DSM criteria Flashcards
1
Q
Major Depressive Disorder
A
A depressed mood or anhedonia¹ for ≥ 2 weeks AND ≥ **4 **of the following symptoms:
SIG E CAPS
Sleep disturbance
——
Guild or low self esteem
Energy Decreased
Concentration issues
Appetite or weight changes
Psychomotor agi/ret
SI (sui idea)
and at least one depressive episode
2
Q
Melancholic MDD
A
A I PA
Anhedonic & IPA
Anhedonic
Insomnia
Psychomotor change
Appetite decreased
3
Q
What is catatonic MDD?
a lazy cat, no speaking
A
major psychomotor disturbances
4
Q
Atypical MDD
A
Reactive to pleasurable stimuli
Hyperphagia
Hypersomnia
ESL - Eats, sleeps, laughs
Eats, sleeps, and laughs
5
Q
Peripartum MDD
A
DURING pregnancy or until 4 weeks AFTER birth
eg, sadness 5 weeks after birth does not qualify
6
Q
Psychotic MDD?
A
MDD with hallucinations and delusions
7
Q
anxiety + sadness could be…?
A
anxiety MDD or seperate MDD + anxiety disorder
8
Q
Define a depressive episode
A
- days to weeks
- average is 20 weeks (5 mo.)
- can be a single episode, and its allowed to fluctuate
- can be a bunch of episodes w/ no s/s between
to be continued after mellert email
9
Q
When is the highest chance a of depressive episode recurring?
A
within the first few months of the episode resolving
10
Q
What is the chance a depressive episode will recur in one year?
A
40%
11
Q
Chance of depressive episode recurring in a lifetime?
A
85%
12
Q
What is grief called?
A
Adjustment disorder
13
Q
What refers to the symptoms of grief, but is not actually a diagnosis?
A
Bereavement
14
Q
Screenings for MDD are? (3)
A
Two Question Screen (PHQ2)
Patient Health Questionaire (PHQ9)
Zung self rated depression scale
15
Q
PHQ2
A
asks about the two key symptoms of depressive episode, 1. Depression or 2. Anhedonia
16
Q
Can you diagnose someone with depression if they take a PHQ2 and its positive?
A
no!
PHQ2 is not a stand alone test. it needs follow up if positive
17
Q
PHQ9
A
Further evaluates prescence and severity of depression from PHQ2
Assist in medication management - take it before and after the medication to gauge if its working
18
Q
Zung Self Rated Depression Scale
A
In depth rating of current depressive symptoms
19
Q
non - pharm treatment for MDD
A
Psychotherapy, ECT, Vagal nerve, transcranial magnetic stimulation, relaxation techniques, behavioral activation, others - massage therapy, spiruality, yoga, acupuncture
20
Q
pharm management (3) of MDD
A
supplements, herbals, antidepressants
21
Q
what does achieving full remission mean?
A
the symptoms are super improved almost to the point of being asymptomatic
22
Q
What goal are we trying to accomplish with MDD?
A
- Full remission of symptoms
- Return to baseline
- Maintain safety w/o SI thoughts or self harm
23
Q
Gold standard of MDD treatment ?
A
combination of
1. psychotherapy
2. pharmocotherapy
But you are allowed to use just one.
24
Q
MC approach to MDD despite gold standard?
A
pharmocotherapy only
25
MDD Inpatient Mneumonic
SI
Psychosis
Catatonia
Impaired judgement putting people in danger/themselves
Can no longer care for themself (grossly)
Self harm or harm to others
Baker Act!
## Footnote
SI psychotic Cat Judging & Grossly Harming
26
MC psychotherapy
CBT
## Footnote
family or couples therapy is also used, but less common
27
what is behavioral activation
restarting positive activities that stopped due to depression
28
How much exercise is needed for MDD
Aerobic or resistance training.
3-5x/week, 45-60min
## Footnote
almost equal to antidepressants in benefits
29
ECT - Electroconvulsive Therapy- what is it?
Induce tiny seizure using electric current while under general anesthesia. Delivered in multiple sessions.
Not grand mal. Only way you know its happening is because their foot will do clonus.
