Anxiety + OCD Flashcards
1
Q
Prevalence any anxiety d/o?
A
31%
2
Q
Gender distribution anxiety d/o?
A
F > M
```
EXCEPT OCD
M > F pre-pubescent, F = M after puberty
~~~
3
Q
Most common mental disorder in women?
A
Specific phobia
4
Q
Most common mental disorder in men?
A
Substance use disorder
specific phobia is 2nd
5
Q
Rate of co-morbidities when have an anxiety d/o?
A
70-95%
6
Q
Co-morbidities when have an anxiety d/o?
A
Anxiety disorders
Mood disorders
SUD
Impulse control disorders
7
Q
Most common anxiety d/o?
A
Specific phobia 1ST
Social phobia 2nd
8
Q
Latest onset anxiety d/o?
A
GAD
9
Q
Walter Cannon
A
Flight or flight hypothesis
10
Q
Harold Wolff
A
Correlation between GI physiology and emotional state
11
Q
Most common presentation of anxiety due to GMC?
A
Panic disorder
12
Q
Least common presentation of anxiety due to GMC?
A
PHOBIA
13
Q
Anxiety due to GMC causes?
A
Hypo or hyper thyroid Hyperparathyroid Pheochromocytoma Vestibular dysfunction Seizures Cardiac problems (arrhythmia)
14
Q
Which anxiety disorders only need 1 month?
A
Selective mutism
Panic disorder
Separation anxiety disorder IN KIDS
All others need 6 months!
15
Q
Most common specific phobia?
A
ANIMALS
Then
- storms
- heights
- illness
- injury
- death
Fear or anxiety may be expressed by crying, tantrums, freezing or clinging in kids.
16
Q
Otto Fenichel
A
Counterphobic attitude (denial of fear)
For example, child afraid of shots plays doctor (identifying with the aggressor).
17
Q
What is unique about blood-injection-injury phobia?
A
Causes OPPOSITE biological reaction (hypotension, low HR, syncope…think vasovagal).
18
Q
Defenses associated with specific phobia?
A
Displacement
Avoidance
Projection
19
Q
Acrophobia?
A
Heights
20
Q
Ailurophobia?
A
Cats
21
Q
Cynophobia?
A
Dogs
22
Q
Venophobia?
A
Strangers
23
Q
Mysophobia?
A
Dirt/contamination
24
Q
Virtual reality good for which phobias (better than imaginal)?
A
Height
Plane
Claustrophobic
Spiders
25
Social anxiety disorder treatment nugget
CBT = Rx
CBT gains last longer
"Although there is limited evidence for Citalopram in SAD, it is likely as effective as the other SSRIs, in contrast there are NEGATIVE trials of PROZAC in SAD suggesting it may be less effective than other SSRIs".
```
CITALOPRAM = 2ND LINE
PROZAC = 3RD LINE
```
26
Nocturnal panic attacks happen during which phase of sleep?
Stage 2/3 (NON-REM)
27
Percentage of co-morbidity in panic disorder?
91%
1/3 have MDD (onset preceding panic attacks)
SAD, GAD, OCD common
28
Panicogens?
```
CO2
Sodium lactate ("suffocation" false alarm)
Bicarbonate
Yohimbine
Isoproterenol
Cholecystokinin
Flumazenil
Theophylline
```
29
Which medication increases flashbacks in PTSD?
YOHIMBINE
30
In which anxiety disorder do women have a 2x higher rate of history of sexual abuse (60%)?
PANIC DISORDER
31
Which medical condition has NO association with panic disorder?
MITRAL VALVE PROLAPSE
32
Panic disorder treatment?
Combo > CBT >>> meds
aka. just meds alone is NOT good
CBT helps avoid relapse at time of treatment discontinuation
PAN SSRIs + Venlafaxine 1st line
33
Fear vs. anxiety
Fear:
- known
- external
- unconflictual threat
Anxiety:
- unknown
- internal
- conflictual threat
34
Male relatives of people with GAD likely to have what?
Alcohol use disorder
35
Highest concentration of benzo receptors where?
OCCIPITAL LOBE
36
Neurotransmitters involved in GAD?
Cholecystoinin system
GABA
glutamate
NE
37
Heritability of GAD?
33%
38
GAD treatment nuggets?
```
CBT = Rx = Relaxation technique
Individual = group (but faster with individual)
```
CELEXA AND PROZAC 3RD LINE
BETA BLOCKERS NOT RECOMMENDED
FLUVOXAMINE NOT LISTED
39
Anxiety in the elderly
Less prevalence overall
More tolerance of negative emotions
PSYCHOTHERAPY = RX
(Psychotherapy less effective than in adults though)
Specific phobia still most prevalent:
FEAR OF FALLING (egosyntonic)
40
Benzos in the elderly
INVERSED therapeutic index:
- side effects at low doses
- therapeutic effect at high doses
41
Perinatal anxiety
GAD in peripartum
GAD and OCD post-partum
42
Anxiety treatment in kids and adolescents?
