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Anxiety, Obsessive-Compulsive, Trauma/Stressor Flashcards

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1
Q

What is anxiety?

A

Defined as individual’s emotional & physical fear response to a perceived threat

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2
Q

What is pathologic anxiety?

A

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

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3
Q

What is maladaptive anxiety?

A

Persists longer & feels more intense than transient, situational anxiety

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4
Q

What are anxiety disorders?

A

Criteria for most anxiety disorders involve symptoms that cause clinically significant distress or impairment in social and/or occupational functioning

Caused by combo of genetic, biological, environmental, & psychosocial factors

Primary anxiety disorders can only be diagnosed after determining that signs & symptoms are NOT due to physiological effects of substance, meds, or medical condition

Late-onset anxiety symptoms without prior or family psychiatric history should increase suspicion of anxiety caused by another medical condition or substance

Most common form of psychopathology

Lifetime prevalence: women 30%, men 19%

More frequently seen in women compared to men (2:1 ratio)

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5
Q

What are the major neurotransmitter systems implicated in anxiety disorders?

A

Norepinephrine (NE)

Serotonin (5-HT)

Gamma-aminobutyric acid (GABA)

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6
Q

Treatment of anxiety disorders

A

Based on level of symptom impairment

Consider psychotherapy for milder presentations

Initiating combination treatment w/ pharmacotherapy for moderate to severe anxiety

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7
Q

What is the assessment for psychopathology based on?

A

Based on if patient’s symptoms are causing Social and/or Occupational Dysfunction (SOD)

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8
Q

Signs & symptoms of anxiety

A

Constitutional:

  • Fatigue
  • Diaphoresis
  • Shivering

Cardiac:

  • Chest pain
  • Palpitations
  • Tachycardia
  • Hypertension

Pulmonary:

  • Shortness of breath
  • Hyperventilation

Neurologic / MSK:

  • Vertigo
  • Lightheadedness
  • Paresthesias
  • Tremors
  • Insomnia
  • Muscle tension

GI:

  • Abdominal discomfort
  • Anorexia
  • Nausea
  • Emesis
  • Diarrhea
  • Constipation
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9
Q

Meds & substances that cause anxiety

A

Alcohol (intoxication / withdrawal)

Sedatives, hypnotics, or anxiolytics (withdrawal)

Cannabis (intoxication)

Hallucinogens - PCP, LSD, MDMA (intoxication)

Stimulants - amphetamines, cocaine (intoxication / withdrawal)

Caffeine (intoxication)

Tobacco (intoxication / withdrawal)

Opioids (withdrawal)

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10
Q

Medical conditions that cause anxiety

A

Neurologic:

  • Epilepsy
  • Migraines
  • Brain tumors
  • MS
  • Huntington’s disease

Endocrine:

  • Hyperthyroidism
  • Thyrotoxicosis
  • Hypoglycemia
  • Pheochromocytoma
  • Carcinoid syndrome

Metabolic:

  • Vitamin B12 deficiency
  • Electrolyte abnormalities
  • Porphyria

Respiratory:

  • Asthma
  • COPD
  • Hypoxia
  • PE
  • Pneumonia
  • Pneumothorax

Cardiovascular:

  • CHF
  • Angina
  • Arrhythmia
  • MI
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11
Q

Treatment for anxiety disorders

A 
PHARMACOTHERAPY 
First-line: SSRIs, SNRIs
Benzodiazepines
Nonaddicdting anxiolytic alternatives for PRN use - diphenhydramine, hydroxyzine
Buspirone
Beta-blockers 
TCAs & MAOIs

Pharmacologic goal is to achieve symptomatic relief & continue treatment for at least 6 months before attempting to titrate off medications

Medications can reduce symptoms enough so that a patient can participate in therapy

PSYCHOTHERAPY
Cognitive behavioral therapy (CBT)
Psychodynamic psychotherapy

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12
Q

SSRI treatment for anxiety disorders

A

E.g. sertraline

Typically take about 4-6 weeks to become fully effective

Higher doses (than used in treating depression) are generally required

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13
Q

Benzodiazepines treatment for anxiety disorders

A

Enhance GABA at GABA-A receptor

If patient has cormobid depressive disorder, consider alternatives to benzos as they may worsen depression

Used to temporarily bridge patients until long-term meds becomes effective

Work quickly & effectively, but they all can be addictive
- Minimize use, duration, & dose