30
ECT
## Footnote
Indications, CI, SE
Indications
- severe referactory depression and can't tolerate other therapies AND has any of these: severe SI, psychosis, catatonia, malnutrition d/t food refusal
- food refusal can't be from a medical problem other than depression
- MOST EFFECTIVE for MDD than any other treatment but is LAST LINE
- only used to get someone to respond to meds if they weren't already
- no CI
- caution in pts with: CVD, neuro path, anticoag therapy
- SE: safe but w/ adverse effects
31
MC adverse effects of ECT and what patients should caution w/ it
-heart&lungs SE, HA, nausea, transient cog impairement muscle aches
-caution in anyone with CVD, neuro. or anyone on anticoagulent medication
These adverse effects go away!
32
Vagal nerve stimulation
-connected to LEFT vagal nerve
implanted in the chest wall for refractory EPILEPSY
-questionable efficacy for refractory DEPRESSION
33
what is Transcranial Magnetic Stimulation
metal coil with magnetic field is placed against scalp to depolarize focal area of neurons
-WITHOUT the use of sedation or anaesthesia
-LESS effective than ECT
34
Transcranial magnetic stimulation indications
I: refractory depression
CI: seizures, implants that are metal, electric, or cochlear
SE: seizures, HA, scalp pain, transient hearing loss
35
MDD Supplements
S-Adenosylmethionine (SAMe)
5-Hydroxytryptophan (5-HTP)
Omega-3 Fatty Acids
36
S-Adenosylmethionine (SAMe)
- Naturally occurs in the body; may raise dopamine levels
- Can be used as an adjunctive for mild to moderate depression in PREGNANT patients
- May trigger manic episodes (dopamine levels going up)
## Footnote
SAM is pregnant and manic
37
5-Hydroxytryptophan (5-HTP)
Natural precursor to serotonin
Risk of GI upset, serotonin syndrome, eosinophilic myalgia syndrome¹
## Footnote
serotonin makes GI upset
38
Omega-3 Fatty Acids
May work better if combined with antidepressants (through reducing inflammation. Inflammation is related to the body feeling depression)
May increase risk of bleeding. Problems with it causing bleeding also depending on their medications.
39
MDD herbals?
St Johns wort, saffron, ginkgo biloba
40
St. John’s Wort
Increases serotonin, and possibly norepinephrine and dopamine levels
Risk of GI upset, serotonin syndrome, photosensitivity
Numerous drug-drug interactions (DDIs)
## Footnote
St jogns wort = plant = need sunlight so photosensitivity
41
Saffron
May help with depression; MOA unclear
Risk of GI upset, induce mania, bleeding; can be fatal at high doses
42
Ginkgo biloba
Improved mood in pts being treated for memory loss; may increase sensitivity to serotonin
May increase risk of bleeding
43
Guidelines for oral antidepressanat use
start low and slow
Titrate dose over 7 to 10 days
4 to 6 week trial
must have 25% improvement from baseline
- should continue the drug for at least 6 months
- gradual down titration to stop at the end of 6 mo.
44
Dream team antidepressants?
## Footnote
which ones work best
SSRI - paroxetine, escitalopram
SNRI - venlafaxine
Serotonin Modulators - mirtazapine, vortioxetine
TCAs- amitriptyline
## Footnote
Taz vortex + VAPE
45
MoA Serotonin
selectively decreases the action of 5-HT reuptake pump
46
What to do about serotonin syndrome?
Sedation with benzos
Normalize vitals and hydration
D/C serotonergic medications
Clinical diagnosis only. labs don't correlate
47
When can I expect serotonin syndrome after prescribing or updating a medication?
within 24 hours.
MC within 1-6 hours
Or if someone tries to overdose
48
What symptoms does someone have from serotonin syndrome?
## Footnote
*important*
Diarrhea, incr. bowel sounds, agitation, hyperrflexia, dry mucous membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, death
49
Persistent Depressive Disorder
PDD (dysthymia)
"persistently depressed mood" for two years or longer.
Do NOT have to have a full major depressive episode for two years straight
-1.5% in the US
50
PDD Dysthymia
- 2+ years of depressed mood MOST of the time.
