Anxiety, obsessive-compulsive, and trauma disorders

Question 1

Medications/substances that cause anxiety in intoxication

Answer 1

Cannabis, hallucinogens (PCP, LSD, MDMA), stimulants, caffeine

Question 2

Medications/substances that cause anxiety in withdrawal

Answer 2

Alcohol, sedatives/hypnotics/anxiolytics, tobacco

Question 3

Neuro conditions that cause anxiety

Answer 3

Epilepsy, migraine, tumors, MS, HD

Question 4

Endo conditions that cause anxiety

Answer 4

Hyperthyroid, hypoglycemia, pheo, carcinoid syndrome

Question 5

Metabolic conditions that cause anxiety

Answer 5

B12 def, electrolyte disturbances, porphyria

Question 6

Respiratory conditions that cause anxiety

Answer 6

Asthma, COPD, hypoxia, PE, PNA, pneumothorax

Question 7

CV conditions that cause anxiety

Answer 7

CHF, angina, arrhythmia, MI

Question 8

Pharmacotherapy options for anxiety

Answer 8

SSRIs and SNRIs = first line
Benzos for quick and effective anxiolysis
Buspirone (5-HT1 partial agonist, not commonly used)
Beta-blockers for autonomic symptoms, panic attacks, or performance anxiety
TCAs and MAOIs if refractory (bad side effect profile)

Question 9

Psychotherapy for anxiety

Answer 9

CBT and psychodynamic

Question 10

Pharmacologic goal for treatment of anxiety

Answer 10

Symptomatic relief and continue tx for 6mos before trying to taper

Question 11

What characterizes panic disorder?

Answer 11

Recurrent, spontaneous panic attacks

Question 12

Symptoms of panic attacks

Answer 12

"Da PANICS"
Dizziness, disconnectedness, derealization, depersonalization
Palpitations
Abdominal distress
Nausea, numbness
Intense fear (e.g. of dying)
Chills, chest pain
Sweating, shaking, SOB

Question 13

What must you rule out when a patient presents with a panic attack?

Answer 13

Medical conditions such as MI, thyrotoxicosis, and PE

Question 14

Criteria for panic disorder

Answer 14

Recurrent, unexpected panic attacks with no identifiable trigger
Panic attacks followed by >1month of continuous worry and/or maladaptive change in behavior
Not substance/medical related

Question 15

Predisposing factors to panic disorder

Answer 15

Family history

Increased stressors, history of childhood trauma

Question 16

Treatment of panic disorder

Answer 16

Pharma + CBT = most effective
SSRIs first line (then TCAs)
Benzos PRN

Question 17

Diagnostic criteria for agoraphobia

Answer 17

• Intense fear/anxiety about >2 situations due to fear of difficulty escaping/getting help (outside of home alone, open spaces, enclosed spaces, public transport, or crowds)
• Fear is out of proportion to potential danger posed
• > 6 months

Question 18

Treatment for agoraphobia

Answer 18

SSRIs and CBT

Same as panic disorder

Question 19

Diagnostic criteria for specific phobia/social anxiety disorder

Answer 19

Fear of specific situation or object out of proportion to actual threat
Exposure to situation triggers immediate fear response
Situation/object avoided when possible
>6 months, dysfunction, etc

Question 20

Treatment for specific phobia

Answer 20

CBT

Question 21

Treatment for social anxiety disorder

Answer 21

CBT

If meds needed: SSRIs or SNRIs, benzos if needed, beta-blockers for performance anxiety

Question 22

Diagnostic criteria for GAD

Answer 22

Excessive anxiety about variety of daily events/activities for >6mos
Difficulty controlling the worry
At least 3 symptoms (restlessness, fatigue, impaired concentration, irritability, muscle tension, insomnia)
Cause dysfunction, not substance-induced, etc

Question 23

Treatment of GAD

Answer 23

CBT + SSRIs or SNRIs

Question 24

Diagnostic criteria for OCD

Answer 24

Obsessions and/or compulsions that are time consuming or cause significant distress/dysfunction
Not caused by substance or medical condition

Question 25

Etiology of OCD

Answer 25

Strong genetic component, also shared genetic component with Tourette's

Question 26

Course/prognosis of OCD

Answer 26

Chronic, waxing and waning <20% remission rate without treatment Suicidal ideation in 50%, attempts in 25% High comorbidity with other anxiety disorders, depressive or bipolar, OCPD, and tic disorders

Question 27

Treatment for OCD

Answer 27

Drugs + CBT SSRIs at higher doses, clomipramine (most serotonin selective TCA) Augment with atypical antipsychotics If severe and refractory, consider cingulotomy or ECT

Question 28

Criteria for body dysmorphic disorder

Answer 28

Preoccupation with one or more perceived deficits or flaws in physical appearance Repetitive behaviors in response to appearance concerns Preoccupation causes significant distress or dysfunction Not better explained by concerns with weight/eating disorder

Question 29

Treatment for body dysmorphic disorder

Answer 29

SSRIs and/or CBT | Surgery/cosmetic procedures often not helpful

Question 30

Criteria for trichotillomania

Answer 30

Recurrent hair-pulling-out leading to hair loss Repeated attempts to stop/decrease hair pulling Causes distress/dysfunction Involves scalp, eyebrows, eyelashes, but may involve other body hair

Question 31

Treatment for trichotillomania

Answer 31

Meds: SSRIs, atypical antipsychotics, N-acetylcysteine, or Li CBT

Question 32

Diagnostic criteria for PTSD

Answer 32

Exposure to death, serious injury, or sexual violence through experiencing or witnessing Recurring intrusions or re-experiencing (memories, nightmares, dissociative reactions) Active avoidance of triggering stimuli At least two negative cognitions: dissociative amnesia, negative feelings of self/others, self-blame, negative emotions, anhedonia, detachment At least two symptoms of increased arousal/reactivity: hypervigilance, exaggerated startle response, irritability/outbursts, impaired concentration, insomnia Not substance or medical

Question 33

Treatment to stop nightmares in PTSD

Answer 33

Prazosin

Question 34

Prognosis for PTSD

Answer 34

50% have complete recovery within 3 months | 80% have another mental health disorder

Question 35

Pharmacologic treatment for PTSD

Answer 35

First line: SSRIs or SNRIs Prazosin for nightmares Augmentation with atypical antipsychotics in severe cases

Question 36

Psychotherapy treatment for PTSD

Answer 36

Exposure therapy and cognitive processing therapy (both types of CBT)

Question 37

Diagnostic criteria for adjustment disorder

Answer 37

Development of emotional or behavioral symptoms within 3 months in response to an identifiable stressful life event -Marked distress in excess of what would be expected -Dysfunction Not symptoms of normal bereavement Resolve within 6 months after stressor has terminated