Lecture 13: Anxiety Disorders & Stress Disorders COPY Flashcards
What is fear?
Emotional reaction to a REAL and EXTERNAL threat.
What is anxiety?
Nervousness/dread associated with an ANTICIPATED event or vague/unknown stimulus.
What is the simplified version of fear vs anxiety?
Fear is a stress response to immediate danger.
Anxiety is a stress response to your thoughts.
When is anxiety pathologic?
Present WITHOUT an obvious or reasonable cause.
EXCESSIVE to actual threat.
CAUSES DISTRESS or FUNCTIONAL IMPAIRMENT or REDUCED QUALITY OF LIFE
What falls under maladaptive cognition?
Judgement biases
Attentive biases
Avoidant behaviors
Low self-confidence in problem solving skills.
What falls under judgement bias?
Interpreting ambiguous events in a threatening manner.
Overestimating the likelihood of a NEGATIVE event.
What falls under attentive biases?
Overreacting to threats.
What falls under avoidant behaviors?
Excessive prep.
Checking behaviors
Procrastination
How does CBT restructure our cognitive thinking?
Identifies negative thoughts
Challenges those negative thoughts
Replaces those negative thoughts with real thoughts.
What are some ways to manage stress that we cannot avoid/modify?
Time management
Relaxation techniques
Social support
What are the 3 types of exposure therapy?
Desensitization
Modeling
Flooding
What is desensitization?
Exposing patients to the stimuli in SMALL DOSES.
Pts are often taught relaxation techniques to reduce their response to the stimuli.
What is modeling?
Patient observes another individual around the stimuli.
Individual should react relaxed around the stimuli.
What is flooding?
Exposing the patient to the stimuli that causes them the WORST ANXIETY and forcing them to use relaxation techniques to get through it.
It is much quicker than desensitization BUT can have spontaneous relapses.
It’s like jumping into a pool, whereas desensitization is like dipping your feet one by one.
What are the short-term/PRN meds for anxiety disorders?
BENZOS
Hydroxyzine
What are the long-term meds for anxiety disorders?
FIRST-LINE: SSRI, SNRI
Second-line: Buspirone, TCAs, Benzos, antipsychotics.
What is the MOA of a benzo?
Enhance the effect of GABA at the GABA receptor.
What does GABA do?
Inhibitory NT. Benzos amplify GABA effect.
What do Benzos do?
Sedate
Hypnotic
ANXIOLYTIC
Anticonvulsant
Muscle relaxant
What can Benzos cause in high doses?
Amnesia
Dissociation
When do we use benzos?
Anxiety
Panic
Insomnia
ETOH withdrawal
Agitation
Seizures
Procedural sedation
What are the main SE of benzos?
Drowsiness
Dizziness
What are the rare SE of benzos?
Respiratory depression
Paradoxical effects
What is the biggest risk in benzos?
DEPENDENCE
WITHDRAWAL
What does a shorter half-life benzo increase the risk of?
Withdrawal S/S
What are the main DDI of Benzos?
ETOH
Opioids
Antifungals (increase serum concentration)
All of these have similar effects to benzos
What are the CIs of benzos?
Pregnancy
Allergy
Myasthenia Gravis
Narrow-angle glaucoma
Which chronic medical conditions are at higher risk for respiratory depression if given a benzo?
COPD
Sleep Apnea
Myasthenia Gravis
What is the fastest acting benzo?
Versed.
Used for procedural sedation.
What is the highest abuse potential benzo?
Xanax/Alprazolam
What benzo is known for causing rebound anxiety? Why?
Xanax/Alprazolam.
It has a fast onset.
What is the main intermediate-acting benzo for insomnia?
Temazepam/Restoril
What is the longest acting benzo?
Flurazepam/Dalmane
What benzo is known for working quickly and having a long duration?
Diazepam/Valium
Intermediate-acting
What kind of patients should we avoid benzo use in?
Substance abuse hx
What should we caution patients on with benzo use?
Potential of dependency, tolerance, and addiction.
How do we taper down benzos?
10-25% every 1-2 weeks.
Slower taper if s/s of withdrawal.
What are the s/s of benzo withdrawal?
Anxiety
Dysphoria
Tremor
Seizures
What is the MOA of hydroxyzine/Vistaril/Atarax?
Histamine (H1) receptor antagonist.
What kind of patient would we give hydroxyzine?
