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

Question 1

Anxiety

Answer 1

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

Question 2

Pathologic anxiety

Answer 2

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

Question 3

Maladaptive anxiety

Answer 3

persists longer and feels more intense than transient, situational anxiety

Question 4

criteria for most anxiety disorders

Answer 4

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

Question 5

neurotransmitters implicated in anxiety

Answer 5

Norepinephrine
Serotonin
GABA

Question 6

Treatment of anxiety

Answer 6

consider psychotherapy for milder

combo treatment with pharm for moderate to severe

Question 7

Signs and symptoms of anxiety

Answer 7

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

Question 8

Medications and substances that cause anxiety

Answer 8

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

Question 9

medical conditions that cause anxiety

Answer 9

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

Question 10

Pharmacotherapy for anxiety

Answer 10

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.

Question 11

Psychotherapy for anxiety

Answer 11

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

Question 12

some tips re: benzodiazepines

Answer 12

Benzos to Bridge until others kick in

don’t use in those with substance abuse

if comorbid depressive disorder, can worsen depression

Question 13

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

Answer 13

think other medical condition or a substance

Question 14

using drugs for anxiety

Answer 14

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

Question 15

Panic attacks

Answer 15

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.

Question 16

mnemonic: symtoms of panic attacks

Answer 16

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

Question 17

risk factor for panic attacks:

Answer 17

smoking

Question 18

PT presents with panic attack. What to rule out?

Answer 18

med conditions such as heart attack, thyrotoxicosis, thromboembolism

Question 19

panic attacks increase risk of

Answer 19

suicidality

Question 20

Panic disorder

Answer 20

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

Question 21

RX for panic disorder

Answer 21

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

Question 22

Agorophobia

Answer 22

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

Question 23

specific phobias/ social anxiety disorder

Answer 23

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%

Question 24

treatment of specific phobia

Answer 24

CBT

Question 25

Treatment of social anxiety disorder

Answer 25

First line: CBT SSRIs for debilitating symptoms Benzos Beta Blockers (performance anxiety/ public speaking)

Question 26

Selective mutism

Answer 26

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.

Question 27

Pts with blood injury injection phobia may experience

Answer 27

bradycardia and hypotension--> vasovagal fainting

Question 28

Dx and DSM-5 criteria for selective mutism

Answer 28

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

Question 29

Selective mutism treatment

Answer 29

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

Question 30

separation anxiety disorder

Answer 30

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.

Question 31

treatment of separation anxiety disorder

Answer 31

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

Question 32

Generalized Anxiety Disorder

Answer 32

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.

Question 33

GAD mnemonic

Answer 33

Worry WARTS ``` Worried Wound up, worn out Absent-minded Restless Tense Sleepless ```

Question 34

anxiety and substances

Answer 34

evaluate for caffeine use, recommend significant reduction or elimination

Question 35

anxiety and exercise

Answer 35

can significantly reduce anxiety

Question 36

treatment of GAD

Answer 36

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

Question 37

OCD

Answer 37

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

Question 38

Obessions

Answer 38

recurrent, intrusive undesired thoughts that increase anxiety.

Question 39

Compulsions

Answer 39

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.

Question 40

DX and DSM-5 criteria for OCD

Answer 40

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.

Question 41

Course/ prognosis of OCD

Answer 41

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)

Question 42

Triad of "uncontrollable urges"

Answer 42

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

Question 43

treatment for OCD

Answer 43

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

Question 44

Body dysmorphic disorder

Answer 44

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

Question 45

OCD vs OCPD

Answer 45

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)

Question 46

DX and DSM-5 Criteria of Body Dysmorphic Disorder

Answer 46

- 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

Question 47

Body dysmorphic higher in

Answer 47

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

Question 48

course/ prognosis of body dysmorphic disorder

Answer 48

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

Question 49

RX for body dysmorphic disorder

Answer 49

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

Question 50

Hoarding disorder dx and DSM-5 criteria

Answer 50

- 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

Question 51

who hoards?

Answer 51

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

Question 52

course/ prognosis of hoarding

Answer 52

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

Question 53

Treatment of hoarding

Answer 53

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

Question 54

Trichotillomania

Answer 54

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

Question 55

Excoriation disorder

Answer 55

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

Question 56

Treatment for trichotillomania

Answer 56

``` specialized CBT (habit reveral training) SSRIs also some benefit ```

Question 57

PTSD

Answer 57

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.

Question 58

Acute Stress Disorder

Answer 58

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.

Question 59

DX and DSM-5 criteria of PTSD

Answer 59

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

Question 60

PTSD vs Acute Stress Disorder

Answer 60

PTSD: - trauma occurred any time in past - symptoms over a month ASD: - trauma less than a month ago - symptoms less than a month

Question 61

mnemonic: treatment of PTSD

Answer 61

PTSD- PrazoSiN to Stop the Nightmares

Question 62

mnemonic TRAUMA

Answer 62

``` Traumatic event Reexperience Avoidance nable to function Month or more of symptoms Arousal increased ```

Question 63

Cognitive Processing Therapy

Answer 63

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

Question 64

PTSD and benzos

Answer 64

avoid because they are addictive | high rate of comorbid substance use disorders

Question 65

course/ prognosis of PTSD

Answer 65

``` 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 ```

Question 66

Treatment of PTSD

Answer 66

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

Question 67

Adjustment disorders

Answer 67

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

Question 68

Dx and DSM-5 criteria of adjustment disorders

Answer 68

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 2. symptoms not of normal breavement 3. resolve within 6 months after stressor has terminated 4. Stress-related disturbance does not meet criteria for another mental disorder

Question 69

Subtypes of adjustment disorders

Answer 69

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.

Question 70

Key fact- adjustment disorder

Answer 70

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.

Question 71

treatment for adjustment disorder

Answer 71

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