Try CBT first (individual = group) then combine with Rx PRN
70% no longer meet criteria after course of CBT
43
Suicide risk SSRIs for kids and adolescents in anxiety?
NON-SIGNIFICANT with antidepressants for anxiety (LOWER than youth MDD, 0.9%)
44
Separation anxiety disorder criteria in KIDS
< 18 years old
Duration of 1 month
At least THREE:
- distress when separation from home/attachment figure
- worry about losing/harm to attachment figure
- worry about experiencing event which will cause separation from attachment figure (kidnapping, lost, ill, accident)
- reluctance/refusal to go to school/work/out due to fear of separation
- reluctance to be alone
- reluctance/refusal to sleep away from home
- nightmares with theme of separation
- somatic complaints when anticipated/experienced separation
Can have perceptual disturbances (clear trigger, reversible)
** Increased sensitivity to stimulation with CO2 enriched air**
45
Separation anxiety disorder criteria in adults?
> 18 years old
Duration of 6 months
At least 3 symptoms
46
Separation anxiety disorder treatment?
Multimodal (CBT, family, meds as per K&S)
Fluoxetine, Fluvoxamine
CBT > Imipramine (as per Nuls)
47
Prognosis anxiety disorder in kids and adolescents?
30% have psychiatric problems as adults (panic, agoraphobia).
48
Selective mutism
Consistent failure to speak in specific social situations where there is expectation to speak (such as at school) despite speaking in other situations.
At least 1 month (NOT LIMITED TO FIRST MONTH OF SCHOOL)
No communication disorder diagnosis and not due to lack of knowledge or comfort with spoken language
Starts < 5 years old but usually problematic at start of school and usually disappears after 8 years of evolution.
49
Selective mutism associated with which other anxiety disorders?
SOCIAL ANXIETY DISORDER
Separation anxiety disorder
Specific phobia
50
Selective mutism treatment?
Multimodal
CBT (group or individual) 1st line
Fluoxetine
No evidence for buspirone or benzos
51
Social anxiety disorder criteria?
At least 6 months
In at least ONE social situation where exposed to scrutiny by others
Specify if performance only
**In kids/adolescents, must be peer-related; not just with adults**
52
Panic disorder criteria?
At least one panic attack followed by at least 1 month of:
1. Persistent worry about additional panic attacks
AND/OR
2. Significant maladaptive behaviour to avoid panic attacks (avoidance)
Recurrent, unexpected panic attacks (from either calm or anxious state) as defined by at least 4/13 symptoms:
- sweating
- shortness of breath
- feeling of choking
- chest pain
- palpitations
- nausea/abdominal pain
- trembling
- dizzy
- chills/heat sensation
- paresthesias
- derealization/depersonalization
- fear of losing control ("I'm going crazy")
- fear of dying
Typical peak in 10 minutes, and lasts 20-30 minutes
Syncope in 20% of patients
53
What is a risk factor for panic attacks (not trigger)?
SMOKING
54
Strongest genetic component of all specific phobias?
AGORAPHOBIA (as per Nuls)
| Heritability 61%
55
Agoraphobia criteria
Marked fear or anxious about at least TWO out of five:
1. Public transportation
2. Open spaces
3. Enclosed spaces
4. Lines/crows
5. Outside home alone
Fear or avoided because escape might be difficult or help not available if develop panic-like symptoms or other symptoms (fear of falling, fear of incontinence).
At least 6 months (but DSM-5 mentions it's only a general guide and there is some flexibility)
56
Fear Questionnaire
Gives scores for
- agoraphobia
- blood-injection-injury phobia
- social phobia
57
Generalized anxiety disorder criteria
Excessive anxiety occurring more days than not for at least 6 months about a number of events.
Difficult to control.
Associated with at least 3 symptoms:
1. Restless/keyed up
2. Easily fatigued
3. Trouble concentrating/blank mind
4. Irritability
5. Muscle tension
6. Sleep disturbance
58
Generalized anxiety disorder criteria in kids and adolescents?
Less stringent criteria as only needs ONE anxiety symptom to accompany during 6 months of worry.
59
Sleep change different in GAD compared to MDD?
Decreased REM in GAD
| versus increased total REM in MDD
60
Other specified anxiety disorders
Limited-symptom attacks
Generalized anxiety not occurring more days than not
Khyal cap (Cambodian)
Attaque de nervios (Latin)
61
Vortioxetine in which anxiety disorder only?