Patients that have insomnia due to anxiety. (1st gen antihistamines make u drowsy. think benadryl)
Patients that we need a short-acting agent in but have high abuse potential.
What is the main SE of hydroxyzine?
Drowsiness
What are the DDIs of hydroxyzine?
POTASSIUM
MAOIs
CNS depressants
What are the CIs of hydroxyzine?
Allergy
1st trimester of pregnancy
Any route of admin that is not oral?
What is the MOA of Buspirone/buspar?
5HT-1a receptor agonist.
Also works on dopamine receptors
What is buspirone most effective for?
Cognitive anxiety s/s rather than somatic.
What kind of pts do we use buspirone for?
Addon for SSRIs/SNRIs.
Pregnant patients
Benzo-naive patients. (It has less anxiolytic effects than a benzo)
What is the main perk of using buspirone?
No abuse/dependence potential.
No withdrawal.
How often can we titrate up buspirone and by how much?
2.5mg every 3 days.
What is the main SE of buspirone and the main concern?
Dizziness
Serotonin syndrome
What are the DDIs of buspirone?
Other psych meds
CNS depressants
What is the CI of buspirone?
Allergy
*SAFE TO USE IN PREGNANCY
What are the 6 anxiety disorders?
Generalized anxiety disorder
Panic disorder
Acute stress disorder
PTSD
OCD
Phobic disorders
What is the MC demographic for generalized anxiety disorder? (GAD)
35+ Women with genetic predisposition or childhood trauma.
How prevalent is GAD?
3% gen pop
8% primary care pts
Lifetime: 12%
What are some common comorbidities for GAD?
MDD
Substance abuse
Other anxiety disorders
Chronic, unexplained pain
What counts as excessive anxiety and worry for GAD according to the DSM V?
About multiple things
Present for 6 months
Difficult to control it
What criteria must anxiety/worry be associated with for a GAD Dx?
3+ of the following:
Restlessness or feeling keyed up/on edge
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbances
What is the full criteria for a GAD Dx according to the DSM-V?
Anxiety must meet criteria.
Anxiety must be associated with 3 of the 6 criteria.
Must cause distress/functional impairment.
Must NOT be due to substance abuse or medical condition.
AND I C REST
Anxious/nervous
No control over worry
Duration of 6 months
Irritability
Concentration impairment
Restlessness
Energy decreased
Sleep impairment
Tension in muscles
How does GAD typically present?
Persistent worry with hyperarousal symptoms.
What are somatic s/s of anxiety?
Muscle tension
HA
Neck/back pain
What does depression mainly focus on if we are ruling it out in a DDx?
It focuses more on past events.
What do other anxiety disorders mainly focus on if we are ruling it out in a DDx?
Specific worries.
GAD is general.
What does OCD mainly focus on if we are ruling it out in a DDx?
Ritualistic behaviors.
What medical disorders are differentials for anxiety?
HYPERthyroidism
Stimulant treatment
How do we screen for GAD?
GAD-7
Beck anxiety inventory
What is the GAD-7?
A 7 question screen used as the INITIAL screening for GAD.
Monitors severity of s/s and response to tx.
What is the Beck anxiety inventory?
21-question self-reported inventory of s/s
Used for GAD or other anxiety disorders.
No overlap with depressive s/s.
What should we keep in mind when treating GAD?
It is often CHRONIC and LIFELONG.
What is first-line treatment for GAD?
SSRI/SNRI, CBT, or both.
What can we use between clinical onset of GAD and clinical onset of a SSRI?
Benzos to bridge gap if severe.
What do we use if patients cannot tolerate/fail first-line tx for GAD?
TCA
Buspirone
Other meds:
Mirtazapine
Serotonin modulators
Pregabalin
2nd gen antipsychotics
Benzos
What is adjunct treatment for GAD?
Relaxation techniques
Acupuncture
Exercise
How long does GAD therapy generally last?
6-12 months.
What is a panic disorder?
RECURRENT episodes of panic attacks.
What are panic attacks?
Intense fear or discomfort with multiple accompanying symptoms.
What is agoraphobia?
Anxiety about and/or avoidance of situations where HELP MAY NOT BE AVAILABLE or leaving would be difficult if pt were to develop incapacitating or embarrassing symptoms.
It is a separate Dx in the DSM V.
What is the MC demographic for panic disorder?
Adolescent women
Middle-aged women
What is the prevalence of panic disorders?