-No more than 2 months free of s/s
- AND two or more of:
Appetite changes (poor appetite or overeating)
Sleep changes (insomnia or hypersomnia)
Energy decreased
Diminished concentration
Low self-esteem
Hopelessness
| LASHED
51
PDD tx
pharm (SSRI) + psychotherapy
2nd line for pharm is TCAs and MAOI
52
Adjustment Disorder with Depressed mood
not a true deppressive disorder
DO NOT meet criteria but are significant depressive symptoms
"depressed in response to stressor"
53
Adjustment disorder presentation
- stressor --> reaction within 3 months
**
Hopelessness
Impaired Function
Low mood
Tearful
Distress (significantly)
**
- Resolution: stressor 1--> 6 month resolved
## Footnote
HILT + D
54
What is adjustment disorder NOT?
an exacerbation of a current psych disorder
bereavement
meeting criteria for a psych disorder besides it
55
Symptoms of SAD fall onset
Increased:
Sleep
Appetite for carbs
Weight
Irritability
Rejection sensitivity
Leaden paralysis
## Footnote
Increased SAW-IRL or ASWIRL
fall looks like two II's. increased everything
55
SAD etiology
* possible genetic link
* link to serotonin activity thats abnormal
* 9.7% prevalence
* MC higher latitudes
56
Seasonal Affective Disorder
Not a mood disorder on its own.
Group of symptoms.
Usually in conjunction with a disorder.
MC Fall onset, winter depression
less common - spring onset, summer depression
57
Spring Onset SAD
Decreased:
SAW Dysphoria
58
SAD Tx
Light Therapy (only for fall onset)
-indicated only for non SI, non psychotic
-use daily until spring
-4 to 6 weeks until a response
- SE: few and reversible
- SE: **Photophobia**, HA, fatigue, irritability, **insomnia, HYPOmania**
59
MDD extra pharmacotherapy
Lithium - not as effective as antidepressant drugs
Antipsychotics - ADD ON only to antidepressants
## Footnote
antipsychotics: Aripiprazole, brexpiprazole,e quetiapine, symbyax
60
Major Depressive Episode
Major Depressive EPISODE
2+ weeks with 5 or more: (nearly all the time/everyday)
DEPRESSED MOOD
Sleep change
Interest decreased
Guilt worthless
Energy decreased
Concentration difficulty
Activity change
Psychomotor change
SI thoughts
must cause distress or impairment
Not due to substance or medication
61
Hypomanic episode criteria
- 4+ days of abnormally elevated OR irritable mood AND abnormally increased energy
Grandiosity
Goal directed activity OR psychomotor agitation (restless)
Sleepless
Talkative
Flight of ideas
Distractability
Risky behavior (spend, sex, bad decisions)
| cant be due to substances or medication
not as severe as mania
## Footnote
Must be a change from baseline
CANNOT cause functional impairment or require hospitalization
Good God, Shut The Front Door alReady
62
Manic Episode
- 1+ week of abnormally elevated OR irritable mood and increased energy
-AND: 3+ of:
Grandiosity
Goal directed activity OR psychomotor agitation (restless)
Sleepless
Talkative
Flight of ideas
Distractability
Risky behavior (spend, sex, bad decisions)
| can't be from substances or medication, must cause distress/impair
## Footnote
but if the starting mood is just irritable and not elated, then they have to meet 4+ of the criteria
mneumonic- Good God, Shut The Front Door alReady
63
BP 1
1 + manic episodes
usually always have hypomanic and major depressive episodes
64
Cyclothymia
periods of hypomanic SYMPTOMS
dont meet criteria for episode, fall short
periods of depressive SYMPTOMS
don't meet criteria for episode, fall short
65
BP2
Never manic
1+ hypomanic episodes
1+ depressive episodes
66
BP Etiology
no gender pref
no race pref
MC onset 18-20 y/o
MC wealthy/upperclass
people with older fathers
stressful life events allowing it to manifest
67
How prevalent is BP in the last 12 months
1%
68
How many BP cases are severe?
82.9%
69
how many BP patients have family members with BP?
2/3
70
Bipolar disorder episode subtypes are the same as MDD except for:
Mixed episode subtype
Interest decreased
Depressed mood
Energy decreased
Guilt/worthlessness
## Footnote
DIG E
71
How long does manic OR hypomanic episode last according to the DSM
onset gradually over a few days.
Mania: once it manifests, resolves after 15-20 weeks
Hypomania: once it manifests, resolves after 4-8 weeks
72
Depressive episodes in bipolar last?
same as MDD
episode develops slower than mania/hypomania.
Manifests after days to weeks.
Lasts 20 weeks.
High risk of recurring in the months following resolution.
