Anxiety, Trauma, & Stress Disorders

Question 1

Generalized Anxiety Disorder

Answer 1

• Definition:
  
  • excessive worry or anxiety occurring more days than not for at least 6 months → significant distress or impairment in social, occupational, or other important areas of life
• Epidemiology:
  
  • average onset early 20s, more common in females
• DSM-V Criteria:
  
  • **3+ of the following:
    
    • -Restlessness
    • -Fatigue
    • -Difficulty concentrating
    • -Irritability
    • -Muscle Tension
    • -Sleep disturbance
• Dx:
  
  • Clinical dx
  • r/o thyroid problems
• Tx:
  
  • SSRIs = mainstay of treatment, (high dose for anxiety, low dose for depression)
  • Cognitive Behavioral Therapy: mainstay of tx
  • Benzos: as needed, not for ongoing treatment
  • Buspirone (Wellbutrin): may be used with SSRIs
  • Off label: propranolol, hydroxyzine, neurontin, seroquel, risperdal

Question 2

Social Anxiety Disorder

Answer 2

• Definition:
  
  • marked fear or anxiety about 1+ social situations in which the individual is exposed to possible scrutiny by others (i.e. observed by others, eating in front of others)
• Epidemiology:
  
  • most common type of phobia (public speaking)
• S/sxs:
  
  • Anxiety provoked by social situations
  • Fear that they will act in a way or show anxiety & be negatively evaluated: out of proportion to threat posed
  • Avoidance of social situations
  • Impairment in social functioning
• Dx:
  
  • Clinical Dx
  • r/o other causes
• Tx:
  
  • SSRIs = mainstay of treatment, (high dose for anxiety, low dose for depression)
  • Cognitive Behavioral Therapy: mainstay of tx
  • Benzos: as needed, not for ongoing treatment
  • Buspirone: may be used adjacent to SSRIs
  • Off label: propranolol, hydroxyzine, neurontin, seroquel, risperdal

Question 3

Panic Attacks

Answer 3

• Definition:
  
  • an abrupt surge of intense fear or discomfort that reaches a peak within 10 minutes
• DSM-V Criteria
  
  • **4+of the following:
    
    • -Palpitations
    • -Sweating
    • -Trembling, shaking
    • -SOB
    • -Feelings of Choking
    • -Chest pain or discomfort
    • -Nausea, abdominal distress
    • -feeling dizzy
    • -chills or heat sensations
    • -Paresthesias
    • -Depersonalization
    • -Fear of losing control
• Dx:
  
  • Need to r/o potentially life-threatening conditions (MI, thyrotoxicosis)
• Tx:
  
  • Acute Attacks: benzos →1st line, alprazolam or clonazepam

Question 4

Panic Disorder

Answer 4

• Definition:
  
  • recurrent, unexpected panic attacks (at least 2).
• DSM-V Criteria
  
  • **4+of the following:
    
    • -Palpitations
    • -Sweating
    • -Trembling, shaking
    • -SOB
    • -Feelings of Choking
    • -Chest pain or discomfort
    • -Nausea, abdominal distress
    • -feeling dizzy
    • -chills or heat sensations
    • -Paresthesias
    • -Depersonalization
    • -Fear of losing control
• DSM-V Criteria:
  
  • At least one of the attacks has been followed by 1 month of one or both of the following:
    
    • persistent concerns or worry about having additional panic attacks
    • a significant maladaptive change in behavior related to the attacks
• Tx:
  
  • SSRIs = mainstay of treatment, (high dose for anxiety, low dose for depression)
  • Cognitive Behavioral Therapy: mainstay of tx
  • Benzos: as needed, not for ongoing treatment
  • Buspirone: may be used adjacent to SSRIs
  • Off label: propranolol, hydroxyzine, neurontin, seroquel, risperdal

Question 5

Obsessive Compulsive Disorder

Answer 5

• Definition:
  
  • presence of obsessions, compulsions, or both
• Specifiers:
  