GAD
| 2ND LINE
62
Fluvoxamine in anxiety disorders except?
GAD
(just not mentioned)
1st line in social, panic and OCD
2nd line in PTSD
63
OCD criteria
Presence of obsessions (2%), compulsions (2%) or both (96%).
Time-consuming > 1hr/day and/or significant functional impact.
64
OCD specifiers
```
Good/fair insight (probably not true)
Poor insight (probably true)
Absent insight/delusional beliefs (convinced true)
```
Tic-related (current or past history of tic disorders
65
What percentage in OCD have hx of tics?
20-30%
66
Lifetime prevalence of MDD on OCD patients?
2/3 (66%)
Suicidal thoughts in 50%
Suicide attempts in 25%
**MDD is the most common SINGLE co-morbidity but anxiety diagnoses more common as a disorder cluster** (as per K&S)
67
OCD co-morbidities
Anxiety (76%)
Mood disorder (63%), MDD (41%)
OCPD (20-30%)
68
Prevalence of OCD higher in which patients?
Schizophrenia
BAD
ED
Tourette's
69
OCD defence mechanisms
Isolation
Reaction formation
Retroactive cancelling
Regression from Oedipal to anal.
Love and hate co-exist.
70
What percentage of OCD have hoarding as a separate diagnosis?
10%
(30% hoard)
Hoarding behaviour in OCD typically involves BIZARRE items (trash, rotten food)
71
What percentage of OCD had premorbid obsessional traits?
Only 15-35%
72
OCD neurobiology
SMALLER CAUDATE
Hyperactivity in orbitorfrontal, basal ganglia (especially caudate) and cingulum.
**NOT AMYGDALA like most anxiety disorder**
73
OCD core belief?
Mistakes are intolerable.
74
OCD treatment in kids and adolescents
POTS trial:
CBT + Sertraline better than CBT alone or Rx alone
CBT alone better than Rx alone
Individual = group
NNT combo = 2
NNT CBT = 3
NNT Rx = 6
NO RX MONOTHERAPY for peds
CBT for mild-moderate
Combination for moderate-severe
75
OCD pharmacological treatment
50-70% respond to treatment
Trial 8-12 weeks, usually need higher doses
ALL SSRIs 1st line except CELEXA (2nd line)
Effexor 2nd line
Clomipramine 2nd line (if failed 2 first line SSRIs)
1ST LINE ADJUNCT BEFORE GOING TO 2ND LINE
Abilify or Risperidone
2nd line adjunct:
quetiapine, topiramate, memantine
```
Not recommended as mono or adjunct:
Desipramine
Benzodiazepine
Clonidine
Lithium
Buspirone
Morphine
```
76
OCD psychological treatment
CBT better for COMPULSIVE component
Requires more motivation than meds
Sometimes maintenance is required
77
YBOCS
```
Total score of 40
Takes 15 minutes
Rates severity and symptom type
Does NOT depend on illness duration
Score of 0-7 = subclinical
```
78
Most common obsession?
Contamination (45%)
79
Most common compulsion?
checking (63%)
| washing (50%)
80
Which OCD symptoms respond less to SSRI?
Symmetry and hoarding
DOPAMINE mediated
Less response to SSRI
81
Which OCD symptoms respond more to SSRI?
Intrusive images
SEROTONIN mediated
Respond better to SSRIs
82
Refractory OCD
3 failed SSRI/SNRI
2 failed augmentations
Combination Rx + CBT failed
83
Refractory OCD treatment
Psychosurgery
Anterior cingulotomy
Anterior capsulotomy
30-70%
Absolute contraindication = CNS LESION
Relative contraindication = seizures, > 65, personality d/o, SUD, medical co-morbidity
DBS: target INTERNAL CAPSULE
84
PANDAS
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal
10-30%
```
Sudden OCD/tics OR worsening OCD/tics
Episodic course
Childhood onset (3yo to PUBERTY)
Documented group A strep infection
Movements = chorea
```
Due to ANTIBODIES, not bacteria so no prophylaxis with antibiotics
BASAL GANGLIA SIZE CORRELATES WITH SYMPTOM SEVERITY
85
Body dysmorphic disorder
Pre-occupation with one or more perceived flaw
NOT OBSERVABLE or appears slight to others
Repetitive behaviours (mirror checking/grooming) or mental acts (comparing to others) in response to appearance concerns.
7-8% of plastic surgery patients!