73
Mixed BP Episodes
meet full criteria for either manic, hypomanic, or major depressive
-AND have 3+ opposite end mood items
74
Rapid-Cycling BP disorder
## Footnote
and etiology
4+ mood EPISODES/year
10-15% of all BP patinets. of those people, 80-95% are women.
-more refractory course of illness (harder to treat)
75
First episode of BPD
## Footnote
age and episode type
* Age of onset is usually 18-20 y/o. Higher risk of 1st episode in young people
* Risk of more frequent episodes in older patinets.
* First Episode of BPD MC is depressive (~50%)
* Half as much chance of first episode being mixed or manic/hypomanic
76
What are the chances of a bipolar person having something else and what is it
- 92% have at least one other PSYCH disorder
- hypothyroidism common in rapid cycling BP
- incr. cardiac, pulm, GI, endocrine
77
What are some of the other psych ddx for BP?
could be a diff mood, psych like schizo, schizoaffect, BPD, ADHD, substance use, medication side effect, and other medical conditions
78
What are bipolar disorder screenings?
MDQ - screens for mania or hypomania
PHQ-2
PHQ-9
Zung
79
Goal of Bipolar Treatment?
First get the acute episode into remission. Then maintain it by preventing new episodes
80
Mania outpatient vs inpatient
Inpatient:
* * inpatient is the judgement is grossly impaired affecting ability to care for oneself
* impaired judgement that puts others or patient at risk for harm
* psychosis
* catatonia
* SI WITH a specific PLAN or INTENT
* Aggressive!
* Acting/ideation suicidal or homicidal
81
Antimanic meds:
* Lithium
* Anticonvulsants: carbamazepine, valproate, divalproex sodium, lamotrigine
* Antipsychotics: quetiapine, lurasidone (+others)
82
What do you do before prescribing for mania/hypomania?
Evaluate for SI, psychotic features, poor judgement, or aggression
83
Tx acute mania map
1. antipsychotic + lithium or valproate
2. monotherapy of antimanic drug
84
Anti manic drugs:
Antipsychotics, lithium, or anticonvulsants
85
If someone is taking an antipsychotic, what test do you perform on them regularly
AIMS - Abnormal Involuntary Movement Scale to test for tardive dyskinesia
86
Cyclothymia overview and epidemiology
Persistently fluctuating MOOD beyond the normal range of symptoms
0.4% to 1%
1/3 of those with cyclothymia have a relative with bipolar disorder
## Footnote
notice it does not say episode
87
Cyclothymia presentation
* 2+ years: peroids of hypomanic symptoms AND peroids of depressive symptoms
* symptoms are present at least 50% of the time
* no more than 2 months of being symptom free
* DOES NOT MEET EPISODE CRITERIA
## Footnote
must cause distress or functional impairment. not due to a medication or another psych disorder
88
Cyclothymia treatment
- combo of medication + therapy
-mood stabilizer like lithium.
-antidepressant in conjunction at a low dose if also frequent or refractory depressive s/s
89
Disruptive Mood Dysregulation Disorder
- Persistently abnormal mood (irate, sad, angry) with severe frequent temper tantrums that interfere with ability to function at school or home.
-happens consistently in many environments
-go on to develop depression
-lithium is not effective. can try therapy, antipsychotic, antidepressant, or ADHD meds.
90
DMDD Presentation
## Footnote
Disruptive Mood Dysregulation Disorder
1+ year of abnormal moods including:
* 3+ temper outbursts/week
* sad, irritable, or angry mood nearly every day
reaction is out of proportion to the stressor and rxn not consistent with developmental level
| not better explained by another psych dx
91
Age requirements for DMDD
at least 6 years old, AND symptoms manifested before age 10
92
Suicide epidemiology - just statistics
* 12 cause of death in us
* 1 successful suicide to 25 unsuccessful suicides
* 46,000 deaths in 2020
* Second leading cause of death for ages 10-34
* Fourth leading cause of death ages 35-54
93
SI epidemiology demographics
-Females think about SI more. We attempt it 3X as often and like poison/overdose.
