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First Aid for Psych Clerkship > Chapter 5: Anxiety, OCD, Trauma, Stress-related disorders > Flashcards

Chapter 5: Anxiety, OCD, Trauma, Stress-related disorders Flashcards

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1
Q

Anxiety

A
  • an individuals emotional and physical fear response to a perceived threat.
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2
Q

Pathologic anxiety

A

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

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3
Q

Maladaptive anxiety

A

persists longer and feels more intense than transient, situational anxiety

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4
Q

criteria for most anxiety disorders

A

involve symptoms that cause clinically significant distress or impairment in social and/or occupational functioning

can only dx if NOT due to a substance, med, or medical condition

MOST COMMON FORM OF PSYCHOPATHOLOGY

Women 2:1 men

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5
Q

neurotransmitters implicated in anxiety

A

Norepinephrine
Serotonin
GABA

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6
Q

Treatment of anxiety

A

consider psychotherapy for milder

combo treatment with pharm for moderate to severe

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7
Q

Signs and symptoms of anxiety

A

Constitutional: fatigue, diaphoresis, shivering
Cardiac: Chest pain, palpitations, tachycardia, hypertension
Pulmonary: SOB, hyperventilation
Nero/ MSK: Vertigo, light-headedness, paresthesias, tremors, insomnia, muscle tension
GI: ab discomfort, anorexia, nausea, emesis, diarrhea, constipation

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8
Q

Medications and substances that cause anxiety

A 
Alcohol- intox or withdrawal
Sedatives, hypnotics or anxiolitics- withdrawal
cannabis- intoxication
hallucinogens- intoxication
stimulants- intoxication OR withdrawal
caffeine- intoxication
tobacco- intoxication or withdrawal
opioids- withdrawal
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9
Q

medical conditions that cause anxiety

A

neurologic- epilepsy, migraines, brain tumors, MS, huntingtons
endocrine: hyperthyroid, thyrotoxicosis, hypoglycemia, pheochromocytoma, carcinoid syndrome
metabolic: vitamin B12 deficiency, electrolyte abnormalities, porphyria
Respiratory- asthma, COPD, hypoxia, PE, pneumonia, pneumothorax
CV- CHF, angina, arrhythmia, MI

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10
Q

Pharmacotherapy for anxiety

A

First line: SSRIs, SNRIs

Benzos (enhance GABA at GABA-A receptor)- quick but addictive
Buspirone- 5HT partial agonist- minimal efficacy. (augment with this)
Beta blockers - panic attacks, performance anxiety
TCAs and MAO inhibitors- if first-line agents not effective. Side-effects–> less tolerable.

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11
Q

Psychotherapy for anxiety

A

Cognitive behavioral therapy- examines relationship between anxiety-driven cognitions (thoughts), emotions, and behavior

Psychodynamic psychotherapy- facilitates understanding and insight into the development of anxiety and ultimately increases anxiety tolerance

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12
Q

some tips re: benzodiazepines

A

Benzos to Bridge until others kick in

don’t use in those with substance abuse

if comorbid depressive disorder, can worsen depression

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13
Q

late-onset anxiety symptoms, no prior or fam psych history?

A

think other medical condition or a substance

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14
Q

using drugs for anxiety

A

achieve symptomatic relief and continue treatment for at least 6 months before attempting to titrate off meds

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15
Q

Panic attacks

A

fear response- abrupt surge of intense anxiety. triggered or spontaneous.
peak within minutes, resolve within half an hour. Anxiety may continue for hours; pts may confuse this for a prolonged attack.

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16
Q

mnemonic: symtoms of panic attacks

A

Da PANICS
Dizziness, disconnectedness, derealization, depersonalization

Palpitations, paresthesias
Abdominal distress
Numbness, Nausea
Intense fear of dying, losing control or "going crazy"
Chills, Chest pain
Sweatin, Shaking, SOB
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17
Q

risk factor for panic attacks:

A

smoking

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18
Q

PT presents with panic attack. What to rule out?

