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Anxiety, Obscessive-Compulsive, Trauma, Stressor related disorders (CH 5) Flashcards

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1
Q

Anxiety

A

individual’s emotional and physical fear response to perceived threat

Most common form of psychopathology
More frequently in women (2:1 ratio)

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2
Q

Pathologic anxiety

A

symptoms are excessive, irrational, out of proportion to the trigger or without an identifiable trigger

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3
Q

Maladaptive anxiety

A

persists longer and feels more intense than transient, situation anxiety

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4
Q

Anxiety Disorder criteria

A

Symptoms cause clinically significant distress or impairment in social and/or occupational functioning

Not due to physiological effects of substance, medication or medical condition

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5
Q

Major neurotransmitter systems implicated in anxiety

A

Norepinephrine, serotonin, GABA

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6
Q

Treatment guidelines for anxiety

A

based on level of symptom impairment

Psychotherapy for milder presentations

Combination treatment with pharmacotherapy for moderate to severe anxiety

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7
Q

First line pharmacotherapy for anxiety

A

SSRIs (sertraline)

SNRIs (venlafaxine)

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8
Q

Benzodiazepines in anxiety

A

enhance activity of GABA at GABA-A receptor

Work quickly and effectively
Can be addictive - minimize use, duration, dose

Avoid if hx of substance use disorders, particularly etOH

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9
Q

Nonaddicticting anxiolytic alternatives in anxiety

A

diphenhydramine or hydroxyzine

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10
Q

Buspirone in anxiety

A

5-HT1a partial agonist
Non-benzodiazepine anxiolytic

minimal efficacy, only prescribed as augmentation

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11
Q

Beta-blockers in anxiety

A

e.g. propranolol

helps control autonomic symptoms - palpitations, tachycardia, sweating with panic attacks or performance anxiety

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12
Q

TCAs and MAOIs in anxiety

A

consider if first line agents not effective, side effect profile make them less tolerable

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13
Q

Psychotherapy in anxiety

A

CBT examines relationship between anxiety driven cognitions (thoughts), emotions, and behavior

Psychodynamic psychotherapy facilitates understanding and insight into development of anxiety and increases anxiety tolerance

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14
Q

Panic attacks

A

fear response involving an abrupt surge of intense anxiety triggered or occurs spontaneously

Peak within minutes, resolve within half an hour

Pt continues to feel anxious for hours afterwards, can be confused as a prolonged panic attack

Can be experienced with other anxiety disorders, psychiatric disorders and other medical condtions

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15
Q

Mnemonic for panic attack symptoms

A

“Da PANICS”

Dizziness, disconnectedness, derealization (unreality), depersonalization (detached from self)
Palpitations, paresthesias
Abdominal distress
Numbness, nausea
Intense fear of dying, losing control, or “going crazy”
Chills, chest pain
Sweating, shaking, shortness of breath

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16
Q

Panic Disorder

A

Spontaneous, recurrent panic attacks, occur suddenly, “out of the blue” or with with clear trigger

Multiple times per day to few monthly

Debilitating anticipatory anxiety about having future attacks “fear of the fear”

Can lead to avoidance behaviors -> homebound

Greater risk if dx in first relatives
Increased stressors prior to onset, hx of childhood physical or sexual abuse

20-24 yo onset

Chronic course with waxing/waning sxs, relapse with dc of meds

65% have major depression; other comorbid syndromes: anxiety disorders (agoraphobia), bipolar disorder, etoh use disorder

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17
Q

Panic disorder DSM5 criteria

A

Recurrent, unexpected panic attacks without identifiable trigger

One or more panic attacks followed by 1 or more month of continuous worry about subsequent attacks or their consequences, and/or maladaptive change in behaviors (avoidance of possible triggers)

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18
Q

Treatment of panic disorder

A

Pharmacotherapy and CBT most effective

First line: SSRI - sertaline, citalopram, escitalopram

Can switch to TCAs (clomipramine, imipramine) if SSRIs not effective

Benzos (clonazepam, lorazepam) scheduled or PRN, especially as a bridge for other meds to reach full efficacy

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19
Q

Agoraphobia

A

intense fear of being in public places where escape or obtaining help may be difficult

Develops with panic disorder

Chronic course, persistent, rare full remission

Avoidance behaviors become extreme as complete confinement to the home.

