Module 3: Anxiety disorders and OCD Flashcards
What is the length of time for separation anxiety symptoms to occur in adults and children?
Children at least 4 weeks and Adults greater than 6 months
What treatments are available for separation anxiety disorder?
Psychoeducation for the family, CBT/Play therapy, SSRI’s
What SSRI’s are first line for separation anxiety?
fluoxetine, fluvoxamine, sertraline, paroxetine
What is the main criteria for selective mutism?
failure to speak in specific social situations for which there is an expectation despite speaking other situations and having no difficulty with speaking or language for at least one month
What is the main differential diagnosis for selective mutism?
social anxiety disorder
What is the treatment for selective mutism?
Psychoeducation for the family, CBT/Play therapy, SSRI’s
What SSRI’s are used to treatm selective mutism?
fluoxetine, fluvoxamine, sertraline, and paroxetine
What is the length of time that symptoms should be present to diagnose a specific phobia?
6 months or more
How prevalent are specific phobias?
One of the most common mental disorders in the US
How likely are patients with specific suicide more likely to commit suicide?
60% more than people without the condition
What is the nonpharmacologic treatment for specific phobias?
behavior therapy, insight oriented psychotherapy, virtual therapy hypnosis, supportive therapy, and family therapy?
What are the pharmocologic treatments for specific phobias?
beta adrenergic receptor antagonists such as propranolol, benzodiazepines in addition to therapy. Do not prescribe benzos alone..
What are the main criteria for diagnosing social anxiety disorder?
individual is exposed to possible scrutiny by others causing fear/anxiety and lasts for more than 6 months
What is the nonpharmacologic treatment for social anxiety disorder?
behavioral and cognitive methods, exposure therapy with performance anxiety
What are pharmacologic treatments for social anxiety disorder?
SSRI’s are first line. SNRI (venlafaxine), Buspirone (in augmentation with SSRI), Benzodiazepine (Alprazolam, Lorazepam, and clonazepam), beta-adrenergic receptor antagonists (atenolol 50 to 100 mg or propranolol 20-40 mg
Combination of pharm and nonpharm is best
What are the 3 main criteria for panic disorder?
- recurrent unexpected panic attack but can occur from calm or anxious state 2. must have 4+ symptoms, 3. must have at least one attack that has been followed by 1 month or more of persistent worry about other panic attacks or a maladaptive change in behavior related to the attacks
What are the main things to think about when diagnosing panic disorder?
be sure to ask about substance use including caffeine and other substances (20-40% have substance abuse disorder), be sure to ask about sleep
What are some differential diagnoses for panic disorder?
thyroid disorder, hyperparathyroidism, pheochromocytomas, hypoglycemia, neuropathological process such as seizure disorder, vestibular dysfunction, neoplasms, and substance use/abuse; cardiac arrhythmias, COPD, and asthma
What is the nonpharmacologic treatment for panic disorder?
CBT (superior to just taking meds alone), and family therapy
How long should pharmacotherapy be used for panic disorder once the effective medication and dose has been found?
6-12 months
What medications are effective for treating panic disorder?
SSRI 1st line treatment (paroxetine, sertraline, citalopram, escitalopram, fluvoxamine, fluoxetine
SNRI (venlafaxine)
Buspirone
Benzodiazepine (alprazolam, lorazepam)
TCA’s clomipramine and imipramine common but can use other
MAOI’s
Mood stabilizer can be used as adjunct
How long should patients be on benzodiazepines in panic disorder?
4-12 weeks
How long should benzos be tapered off with panic disorder?
4-10 weeks
what are some things to consider when using TCA’s for panic disorder?
slowly titrate up (can take up to 8-12 weeks and high doses are often needed but can cause problematic side effects)
What is the main panic attack specifier criteria?
this is different that panic disorder but must still have 4+ symptoms. This is added to the diagnosis (ie. major depressive disorder with panic attack)
What is included in the diagnosis of panic attack specifier?
other paroxysmal episodes such as anger or grief, anxiety disorder due to another medical condition, substance/medication induced anxiety disorder, panic disorder
What is the treatment for panic attack specifier?
Same as panic disorder treatment
How many criteria must be met to diagnose agoraphobia?