A

med conditions such as heart attack, thyrotoxicosis, thromboembolism

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19
Q

panic attacks increase risk of

A

suicidality

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20
Q

Panic disorder

A

spontneous** recurrent panic attacks. (no clear trigger)

can be followed by continuous worry about having more attacks (>1 month by DSM-5)

relapses common with discontinuation of medical therapy

Up to 65% have comorbid major depression

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21
Q

RX for panic disorder

A

SSRIs (sertraline, citalopram, esitalopram)
Can switch to TCAs (clomipramine, imipramine)
Can use benzos as schedule or PRN, esp. until other meds reach full efficacy

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22
Q

Agorophobia

A

intense fear of being in public places where escape or obtaining help may be difficult.
often with panic disorder
usually chronic. Very genetic.

DSM criteria: intense fear about > 2 situations
–> out of proportion to potential danger (even if they have something embarassing like IBS making it difficult to be in public)
sig social or occupational dysfunction
symptoms > 6 months
not better explained by another mental disorder

Treat with CBT and SSRIs

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23
Q

specific phobias/ social anxiety disorder

A

a phobia is an irrational fear that –> endurance of anxity and/ or avoidance of feared object/ situation.

Social anxiety disorder- fear or scrutiny by others/ fear of acting in a humiliating or embarrassing way.

PHOBIAS- most common psych d/o in women; > 10%

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24
Q

treatment of specific phobia

A

CBT

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25
Q

Treatment of social anxiety disorder

A

First line: CBT

SSRIs for debilitating symptoms
Benzos
Beta Blockers (performance anxiety/ public speaking)

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26
Q

Selective mutism

A

rare
failure to speak in specific situations at least one month, despite ability to comprehend and use language.
onset typically during childhood
most- anxiety, esp. social anxiety
may be silent or whisper.
may use nonverbal commo; writing or gesturing.

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27
Q

Pts with blood injury injection phobia may experience

A

bradycardia and hypotension–> vasovagal fainting

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28
Q

Dx and DSM-5 criteria for selective mutism

A

consistent failure to speak in select situations (e.g. school)
not due to language difficlaty or communication disorder
significant impairment in academic, occupational or social functioning
> 1 month

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29
Q

Selective mutism treatment

A

psychotherapy: CBT, family therapy
meds: SSRIs for anxiety (esp. with comorbid social anxiety disorder)

30
Q

separation anxiety disorder

A

normal human development: infants distressed when separated from primary caregiver.
Stranger anxiety- peaks at 9 months
separation anxiety peaks by 18 months

if extreme or inappropriate, = pathologic. May be preceded by stressful life event.

31
Q

treatment of separation anxiety disorder

A

Psychotherapy: CBT, family therapy
meds: SSRIs can be effective as an adjunct to therapy

32
Q

Generalized Anxiety Disorder

A

persistent, excessive anxiety about many aspects of daily lives. Often experience somatic symptoms including fatigue and muscle tension. Not uncommonly, –> present to primary care physician. Comorbid with other anxiety and depressive disorders.

33
Q

GAD mnemonic

A

Worry WARTS

Worried
Wound up, worn out
Absent-minded
Restless
Tense
Sleepless
34
Q

anxiety and substances

A

evaluate for caffeine use, recommend significant reduction or elimination

35
Q

anxiety and exercise

A

can significantly reduce anxiety

36
Q

treatment of GAD

A

combine psychotherapy and pharmacotherapy:
CBT
SSRI (sertraline, citalopram) or SNRI (venlafaxine)
Can also cnsider a short-term course of benzos or augmentation with buspirone
much less commonly used meds are TCAs and MAOIs

37
Q

OCD

A

obsessions and/ or compulsions that are time-consuming, distressing, and impairing.

38
Q

Obessions

A

recurrent, intrusive undesired thoughts that increase anxiety.

39
Q

Compulsions

A

patients may attempt to relieve obsessive anxiety by performing compulsions, which are repetitive behaviors or mental rituals. Anxiety may increase when a patient resists acting out a compulsion.