-Males are 4X likely to commit suicide successfully
-MC Alaksa Native, American Indian, White
94
Suicide in Mood Disorders
15% of MDD and 10-15% of bipolar will die by suicide
95
Risk factors to suicide
elderly white men MC
young people
males successful
+ fmhx
- poor health or anticipate it
- access to firearms 53% of the methods used
- living alone, never married, widowed, divorced, separated
- lack of suport, financial
96
SI risk factors for psychiatric illness
hopelessness
impulsivity
hx self harm
comorbid alcohol/drug
psychosis
specific detailed plan
lack of protective factors
97
SI protective factors
- Social support
- family
- pregnancy
- parenthood
- religious beliefs about suicide
98
SI assessment tools
Columbia Suicide Severity Rating Scale
-PHQ2
-PHQ9
99
Tx for SI inpatient
Hospitalize if they made a suicide attempt, have moderate to severe SI ideation, stated a intent and specific plan. Ensure patient safety, have a staff member present, limit access to objects, transport via ambulance to inpatient facility, inpatient treatment of comorbid psychiatric disorders.
-lithium has reduce suicide rates
-ECT may be life saving due to short latency period
100
Outpatient
Elevated but not imminent risk
family and friends to care for them
urgent psychaitric consult
firearms are put away
increase frequency of patient contact
aggresively treat the problem
DO NOT USE A NO HARM CONTRACT.
they will break their promise.
101
maladaptive cognition
* Judgement Biases - interpreting ambigous situation in threatening manner or overestimating neg outcomes
* Attentive Biases overreact to threatening stimuli
* Avoidant behaviors prepare, check, procrastinate
* Low self confidence in problem solving skills
## Footnote
its going to take more than just medication to change these
102
CBT
involves recognizing anxiety s/s and learning mechanisms to implement when anxiety is building
103
CBT example
Cognitive Restructuring
Identifying negative thoughts
What were you thinking when you started feeling anxious?
Challenging negative thoughts
Is this thought likely or true?
104
When you can't change the exposure of the stressor
Time management techniques
To-do lists, schedules, organization
Relaxation techniques
Yoga, meditation, exercise, deep breathing, biofeedback, muscle relaxation
Social support systems
105
Exposure Therapy
Desensitization - exposing patients to anxiety-inducing stimuli in small doses that gradually become more intense
Patients are taught relaxation techniques to employ to help reduce anxiety to stimulus
106
Exposure therapy part 2
Modeling - patient observes other individuals who are around anxiety-inducing stimuli
Individuals react in relaxed manners, rather than with fear
107
Exposure therapy part 3
Flooding - patient is exposed to stimulus that causes anxiety at its worst and made to use relaxation techniques to get through the experience
*Quicker than systematic desensitization
*May have spontaneous relapses*
108
Short Term PRN therapy
Benzos
Hydroxyzine
109
Long Term Therapy
First line - SSRI, SNRI
Second Line - buspirone, TCAs, BZDs, antipsychotics
110
Anxiety disorders tx short term therapy
BZDs (benzos) and hydroxyzine
111
anxiety tx long term
* 1st line SSRI- SNRI
* 2nd line- Buspirone, TCAs, BZDs, antipsychotics
112
Benzos MOA and action, uses
- enchance GABA effect at the GABA receptor
- sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant
- uses for anxiety, panic, insomnia, ETOH withdrawl, agitation, seizures, procedural sedation
113
Benzo side effects
drowsiness, dizziness, decreased motor coordination, decreased libido, disinhibition, rebound anxiety, amnesia, SI
rare: respiratory depression, paradoxical effects
114
What do we worry about benzos
risk for dependance and withdrawl, especially higher with a shorter half life
115
benzo drug interactions
ETOH, opiods, other CNS depressants, anticonvulsants, antidepressants, antifungals
116
Benzos CI
pregnancy, MG, narrow angle glaucoma.
If you have COPD, sleep apnea, MG there's a risk for respiratory depression so CI
117
Alprazolam indications, half life, notes
prescribed for panic and anxiety
15-30m onset, half life is 11-16 hrs
-high abuse potential and rebound anxiety possible
118
Lorazepam uses and half life
Anxiety, Seizures, Agitation, ETOH withdrawal, Insomnia, Procedural sedation
10-14 hrs
30-60 m onset
not detected by urine drug screen
119
Clonazepam uses
Panic, Anxiety, Seizures, Tremor
RLS, Insomnia
30-60m onset
half life 18-39 hours
120
Chlordiazepoxide
ETOH withdrawl, anxiety
60 m onset
30-100 hr half life
121
Diazepam uses
anxiety, seizure, agitation, ET OH withdrawl, muscle spasm, procedural sedation
- 30 m onset and 50-100 hr half life
- works quick, long duration, longer in elderly and those with hepatic impairment
122
Flurazepam
Insomnia
120 m onset
40-114hrs half life
123
Oxazepam
insomnia, etoh withdrawl
- 60-120 m onset
- 5-15 h half life
- no active metabolite
124
Do we prescribe benzos daily?
