Chapter 5_Anxiety, OCD, Trauma, Stressor Related Disorders Flashcards
General way to treat anxiety?
Milder: psychotherapy
Moderate to severe: psychotherapy + combination pharmacotherapy
severity is gauged based on amount of distress/impairment
What medications/substances cause anxiety?
alcohol (toxication and withdrawal), sedatives, hypnotics withdrawal, cannabis, hallucinogens, stimulants, caffeine, tobacco, opioid withdrawal
What medical conditions cause anxiety?
neuro: epilepsy, migrianes, brain tumors, MS, Huntingons
endocrine: hyperthyroid, thyrotoxicosis, hypoglycemia, pheochromocytoma, carcinoid syndrome
metabolic: vitamin b12 deficiency, electrolyte abnormalities
respiratory: asthma, COPD, hypoxia, PE
CV: CHF, angina, arrhythmia
What NT systems are implicated in anxiety?
NE, serotonin, and GABA
First line pharmacotherapy for anxiety?
SSRIs (sertraline) and SNRIs (venlafaxine)
low doses for depression
HIGHER DOSES FOR ANXIETY
How are benzodiazepines involved in treatment of anxiety?
Enhance GABA activity, but can be ADDICTIVE! Only use this to temporarily bridge patients until long term medication can be used. Avoid in patients with comorbid substance use
What are some nonaddicting PRN anxiolytics?
diphenhydramine (benadryl), hydroxyzine (atarax)
Beta-blockers (propanolol) can also be useful in treating anxiety; especially in….?
controlling autonomic symptoms (palpitations, tachycardia, sweating)
also for PANIC ATTACKS AND PERFORMANCE ANXIETY
Use B’s to Block P’s (Panic attacks, and Performance anxiet)
When should benzodiazepines be avoided?
Patients with comorbid substance use disorder and depression disorder (may worsen depression)
What is the pharmalogic goal of anxiety treatment?
achieve symptomatic relief for at least 6 months before tapering off meds, or at least until therapy can be initiated
What two types of therapy are useful for anxiety treatment?
CBT (relationship between anxiety driven cognitions/thoughts, emotions, and behavior)
psychodynamic psychotherapy - insight into development of anxiety and increases tolerance
Panic attacks
type of fear response involving sudden anxiety surge (spontaneous or from trigger). Peak within minutes and resolve within half an hour.
Symptoms: dizziness, disconnectedness, depersonalization, palpitations, paresthesias, abdominal distress, numbness/nausea, intense fear of dying or losing control, chills, sweating, SOB
DSM criteria for panic disorder
- Recurrent and UNEXPECTED panic attacks without identifiable trigger
- one or more panic attacks followed by at least one month of continuous worry of FUTURE panic attack
- not due to substance/medical condition
When patient presents with panic attack, what to rule out?
MI, thyrotoxicosis, and thromboembolism
Treatment for panic disorder
Pharmacotherapy (first line SSRIs like sertraline (zoloft) citalopram (celexa), or escitalopram (lexapro) then TCAs if not effective or PRN benzos) PLUS CBT
What other psych disorders are often comorbid with anxiety
Major depression, other anxiety disorders, bipolar disorder, and alcohol use disorder
DSM criteria for agoraphobia
- Intense fear/anxiety of >2 situations for concern of difficulty escaping/accessing help in case of panic disorder/embarassing situation (i.e. outside of home alone, open spaces, enclosed places, public transport, crowds)
- fear out of proportion to trigger, usually involving prolonged anxiety, need for companion, or avoidance
- symptoms last longer than 6 months
- significant impairment
- not due to any other disorder/substance
What are some characteristic situations avoided in agoraphobia?
Bridges, crowds, buses, trains, open areas outside of home
Treatment of agoraphobia?
Same as panic disorder (SSRIs and CBT)
DSM criteria for specific phobia
- Persistent, excessive fear of specific situation or object which is out of proportion
- exposure to trigger = IMMEDIATE fear response
- symptoms lasting more than 6 months
What are common situations that people with social phobia avoid?
public speaking, eating in public, using public restrooms
fear of scrutiny by others or acting in humiliating/embarassing way
How to treat specific phobia?
CBT
How to treat social anxiety disorder/phobia
CBT
SSRIs first line or SNRIs for debilitating symptoms
PRN Benzos
PROPOANOLOL FOR PERFORMANCE ANXIETY/PUBLIC SPEAKING/PANIC ATTACKS
DSM criteria for selective mutism
- consistent failure to speak in select social situations (ie school)
- mutism not due to communication/language difficulty
- symptoms last for more than 1 month, and impairment
Treatment for selective mutism
CBT, family therapy
can use SSRIs to help treat (esp with comorbid social anxiety
DSM criteria for separation anxiety
- excessive and developmentally inappropriate fear/anxiety regarding separation from attachment figures.