40
Q

DX and DSM-5 criteria for OCD

A

obsessions/ compulsions that are time-consuming (more than 1 hour daily) or cause significant distress or dysfunction

  • obsessions- recurrent, intrusive, anxiety-provoking thoughts, images, or urges that the patient attempts to suppress, ignore, or neutralie by some othe thought or action (i.e. by performing a compulsion)
  • Compulsions: repetitive behaviors ormental acts the patient feels driven to perform in response to an obsession or a rule aimed at stress reduction or disaster prevention. Not realistically linked with what they are to prevent or are excessive.

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

41
Q

Course/ prognosis of OCD

A

chornic, with waxing and waning symptoms
less than 20 % remission without treatment
SI in 50%, attempts in 25%
High comorbidity with other psych disorders (anxiety, depressive, bipolar, OC personallity, tic disorder)

42
Q

Triad of “uncontrollable urges”

A

OCD, ADHD, tic disorder- usually first seen in children or adolescents

43
Q

treatment for OCD

A

combo of psychopharm and CBT

CBT- focus on exposure and response prevention: prolonged, graded, exposure to ritual-eliciting stimulus and prevention of the relieving compulsion

First line meds: SSRIs (sertraline, fluoxetine), typically at higher doses
also most serotonin selective TCA: Clomipramine
can augment with atypical antipsychotics
Last resort: psychosurgery (cingulotomy) or ECT, esp. if comorbid depression

44
Q

Body dysmorphic disorder

A

preoccupied with body parts that they perceive as flawed or defective, having strong beliefs that they are unattractive or repulsive
physical imperfections are minimal or not observable; pts view them as severe and grotesque
spent significant time trying to correct perceived flaws with makeup, dermatological procedures, or plastic surgery

45
Q

OCD vs OCPD

A

Individuals with Obsessive Compulsive Personality Disorder have distinct presentations: obsessed with details, control, and perfectionism; not intruded upon by unwanted preoccupations nor compelled to carry out compulsions.

OCD patients are DIStressed by their symptoms (ego-DYStonic);
OCPD pts do not perceive them as an ISSue (ego-SYNtonic)

46
Q

DX and DSM-5 Criteria of Body Dysmorphic Disorder

A
  • preoccoupation with one 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 (comparing appearance to others) are performed in response to the appearance concerns
  • preoccupation causes significant distress orimpairment in functioning
  • apperance preoccupation is not better accounted for by concerns with body fat/ weight in an eating disorder
47
Q

Body dysmorphic higher in

A

childhood abuse and neglect
women
people with first-degree relatives with OCD
dermatologic and cosmetic surgery patients
mean onset: 15 years

48
Q

course/ prognosis of body dysmorphic disorder

A

onset gradual
begins early adolescence
symptoms tend to be chronic
surgical/ derm procedures are routinely unsuccessful in satisfying the patient
high rate of SI/ SA
Comorbidity with major depression, social anxiety disorder (social phobia) and OCD

49
Q

RX for body dysmorphic disorder

A

SSRIs and/or CBT may reduce the obsessive and compulsive symptoms in many patients

50
Q

Hoarding disorder dx and DSM-5 criteria

A
  • persistent difficulty discarding possessions, regardless of value
  • difficulty is due to need to save the items and distress associated with discarding them
  • results in accumulation of possessions that congest/ clutter living areas and 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
51
Q

who hoards?

A

3x more in older population
stressful and traumatic events preceding onset of hoarding
large genetic component: 50% have a relative who also hoards

52
Q

course/ prognosis of hoarding

A 
ost start in early teens
tends to worsen
usually chronic
75% have comorbid mood (MDD) or anxiety disorder (social anxiety)
20% have comorbid OCD
53
Q

Treatment of hoarding

A

very difficult
Specialized CBT for hoarding
SSRIs can be used, but not as beneficial unless OCD symptoms are present

54
Q

Trichotillomania

A

hair-pulling disorder

DX and DSM-5 criteria:

  • 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 the scalp, eyebrows, or eyelashes, but may include facial, axillary, and pubic hair
55
Q