86
Body dysmorphic disorder specifiers
WITH MUSCLE DYSMORPHIA
With good/fair insight
With poor insight
With absent insight/delusional beliefs
Lower insight compared with OCD
87
Most common co-morbidity in body dysmorphic disorder?
MDD (90%)
20% attempt suicide
88
Most common perceived flaw in body dysmorphic disorder?
HAIR (63%)
```
Then:
Nose (50%)
Skin (50%)
Eyes
Head/face
```
On average: 4 PARTS
89
Body dysmorphic disorder treatment?
Most respond to SEROTONERGIC drugs (high dose)
CBT
Safety (risk of self-surgery, suicide attempt)
90
Koro
Fear genital will retract into abdomen and result in death!
91
Hoarding disorder
Difficulty discarding
Need to save items or distressed when discarding
Results in substantial clutter (unless 3rd party intervened)
92
Hoarding disorder specifiers
WITH EXCESSIVE ACQUISITION (80-90%)
With good/fair insight
With poor insight
With absent insight/delusional beliefs
93
Hoarding co-morbidities
MDD (50%)
SAD, GAD
ADHD (20% of hoarders)
94
Differences hoarding and OCD?
Hoarding INCREASES with time
Rituals not fixed
Ego-SYNTONIC (unlike OCD where hoarding is bizarre items like trash and rotten food)
LESS response to treatment
95
Hoarding treatment
CBT leads to 25-34% symptom decrease
| Mixed results with SSRI
96
Trichotillomania
Often in ONLY child or ELDEST
35-40% chew/swallow hair
1/3 develop bezoars
Pain doesn't usually accompany hair pulling
Focused pulling vs. automatic pulling (most have COMBINATION)
Decreased volume of LEFT putamen & lenticulate areas
5HT2A gene polymorphism
97
Trichotillomania treatment
Habit reversal (substitute behaviour with something incompatible with pulling)
SSRIs NOT EFFECTIVE
2nd line Clomipramine, N-acetylcysteine, antipsychotics, naltrexone
98
Which developmental disorder has high rates of excoriation (skin picking)?
PRADER-WILLI
99
Excoriation treatment
SSRI 1st line
| NALTREXONE 2nd line
100
Other specified obsessive-compulsive & related disorders
Body-focused repetitive behaviour disorder (nail biting, cheek chewing)
Obsessional jealousy
Shubo-Kyofu (fear of having body deformity)
Jikoshu-Kyofu (fear of bad body odour)
101
Buspirone monotherapy for which anxiety disorders?
GAD (2nd line)
| PTSD (3rd line)
102
Buspirone not recommended monotherapy for which anxiety disorders?
SAD
| PANIC DISORDER
103
Bupropion not monotherapy for which anxiety disorder?
OCD
104
Moclobemide not monotherapy for which anxiety disorders?
GAD
| OCD
105
Phenelzine not monotherapy for which anxiety disorder?
GAD
106
Trazodone monotherapy for which anxiety disorders?
GAD (3rd line)
| PTSD (3rd line)
107
Imipramine not recommended monotherapy for which anxiety disorder?
SAD
| and not mentioned for OCD
108
Benzos not recommended monotherapy for which anxiety disorder?
OCD
109
Zyprexa not recommended monotherapy for which anxiety disorder?
PTSD
110
Epival not recommended monotherapy for which anxiety disorder?
PTSD
111
Topiramate recommended monotherapy for which anxiety disorder?
SAD (3rd line)
112
Tramadol recommended monotherapy for which anxiety disorder?
OCD (3rd line)
113
Memantine recommended monotherapy for which anxiety disorder?
PTSD (3rd line)
114
Vortioxetine recommended monotherapy for which anxiety disorder?
GAD (2nd line)
115
Benzos not recommended adjunct for which anxiety disorders?
SAD
| OCD
116
Ziprasidone not recommended adjunct for which anxiety disorder?
GAD
117
Lithium not recommended adjunct for which anxiety disorder?
OCD
118
Buspirone not recommended adjunct for which anxiety disorder?
OCD
119
Morphine not recommended adjunct for which anxiety disorder?
OCD
120
Epival adjunct for which anxiety disorder?
PANIC DISORDER (3rd line)
121
Topiramate recommended adjunct for which anxiety disorder?
OCD (2nd line)
122
Gabapentin adjunct for which anxiety disorder?
PTSD (3rd line)
123
Celexa adjunct for which anxiety disorder?
OCD (3rd line)
124
Paxil adjunct for which anxiety disorder?
SAD (3rd line)
125
Seroquel not recommended as monotherapy for which anxiety disorder?
SAD
126
What monotherapies not recommended in SAD?
```
Buspirone
Seroquel
Propranolol
Imipramine
Atenolol
Levetiracetam
```
