anxious or uncomfortable being around other people?
- Do social situations make you feel anxious or nervous?
- Are you avoiding these social situations because you are worried about being embarrassed or criticized by others?
- In what ways has this anxiety interfered with your life?
- Do you have to use alcohol or other substances in order to feel comfortable in social situations?