Excoriation disorder

A

Skin-picking

recurrent skin-picking resulting in lesions
repeated attempts to decrease or stop
cuases significant distress or impairment in daily functioning
skin picking is not due to substance, othe rmed condition, or other psychiatric disorder

begins in adolescence
chronic, with waxing and waning periods if untreated
comorbidity with OCD, trichotillomania, and MDD

56
Q

Treatment for trichotillomania

A 
specialized CBT (habit reveral training)
SSRIs also some benefit
57
Q

PTSD

A

multiple symptoms after exposure to one or more traumatic events: intrusive symptoms (e.g. nightmares, flashbacks), avoidance, negative alterations in thoughts and mood, and increased arousal. Symptoms last at least a month and may occur immediately after the trauma or with delayed expression.

58
Q

Acute Stress Disorder

A

dx in pts who experience a major traumatic event and suffer from similar symptoms as PTSD but for a shorter duration. onset of symptoms occurs within 1 month of the trauma and symptoms last for less than 1 month.

59
Q

DX and DSM-5 criteria of PTSD

A

Exposure to the trauma
recurrent intrusions of reexperiencing it (memories, nightmares, etc.)
Active avoidance of triggers
at least 2 of: negative cognitions/ mood, dissociative amnesia, neg feelings of self/ others/ world, self-blame, neg emotions (fear, horror, anger, guilt), anhedonia, feelings of detachment, estrangement, inability to experience positive emotions
at least 2: increased arousal/ reactivity; hypervigilance; exaggerated startle response; irratibility/ angry outbursts; impaired concentration; insomnia
symptoms not caused by direct effects of a substance or other med condition
result in significant impairment in social or occupational functioning
presentation differs in kids under 7

60
Q

PTSD vs Acute Stress Disorder

A

PTSD:

  • trauma occurred any time in past
  • symptoms over a month

ASD:

  • trauma less than a month ago
  • symptoms less than a month
61
Q

mnemonic: treatment of PTSD

A

PTSD- PrazoSiN

to Stop the Nightmares

62
Q

mnemonic TRAUMA

A 
Traumatic event
Reexperience
Avoidance
nable to function
Month or more of symptoms
Arousal increased
63
Q

Cognitive Processing Therapy

A

modified form of cognitive-behavioral therapy in which thoughts, feelings, and meanings of the event are revisited and questioned

64
Q

PTSD and benzos

A

avoid because they are addictive

high rate of comorbid substance use disorders

65
Q

course/ prognosis of PTSD

A 
usually 3 within 3 months of trauma
symptoms may have delayed expression
50% complete recovery within 3 months
symptoms diminish with older age
80% have another mental disorder
66
Q

Treatment of PTSD

A

Pharm: First-line antidepressants: SSRIS (sertraline, citalopram), SNRIs (venlafaxine)
- Prazosin, alpha-1 receptor antagonist, targets nightmares and hypervigilance

psychotherapy: specialized forms of CBT (exposure therapy, cognitive processing therapy)
- supportive and psychodynamic therapy
- couples/ family therapy

67
Q

Adjustment disorders

A

occur when behavioral or emotional symptoms develop after a stressful life event

68
Q

Dx and DSM-5 criteria of adjustment disorders

A

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

  • marked distress in excess of what would be expected after such ane vent or
  • significant impairment in daily functioning
  1. symptoms not of normal breavement
  2. resolve within 6 months after stressor has terminated
  3. Stress-related disturbance does not meet criteria for another mental disorder
69
Q

Subtypes of adjustment disorders

A

coded based on a predominance of ether depressed mood, anxiety, mixed anxiety and depression, disturbance of conduct (such as aggression) or mixed disturbance of emotions and conduct.

70
Q

Key fact- adjustment disorder

A

stressful event is NOT life threatening (e.g. divorce, death of a loved one, or loss of a job). In posttraumatic stress disorder, it is.

71
Q

treatment for adjustment disorder

A

supportive psychotherapy (most effective)
group therapy
occasionally pharmacotherapy is used to treat associated symptoms (insomnia, anxiety or depression) in a time-limited fashion

First Aid for Psych Clerkship (7 decks)

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