5% lifetime.
33% for panic attacks in general.
What are the comorbidities associated with panic disorder?
MDD
BPD
Substance use
Anxiety disorders
What are the the etiologies of panic disorder?
Genetics
Childhood trauma (such as childhood asthma attacks)
Smoking
Life stressors
What is the criteria for a panic attack?
Abrupt surge of intense fear/discomfort that peaks within minutes
+ 4 of the following in STUDENTS FEAR the 3 C’s:
Sweating
Trembling
Unsteadiness/dizziness
Depersonalization, derealization
Excessive HR, palps
Nausea
Tingling
SOB
Fear of dying
Fear of losing control
Fear of going crazy
Chest pain
Chills
Choking
What is the criteria for a panic disorder?
Recurrent, unexpected panic attacks
1+ attacks followed by 1+ months of 1+ of the following:
Persistent concern or worry about addl panic attacks.
Significant maladaptive change in behavior due to the attacks.
Not due to substance or medical condition.
Not better explained by a different disorder.
What are some DDx for a panic disorder?
Somatization disorder (more focused on physical symptoms)
Anxiety/depressive disorder (other symptoms are more predominant)
Substance use
Organic disorders
What is the first-line treatment for panic disorder?
CBT, SSRI, both
What is the preferred SSRI in panic disorder?
Paroxetine (sedating effects as well)
What is the second-line treatment for panic disorder?
SNRIs or TCAs
What are the adjunct benzos for panic disorders?
Alprazolam/Xanax
Clonazepam (less risk of dependency and rebound anxiety than alprazolam)
Lorazepam
Diazepam
Who is agoraphobia most often seen in?
Women
What is agoraphobia most commonly associated with in terms of psychiatric disorder?
Panic disorder.
1.1% lifetime with.
0.8% without.
What is the criteria for agoraphobia?
6+ months of marked fear/anxiety about at least 2 of the following:
Using public transportation
Being in open spaces
Being in enclosed spaces
Being in a crowd or line
Being outside alone
Causes distress/functional impairment
Not better explained by a diff disorder
What are common DDx for agoraphobia?
Social anxiety disorder (only social situations)
PTSD
OCD
MDD (lack of motivation to even be in social/public rather than fear)
Medical conditions
What is the treatment for agoraphobia?
Same as panic disorder since it is a new diagnosis.
Paroxetine most likely to be beneficial.
What is the MC demographic for social anxiety disorder?
Late childhood/early adolescence females.
What medical conditions are known for causing social anxiety disorder?
Tourette’s
Torticollis
Tremor
Disfiguring scars
What is the criteria for social anxiety disorder?
6+ months of marked fear/anxiety about 1+ SOCIAL situations in which pt is exposed to possible scrutiny.
For children, what kind of setting must they be fearful of to be diagnosed with social anxiety disorder?
Peer setting.
They cannot just be with adults.
What modifier may be applied to social anxiety disorder?
Performance only anxiety disorder instead of generalized.
What are common DDx for social anxiety disorder?
Shyness
Agoraphobia
Depression
Panic Disorder
Medical disorder
What is the treatment for generalized social anxiety disorder?
First-line: CBT, SSRI or SNRI, or both + PRN Benzo for 6-12 months.
What is the treatment for performance only social anxiety disorder?
PRN Benzo
PRN propanolol
What trauma is most likely to cause acute stress?
Witnessing a mass shooting.
What gender is more likely to have an acute stress reaction?
Female
What is an acute stress reaction?
Reaction that occurs within the initial month after an individual experiences a trauma.
What is acute stress disorder defined as?
Exposure to actual or threatened death, serious injury, or sexual violation in 1+ of the ways:
Direct experience
Witnessing as it occurred to others.
Learning about it occurring to a close family/friend
Experiencing repeated or extreme exposure to aversive details of the event.
What exposure does NOT qualify for acute stress disorder?
Electronic media
TV
Movies
Pictures
Unless work-related exposure (AKA you’re a journalist on the scene)
What is the criteria for acute stress disorder in terms of symptoms?
9+ from any of the following that lasts anywhere from 3 days to 1 month:
Intrusion symptoms
Negative mood
Dissociative symptoms
Avoidance symptoms
Arousal symptoms
What falls under arousal symptoms for stress?
Sleep disturbance
Irritable behavior
Hypervigilance
Concentration issues
Exaggerated startle response
What falls under intrusion symptoms for stress?
