Anxiety, Obscessive-Compulsive, Trauma, Stressor related disorders (CH 5) Flashcards
Anxiety
individual’s emotional and physical fear response to perceived threat
Most common form of psychopathology
More frequently in women (2:1 ratio)
Pathologic anxiety
symptoms are excessive, irrational, out of proportion to the trigger or without an identifiable trigger
Maladaptive anxiety
persists longer and feels more intense than transient, situation anxiety
Anxiety Disorder criteria
Symptoms cause clinically significant distress or impairment in social and/or occupational functioning
Not due to physiological effects of substance, medication or medical condition
Major neurotransmitter systems implicated in anxiety
Norepinephrine, serotonin, GABA
Treatment guidelines for anxiety
based on level of symptom impairment
Psychotherapy for milder presentations
Combination treatment with pharmacotherapy for moderate to severe anxiety
First line pharmacotherapy for anxiety
SSRIs (sertraline)
SNRIs (venlafaxine)
Benzodiazepines in anxiety
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
Nonaddicticting anxiolytic alternatives in anxiety
diphenhydramine or hydroxyzine
Buspirone in anxiety
5-HT1a partial agonist
Non-benzodiazepine anxiolytic
minimal efficacy, only prescribed as augmentation
Beta-blockers in anxiety
e.g. propranolol
helps control autonomic symptoms - palpitations, tachycardia, sweating with panic attacks or performance anxiety
TCAs and MAOIs in anxiety
consider if first line agents not effective, side effect profile make them less tolerable
Psychotherapy in anxiety
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
Panic attacks
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
Mnemonic for panic attack symptoms
“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
Panic Disorder
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
Panic disorder DSM5 criteria
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)
Treatment of panic disorder
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
Agoraphobia
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
Agoraphobia DSM5 criteria
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
Treatment of Agoraphobia
CBT and SSRIs (for panic sxs)
Phobia
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
Specific phobia
an intense fear of a specific object or situation (phobic stimulus)
Mean onset 10 yo
Treatment: CBT
Social anxiety disorder
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
Specific phobias/social anxiety disorder DSM5 criteria
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
Treatment of Social anxiety disorder
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
Selective mutism
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
Selective mutism DSM5 criteria
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)
Treatment of selective mutism
Psychotherapy: CBT, family therapy
Medications: SSRIs for anxiety (esp. with comorbid social anxiety disorder)
Stranger anxiety
begins at 6 mo, peaks around 9 mo
Separation anxiety
emerges by 1 year, peaks by 18 mo
Separation anxiety disorder DSM5 criteria
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
Treatment of separation anxiety disorder
Psychotherapy: CBT, family therapy
Medications: SSRI as adjunct to therapy
Generalized anxiety disorder (GAD)
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
Generalized Anxiety Disorder DSM5 Criteria
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
Treatment of Generalized Anxiety Disorder
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
Obsessive compulsive disorder
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
Obsessions
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
Compulsions
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
Obsessive-compulsive disorder DSM5 criteria
Obsessions and/or compulsions that are time-consuming (>1 hr/day) or cause significant distress or dysfunction
Triad of uncontrollable urges
OCD, ADHD, tic disorder
first seen in children or adolescents
Treatment of Obsessive-compulsive disorder
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)
Body dysmorphic disorder
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
Body dysmorphic disorder DSM5 criteria
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
Treatment of body dysmorphic disorder
SSRIs and/or CBT reduce obsessive compulsive sxs
Hoarding disorder DSM5 criteria
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
Hoarding disorder
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
Treatment of hoarding disorder
specialized CBT for hoarding
SSRIs not beneficial unless OCD sxs present
Trichotillomania DSM5 criteria
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
Trichotillomania
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
Treatment of trichotillomania
SSRIs, second gen antipsychotics, N-acetylcysteine, or lithium
CBT - habit reversal training
Excoriation (skin picking) disorder DSM5 criteria
Recurrent skin picking resulting in lesions
Repeated attempts to decrease or stop
Significant distress or impairment in daily functioning
Excoriation disorder
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
Treatment of Excoriation disorder
CBT - habit reversal training
SSRIs some benefit
PTSD
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
Acute Stress Disorder
major traumatic event -> sxs similar to PTSD for shorter duration
Onset of sxs within 1 month of trauma, last less than 1 month
PTSD/Acute Stress Disorder DSM5 Criteria
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
Treatment of PTSD - pharmacological
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
Treatment of PTSD - psychotherapy
CBT - exposure therapy, cognitive processing therapy
supportive and psychodynamic therapy
couples/family therapy
Adjustment disorders
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
Adjustment disorders DSM5 criteria
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
Treatment of adjustment disorder
Supportive psychotherapy (most effective) Group therapy
Occasionally tx associated sxs: insomnia, anxiety, depression in time-limited fashion
