DSM Anxiety Part 2 (Panic Disorder, Panic Attack Specifiers, Agoraphobia, GAD, Sub/Med, Other) Flashcards
how many symptoms are there for panic attack
13
what are the possible symptoms of a panic attack
- palpitations, pouding heart, accelerated HR
- sweating
- trembling or shaking
- sensations of SOB or smothering
- feelings of choking
- chest pain or discomfort
- nausea or abdominal distress
- feeling dizzy, unsteady, lightheaded or faint
- chills or heat sensations
- parethesias (numbness/tingling)
- derealization (feelings of unreality) or depersonalization (being detached from oneself)
- fear of losing control or “going crazy”
- fear of dying
how many symptoms of the 13 for panic attack must you have to meet criteria A for panic disorder
4
what is a panic attack
abrupt surge of intense FEAR or intense DISCOMFORT that reaches a peak within minutes, and during which you have the required symptoms
what is criterion A for panic disorder
recurrent UNexpected panic attacks
(that meet criteria with 4/13 symptoms)
criterion B for panic disorder
at least one of the panic attacks has been followed by ONE MONTH or more of one or both of the following:
- persistent concern or worry about additional panic attacks or their consequences (i.e losing control, going crazy, having a heart attack)
- a significant maladaptive change in behaviour related to the attacks (i.e behaviours designed to avoid panic attacks, such as avoidance of exercise or unfamiliar situations)
criteria C and D for panic disorder
not attributable to med or substance, to another med condition or to another mental disorder
what is the 12 month prevalence of panic disorder
2-3% in adults and teens
what populations have higher rates of panic disorder
non-latino whites and american indians (in usa)
what is the gender difference in panic disorder
female:male 2:1
gender difference is already observable before age 14 years
can panic disorder occur in children
panic attacks occur in children but overall prevalence of panic disorder is low before age 14
what is the median age at onset for panic disorder
20-24
what is the usual course of panic disorder if untreated
chronic, but waxing and waning
some people have episodic outbreaks with years of remission in between and others may have continuous severe symptomatology
name two temperamental risk factors for panic attacks
negative affectivity and anxiety sensitivity (disposition to believing that symptoms of anxiety are harmful)
what early childhood adverse experiences may precipitate panic disorder
reports of sexual and physical abuse in childhood more common in panic disorder than in other anxiety disorders
list environmental risk factors for panic disorder
childhood physical/sexual abuse
smoking
identifiable stressors in months prior to first panic attack
what medical condition is associated with panic disorder
respiratory disturbance such as asthma
there is an association between panic disorder and what gene
COMT gene–> in FEMALES only
list some agents than can provoke panic attacks in individuals with panic disorder (at greater rates than in general pop)
sodium lactate
caffeine
isoproterenol
yohimbine
CO2
cholecystokinin
how do panic attacks affect suicide risk
panic disorder and panic attacks increase risk of suicide even when other risk factors are controlled for
ddx panic disorder
other specified anxiety disorder or unspecified anxiety disorder
anxiety due to another medical condition
sub/med induced anxiety disorder
other mental disorders with panic attacks as an assoc. feature
list medical conditions that can cause panic attacks
hyperthyroidism
hyperparathyroidism
pherchromocytoma
vestibular dysfunctions
seizure disorders
cardiopulmonary conditions like arrhythmias, SVTs, COPD
what is the usual amount of time to peak intensity of symptoms in panic attacks
withi minutes
what is the 12 month prevalence of panic attacks in the USA
11.2%
are panic attacks common in kids?