No.
PRN only, and for a limited time 1-4 weeks
avoid in substance abuse pts
125
How to taper someone on benzos
10% reduction per 1-2 weeks
slowly taper if s/s of withdrawl
126
what do benzo withdrawl sx look like
anxiety, dysphoria, tremor, seizures
127
Hydroxyzine - MoA, indications, special
Histamine receptor antagonist
- short term therapy for anxiety
- those who have trouble falling asleep
- SE: drowsiness, dizzy, dry mouth, rash, respiratory depression
- DDI- potassium, MAOI, CNS depressants
- CI 1st trimester of pregnancy, or admin via parenteral
128
Buspirone
For benzo naive patients only
5HT1a receptor agonist; also acts on dopamine receptors
More effective for cognitive anxiety s/s than somatic s/s
Less anxiolytic effects than BZDs
Often used to augment SSRIs/SNRIs or in pregnant pts
No abuse/dependence potential, no withdrawal*
2-4 weeks to full onset of action
SE - dizziness, drowsiness, nausea, headache
Concern over potential for Serotonin Syndrome
DDI - other psych meds, CNS depressants
CI - allergy to medication
129
GAD
* lifetime - 12%
* in the last year - 3% general population
* 8% of primary care patients
* 2X as common in women
* MC in 35+
* genetic predisposition and childhood truama
130
GAD comorbid
MDD, substance abuse, other anxiety disorders, chronic unexplained pain
131
What is GAD
* Excessive anxiety and worry (apprehensive expectation) more days than not
* Anxiety/worry is about multiple things
* Anxiety/worry is present for at least 6 months
* Patient finds it difficult to control anxiety/worry
132
What symptoms are they for GAD
Anxiety associated with 3+:
- Restlessness or on edge
- fatigued easiliy
- concentrating difficulty
- irritability
- muscle tension
- sleep disturbances
| C anxious FIRMS
## Footnote
must cause distress and or functinal impairment
not due to substance use or medical condition
133
GAD also is coupled with hyperarousal which is:
-minor matters worry me
- hyperarousal is easily startled and cant sleep
- somatic: muscle tension, headaches, neck back pain
134
DDx
depression - more focus on past events
other anxiety disorders - more focus on specific worries
OCD- more ritualistic
hyperthyroidism
stimulant treatments
135
screening for anxiety
GAD7 - intial screening for GAD
* monitors response to treatment and severity of symptoms
Beck Anxiety inventory
* 21 question self reported. no overlap with depressive symptoms. can be used for anxiety of GAD or others
136
GAD tx
SSRI/SNRI, CBT or both
BZDs may be used as a short term tx for severe s/s
2nd line - TCAs, Buspirone, others
Adjunt - relaxation techniques, acupuncture, exercise. limited evidence for herbals
Continue therapy for 6 to 12 months
137
Agoraphobia
- anxiety about and/or avoidance of situations where help may not be available or leaving would be difficult if the patient were to develop incapacitating or embarrassing symptoms (e.g. panic attacks, incontinence)
138
Panic disorder etiology
2x in women
15-19 and 35-60
genetic presdisposition, childhood trauma, smoking, life stressors
-3% in the general population, 8% primary care patients
5% in a lifetime
up to 1/3 of people have a panic attack (it does not mean they have panic disorder)
139
Panic ATTACK criteria
Abrupt surge of intense fear/discomfort that peaks within minutes
AND, Accompanied by 4+ of the following:
* Palpitations, pounding heart, or accelerated heart rate
* Sweating
* Trembling or shaking
* Sensations of shortness of breath, choking, or smothering
* Chest pain or discomfort
* Nausea or abdominal distress
* Feeling dizzy, unsteady, lightheaded, or faint
* Chills or heat sensations
* Paresthesias
* Derealization¹ or depersonalization²
* Fear of losing control, dying, or "going crazy"
140
Panic DISORDER criteria
Recurrent unexpected panic attacks
1+ attacks have been followed by 1+ months of one or both of the following:
* Persistent concern or worry about additional panic attacks or their consequences
* Significant maladaptive change in behavior due to the attacks
## Footnote
Syndrome is not due to substance or medical condition
Syndrome is not better explained by other mental disorder
Panic attacks do not occur only in response to specific triggers
141
Somatization Disorder -
Somatization Disorder - more emphasis on physical symptoms, hx of somatization
142
Panic Disorder treatment
First-Line - CBT, SSRI like paroxetine, or combination. start low&slow
1st Paroxetine - sedating effects, can help calm patients+ CBT
Second-Line - SNRIs; may also try TCAs
- Adjunct - BZDs (short-term/PRN use)
BZDs - Alprazolam
- Risk of dependency, rebound anxiety
Clonazepam
-Less risk of rebound anxiety, fewer doses/day
-Lorazepam and diazepam also have been used
143
Epidemiology of agoraphobia
1% lifetime w/ panic disorder, 0.8% without panic disorder
comorbid w/ substance use, depression, anxiety disorder