Recurrent memories of the event
Recurrent dreams of the event
Dissociative reactions in which you feel like its recurring
Stress in response to things that resemble the trauma
What are some DDx for acute stress disorder?
Panic or phobic disorder
PTSD
Concussions
TBI
Alzheimer’s
What is the main goal of treating acute stress disorder?
Lessening the response.
Reducing/preventing progression into PTSD.
What is the first-line treatment for acute stress disorder?
Trauma-oriented CBT with exposure therapy.
May need suicide intervention.
May need antidepressants but limited by onset.
What adjunctive therapy can be used for acute stress disorder?
Benzos if severe s/s.
What is the MC trauma in women with PTSD?
Sexual assault.
What is the MC trauma for PTSD that comes with a TBI?
Military combat
What are the main risk factors for PTSD?
Female
Severe trauma
FMHx of anxiety disorders
What comorbidities are far more common in PTSD pts?
Substance abuse (self-medicating)
Somatization disorder (90x more in PTSD)
TBI (60% of TBI pts have PTSD)
What is the main difference between PTSD and Acute stress disorder?
Duration.
Symptoms have to last more than 1 month for PTSD.
In what symptom criteria for PTSD do you need at least 2+ symptoms?
Negative changes in cognition/mood
Alterations in arousal/reactivity
What is the symptom criteria for PTSD?
1+ intrusion symptoms
1+ avoidance symptoms
2+ hyperarousal symptoms
2+ negative cognition and mood
What are the DDx for PTSD?
Acute stress disorder
OCD
Psychosis
Medical conditions
What is the first line treatment for PTSD?
Trauma-oriented CBT with exposure therapy’ plus SSRIs or SNRIs.
Pharmacotherapy alone is NOT first-line.
What medications are preferred for PTSD?
SSRIs, SNRIs.
Atypical antipsychotics can be added on for refractory.
Prazosin for insomnia
Benzos if severe agitation/hyperarousal
What is an obsession?
Mental event that causes anxiety or distress.
What is a compulsion?
Behavioral event that is carried out due to an obsession or rule/ritual.
What is OCD?
Presence of pathologic obsessions, compulsions, or both.
Usually its both.
Must be time-consuming and distressing.
What are some obsessions/compulsions?
Cleaning
Symmetry
Forbidden/taboo thoughts
Harm
Who is OCD most common in?
Children: Males
Adulthood: females
What are obsessions defined as in the DSM V?
Intrusive/unwanted recurrent thoughts that cause marked anxiety/distress.
Pt attempts to ignore or suppress thoughts.
What are compulsions defined as in the DSM V?
Repetitive behaviors or mental acts that pt feels driven to perform.
Compulsions are aimed at preventing or reducing anxiety, but are either not connected or excessive.
What are some specifiers that we add to OCD?
Degree of insight.
Tic-related
What are the levels of insight we can add to OCD?
Good or fair insight (May or may not be true)
Poor insight (thinks their OCD beliefs are prob true)
Absent insight/delusional (Fully convinced they’re true)
What are some DDx for OCD?
Phobic disorders
Body dysmorphic disorder
OCPD (also believe people should follow their OCD with them)
Trichotillomania (compulsive hair pulling that bring sense of satisfaction)
What is the treatment for OCD?
First-line: CBT with exposure therapy, SSRI, or combo.
Preferred is just psychotherapy.
SSRI is mainly because of comorbid psych disorders.
If I give an OCD pt a SSRI, what should I keep in mind?
They need higher maintenance doses of SSRIs usually.
What is a phobia?
Intense, irrational fear of a particular object or situation.
What 3 ways are phobias triggered?
Anticipation of stimulus
Actual exposure to stimulus
Non-stimulus reminders
What demographic is MC for phobias?
Females and young adults
What is the criteria for a phobic disorder?
6+ months of marked fear/anxiety about specific situation.
Almost always causes immediate fear/anxiety
Actively avoided or endured with intense fear/anxiety
Out of proportion to actual danger
Causes distress or functional impairment
Not better explained by something else
What are some DDx for a phobic disorder?
Agoraphobia
Panic disorder
Social anxiety
PTSD
What is the first-line therapy for a phobic disorder?
CBT with exposure therapy.
What is the second-line therapy for an infrequently encountered phobia?
PRN with benzo
What is the second-line therapy for a frequently encountered phobia?
SSRI, may use SNRI