not before puberty but then increases
how many “agoraphobia situations” are there
5
how many situations must someone fear to meet criterion A for agoraphobia
2/5
list the 5 “agoraphobia situations” listed in criterion A for agoraphobia
- using public transportation
- being in open spaces
- being in enclosed spaces
- standing in line or being in a crowd
- being outside of the home alone
what is criterion A for agoraphobia
marked fear or anxiety about 2+ of the 5 situations
criterion B agoraphobia
individual fears or avoids these situations because of thoughts that ESCAPE might be difficult or fears help might not be available in the event of developing panic-like symptoms
or other incapacitating or embarrassing symptoms
criterion C agoraphobia
the agoraphobic situations almost always provoke fear or anxiety
criterion D agoraphobia
the agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety
criterion E agoraphobia
fear/anxiety is out of proportion to actual danger
criterion F agoraphobia
persistent–6+ months
criteria G-I agoraphobia
clinically significant distress/impairment
if another medical condition is present, the fear/anxiety or avoidance is clearly excessive
not better explained by another mental disorder
what are considered “panic like symptoms” in agoraphobia
any of the 13 symptoms of panic attacks
what are considered “other incapacitating or embarrassing symptoms” in agoraphobia
vomiting or IBS symptoms
fear of falling
sense of disorientation or getting lost (esp. in kids)
what are considered “other incapacitating or embarrassing symptoms” in agoraphobia
vomiting or IBS symptoms
fear of falling
sense of disorientation or getting lost (esp. in kids)
what is the prevalence of agoraphobia
1.7% of teens and adults
what is the gender disparity in agoraphobia
females 2x as likely to have agoraphobia compared to men
when does incidence of agoraphobia peak
late adolescence and early adulthood
in 2/3 of people onset is before age 35; second high incidence risk phase after age 40
mean age at onset is 17 years for agoraphobia (25-29 if no preceding panic attacks/disorder)
what % of people report panic attacks or panic disorder preceding onset of agoraphobia
community–30%
clinical–50%
what is the typical course of agoraphobia
typically PERSISTENT and CHRONIC
complete remission is rare unless agoraphobia is treated
agoraphobia is associated as a risk factor for what other disorders
substantially elevated risk of secondary MDD, PDD and SUDs
what is the heritability for agoraphobia
61%
*of the various phobias, agoraphobia has the STRONGEST and MOST SPECIFIC association with the genetic factor that represents proneness to phobias
what is a major determinant of degree of disability associated with agoraphobia
agoraphobia severity–> irrespective of the presence of comorbid panic disorder, attacks and other comorbid conditions
what proportion of those with agoraphobia are completely homebound and unable to work
about 1/3
ddx agoraphobia
*note that when criteria for agoraphobia and another disorder are both fully met, both diagnoses can be given (unless fear is entirely explained by the other disorder)
specific phobia–situational type
separation anxiety disorder
social anxiety disorder
panic disorder
acute stress and PTSD
MDD
other medical conditions
how do you distinguish agoraphobia from specific phobia–situational type
in agoraphobia there are MORE situations feared (2+) and the cognition is around fear of panic sx or other incapacitating symptoms/unable to escape
in specific phobia, its just one situation and the cognitions are different i.e fear of plane crashing (cognitions usually around being harmed by the situation directly)
what are the most frequent additional diagnoses in those with agoraphobia
anxiety disorders–often preceeds agoraphobia
depressive disorders–typically secondary to agoraphobia
PTSD
AUD–typically secondary to agoraphobia
criterion A for GAD
excessive anxiety and worry (apprehensive expectation), occurring more days than not for AT LEAST 6 MONTHS, about a NUMBER of events or activities (i.e work or school performance)
criterion B for GAD
the individual finds it difficult to control the worry
criterion C for GAD
the anxiety and worry are associated with THREE (or more) of the following SIX symptoms (with at least some of the symptoms having been present for more days than not for the past 6 months)
- restlessness or feeling keyed up or on edge
- being easily fatigued
- difficulty concentrating or mind going blank
- irritability
- muscle tension
- sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
how many symptoms must you have to meet criteria for GAD
3/6
criteria D-F GAD
clinically significant distress/impairment