Should be avoided in patients w/ history of substance use disorders

Consider nonaddicting anxiolytic alternatives for PRN use = diphenhydramie, hydroxyzine

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14
Q

Buspirone treatment for anxiety disorders

A

5-HT1A partial agonist

Non-benzodiazepine anxiolytic

Not commonly used due to minimal efficacy & often only prescribed augmentation

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15
Q

Beta-blockers treatment for anxiety disorders

A

E.g. Propranolol

May be used to help control autonomic symptoms (e.g. palpitations, tachycardia, sweating) w/ panic attacks or performance anxiety (use the Bs to Block the Ps)

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16
Q

TCAs & MAOIs treatment for anxiety disorders

A

May be considered if first-line agents are not effective

Their side-effect profile makes them less tolerable

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17
Q

CBT treatment for anxiety disorders

A

Proven effective for anxiety disorders

Examines relationship between anxiety-driven conditions (thoughts), emotions, & behavior

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18
Q

Psychodynamic psychotherapy treatment for anxiety disorders

A

Facilitates understanding & insight into development of anxiety & ultimately increases anxiety tolerance

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19
Q

What are panic attacks?

A

Type of fear response involving an abrupt surge of intense anxiety which may be triggered or occur spontaneously

Attacks peak within mins. & usually resolve within half an hour

May continue to feel anxious for hours afterwards & confuse this for a prolonged panic attack

Although classically associated w/ panic disorder, panic attacks can also be experienced w/ panic disorder, panic attacks can be experienced with other anxiety disorders, psychiatric disorders, & other medical conditions

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20
Q

Symptoms of panic attacks

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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21
Q

What are panic disorders?

A

Characterized by spontaneous, recurrent panic attacks
Attacks occur suddenly, “out of the blue”

May experience panic attacks w/ a clear trigger

Frequency of attacks ranges from multiple times per day to a few monthly

Develop debilitating anticipatory anxiety about having future attacks - “fear of the fear”
- Can lead to avoidance behaviors & become so severe as to leave patients homebound (i.e. agoraphobia)

Smoking is a risk factor for panic attacks

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22
Q

Diagnosis & DSM-V criteria of panic disorders

A

Recurrent, unexpected panic attacks without an identifiable trigger

1 or more panic attakcs followed by >=1 month of continuous worry about experiencing subsequent attacks or their consequences and/or maladaptive change in behaviors (e.g. avoidance of possible triggers)

Not cause by direct effects of substance, another mental disorder, or another medical condition

When patient presents w/ panic attack, rule out potentially life-threatening medical conditions (e.g. heart attack, thyrotoxicosis, thromboembolism)

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23
Q

Etiology of panic disorders

A

Genetic factors:
- Greater risk if first-degree relative affected

Psychosocial factors:

  • Increase incidence of stressors (especially loss) prior to onset of disorder
  • History of childhood physical or sexual abuse
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24
Q

Epidemiology of panic disorders

A

Lifetime prevalence: 4%

Higher rate in women compared to men (2:1 ratio)

Median age of onset: 20-24 years old

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25
Q

Course & prognosis of panic disorders

A

Panic disorder has chronic course w/ waxing & waning symptoms
- Relapses are common w/ discontinuation of medical therapy

Only minority of patients has full remission of symptoms

Up to 65% of patients w/ panic disorder have major depression

Other comorbid syndromes:

  • Other anxiety disorders (especially agoraphobia)
  • Bipolar disorder
  • Alcohol use disorder

Carefully screen patients w/ panic attacks for suicidality
- They are at an increased risk for suicide attempts

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26
Q

Treatment of panic disorders

A

Most effective: pharmacotherapy & CBT

  • First line: SSRIs (e.g. sertraline, citalopram, escitalopram)
    • Start SSRIs or SNRIs at low doses & increase slowly because side effects may initially worsen anxiety, especially in panic disorder
  • Can switch to TCAs (clomipramine, imipramine) if SSRIs are not effective
  • Can use benzodiazepines (clonazepam, lorazepam) as scheduled or PRN, especially until other meds reach full efficacy
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27
Q

What is agoraphobia?