Strong genetic factor - 60%
Onset follows traumatic event

Onset before 35

Comorbid: other anxiety disorders, depressive disorders, substance use disorders

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20
Q

Agoraphobia DSM5 criteria

A

Intense fear/anxiety about more than 2 situaiton d/t concern of difficulty escaping or obtaining help in case of panic or other humiliating sxs

  • outside of home alone
  • open spaces (bridges)
  • enclosed places (stores)
  • public transportation (trains)
  • crowds/lines

Triggering situations cause fear/anxiety out of proportion to the potential danger posed -> endurance of intense anxiety, avoidance, or requiring a companion. True even if pt has medical conditions like IBS -> embarrasing public scenarios

Sxs cause significant social or occupational dysfunction

lasts 6 or more months

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21
Q

Treatment of Agoraphobia

A

CBT and SSRIs (for panic sxs)

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22
Q

Phobia

A

irrational fear -> endurance of anxiety and/or avoidance of the feared object or situation

Develop in wake of a negative or traumatic encounter with the stimulus

Most common psychiatric disorder in women, second in men

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23
Q

Specific phobia

A

an intense fear of a specific object or situation (phobic stimulus)

Mean onset 10 yo

Treatment: CBT

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24
Q

Social anxiety disorder

A

Social phobia
fear of scrutiny by others or fear of acting in a humiliating or embarrassing way, negative evaluation, rejection

Fear may be limited to performance or public speaking

social situations causing significant anxiety may be avoided altogether ->social and academic/occupational impairment

mean onset 13 yo

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25
Q

Specific phobias/social anxiety disorder DSM5 criteria

A

Persistent, excessive fear elicited by specific situation or object, out of proportion to any actual danger/treat

Exposure to situaiton triggers immediate fear response

Situation or object is avoided or tolerated with intense anxiety

Causes significant social or occupational dysfunction

Lasts 6 or more months

26
Q

Treatment of Social anxiety disorder

A

Treatment of choice: CBT

First line medications: SSRI (sertraline, fluoxetine) or SNRIs (venlafaxine) for debilitating sxs

Benzodiazepines (clonazepam, lorazepam) scheduled or PRN

Beta-blockers (atenolol, PRORPANOLOL) for performance anxiety/public speaking

27
Q

Selective mutism

A

failure to speak in specific situations for at least 1 month, despite intact ability to comprehend and use language

Starts in childhood

manifests in social settings
Pt may remain completely silent or whisper, may use nonverbal communication - writing or gesturing

28
Q

Selective mutism DSM5 criteria

A

Consistent failure to speak in select social situations (school), despite ability in other scenarios

Mutism not due to language difficulty or communication disorder

Significant impairment in academic, occupational, social functioning

Sxs last longer than 1 mo (beyond first month of school)

29
Q

Treatment of selective mutism

A

Psychotherapy: CBT, family therapy

Medications: SSRIs for anxiety (esp. with comorbid social anxiety disorder)

30
Q

Stranger anxiety

A

begins at 6 mo, peaks around 9 mo

31
Q

Separation anxiety

A

emerges by 1 year, peaks by 18 mo

32
Q

Separation anxiety disorder DSM5 criteria

A

Excessive and developmentally inappropriate fear/anxiety re: separation from attachment figures

At least three:
1. separation leads to extreme distress
2 excessive worry about loss of or harm to attachment figures
3. Excessive worry about event that leads to separation from attachment figures
4. Reluctance to leave home, or attend school or work
5. Reluctance to be alone
6. Reluctance to sleep alone or away from home
7. Complaints of physical symptoms when separated
8. Nightmares of separation and refusal to sleep without proximity to attachment figure
9. Lasts more than 4 weeks in children/adolescents, longer than 6 mo in adults
10. sxs cause significant social, academic, or occupational dysfunction