- excesssive worry about loss/harm to attachment figure or an event that leads to separation
- reluctance to leave home, school, work
- physical symptoms to avoid school/work
- significant impairment
- symptoms last greater than 4 weeks in children/adolescents and 6 months in adults
Treatment for separation anxiety?
CBT, family therapy, SSRIs adjunct
Symptoms of generalized anxiety disorder (GAD)?
Worry WARTS
Worried Worn out, wound up Absent minded Tense (muscles) Restless Sleepless/insomnia
DSM criteria for generalized anxiety disorder?
- excessive anxiety/worry about various daily activities/events (EVERYTHING) for more than 6 months
- difficulty controlling anxiety
- at least three WARTS (worn up/wound out, absent minded, restless, tense (muscle),sleepless
- no other d/o, impairment
T/F: Most patients with GAD are able to attain full remission with CBT
False. Remission rates are low.
What are two lifestyle modifications that help reduce anxiety?
- reducing/eliminating caffine
- exercise!
Treatment for GAD
Combined CBT and SSRI/SNRI
May consider short term Benzo or augmentation with buspirone
Obsession vs. compulsion
Obsessions are recurrent, intrusive thoughts that increase anxiety. Compulsions are attempts to reduce this anxiety via repetitive actions or mental rituals (i.e. repeated checking/counting)
DSM criteria for OCD
experiencing obsessions and/or compulsions that are time consuming (>1hr daily) or cause significant distress/dysfunction
Common obsessions and their compulsions
Contamination - cleaning/avoiding contaminant
doubt/harm - checking multiple times to avoid danger (checking oven)
symmetry - lining/ordering things
Treatment for OCD
Combo high dose SSRI (fluoxetine, sertraline) or clompiramine (most serotonin selective TCA)
can also augment with atypicals
last resort: cingulotomy or ECT (esp of comorbid depression)
What does CBT for OCD involve?
exposure and response prevention
Difference between OCD and OCPD
OCPD - obsessed with details, control, perfectionism (not intruded on by thoughts or compelled to do compulsions), EGO-SYNTONIC
OCD - distressed by obsessions and compulsions, EGO-DYSTONIC
DSM criteria for body dysmorphic disorder
- preoccupations with one or more perceived physical “flaws” or “defects” that aren’t apparent to others
- repetitive behaviors in response to this (grooming, make up, comparing self to others)
- cannot be explained by other disorder (i.e eating disorder)
Treatment for body dysmorphic disorder
SSRIs/CBT may help in reducing obsessive and compulsive symptoms
DSM criteria for hoarding disorder
- persistent difficulty discarding possessions, regardless of value, due to the need to save items and distress associated with discarding them
- accumulation of possessions that congest/clutter living areas
DSM criteria for trichotillomania (hair pulling disorder)
recurrent pulling out of one’s hair resulting in hair loss (anywhere on body)
repeated attempts to decrease/stop hair pulling
impairment + no other disorder
treatment for trichotillomania
SSRIs, atypicals, N-acetylcysteine, or lithium
CBT
criteria for excoriation disorder (skin picking)
recurrent skin picking resulting in lesions
repeated attempts to stop
treatment same as trichillomania
Criteria for PTSD
- exposure to LIFE THREATENING trauma (injury, near death, sexual violence, etc) via witnessing or actually experiencing the trauma
- recurrent intrusive re-experiencing of event via flashbacks, nightmares, distress @ cues
- at least two symptoms of negative mood/cognition: anhedonia, feelings of detachment, self blame, negative emotions
- at least two symptoms of arousal: hypervigilance, exaggerated startle, irritability, impaired concentration, insomnia
Difference between PTSD and acute stress disorder
Unlike PTSD, acute stress disorder…
- trauma has occured less than 1 month ago (PTSD trauma can happen any time from past)
- symptoms last
T/F: PTSD symptoms may sometimes be delayed
True. usually begins 3 months after trauma, but 50% of patients have complete recovery within 3 months
Symptoms of PTSD
TRAUMA
traumatic event re-experience avoidance unable to function month or more of symptoms arousal increased
Treatment for PTSD
- first line SSRIs/SNRIs
- PRAZOSIN (a1 receptor antagonist) FOR NIGHTMARES :)
- can augment with atypicals if severe
- CBT (specialized exposure and cognitive processing)
Adjustment disorder criteria
- development of emotional/behavioral symptoms within 3 months in response to identifiable stressful life event (distress in excess of what is expected/significant impairment
- Symptoms not due to normal bereavement
- Symptoms resolve within 6 months of stressor terminating
Which psychotherapy is most helpful in treating adjustment disorder?
supportive psychotherapy