-genetic predisposition, introversion, fear of having an illness, low self efficacy
144
Agoraphobia in the DSM
Persistent (6+ months) of marked fear/anxiety about 2+ of the following:
* public transportation
* open spaces (e.g., parking lots, marketplaces, bridges)
* enclosed places (e.g., shops, theaters, cinemas)
* line or being in a crowd
* outside of the home alone
## Footnote
LOOPE (with an E). Loop of the same thing every day. stuck inside.
145
Why are agoraphobia people afraid? What are they afriad of
escape not available and they can't leave
-maybe they have a disorder of some kind that they fear will embarass them and they will be stuck forever in that situation
-they need a companion to go with them, or endure it with intense fear/anxiety that is out of proportion to the danger
146
Agoraphobia treatment
SSRI, CBT, or both
147
Social Anxiety Disorder prevalence
- last 12 months 7%
- lifetime up tp 12%
- women MC
- age in late childhood early adolescent
- Comorbid with other anxiety disorders, mood disoders, substance abuse
- medical disorders common is tremor, torticollis, tourettes, disfiguring scars
- genetic predisposition, early childhod shyness, behavioral inhibition, frequent parental anger at child, overprotective parenting, childhood teasing
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Social Anxiety in the DSM
Persistent (6+ months) of marked fear/anxiety about 1+ social situations in which the pt is exposed to possible scrutiny by others
Ex: social interactions, being observed, performing in front of others
In children, anxiety must occur in peer settings (not just with adults)
In children - crying, tantrums, freezing, clinging, shrinking, failing to speak
The social situations are avoided or endured with intense fear or anxiety
Fear/anxiety is out of proportion to the actual threat posed
Fear/anxiety or avoidance causes distress or functional impairment
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Social Anxiety subtype
If only related to performance and not general social interaction, may use modifier “performance-only” (versus “generalized”)
## Footnote
for example performing in front of a crowd
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Treatment Social anxiety
CBT, SSRI, SNRI, or both for 6-12 months
- may choose to augment with BZD PRN
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Performance only social anxiety disorder
* PRN BZD dosing 30-60 min before performance
* PRN beta blocker dosing is a reasonable alternative (propanolol 30-60 min before performance)
* may augment with relaxation techniques
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Acute Stress reactions
- Acute stress reactions occur like:
- trigger 0 -1 mo.
- within the month it happens
- tx can help reduce progression to PTSD
- lasts 3 days to 1 month after trauma
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Acute Stress Reaction Etiology
roughly 5-20%, depending on trauma
Work accident - 6-12%
MVA - 13-21%
Assault - 16-19%
Witnessing a mass shooting - 33%
Risk Factors - history of other psych disorder, female gender, severe trauma, avoidant coping mechanisms
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Acute distress DSM criteria part 1
Exposure to actual or threatened death, serious injury, or sexual violation in 1+ of the following ways:
* Directly experiencing traumatic event(s)
* Witnessing, in person, event(s) as it occurred to others
* **Learning that violent or accidental event(s) occurred to close family/friend**
* Experiencing repeated or extreme exposure to aversive details of traumatic event(s)
Does not apply to exposure through electronic media, TV, movies, or pictures, unless exposure is work-related
## Footnote
criteria for the traumatic event
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Acute Stress Disorder part 2 DSM criteria
9+ beginning or worsening afer event lasting 3 d to 1 mo. in the initial month after trauma happens
- Recurring memories of truamatic event
- Recurring dreams related to the event
- dissociative reaction in which pt feels or acts as if truama were recurring
- physiological reactions in response
- persistent inability to experience positive emotions
- altered sense of the reality of one's surroundings or oneself
- inability to remember an important aspect of the trauma
- avoid distressing memories, thoughts, or feelings about the trauma
- efforts to avoid reminders
- sleep disturbance
- irritable behavior and angry outbursts w/ no provocation
- concentration problems
- exaggerated startle response
| must cause distress or functional impairment
## Footnote
criteria for the symptoms after the stressful event
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If someone has a TBI, why is this important in diagnosing stress disorders?