A

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

  • Bridges
  • Crowds
  • Buses
  • Trains
  • Open areas outside the home

Often develops w/ panic disorder

Course of disorder is chronic

Avoidance behaviors may become as extreme as complete confinement to home

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28
Q

Diagnosis & DSM-V criteria of agoraphobia

A

Intense fear/anxiety about >2 situations due to concern of difficulty escaping or obtaining help in case of panic or other humiliating symptoms:

  • Outside of the home alone
  • Open spaces (e.g. bridges)
  • Enclosed places (e.g. stores)
  • Public transportation (e.g. trains)
  • Crowds / lines

Triggering situations cause fear / anxiety out of proportion to potential danger posed, leading to endurance of intense anxiety, avoidance, or requiring companion
- Holds true even if patient suffers from medical condition (e.g. IBS) which may lead to embarrassing public scenarios

Symptoms cause significant social or occupational dysfunction

Symptoms last >= 6 months

Symptoms not better explained by another mental disorder

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29
Q

Etiology of agoraphobia

A

Strong genetic factor:
- Heritability abut 60%

Psychosocial factor:
- Onset frequently follows traumatic event

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30
Q

Course / prognosis of agoraphobia

A

> 50% of patients experience panic attack prior to developing agoraphobia

Onset is usually before age 35

Course is persistent & chronic, w/ rare full remission

Comorbid diagnoses include other anxiety disorders, depressive disorders, & substance use disorders

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31
Q

Treatment of agoraphobia

A

Similar approach as panic disorder:

- CBT & SSRIs (for panic symptoms)

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32
Q

Common domains of social anxiety disorder (social phobia)

A

Speaking in public

Eating in public

Using public restrooms

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33
Q

What is a phobia?

A

Irrational fear that leads to endurance of anxiety and/or avoidance of feared object or situation

Phobia may develop in wake of negative or traumatic encounters w/ stimulus

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34
Q

What is a specific phobia?

A

Intense fear of specific object or situation (i.e. phobic stimulus)

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35
Q

What is social anxiety disorder (social phobia)?

A

Fear of scrutiny by others or fear of acting in humiliating or embarrassing way

Social situations causing significant anxiety may be avoided altogether, resulting in social & academic / occupational impairment

Substance use & depressive disorders frequently co-occur w/ phobias

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36
Q

Diagnosis & DSM-V criteria of specific phobias / social anxiety disorder (social phobia

A

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

Exposure to situation triggers an immediate fear response

Situation or object is avoided when possible or tolerated w/ intense anxiety

Symptoms cause significant social or occupational dysfunction

Duration >= 6 months

Symptoms not solely due to another mental disorder, substance (medication or drug), or another medical condition

Diagnostic criteria for social anxiety disorder (social phobia) are similar to above except phobic stimulus is related to social scrutiny & negative evaluation

  • Patients fear embarrassment, humiliation, & rejection
  • Fear may be limited to performance or public speaking
37
Q

Epidemiology of specific phobias / social anxiety disorder (social phobia

A

Phobias are most common psychiatric disorder in women & 2nd most common in men (substance-related is first)

Lifetime prevalence of specific phobia: >10%

Mean age of onset for specific phobia is 10 years old
- Median age of onset for social anxiety disorder is 13 years old

Specific phobia rates are higher in women compared to men (2:1)

Social anxiety disorder occurs equally in men & women

38
Q

Treatment of specific phobias / social anxiety disorder (social phobia

A

Specific phobia:
- Treatment of choice: CBT

Social anxiety disorder (social phobia):

  • Treatment of choice: CBT
  • First-line meds, if needed: SSRIs (e.g. sertraline, fluoxetine) or SNRIs (e.g. venlafaxine) for debilitating symptoms
  • Benzodiazepines (e.g. clonazepam, lorazepam) can be used as scheduled or PRN
  • Beta blockers (e.g. atenolol, propranolol) for performance anxiety / public speaking
39
Q

What are common specific phobias?

A

Animal - spiders, insects, dogs, snakes, mice

Natural environment - heights, storms, water

Situational - elevators, airplanes, enclosed spaces, buses

Blood-injection injury - needles, injections, blood, invasive medical procedures, injuries
- May experience bradycardia & hypotension –> vasovagal fainting

40
Q

What is selective mutism?