  • with good or fair insight: recognizes OCD beliefs are not true or may not be true
  • With poor insight: thinks OCD beliefs are probably true
  • With absent insight or delusional beliefs: completely convinced OCD beliefs are true
• Patterns:
  
  • contamination, pathologic doubt, symmetry/precision, intrusive/obsessive thoughts
• Obsessions:
  
  • Recurrent & persistent thoughts, urges, or imagines that are experienced at some time during the disturbance (intrusive & unwanted)
    
    • causes stress & anxiety
• Compulsions:
  
  • Repetitive behaviors (hand washing, ordering, checking), or mental acts (counting, repeating words), patient feels drive to perform according to certain rules
  • -Aimed at preventing or reducing the anxiety or distress
• General Info:
  
  • obsessions & compulsions are time consuming or cause significant distress in social or occupational functioning. Not attributable to a medical condition or better explained by another mental disorder.
• Dx:
  
  • Clinical Dx
• Tx:
  
  • low dose for depression)
  • Cognitive Behavioral Therapy: mainstay of tx
  • Benzos: as needed, not for ongoing treatment
  • Buspirone: may be used adjacent to SSRIs
  • Off label: propranolol, hydroxyzine, neurontin, seroquel, risperdal

Question 6

Phobias

Answer 6

• Definition:
  
  • persistent intense fear or anxiety of a specific situation, object, or place
• DSM-V Criteria:
  
  • -Persists for at least 6 months
  • -Exposure to situation triggers an immediate response
  • -Fear out of proportion to any real danger
  • -Everyday activities impaired by distress or avoidance
• Tx:
  
  • 1st line = exposure & desensitization therapy
  • Short term therapy: benzos or beta-blockers

Question 7

Adjustment Disorders

Answer 7

• Definition:
  
  • maladaptive emotional or behavioral rxn to an identifiable stressor (job loss, physical illness, divorce, etc.) or a non-life threatening event that causes a disproportionate response that would normally be expected within 3 months of a stressor
• S/sxs:
  
  • Marked distress out of proportion to the severity of stressors
  • -significant impairment in areas of functioning
  • -depressed mood, anxiety
• Pt may try to self-medicate with alcohol or drugs
• Tx:
  
  • Psychotherapy = 1st line

Question 8

Post-Traumatic Stress Disorders

Answer 8

• Definition:
  
  • exposure to traumatic event at any time in the past → sxs > 1 month
• DSM-V Criteria:
  
  • Stressor: exposure or threat of death, serious injury, sexual violence
  • Intrusion Symptoms: traumatic event persistently re experienced (via nightmares, flashbacks, intrusive memories)
  • Avoidance: persistent avoidance of distressing trauma-related reminders after the event
  • Negative Alterations in Mood: negative beliefs, distorted blame, diminished interest
  • Alterations in Arousal/Reactivity: irritability, aggression, “on guard”, exaggerated startle, disturbed sleep, poor concentration, reckless or self-destructive behavior
  • Duration > 1 month
• Dx:
  
  • Screening:
    
    • -PTSD Checklist-17 (PCL-17)
    • -National Stressful Events Survey PTSD Short Scale (NSESSS)
    • -Post Traumatic Cognitions Inventory (PTCI)
    • -Generalized Anxiety Disorder Screen:
      
      • → GAD-7 (score over 8)
      • → GAD-2 (score over 3)
• Tx:
  
  • SSRIs = 1st line
    
    • → Paroxetine and sertraline are FDA approved, may take longer to be effective (up to 24 weeks) (PTSD)
  • Clonidine and Prazosin can help hypervigilance and nightmares
  • Benzos not encouraged
  • non-pharmacologic:
    
    • social engagement, exercise, journaling, lifestyle changes
  • CBT

Question 9

Acute Stress Disorder

Answer 9

• Definition:
  
  • sxs similar to PTSD except the traumatic event occurred < 1 month ago and the sxs last < 1 month
• S/sxs:
  
  • Intrusive sxs
  • -avoidance
  • -increased arousal
  • -negative alterations in thought & mood
• Tx:
  
  • Counseling & psychotherapy = 1st line
  • *If sxs persist >1 month then tx as PTSD