33
Q

Treatment of separation anxiety disorder

A

Psychotherapy: CBT, family therapy
Medications: SSRI as adjunct to therapy

34
Q

Generalized anxiety disorder (GAD)

A

Persistent, excessive anxiety about many aspects of daily lives

Somatic sxs: fatigue, muscle tension -> PCP visit

Highly comorbid with other anxiety and depressive disorders

Higher in women
1/3 risk is genetic

Worry begins in childhood
Onset mean 30 yo
Chronic course w/ waxing/waning sxs

35
Q

Generalized Anxiety Disorder DSM5 Criteria

A

Excessive, anxiety/worry about various daily events/activities longer than 6 mo
Difficulty controlling worry
Associated with 3 or more sxs: restlessness, fatigue, impaired concentration, irritability, muscle tension, insomnia
Cause social or occupational dysfunction

36
Q

Treatment of Generalized Anxiety Disorder

A

Most effective approach psychotherapy combined with pharmacotherapy

CBT
SSRI (sertraline, citalopram) or SNRI (venlafaxine)

Consider short term benzo or augment with buspirone

Much less commonly used: TCAs, MAOIs

37
Q

Obsessive compulsive disorder

A

obsessions and/or compulsions that are time consuming, distressing, and impairing

varying degrees of insight

Mean onset 20 yo

Higher rates in 1st degree relatives with OCD and Tourette’s disorder

Chronic course, waxes/wanes

SI in 50%, attempts in 25%

High comorbidity: 75% other anxiety disorders, 60% depressive or bipolar, 30% OCPD and tic disorder

38
Q

Obsessions

A

recurrent, intrusive, anxiety-provoking thoughts, images, or urges that the patient attempts to suppress, ignore or neutralize by some other thought or action

anxiety relieved by compulsions, anxiety increases if resist compulsions

39
Q

Compulsions

A

repetitive behaviors or mental rituals the patient feels driven to perform in response to an obsession or a rule aimed at stress reduction or disaster prevention.

behaviors not realistically linked with what they are to prevent or are excessive

40
Q

Obsessive-compulsive disorder DSM5 criteria

A

Obsessions and/or compulsions that are time-consuming (>1 hr/day) or cause significant distress or dysfunction

41
Q

Triad of uncontrollable urges

A

OCD, ADHD, tic disorder

first seen in children or adolescents

42
Q

Treatment of Obsessive-compulsive disorder

A

Utilize combination of psychopharmacology and CBT

CBT focuses on exposure and response prevention - prolonged, graded exposure to ritual-eliciting stimulus and prevention of relieving compulsions

First line medications: SSRIs (sertraline, fluoxetine) - higher doses

Can use most serotonin selective TCA - Clomipramine

Can augment with atypical antipsychotics

Last resort: severely debilitating cases - psychosurgery (cingulotomy) or ECT (esp if depression present)

43
Q

Body dysmorphic disorder

A

preoccupied with body parts perceived as flawed or defective
strong beliefs that they are unattractive or repulsive

imperfections either minimal or not observable, but pt views as severe and grotesque

Spend significant time trying to correct flaws, make up, derm procedures, plastic surgery

risk: child abuse/neglect, first degree relatives with OCD

Mean onset 15

Gradual course in early adolescence, tends to be chronic
high rater of SI and attempts
Comorbids: major depression, social anxiety disorder, OCD

44
Q

Body dysmorphic disorder DSM5 criteria

A

Preoccupation with one or more perceived defects or flaws in appearance, not observable by or appear slight to others

repetitive behaviors (skin picking, excessive grooming) or mental acts (compairing appearance to others) in response to appearance concerns

Significant distress or impairment of functioning

45
Q

Treatment of body dysmorphic disorder

A

SSRIs and/or CBT reduce obsessive compulsive sxs

46
Q

Hoarding disorder DSM5 criteria

A

Persistent difficulty discarding possessions, regardless of value

need to save the items, distress associated with discarding them

Accummulation of possessions -> congest/clutter living areas and compromise use

significant distress or impairment in social, occupational, or other areas of functioning

47
Q

Hoarding disorder

A

3x more prevalent in older population
Stressful and traumatic events precede onset
Large genetic component

begins early teens, tends to be women
Chronic course
75% have MDD or anxiety disorder (social anxiety)
20% have OCD