A

Rare condition characterized by failure to speak in specific situations for at least 1 month, despite intact ability to comprehend & use language

Symptom onset typically starts during childhood

Majority of these patients suffer from anxiety (social anxiety) as mutism manifests in social setting

Patients may remain completely silent or whisper
- May use nonverbal means of communication (e.g. writing, gesturing)

Communication delays or disorders may co-occur, but they would not account for selective mutism

41
Q

Diagnosis & DSM-V criteria of selective mutism

A

Consistent failure to speak in select social situations (e.g. school) despite speech ability in other scenarios

Mutism is not due to language difficulty or communication disorder

Symptoms cause significant impairment in academic, occupational, or social functioning

Symptoms last >1 month (extending beyond 1st month of school)

42
Q

Treatment of selective mutism

A

Psychotherapy:

  • CBT
  • Family therapy

Medications:
- SSRIs for anxiety

43
Q

What are stranger anxiety & separation anxiety?

A

As part of normal human development, infants become distressed when they are separated from primary caregiver

Stranger anxiety: begins around 6 months & peaks around 9 months

Separation anxiety: emerges by 1 year old & peaks by 18 months

44
Q

What is separation anxiety disorder?

A

When anxiety due to separation becomes extreme or developmentally inappropriate

Considered pathologic

May be preceded by stressful life event

May lead to complaints of somatic symptoms to avoid school/work

45
Q

Diagnosis & DSM-V criteria of separation anxiety disorder

A

Excessive & developmentally inappropriate fear / anxiety regarding separation from attachment figures, with at least 3 of the following:

  • Separation from attachment figures leads to extreme distress
  • Excessive worry about loss of or harm to attachment figures
  • Excessive worry about experiencing an event that leads to separation from attachment figures
  • Reluctance to leave home, or attend school / work
  • Reluctance to be alone
  • Reluctance to sleep alone or away from home
  • Complaints of physical symptoms when separated from major attachment figures
  • Nightmares of separation & refusal to sleep without proximity to attachment figure
  • Lasts for >=4 weeks in children / adolescents & >= 6 months in adults
  • Symptoms cause significant social, academic, or occupational dysfunction
  • Symptoms not due to another mental disorder
46
Q

Treatment of separation anxiety disorder

A

Psychotherapy:

  • CBT
  • Family therapy

Medications:
- SSRIs can be effective as an adjunct to therapy

47
Q

What is generalized anxiety disorder (GAD)?

A

Have persistent, excessive anxiety about many aspects of their daily lives

Often experience somatic symptoms (e.g. fatigue, muscle tension)
- The physical complains lead patients to initially present to PCP

Highly cormorbid w/ other anxiety & depressive disorders

48
Q

Diagnosis & DSM-V criteria of GAD

A

Worry WARTS:

  • Worried
  • Wound up, worn out
  • Absent-minded
  • Restless
  • Tense
  • Sleepless

Excessive, anxiety/worry about various daily events/activities >= 6 months

Difficulty controlling the worry

Associated >= 3 symptoms:

  • Restlessness
  • Fatigue
  • Impaired concentration
  • Irritability
  • Muscle tension
  • Insomnia

Symptoms are not caused by direct effects of substance or another mental disorder or medical condition

Symptoms cause significant social or occupational dysfunction

Evaluate for caffeine use & recommend significant reduction or elimination

49
Q

Epidemiology / etiology of GAD

A

Lifetime prevalence: 5-9%

GAD rates higher in women compared to men (2:1)

1/3 of risk of developing GAD is genetic

50
Q

Course / prognosis of GAD

A

Symptoms of worry begin in childhood

Median age of onset of GAD: 30 years old

Course is chronic, w/ waxing & waning symptoms

Rates of full remission are low

Comorbid diagnoses include other anxiety disorders & depressive disorders

Exercise can significantly reduce anxiety

51
Q

Treatment of GAD

A

Most effective treatment approach: combo of psychotherapy & pharmacotherapy:

  • CBT
  • SSRI (e.g. sertraline, citalopram) or SNRI (e.g. venlafaxine)
  • Can consider shot-term course of benzodiazepines or augmentation w/ buspirone
  • Much less commonly used meds are TCAs & MAOIs
52
Q

What is obsessive-compulsive disorder (OCD)?

