First Aid: Anxiety and Adjustment Disorders Flashcards
1
Q
List some autonomic s/s of anxiety.
A
- Palpitations
- Perspiration
- Dizziness
- Mydriasis
- GI disturbances
- Urinary frequency/urgency
2
Q
What are the neurochemical imbalances of anxiety?
A
- Increased NE
- Decreased GABA
- Decreased serotonin
3
Q
What is the lifetime prevalence of anxiety disorders in women?
A
30%
4
Q
What is the lifetime prevalence of anxiety disorders in men?
A
19%
5
Q
True or false: anxiety disorders are more common in low SES groups.
A
FALSE: more common in high SES
6
Q
Panic attacks are typically seen with what disorders?
A
- Panic disorder (classically)
- Phobic disorders
- PTSD
7
Q
What is the timeline for a panic attack?
A
- Peaks in several minutes
- Subsides within 25 minutes
- Rarely last > 1 hour
8
Q
What is the DSM-IV criteria for panic attacks?
A
-Discrete period of intense fear and discomfort that is accompanied by at least 4 s/s
9
Q
What are the s/s of a panic attack?
A
D-PANICS
- Depersonalization (feel detached from oneself), dizziness (light-headedness)
- Palpitations
- Abdominal distress (nausea)
- Numbness or tingling
- Intense fear of death, fear of losing control or “going crazy”
- Choking sensation, chest pain, chills (or hot flashes)
- Shortness of breath, sweating, shaking
10
Q
What is the experience of panic attacks accompanied by persistent fear of having additional attacks?
A
Panic Disorder
11
Q
What is the DSM-IV diagnostic criteria for panic disorder?
A
- Spontaneous recurrent panic attacks with no obvious precipitant
- At least one of the attacks has been followed by a minimum of 1 month of either persistent concern about additional attacks, worry about implications of attack (Am I out of control?), and/or a significant change in behavior related to attacks (avoid situations, etc.)
12
Q
What specifier do you need to add to the diagnosis of panic disorder?
A
with or without agoraphobia
13
Q
What is agoraphobia?
A
fear of being alone in public places
14
Q
What percentage of patients who present with chest pain (with normal angiograms) have panic disorder?
A
43%
15
Q
On average, how frequent are attacks in those with panic disorder/
A
2 times per week (but can go from several times a day to a few times per year)
16
Q
What is common in individuals with panic disorder between episodes?
A
anticipatory anxiety
17
Q
What common substances may exascerbate anxiety in patients with panic disorder?
A
caffeine
nicotine
18
Q
What is the lifetime prevalence of panic disorder?
A
2-5%
19
Q
What is the gender most commonly affected with panic d/o?
A
females (2-3X more likely)
20
Q
How much more likely are you to develop panic d/o if you have a first degree relative with it?
A
4-8X
21
Q
What is the average age of onset for panic d/o?
A
- Late teens to early thirties
- Average 25
- May occur at any age
22
Q
List the 4 conditions frequently associated with panic d/o and agoraphobia?
A
- MDD (depressive symptoms in 40-80%)
- Substance dependence (20-40%)
- Social and specific phobias
- OCD
23
Q
What is the prognosis for panic d/o?
A
- 10-20% of patients continue to have significant symptoms that interfere with daily functioning
- 50% have mild, infrequent symptoms
- 30-40% remain free of symptoms after treatment
24
Q
What is the acute initial treatment of anxiety?
A
Benzos (only short course) and taper off as you begin maintenance treatment
25
What is the maintenance treatment of anxiety?
- SSRIs (paroxetine and sertraline)--FIRST LINE
| - Clomipramine, imipramine or other antidepressants
26
Why do you go low and slow with SSRIs?
Activation side effects are common in panic disorder patients which are anxiety symptoms that mimic those of panic
27
What is the differences in dosing of SSRIs for panic d/o versus MDD?
-Need higher doses than those required to treat depression
28
How long do you continue therapy for panic d/o?
8-12 months on SSRI (relapse is common after discontinuation)
29
True or false: beta blockers are equally effective in controlling anxiety symptoms in people with panic d/o as benzodiazepines
FALSE: they are not as effective as benzos
30
What percentage of patients with agoraphobia have coexisting panic d/o?
50-75% of patients
31
What is the DSM-IV criteria for diagnosis of agoraphobia?
- Anxiety about being in places or situations from which escape might be difficult/help would not be readily available in the event of a panic attack.