not attributable to physiological effects of med/substance
not better explained by another mental disorder
what types of things do people with GAD worry about
everyday, routine life circumstances i.e possible job responsibilities, health and finances, health of family members etc
what is the 12 month prevalence of GAD in teens and adults
0.9% in teens
2.9% in adults
in the general community in the usa
how many criteria are required for diagnosis of GAD in kids (i.e out of the 6 symptoms in addition to worry)
1
what is the gender disparity in GAD
females 2x more likely to have than males
when does the prevalence of GAD peak
in middle age
declines across later years of lfie
what population is more likely to experience GAD
those of European descent
what is the lifetime morbid risk of GAD
9%
what is the median age at onset for GAD
30–but broad range
what is the usual course of GAD
chronic
wax and wane across the lifespan
fluctuates between syndromal and subsyndromal level
rates of full remission are very low
list 3 temperamental risk factors for GAD
behavioural inhibition
negative affectivity
harm avoidance
what proportion of the risk of having GAD is genetic
about 33%
ddx GAD
anxiety due to another medical condition
sub/med induced anxiety disorder
social anxiety disorder
OCD
PTSD and adjustment disorders
depressive, bipolar, adjustment disorders
what are the criteria for substance/medication induced anxiety disorder
basically same as sub/med induced mood disorder–>
anxiety/panic attacks predominate in clinical picture, there is evidence that symptoms started during intox or withdrawal or after exposure to a med, and its not better explained by another anxiety disorder
not during only the course of a delirium
causes clinical impairment/distress
once substance or treatment is discontinued, how long does it usually take the symptoms of anxiety/panic to resolve in substance/medication induced anxiety disorder
within days to weeks to a month
if lasting longer than a month from sub/med/withdrawal d/c, should consider other dx possibilities
list classes of substances that can result in substance/medication induced anxiety disorder due to intoxication
alcohol
caffeine
cannabis
phencyclidine
other hallucinogens
inhalants
stimulants
other
what classes of medications can cause panic/anxiety in withdrawal states
alcohol
opioids
sedatives
hypnotics
anxiolytics
stimulants
what classes of drugs can invoke panic/anxiety symptoms
anesthetics and analgesics
sympathomimetics or other bronchodilators
anticholinergics
insulin
thyroid preparations
oral contraceptives
antihistamines
antiparkinsonian agents
corticosteroids
antihypertensives
cardiovascular meds
anticonvulsants
lithium
antipsychotics meds
antidepressant meds
*heavy metals and toxins can also do this
ddx substance/medication induced anxiety disorder
substance intox or withdrawal
anxiety disorder
delirium
anxiety disorder due to another medical condition
what are the criteria for anxiety disorder due to another medical condition
“Panic attacks or anxiety is predominant in the clinical picture.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
The disturbance is not better explained by another mental disorder.
The disturbance does not occur exclusively during the course of a delirium.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
list diseases known to cause anxiety and a symptomatic presentation
endocrine disease–> hyperthyroid, pheochromocytoma, hypoglycemia, hyperadrenocortisolism
cardiovascular disease–> CHF, PE, arrhythmia
respiratory illness–> COPD, asthma, pneumonia
metabolic disturbance–> B12 deficiency, porphyria
neuro illness–> neoplasms, vestibular dysfunction, encephalitis, seizure disorders
ddx for anxiety disorder due to another medical condition
delirium
mixed presentation of symptoms i.e mood and anxiety
substance or med induced anxiety disorder
primary anxiety disorder
illness anxiety disorder
adjustment disorders
associated feature of another mental disorder (AN, schizophrenia)
name two scales that can be used to assess anxiety
GAD-7 and Beck Anxiety Inventory (BAI)
what brain structures are thought to be implicated in the worry in anxiety disorders
the cortico-striatal-thalamic-cortical (CSTC) loop
(also for obsessions in OCD)
if anxiety is due to a fear of panicking, dying or losing control, what disorder should you think of?
panic disorder
if anxiety is due to worry about being trapped or unable to escape, what disorder should you think of?
agoraphobia
if anxiety is due to being embarrassed in front of, or judged by others, what disorder should you think of?
social anxiety
if anxiety is due to constant, pervasive worries and they cant stop worrying, what disorder should you think of?
GAD