A

Characterized by obsessions and/or compulsions that are time-consuming, distressing, & impairing

Obsessions: recurrent, intrusive, undesired thoughts that increase anxiety
- Attempt to relieve this anxiety by performing compulsions

Compulsions: repetitive behaviors or mental rituals

  • Anxiety may increase when patient resists acting out compulsion
  • Can take form of repeated checking or counting

Have varying degrees of insight

Often initially seek help from PCP & other nonpsychiatric providers for help w/ consequences of compulsions (e.g. excessive washing)

53
Q

Diagnosis & DSM-V criteria of OCD

A

Experiencing obsessions and/or compulsions that are time-consuming (e.g. >1 hour / daily) or cause significant distress or dysfunction

Obsessions: recurrent, intrusive, anxiety-provoking thoughts, images, or urges that patient attempts to suppress, ignore, or neutralize by some other thought or action (i.e. by performing a compulsion)

Compulsions: repetitive behaviors or mental acts the patient feels driven to perform in response to an obsession or rule aimed at stress reduction or disaster prevention
- Behaviors are not realistically linked w/ what they are able to prevent or are excessive

Not caused by direct effects of a substance, another mental illness, or another mental condition

54
Q

What is the triad of “uncontrollable urges”?

A

OCD

ADHD

Tic disorder

Usually first seen in children / adolescents

55
Q

Epidemiology of OCD

A

Lifetime prevalence: 2-3%

Mean age of onset: 30 years old

No gender difference in prevalence

56
Q

Etiology of OCD

A

Significant genetic component:

  • Higher rates of OCD in first-degree relatives & monozygotic twins than in general population
  • Higher rate of OCD in first-degree relatives w/ Tourette’s disorder
57
Q

Course / prognosis of OCD

A

Chronic, w/ waxing & waning symptoms

<20% remission rate without treatment

Suicidal ideation in 50%, attempts in 25% of patients

High comorbidity w/ other anxiety disorders (>75%), depressive or bipolar disorder (>60%), obsessive-compulsive personality disorder (up to 32%), & tic disorder (up to 30%)

58
Q

Common patterns of obsessions & compulsions in OCD

A

Obsession: contamination
Compulsion: cleaning or avoidance of contaminant

O: doubt or harm (e.g. oven)
C: Checking multiple times to avoid potential danger

O: symmetry
C: ordering or counting

O: intrusive, taboo thoughts (e.g. sexual, violent)
C: w/ or w/o related compulsion

59
Q

Treatment of OCD

A

Utilize combo of psychopharmacology & CBT

CBT:

  • Focuses on exposure & response prevention
  • Prolonged, graded exposure to ritual-eliciting stimulus & prevention of the relieving compulsion

Meds:

  • First-line meds: SSRIs (e.g. sertraline, fluoxetine), typically at higher doses
  • Can use most serotonin selective TCA (clomipramine)
  • Can augment w/ atypical antispychotics

Last resort:
- In treatment-resistant, severely debilitating cases, can use psychosurgery (cingulotomy) or ECT

60
Q

What is the difference between OCD & OCPD?

A

OCPD:

  • Obsessed w/ details, control, & perfectionism
  • Not intruded upon by unwanted preoccupations nor compelled to carry out compulsions
  • Do not perceive their symptoms as an issue (ego-systonic)

OCD:
- Distressed by their symptoms (ego-dystonic)

61
Q

What is body dysmorphic disorder?

A

Patients are preoccupied w/ body parts that they perceive as flawed or defective, having strong beliefs that they are unattractive or repulsive

Though their physical imperfections are either minimal or not observable, patients view them as severe & grotesque

Spend significant time trying to correct perceived flaws w/ makeup, dermatological procedures, or plastic surgery

62
Q

Diagnosis & DSM-V criteria of body dysmorphic disorder

A

Preoccupation w/ 1 or more perceived defects or flaws in physical appearance that are not observable by or appear slight to others

Repetitive behaviors (e.g. skin picking, excessive grooming) or mental acts (e.g. comparing appearance to others) are performed in response to appearance concerns

Preoccupation causes significant distress or impairment in functioning

Appearance preoccupation is not better accounted for by concerns w/ body fat / weight in an eating disorder

63
Q

Epidemiology of body dysmorphic disorder

A

May be slightly more common in women than men

Prevalence elevated in those w/ high rates of childhood abuse & neglect & first-degree relatives w/ OCD

Higher prevalence in dermatologic & cosmetic surgery patients

Mean age of onset: 15 years old

64
Q

Course / prognosis of body dysmorphic disorder

A

Onset is usually gradual, beginning in early adolescence

Symptoms tend to be chronic

Surgical / dermatological procedures are routinely unsuccessful in satisfying patient