- Situations are either avoided, endured with severe distress, or faced only with the presence of a companion
- These symptoms cannot be better explained by another mental disorder
32
What is first line treatment for agoraphobia?
SSRIs
33
Which is worse, agoraphobia associated with or NOT associated with panic d/o?
if not associated with panic d/o, it is usually chronic and debilitating
34
Irrational fear that leads to avoidance of the feared object or situation.
Phobia
35
What are some common "specific phobias"?
```
Animals
Heights
Blood or needles
Illness/injury
Death
Flying
```
36
What is another name for social phobia?
social anxiety disorder
37
What are some common social phobias?
Public speaking
Eating in public
Using public restrooms
38
What is the DSM-IV criteria for specific phobias?
- Persistent excessive fear brought on by a specific situation or object
- Exposure to situation brings about an immediate anxiety response
- Patient recognizes that fear is excessive
- Situation is avoided when possible or tolerated with intense anxiety
- If person is under age 18, duration must be at least 6 months
39
What is different about the DSM-IV criteria for social versus specific phobia?
social phobia has a feared situation related to social settings in which patient might be embarrassed or humiliated in front of other people
40
What are the 4most common mental disorders in the US?
1) phobias
2) Substance-induced disorders
3) Major depression
4) OCD
41
What is the prevalence of phobias in the US?
5-10% (up to 25%)
42
Which is more common, specific or social phobias?
specific
43
What is the average age of onset for social phobias?
mid teens
44
What is the gender differences in likelihood of having a phobia?
- Specific: women 2X more likely
| - Social: women=men
45
What are 2 common comorbidities associated with phobias?
- Substance related disorder (esp. ETOH)
| - Major depression (around 1/3)
46
What specific phobia runs in families and may be associated with inherited, exaggerated vasovagal response?
fear of seeing blood
47
What is the genetic component of social phobia?
People with 1st degree relatives are 3X more likely
48
What neurochemical imbalances are associated with phobias?
overproduction of adrenergic neurotransmitters
49
What is used to treat performance anxiety?
beta blockers
50
What is the treatment used for specific phobia?
- Systemic desensitization (with or without hypnosis)
| - Supportive psychotherapy (short course of benzos or beta blockers to help control autonomic symptoms)
51
What is systemic desensitization?
Gradually expose pt to feared object to feared object or situation while teaching relaxation and breathing techniques
52
What is the SSRI that is FDA approved for social anxiety disorder?
Paroxetine (paxil)
53
A recurrent and intrusive thought, feeling or idea
Obsession
54
A conscious repetitive behavior linked to an obsession that, when performed, functions to relieve anxiety caused by the obsession
Compulsion
55
True or false: patients with OCD have insight into their disorder.
TRUE
56
What is another word for the feelings OCD patients have about their symptoms?
ego-dystonic (want to get rid of them)
57
What percentage of OCD patients have both obsessions and compulsions?
75%
58
What is the DSM-IV criteria for OCD?
- Either obsessions (person tries to suppress and realizes they are product of their own mind) or compulsions (behavior linked to reducing distress but there is no realistic link between the distress and behavior)
- Person is aware that the obsessions and compulsions are unreasonable and excessive
- Obsessions cause marked distress, are time consuming, or significantly interfere with daily functioning
59
What are 3 common obsessions seen in OCD?
- Contamination (with excessive washing)
- Doubt (with checking)
- Symmetry (with slow performance of tasks)
60
What are intrusive thoughts with OCD usually about?
- Sexual
| - Violent
61
What is the lifetime population prevalence of OCD?
2-3%
62
What is the typical onset of OCD?
Early adulthood
63
What are some common comorbidities of OCD?
- MDD
- Eating disorders
- Anxiety disorders
- OCPD
64
What is the difference between OCD and OCPD?
OCPD is a personality disorder and the symptoms are ego-syntonic (patients lack insight to problems and are inflexible)
65
Rate of OCD is higher in patients with first degree relatives with what disorder?
Tourette's
66
What is the neurochemical change seen in patients with OCD?
abnormal regulation of serotonin
67
What triggers onset of OCD in 60% of patients?
stressful life event
68
What is the prognosis for OCD?
- 30% have significant improvement with treatment
- 40-50% have moderate improvement with treatment
- 20-40% remain impaired or have worsening of s/s
69
What is the treatment for OCD?