2+ out of 5
What are the 5 situations used for diagnosing agoraphobia?
fear or anxiety in 2 of these 5 situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, being outside of the home alone
What is the treatment for panic attack specifier?
treat the primary disorder then adjunct as needed
Diagnosis of agoraphobia include what main two things?
fits DSM criteria and oftentimes has another mental illness such as anxiety disorder, MDD, PTSD panic disorder, etc.
What is the nonpharmacologic treatment for agoraphobia?
supportive or insight-oriented psychotherapy, cognitive or behavioral therapy, or virtual therapy
What is the pharmacologic treatment for agoraphobia?
SSRI’s are first line. Benzodiazepines and TCA’s including clomipramine and imipramine
What are the three main criteria necessary to meet diagnosis for generalized anxiety disorder?
excessive anxiety and worry more days than not for more than 6 months
difficult to control the worry
Have had 3+ symptoms for the past 6 months
What are the 6 possible symptoms used for diagnosing general anxiety disorder?
being restless or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance
How many symptoms must be present to diagnose general anxiety symptoms in children?
One
What lab testing could be considered when diagnosing generalized anxiety disorder?
TSH, Free T4, drug screen, PFT’s, ECG, EEG, Echo, 24 hour urine, etc
What is one important thing to consider when considering treatment for generalized anxiety disorder?
symptom relief is not always the most appropriate course of action
consider if the anxiety is normal, adaptive, maladaptive, too intense, or too mild
What percent of patients will relapse within one month of stopping treatment of GAD?
25%
What percent of GAD patients will relapse of stopping treatment within 12 months?
60-80%
What is the nonpharmacological treatment for GAD?
CBT, supportive, insight-oriented, psychodynamic
What is the length of time for pharmacologic treatment for GAD?
minimum of 6-12 months up to long term or even life-long
What medications could be considered for treatment in GAD?
SSRI’s (sertraline, citalopram, paroxetine, and could consider fluoxetine, fluvoxamine or escitalopram)
SNRI (venlafaxine)
Buspirone (works in 60-80% of those with GAD)
Benzodiazepine (25-30% will respond; give 2-3 weeks then taper over 1-2 weeks)
Antihistamine (hydroxizine)
TCA’s
Beta adrenergic antagonists (propranolol can be used for somatic symptoms)
What are the primary criteria for substance/medication-induced anxiety disorder?
panic attack or anxiety is predominant, development of symptoms during or soon after substance intoxication or withdrawal
What are the common offenders of substance/medication-induced anxiety disorder?
amphetamine, cocaine, caffeine, alcohol, LSD, MDMA
What are the criteria for anxiety disorder due to another medical condition?
Panic attack or anxiety is predominant; direct pathophysiological consequence or another medical condition such as anxiety disorder due to pheochromocytoma
What is the treatment for anxiety disorder due to another medical condition?
referral to PCP or specialist for treatment of medical condition, obtain appropriate labs as needed, treat symptoms as needed
What is the main criteria for “other specified and unspecified anxiety disorder?
symptoms causing functional impairment but not meeting full criteria of other anxiety disorders
What is considered an obsession?
recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted
What are compulsions?
repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
What is most pertinent about obsessive/ compulsive symptoms regarding obsessive compulsive and related disorders?
must be excessive or persisting beyond developmentally appropriate periods
What is the main criteria for OCD?
presence of obsessions, compulsions, or both; time consuming taking more than 1 hour
What is the rate of suicide attempts in individuals with OCD?
25%
What is the nonpharmacologic treatment of OCD?
behavioral therapy (as effective as medication); supportive psychotherapy, family therapy, insight oriented psychotherapy; ECT
What is the pharmacologic treatment for OCD?
SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
TCA: clomipramine (1st OCD med approved by the FDA- no longer first line treatment)
Mood stabilizers: valproate, lithium, carbamazepine
SNRIs: venlafaxine
Others: pindolol, phentzine, buspirone, L-tryptophan, clonazepam, risperidone
What is the criteria for body dysmorphic disorder?
preoccupation with 1+ perceived effects or flaws in physical appearance that are not observable to appear slight to others causing repetitive behaviors or mental acts in response
Are there any major concerns with body dysmorphic disorder?
High rates of suicide
What is the main idea of treatment with body dysmorphic disorder?
treat the co-existing disorder first
What are the main criteria for hoarding disorder
holding on to objects regardless of value and distress with discarding objects; specifiers related to insight and excessive acquisition which is common in 80-90% of cases
What are 2 things to remember when diagnosing hoarding disorder?