High rate of suicidal ideation & attempts

Comorbidity w/ major depression, social anxiety disorder (social phobia), & OCD

65
Q

Treatment of body dysmorphic disorder

A

SSRIs and/or CBT

- May reduce obsessive & compulsive symptoms in many patients

66
Q

Diagnosis & DSM-V criteria of hoarding disorder

A

Persistent difficulty discarding possessions, regardless of value

Difficulty is due to need to save the items & distress associated w/ discarding them

Results in accumulation of possessions that congest/clutter living areas & compromise use

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

Hoarding is not attributable to another medical condition or another mental disorder

67
Q

Epidemiology / etiology of hoarding disorder

A

Unclear lifetime prevalence, but point prevalence of significant hoarding is 2-6%

Unclear gender preference

Hoarding 3x more prevalent in older population

Individuals w/ hoarding often report stressful & traumatic events preceding onset of hoarding

Large genetic component, w/ 50% of individuals w/ hoarding having a relative who also hoards

68
Q

Course / prognosis of hoarding disorder

A

Hoarding behavior begins in early teens

Hoarding tends to worsen

Usually chronic course

75% of individuals have comorbid mood (MDD) or anxiety disorder (social anxiety disorder)

20% of individuals have comorbid OCD

69
Q

Treatment of hoarding disorder

A

Very difficult to treat

Specialized CBT for hoarding

SSRIs can be used, but not as beneficial unless OCD symptoms are present

70
Q

Diagnosis & DSM-V criteria of trichotillomania (hair-pulling disorder)

A

Recurrent pulling out of one’s hair, resulting in hair loss

Repeated attempts to decrease or stop hair pulling

Causes significant distress or impairment in daily functioning

Hair pulling or hair loss is not due to another medical condition or psychiatric disorder

Usually involves scalp, eyebrows, or eyelashes, but may include facial, axillary, & pubic hair

71
Q

Epidemiology / etiology of trichotillomania

A

Lifetime prevalence: 1-2% of adult population

More common in women than men (10:1 ratio)

Onset usually at time of puberty & frequently associated w/ stressful event

Site of hair pulling may vary & specific hair textures may be preferred

Etiology may involve biological, genetic, & environmental factors

Increased incidence of comorbid OCD, MDD, & excoriation (skin-picking) disorder

Course may be chronic w/ waxing & waning periods
- Adult onset is generally more difficult to treat

72
Q

Treatment of trichotillomania

A

Treatment includes:

  • SSRIs
  • Second-generation antipsychotics
  • N-acetylcysteine
  • Lithium

Forms of CBT (e.g. habit reversal training) are best-evidenced psychotherapy

73
Q

Diagnosis & DSM-V criteria of excoriation (skin-picking) disorder

A

Recurrent skin picking resulting in lesions

Repeated attempts to decrease or stop skin picking

Causes significant distress or impairment in daily functioning

Skin picking is not due to a substance, another medical condition, or another psychiatric disorder

74
Q

Epidemiology / etiology of excoriation disorder

A

Lifetime prevalence: 1.4% of adult population

> 75% of cases are women

More common in individuals w/ OCD & first-degree family members

75
Q

Course / prognosis of excoriation disorder

A

Skin picking begins in adolescence

Course is chronic, w/ waxing & waning periods if untreated

Comorbidity w/ OCD, trichotillomania, & MDD

76
Q

Treatment of excoriation disorder

A

Similar to that for trichotillomania

Specialized types of CBT (e.g. habit reversal training)

SSRIs have also shown some benefit

77
Q

What is posttraumatic stress disorder (PTSD)?

A

Characterized by development of multiple symptoms after exposure to 1 or more traumatic events:

  • Intrusive symptoms (e.g. nightmares, flashbacks)
  • Avoidance
  • Negative alterations in thoughts & mood
  • Increased arousal

Symptoms last for at least 1 month

May occur immediately after trauma or w/ delayed expression

78
Q

What is acute stress disorder?

