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Anxiety + OCD Flashcards

1
Q

Prevalence any anxiety d/o?

A

31%

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2
Q

Gender distribution anxiety d/o?

A

F > M

```
EXCEPT OCD
M > F pre-pubescent, F = M after puberty
~~~

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3
Q

Most common mental disorder in women?

A

Specific phobia

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4
Q

Most common mental disorder in men?

A

Substance use disorder

specific phobia is 2nd

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5
Q

Rate of co-morbidities when have an anxiety d/o?

A

70-95%

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6
Q

Co-morbidities when have an anxiety d/o?

A

Anxiety disorders
Mood disorders
SUD
Impulse control disorders

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7
Q

Most common anxiety d/o?

A

Specific phobia 1ST

Social phobia 2nd

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8
Q

Latest onset anxiety d/o?

A

GAD

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9
Q

Walter Cannon

A

Flight or flight hypothesis

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10
Q

Harold Wolff

A

Correlation between GI physiology and emotional state

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11
Q

Most common presentation of anxiety due to GMC?

A

Panic disorder

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12
Q

Least common presentation of anxiety due to GMC?

A

PHOBIA

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13
Q

Anxiety due to GMC causes?

A 
Hypo or hyper thyroid
Hyperparathyroid
Pheochromocytoma
Vestibular dysfunction
Seizures
Cardiac problems (arrhythmia)
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14
Q

Which anxiety disorders only need 1 month?

A

Selective mutism
Panic disorder
Separation anxiety disorder IN KIDS

All others need 6 months!

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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.

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16
Q

Otto Fenichel

A

Counterphobic attitude (denial of fear)

For example, child afraid of shots plays doctor (identifying with the aggressor).

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17
Q

What is unique about blood-injection-injury phobia?

A

Causes OPPOSITE biological reaction (hypotension, low HR, syncope…think vasovagal).

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18
Q

Defenses associated with specific phobia?

A

Displacement
Avoidance
Projection

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19
Q

Acrophobia?

A

Heights

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20
Q

Ailurophobia?

A

Cats

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21
Q

Cynophobia?

A

Dogs

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22
Q

Venophobia?

A

Strangers

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23
Q

Mysophobia?

A

Dirt/contamination

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24
Q

Virtual reality good for which phobias (better than imaginal)?

A

Height
Plane
Claustrophobic
Spiders

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25
Q

Social anxiety disorder treatment nugget

A

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
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26
Q

Nocturnal panic attacks happen during which phase of sleep?

A

Stage 2/3 (NON-REM)

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27
Q

Percentage of co-morbidity in panic disorder?

A

91%

1/3 have MDD (onset preceding panic attacks)
SAD, GAD, OCD common

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28
Q

Panicogens?

A 
CO2
Sodium lactate ("suffocation" false alarm)
Bicarbonate
Yohimbine 
Isoproterenol
Cholecystokinin
Flumazenil
Theophylline
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29
Q

Which medication increases flashbacks in PTSD?

A

YOHIMBINE

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30
Q

In which anxiety disorder do women have a 2x higher rate of history of sexual abuse (60%)?

A

PANIC DISORDER

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31
Q

Which medical condition has NO association with panic disorder?

A

MITRAL VALVE PROLAPSE

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32
Q

Panic disorder treatment?

A

Combo > CBT&raquo_space;> meds
aka. just meds alone is NOT good

CBT helps avoid relapse at time of treatment discontinuation

PAN SSRIs + Venlafaxine 1st line

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33
Q

Fear vs. anxiety

A

Fear:

  • known
  • external
  • unconflictual threat

Anxiety:

  • unknown
  • internal
  • conflictual threat
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34
Q

Male relatives of people with GAD likely to have what?

A

Alcohol use disorder

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35
Q

Highest concentration of benzo receptors where?

A

OCCIPITAL LOBE

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36
Q

Neurotransmitters involved in GAD?

A

Cholecystoinin system
GABA
glutamate
NE

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37
Q

Heritability of GAD?

A

33%

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38
Q

GAD treatment nuggets?

A 
CBT = Rx = Relaxation technique
Individual = group (but faster with individual)

CELEXA AND PROZAC 3RD LINE
BETA BLOCKERS NOT RECOMMENDED
FLUVOXAMINE NOT LISTED

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39
Q

Anxiety in the elderly

A

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)

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40
Q

Benzos in the elderly

A

INVERSED therapeutic index:

  • side effects at low doses
  • therapeutic effect at high doses
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41
Q

Perinatal anxiety

A

GAD in peripartum

GAD and OCD post-partum

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42
Q

Anxiety treatment in kids and adolescents?