Often times 75% will have another mood or anxiety disorder; be sure to assess their overall health and safety
What is important to remember about hoarding disorder?
It is very hard to treat because their insight can be poor and they usually don’t want treatment. There is only an 18% response rate.
What is the main criteria for diagnosing trichtillomania?
pulling out hair which results in hair loss, attempts to stop, and causing significant distress
What are some important things to remember when diagnosing trichtillomania?
rule out other conditions associated with this (carpal tunnel syndrome, neck, back, shoulder pain, blepharitis, dental damage, digit purpura); also find out how they are disposing of the hair.
What is trichophagia?
swallowing of hair and can cause serious problems
What is non-pharmacological treatment of trichtillomania?
dermatology for topical steroids, behavioral therapy, insight-oriented therapy, hypnotherapy
What is pharmacological treatment of trichtillomania?
hydroxyzine, SSRIs- fluvoxamine, citalopram; augment with pimozide; can also try venlafaxine, naltrexone, lithium, buspirone, clonazepam, and trazedone
What are the main criteria of excoriation disorder?
recurrent skin picking resulting in lesions; attempts to decrease or stop
What are some things to think about when diagnosing excoriation disorder?
assess for infection/other compilations; often has the comorbid mental health conditions (MDD, anxiety diorders, OCD)
What is the non-pharmacological treatment for excoriation disorder?
CBT
What is the pharmacologic treatment for excoriation disorder?
SSRIs- fluoxetine; naltrexone, lamotrigine
What is the indication in the DSM for substance/medication-induced OC and related disorders?
obsessions compulsions, skin picking, hair pulling, other body focused repetitive behaviors that occur soon after substance intoxication or withdrawal or other exposure to a medication
What is the treatment for substance/medication-induced OC and related disorders?
stop the medication or substance; treatment as needed; monitor for any physical complications related to the cessation of substance or medication or related to the behavior- referral if needed
What is the indication for OC and related disorder due to another medical condition?
obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors that occur related to a direct pathophysiological consequence of another medical condition
What are two common medical conditions found with OC and related disorder due to another medical condition?
Sydenham’s chorea, PANDA’s
What is the criteria for other and unspecified obsessive-compulsive and related disorder?
Cause significant distress but doesn’t meet full criteria of the other disorders: body dysmorphic like disorder with actual flaw, body dysmorphic like disorder without repetitive behaviors, body-focused repetitive behavior disorder, obsessional jealousy
what is the most common mental health problem in children and teens?
anxiety and OCD disorders
Co-morbidities are the rule, not the exception. What are common co-morbidities?
depression, ODD, learning disorders, eating disorders, ADHD, substance abuse; often misdiagnosed with ADHD
What types of symptoms may look different regarding anxiety and OCD in children?
somatic/physical signs/symptoms; behavioral signs/symptoms
What are some somatic/physical signs/symptoms seen in children with anxiety and OCD disorders?
stomach pain, headache, chest pain fatigue, restlessness, irritability, sleep difficulties, palpitations, increased HR;BP, dizziness, tingling, weakness, tremors, SOB
What are some behavioral signs/symptoms of children with anxiety/OCD disorders?
escape/avoidant behaviors, crying, clinging to parents, soft voice, variations in speech, nail-biting, thumb-sucking, hypervigilance, freezing, regression, insomnia, poor concentration, social withdrawal, anger
What is the anxiety screening tool for teens?
GAD-7
What is the anxiety screening tool for ages 10-21?
KYSS Worries Questionnaire
What is the anxiety screening tool for ages 8-17?
SCARED
What are somethings to rule out when diagnosing anxiety in children?
hypoglycemia, hyperthyroidism, pheochromocytoma, seizure disorder, cardiac arrhythmia, migraine headaches, brain tumor, hypoxia, asthma, lead intoxication
What are some common meds/drugs that can cause anxiety in children?
nicotine, diet pills, antihistamines, anti-asthmatics, marijuana, sympathomimetics, stimulants, steroids, antipsychotics, SSRIs
What are non-pharmacological interventions for children with anxiety/OCD?
psychoeducation for the family and cooperation is essential; environmental changes in sleep stressors, routine
What is first line pharmacological treatment for anxiety in children?
SSRI’s and buspirone
What medication can be used for sleep disturbance?
Benadryl
What is second line treatment for anxiety in children?
Venlafaxine and benzos