- SSRIs (higher than normal doses may be required to be effective)
- TCAs (clomipramine)
- Behavioral therapy is JUST as effective as pharmacotherapy but best effects if used concurrently
70
True or false: OCD patients typically present to the psychiatrist because they have insight
FALSE- usually present to nonpsychiatric physicians for medical problems associated with compulsions (ex. dermatology)
71
What behavioral therapy technique is used in OCD patients?
Exposure and response prevention (ERP)
72
What does ERP involve?
prolonged exposure to ritual-eliciting stimulus and prevention of the relieving compulsion
-Relaxation techniques
73
What are the last resort treatments for OCD?
- ECT
- Cingulotomy (surgery)
*ONLY in treatment-resistant cases
74
What is the DSM-IV criteria for PTSD?
- Having experienced or witnessed a traumatic event which was potentially harmful or fatal and initial reaction was intense fear or horror
- Persistent re-experiencing of the event (dreams, flashbacks, etc.)
- Avoidance of stimuli associated with the trauma
- Numbing of responsiveness (limited range of affect, feelings of detachment or estrangement from others, etc.)
- Persistent symptoms of increased arousal (trouble sleeping, exaggerated startle response, etc.)
- Symptoms must be present for at least 1 month
75
What are the common comorbidities of PTSD?
- Substance abuse (avoid addictive treatments like benzos)
| - Depression
76
What is the prognosis for PTSD?
-50% remain symptom free after 3 months of treatment
77
What are the pharmacologic treatments for PTSD?
TCAs (imipramine or doxepin)
SSRIs, MAOIs
Anticonvulsants (for flashbacks and nightmares)
78
What is the DSM-IV criteria for acute stress disorder?
- Pt experiences a major traumatic event but have anxiety symptoms for only a short duration
- Symptoms (similar to PTSD) must occur within 1 month of the trauma and last for a maximum of 1 month
79
What are the major differences between PTSD and acute stress d/o?
PTSD symptoms last >1 months and traumatic event could have occurred at any time in the past. Acute stress disorder symptoms last
80
How do you treat acute stress d/o?
same as PTSD
81
How does adjustment d/o differ from PTSD (as far as trigger)?
psychological symptoms occur after a stressful but NON-LIFE THREATENING event
82
What is the DSM-IV criteria for diagnosis of Generalized Anxiety Disorder?
- Excessive anxiety and worry about daily events and activities for at least 6 months
- Difficult to control the worry
- Associated with 3 anxiety symptoms
83
What are the symptoms associate with GAD?
```
Restlessness
Fatigue
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
```
84
What is the lifetime prevalence of GAD?
45%
85
Which gender is more likely to develop GAD?
women 2X more likely
86
What is the normal age of onset for GAD?
usually before age 20 (many patients say they have felt anxious their entire life)
87
Where do GAD patients normally present?
Specialists due to somatic complaints (muscle tension or fatigue) that accompany d/o
88
What are the common comorbidities of GAD?
-50-90% of patients with GAD have a coexisting mental disorder like: MDD, social or specific phobia, panic d/o
89
What is the prognosis for GAD?
- Chronic with life-long fluctuating symptoms in 50%
| - 50% fully recover within several years of therapy
90
List some pharmacological therapies for treating GAD.
- Buspirone
- Benzodiazepines (clonazepam or diazepam) but taper off as soon as possible
- SSRIs
- Venlafaxine (extended release)
91
True or false: pharmacological therapies alone are most effective in treating GAD
FALSE: best treatment is combo or pharm and psychotherapy (behavioral therapy too)
92
Are adjustment disorders considered to be anxiety disorders?
NO
93
What is the DSM-IV criteria for adjustment d/o?
- Development of emotional or behavioral symptoms within 3 months after a stressful life event that produce either severe distress in excess of what is to be expected after such an event or significant impairment in daily functioning
- Symptoms are NOT those of bereavement
- Symptoms resolve within 6 months after stressor has terminated
94
How are symptoms coded in adjustment d/o?
Based on predominance of:
- Depressed mood
- Anxiety
- Disturbance of conduct (ex. aggression)
- Combinations of above
95
What gender more commonly gets adjustment d/o?
women 2X more common
96
What age does adjustment d/o usually present?
Most frequently diagnosed in adolescents but may occur at any age
97
What is the prognosis for adjustment d/o?
- May be chronic if the stressor is recurrent
| - Symptoms resolve within 6 months of cessation of stressor (by definition)
98
How do you treat adjustment d/o?
- Supportive psychotherapy
- Group therapy
- Pharmacotherapy for associated s/s (ex. insomnia, anxiety, depression)