A

Try CBT first (individual = group) then combine with Rx PRN

70% no longer meet criteria after course of CBT

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43
Q

Suicide risk SSRIs for kids and adolescents in anxiety?

A

NON-SIGNIFICANT with antidepressants for anxiety (LOWER than youth MDD, 0.9%)

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44
Q

Separation anxiety disorder criteria in KIDS

A

< 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**

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45
Q

Separation anxiety disorder criteria in adults?

A

> 18 years old
Duration of 6 months
At least 3 symptoms

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46
Q

Separation anxiety disorder treatment?

A

Multimodal (CBT, family, meds as per K&S)
Fluoxetine, Fluvoxamine
CBT > Imipramine (as per Nuls)

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47
Q

Prognosis anxiety disorder in kids and adolescents?

A

30% have psychiatric problems as adults (panic, agoraphobia).

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48
Q

Selective mutism

A

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.

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49
Q

Selective mutism associated with which other anxiety disorders?

A

SOCIAL ANXIETY DISORDER
Separation anxiety disorder
Specific phobia

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50
Q

Selective mutism treatment?

A

Multimodal
CBT (group or individual) 1st line
Fluoxetine

No evidence for buspirone or benzos

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51
Q

Social anxiety disorder criteria?

A

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
Q

Panic disorder criteria?

A

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
Q

What is a risk factor for panic attacks (not trigger)?

54
Q

Strongest genetic component of all specific phobias?

A

AGORAPHOBIA (as per Nuls)

Heritability 61%

55
Q

Agoraphobia criteria

A

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
Q

Fear Questionnaire

A

Gives scores for

  • agoraphobia
  • blood-injection-injury phobia
  • social phobia
57
Q

Generalized anxiety disorder criteria

A

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
Q

Generalized anxiety disorder criteria in kids and adolescents?

A

Less stringent criteria as only needs ONE anxiety symptom to accompany during 6 months of worry.

59
Q

Sleep change different in GAD compared to MDD?

A

Decreased REM in GAD

versus increased total REM in MDD

60
Q

Other specified anxiety disorders

A

Limited-symptom attacks
Generalized anxiety not occurring more days than not
Khyal cap (Cambodian)
Attaque de nervios (Latin)

61
Q

Vortioxetine in which anxiety disorder only?

A

GAD

2ND LINE

62
Q

Fluvoxamine in anxiety disorders except?

A

GAD
(just not mentioned)

1st line in social, panic and OCD
2nd line in PTSD

63
Q

OCD criteria

A

Presence of obsessions (2%), compulsions (2%) or both (96%).

Time-consuming > 1hr/day and/or significant functional impact.

64
Q

OCD specifiers

A 
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
Q

What percentage in OCD have hx of tics?

66
Q

Lifetime prevalence of MDD on OCD patients?

A

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
Q

OCD co-morbidities

A

Anxiety (76%)
Mood disorder (63%), MDD (41%)
OCPD (20-30%)

68
Q

Prevalence of OCD higher in which patients?

A

Schizophrenia
BAD
ED
Tourette’s

69
Q

OCD defence mechanisms

A

Isolation
Reaction formation
Retroactive cancelling

Regression from Oedipal to anal.
Love and hate co-exist.

70
Q

What percentage of OCD have hoarding as a separate diagnosis?

A

10%
(30% hoard)

Hoarding behaviour in OCD typically involves BIZARRE items (trash, rotten food)

71
Q

What percentage of OCD had premorbid obsessional traits?

A

Only 15-35%

72
Q

OCD neurobiology

A

SMALLER CAUDATE

Hyperactivity in orbitorfrontal, basal ganglia (especially caudate) and cingulum.

NOT AMYGDALA like most anxiety disorder

73
Q

OCD core belief?

A

Mistakes are intolerable.

74
Q

OCD treatment in kids and adolescents

A

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
Q

OCD pharmacological treatment

A

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
Q

OCD psychological treatment

A

CBT better for COMPULSIVE component
Requires more motivation than meds
Sometimes maintenance is required

77
Q

YBOCS

A 
Total score of 40
Takes 15 minutes
Rates severity and symptom type
Does NOT depend on illness duration
Score of 0-7 = subclinical
78
Q

Most common obsession?

A

Contamination (45%)

79
Q

Most common compulsion?

A

checking (63%)

washing (50%)

80
Q

Which OCD symptoms respond less to SSRI?

A

Symmetry and hoarding
DOPAMINE mediated
Less response to SSRI

81
Q

Which OCD symptoms respond more to SSRI?

