Anxiety - MH Flashcards

1
Q

Definition of Anxiety

A
  • 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?
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2
Q

Anxiety Disorder

A

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
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3
Q

Primary Anxiety: Generalized Anxiety Disorder

A

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
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4
Q

Generalized Anxiety Disorder H&P

A

-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
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5
Q

GAD - Tx

A

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
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6
Q

Primary Anxiety: Panic Disorder

A

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)

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7
Q

Panic disorder - Tx

A

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
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8
Q

Diagnostic Criteria for Panic Attack:4 or more of the following develop abruptly and reach a peak within 10 minutes

A
  • 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
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9
Q

Primary Anxiety: Obsessive Compulsive Disorder

A

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”
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10
Q

Obsessive Compulsive Disorder - Tx

A
  • 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
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11
Q

Primary Anxiety: Post-Traumatic Stress Disorder

A

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
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12
Q

PTSD - H&P

A

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

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13
Q

Post-Traumatic Stress Disorder -Tx

A

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
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14
Q

Primary Anxiety: Social Anxiety Disorder

A

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
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15
Q

Social Anxiety Disorder

A

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?
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16
Q

Social Anxiety Disorder - Tx

A

-Therapy: CBT for 4-6 months

Medication

  • Antidepressants: Sertraline, Paroxetine, Escitalopram, 7-17 yo, Sertraline is the only studied rx
  • Venlafaxine works, but may take 12 weeks
  • BZD: Be very careful, given propensity to self-medicate with social anxiety, higher risk of abuse, Clonazepam, Alprazolam
  • Beta blocker: Propranolol 20-40 mg PO prn 1 hour before activity, use prn before performances (not athletic activities)

Follow-up

  • Relapse common after discontinuation
  • Trial successful medication 12 months before attempting to wean
17
Q

Secondary Anxiety

A

Watch medications

  • Asthma medicines
  • Beta blockers
  • Corticosteroids
  • Antidepressants
  • Herbal Supplements: Ma Huang, St John’s Wort, Ginseng
  • Illegal substances: Cocaine, amphetamine, marijuana, LSD
  • Addiction and withdrawal
  • Secondary to other diseases: Cardiovascular, Endocrine, Neurologic, Psychiatric