48
Q

Treatment of hoarding disorder

A

specialized CBT for hoarding

SSRIs not beneficial unless OCD sxs present

49
Q

Trichotillomania DSM5 criteria

A

Recurrent pulling out of one’s hair, resulting in hair loss
Repeated attempts to decrease or stop
Significant distress or impairment in daily functioning
Usually involves scalp, eyebrows, eyelashes, facial, axillary, and pubic hair

50
Q

Trichotillomania

A

more common in women (10:1)
onset puberty, associated with stressful event
Site of hair pulling vary, texture preference

Increased OCD, MDD, and excoriation disorder

Chronic course w/ waxing/waning periods. Adult onset more difficult to treat

51
Q

Treatment of trichotillomania

A

SSRIs, second gen antipsychotics, N-acetylcysteine, or lithium

CBT - habit reversal training

52
Q

Excoriation (skin picking) disorder DSM5 criteria

A

Recurrent skin picking resulting in lesions
Repeated attempts to decrease or stop
Significant distress or impairment in daily functioning

53
Q

Excoriation disorder

A

3/4 women
More common with OCD and first degree relatives

begins in adolescence
chronic course w/ waxing/waning if untreated
Comorbid: OCD, trichotillomania, MDD

54
Q

Treatment of Excoriation disorder

A

CBT - habit reversal training

SSRIs some benefit

55
Q

PTSD

A

development of multiple sxs after exposure to one or more traumatic events

Intrusive symptoms: nightmares, flashbacks
Avoidance
Negative alterations in thoughts and mood
Increased arousal

Sxs last at least 1 month and occur immediately after or with delayed expression (usually within 3 mo)

80% have other mental disorder: MDD, bipolar, anxiety, substance use

56
Q

Acute Stress Disorder

A

major traumatic event -> sxs similar to PTSD for shorter duration

Onset of sxs within 1 month of trauma, last less than 1 month

57
Q

PTSD/Acute Stress Disorder DSM5 Criteria

A

Exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing or witnessing the trauma

Recurrent intrusions of reexperiencing the event via memories, nightmares, or dissociative reactions (flashbacks); intense distress at exposure to cues relating to trauma; or physiological reactions to cues relating to trauma

Active avoidance of triggering stimuli (memories, feelings, people, places, objects) associated with the trauma

At least two negative cognitions/mood: dissociative amnesia, negative feelings of self/other/world, self-blame, negative emotions (fear, honor, anger, guilt), anhedonia, feelings of detachment/estrangement, inability to experience positive emotions

At least two increased arousal/reactivity: hypervigilance, exaggerated startle response, irritability/angry outbursts, impaired concentration, insomnia

Significant impairment of social or occupational functioning

Presentation differs in kids under 7 yo

58
Q

Treatment of PTSD - pharmacological

A

First line: SSRIs (sertraline, citalopram) or SNRIs (venlafaxine)

Prazosine - a1 receptor antagonist - targets nightmares and hypervigilance

augment with atypical (2nd gen) antipsychotics in severe cases

59
Q

Treatment of PTSD - psychotherapy

A

CBT - exposure therapy, cognitive processing therapy

supportive and psychodynamic therapy

couples/family therapy

60
Q

Adjustment disorders

A

behavioral or emotional sxs after stressful life event

Chronic if stressor is chronic or recurrent, resolves within 6 months of cessation of stressor

Subtypes: depressed mood, anxiety, mixed anxiety/depression, disturbance of conduct (aggression), mixed disturbance of emotions and conduct

61
Q

Adjustment disorders DSM5 criteria

A

emotional or behavioral sxs within 3 months in response to identifiable stressful life event producing:

  • marked distress in excess of what would be expected after such event
  • significant impairment in daily functioning

sxs not those of normal bereavement

resolve within 6 months after stressor terminated

62
Q

Treatment of adjustment disorder

A 
Supportive psychotherapy (most effective)
Group therapy

Occasionally tx associated sxs: insomnia, anxiety, depression in time-limited fashion

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