A

Diagnosed in patients who experience major traumatic event & suffer from similar symptoms as PTSD, but for a shorter duration

Onset of symptoms occurs within 1 month of the trauma & symptoms last for less than 1 month

79
Q

Diagnosis & DSM-V criteria of PTSD & acute stress disorder

A

PTSD: TRAUMA

  • Traumatic event
  • Reexperience
  • Avoidance
  • Unable to function
  • Month or more of symptoms
  • Arousal increased

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

Recurrent intrusions of re-experiencing event via memories, nightmares, or dissociative reactions (e.g. flashbacks); intense distress at exposure to cues relating to trauma; or physiological reactions to cues relating to trauma

Active avoidance of triggering stimuli (e.g. memories, feelings, people, places, objects) associated w/ trauma

At least 2 of following negative cognitions / mood:

  • Dissociative amnesia
  • Negative feelings of self/others/world
  • Self-blame
  • Negative emotions (e.g. fear, horror, anger, guilt)
  • Anhedonia
  • Feelings of detachment / estrangement
  • Inability to experience positive emotions

At least 2 of the following symptoms of increased arousal / reactivity:

  • Hypervigilance
  • Exaggerated startle response
  • Irritability / angry outbursts
  • Impaired concentration
  • Insomnia

Symptoms not caused by direct effects of substance or another medical condition

Symptoms result in significant impairment in social or occupational functioning

Presentation differs in children <7 years of age

80
Q

PTSD vs. acute stress disorder

A

PTSD:

  • Trauma occurred at any time in the past
  • Symptoms last >1 month

Acute stress disorder:

  • Trauma occurred <1 month ago
  • Symptoms last <1 month
81
Q

Epidemiology / etiology of PTSD

A

Lifetime prevalence of PTSD: >8%

Higher prevalence in women, most likely due to greater risk of exposure to traumatic events

  • Rape
  • Other forms of interpersonal violence

Risk factor:
- Exposure to prior trauma, especially during childhood

82
Q

Course / prognosis of PTSD

A

Usually begins within 3 months after trauma

Symptoms of PTSD may have dealyed expression

50% of patients have complete recovery within 3 months

Symptoms tend to diminish w/ older age

80% of patients w/ PTSD have another mental disorder (e.g. MDD, bipolar disorder, anxiety disorder, substance use disorder)

83
Q

Treatment of PTSD & acute stress disorder

A

PHARMACOLOGICAL

  • First-line antidepressants: SSRIs (e.g. sertraline, citalopram) or SNRIs (e.g. venlafaxine)
  • Prazosin (alpha1-receptor antagonist): targets nightmares & hypervigilance (for Ptsd, use PrazoSiN to Stop Nightmares)
  • May augment w/ atypical (second-generation) antipsychotics in severe cases
  • Addictive meds (e.g. benzo) should be avoided in treatment of PTSD because of high rate of comorbid substance use disorders

PSYCHOTHERAPY

  • Specialized forms of CBT (e.g. exposure therapy, cognitive processing therapy) = thoughts, feelings, & meanings of event are revisited & questioned
  • Supportive & psychodynamic therapy
  • Couples / family therapy
84
Q

What is adjustment disorder?

A

Adjustment disorders occur when behavioral or emotional symptoms develop after a stressful life eent

85
Q

Diagnosis & DSM-V criteria of adjustment disorder

A

Development of emotional / behavioral symptoms within 3 months in response to an identifiable stressful life event. These symptoms produce either:

  • Marked distress in excess of what would be expected after such an event
  • Significant impairment in daily functioning
  • Stressful event is not life-threatening (e.g. divorce, death of loved one, or loss of job)

Symptoms are not those of normal bereavement

Symptoms resolve within 6 months after stressor has terminated

Stress-related disturbance does not meet criteria for another mental disorder

Subtypes: symptoms are coded based on predominance of either depressed mood, anxiety, mixed anxiety & depression, disturbance of conduct (such as aggression), or mixed disturbance of emotions & conduct

86
Q

Epidemiology of adjustment disorder

A

Very common (5-20% of patients in outpatient mental health clinics)

May occur at any age

87
Q

Etiology of adjustment disorder

A

Triggered by psychosocial factors

88
Q

Prognosis of adjustment disorder

A

May be chronic if stressor is chronic or recurrent

Symptoms resolve within 6 months of cessation of stressor

89
Q

Treatment of adjustment disorder

A

Supportive psychotherapy (most effective)

Group therapy

Occasionally pharmacotherapy is used to treat associated symptoms (insomnia, anxiety, or depression) in time-limited fashion

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