A

Intrusive images
SEROTONIN mediated
Respond better to SSRIs

82
Q

Refractory OCD

A

3 failed SSRI/SNRI
2 failed augmentations
Combination Rx + CBT failed

83
Q

Refractory OCD treatment

A

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
Q

PANDAS

A

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
Q

Body dysmorphic disorder

A

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
Q

Body dysmorphic disorder specifiers

A

WITH MUSCLE DYSMORPHIA

With good/fair insight
With poor insight
With absent insight/delusional beliefs

Lower insight compared with OCD

87
Q

Most common co-morbidity in body dysmorphic disorder?

A

MDD (90%)

20% attempt suicide

88
Q

Most common perceived flaw in body dysmorphic disorder?

A

HAIR (63%)

Then:
Nose (50%)
Skin (50%)
Eyes
Head/face

On average: 4 PARTS

89
Q

Body dysmorphic disorder treatment?

A

Most respond to SEROTONERGIC drugs (high dose)
CBT
Safety (risk of self-surgery, suicide attempt)

90
Q

Koro

A

Fear genital will retract into abdomen and result in death!

91
Q

Hoarding disorder

A

Difficulty discarding
Need to save items or distressed when discarding
Results in substantial clutter (unless 3rd party intervened)

92
Q

Hoarding disorder specifiers

A

WITH EXCESSIVE ACQUISITION (80-90%)

With good/fair insight
With poor insight
With absent insight/delusional beliefs

93
Q

Hoarding co-morbidities

A

MDD (50%)
SAD, GAD
ADHD (20% of hoarders)

94
Q

Differences hoarding and OCD?

A

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
Q

Hoarding treatment

A

CBT leads to 25-34% symptom decrease

Mixed results with SSRI

96
Q

Trichotillomania

A

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
Q

Trichotillomania treatment

A

Habit reversal (substitute behaviour with something incompatible with pulling)

SSRIs NOT EFFECTIVE
2nd line Clomipramine, N-acetylcysteine, antipsychotics, naltrexone

98
Q

Which developmental disorder has high rates of excoriation (skin picking)?

A

PRADER-WILLI

99
Q

Excoriation treatment

A

SSRI 1st line

NALTREXONE 2nd line

100
Q

Other specified obsessive-compulsive & related disorders

A

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
Q

Buspirone monotherapy for which anxiety disorders?

A

GAD (2nd line)

PTSD (3rd line)

102
Q

Buspirone not recommended monotherapy for which anxiety disorders?

A

SAD

PANIC DISORDER

103
Q

Bupropion not monotherapy for which anxiety disorder?

104
Q

Moclobemide not monotherapy for which anxiety disorders?

105
Q

Phenelzine not monotherapy for which anxiety disorder?

106
Q

Trazodone monotherapy for which anxiety disorders?

A

GAD (3rd line)

PTSD (3rd line)

107
Q

Imipramine not recommended monotherapy for which anxiety disorder?

A

SAD

and not mentioned for OCD

108
Q

Benzos not recommended monotherapy for which anxiety disorder?

109
Q

Zyprexa not recommended monotherapy for which anxiety disorder?

110
Q

Epival not recommended monotherapy for which anxiety disorder?

111
Q

Topiramate recommended monotherapy for which anxiety disorder?

A

SAD (3rd line)

112
Q

Tramadol recommended monotherapy for which anxiety disorder?

A

OCD (3rd line)

113
Q

Memantine recommended monotherapy for which anxiety disorder?

A

PTSD (3rd line)

114
Q

Vortioxetine recommended monotherapy for which anxiety disorder?

A

GAD (2nd line)

115
Q

Benzos not recommended adjunct for which anxiety disorders?

116
Q

Ziprasidone not recommended adjunct for which anxiety disorder?

117
Q

Lithium not recommended adjunct for which anxiety disorder?

118
Q

Buspirone not recommended adjunct for which anxiety disorder?

119
Q

Morphine not recommended adjunct for which anxiety disorder?

120
Q

Epival adjunct for which anxiety disorder?

A

PANIC DISORDER (3rd line)

121
Q

Topiramate recommended adjunct for which anxiety disorder?

A

OCD (2nd line)

122
Q

Gabapentin adjunct for which anxiety disorder?

A

PTSD (3rd line)

123
Q

Celexa adjunct for which anxiety disorder?

A

OCD (3rd line)

124
Q

Paxil adjunct for which anxiety disorder?

A

SAD (3rd line)

125
Q

Seroquel not recommended as monotherapy for which anxiety disorder?

126
Q

What monotherapies not recommended in SAD?

A 
Buspirone
Seroquel
Propranolol
Imipramine
Atenolol
Levetiracetam

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