Because it can mimic PTSD or acute stress disorder
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Acute stress disorder tx
Trauma oriented CBT with incorporated exposure therapy
2 weeks use of BZDs if you have severe agitation and insomnia
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PTSD etiology
lifetime - 6.8-12%
last 12 mo - 3.5 to 6%
Gender more common
Causes - assualt, rape, incest, military combat, diseaster, MVAs, diagnosis of severe illness
-sexual assult - MC trauma in women with PTSD
- miltary combat - risk of PTSD correlated with severity of injury and TBI
- 50-60% of individuals report at least one severe stressful event that could trigger PTSD, but not all indivduals go on to develop PTSD
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PTSD
Risk Factors -
- female gender, severe trauma, family history of anxiety disorders
- comorbities: depressive disorders, anxiety disorders, and substance abuse are 2-4x more common than in the general population
-substance abuse - self medicate
- 90x more common in PTSD
- TBI- 60% of TBI patients also have PTSD
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How is PTSD different from acute stress
PTSD is 1+ month of symptoms
- doesn't matter when the onset is
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PTSD categories
Exposure, intrusion, avoidance, negative cognition/mood, hyperarousal, duration more than a month
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Psychosis - ddx
hallucinations and beliefs are not specific to a traumatic event
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PTSD treatment
* trauma oriented CBT w/ exposure therapy
* combo always better than meds
* Meds- SSRI or SNRI only
* -atypical antipsychotics add on for refractory
* -prazosin for insomnia
* -BZSDs for occasional severe agitation and hyperarousal
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OCD overview
MC suffer from both obsessions AND compulsions
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OCD etiology
1% is the last 12 months
2% lifetime
MC males in children
MC females in adult
Etiology - generic predisposition, hormonal influences (premenstrual, postpartum), exposure traumatic events, neural lesions
Comorbid - other anxiety disorders, tics, mood disorders
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Compulsions are-
are not realistically connected with what they are designed to neutralize or prevent, or are clearly excessive
167
Good vs poor vs absent insight
are my OCD beliefs true
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OCD specifiers
"Tic Related" current/past hx of tic disorder
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What is Obsessive Compulsive Personality Disorder?
similar obsessions and compulsions, but also have desire that other individuals should follow their OCD beliefs, and less distress caused by OCD beliefs
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Trichotillomania
Trichotillomania - compulsive hair-pulling is done because it brings a sense of satisfaction, instead of done to avoid negative outcomes; no obsessive thoughts
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OCD treatment
1st line- CBT with exposure therapy, SSRI, or combo
-need higher maintenance doses of SSRI therapy, still go low and slow titrating
2nd line - another SSRI or SNRI
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Phobia definition
Persistent (6+ months) of marked fear/anxiety about a specific object or situation
In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging
Phobic object/situation almost always causes immediate fear/anxiety
Phobic object/situation is actively avoided or endured with intense fear or anxiety
Fear/anxiety is out of proportion to the actual danger posed by object/situation
Fear/anxiety or avoidance causes distress or functional impairment
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Fever vs phobic fear
Unlike normal fear, phobic fear…
Is excessive and out of proportion
Cannot be alleviated with rational explanation
Is out of voluntary control
Leads to situational avoidance
Is maladaptive and persistent over time
Is not age or stage-specific
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Agoraphobia vs phobia specific
Agoraphobia - fear is focused on lack of escape or help, not specific situation
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Phobic Disorder
1st line tx CBT with exposure therapy
2nd line - PRN BZD
3rd line - SSRI, may use SNRI
