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Psych > Rosenthal - Mood and Anxiety Disorders > Flashcards

Rosenthal - Mood and Anxiety Disorders Flashcards

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1
Q

What do you need to do before working up a pt for a psych disorder/panic attack?

A
  • Make sure they are not presenting with a medical disorder -> ex: start with an EKG with pt coming in with palpitations
  • Once you’ve ruled out potential medical causes, calmly explain to the pt what you think is going on
  • For immediate relief, you can give a BNZ
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2
Q

How can diet pills affect people with panic disorder?

A
  • Can exacerbate panic attacks

- People may not realize the effects these drugs are having

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3
Q

When treating BNZ withdrawal, why is drug concentration so important?

A
  • It is crucial to try and DEC drug levels in the body at a protracted rate
  • Will need to be several days (to weeks) of tx and taper
  • REMEMBER: Flumazenil is a last resort, and can facilitate convulsions if administered too rapidly
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4
Q

How can HIV present as a psych case?

A
  • Can cause medically-induced mania
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5
Q

What is anxiety?

A
  • Fear: fight or flight
  • Stress
  • Both physiological and psych symptoms
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6
Q

What is mood?

A
  • A persistent state, expressed in thought, emotion, behavior, and bodily functions
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7
Q

What are the unifying features of anxiety disorders?

A
  • Share features of excessive and persistent bouts of fear (emotional response to real or perceived imminent threat) and anxiety (anticipation of future threat)
  • Related behavioral disturbances
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8
Q

What are the 6 major anxiety disorders?

A
  • Specific (simple) phobia
  • Social anxiety disorder (social phobia)
  • Panic disorder
  • Agoraphobia
  • Generalized anxiety disorder
  • Substance-induced anxiety disorders
  • NOTE: like all other categories, there is also anxiety disorder due to another medical condition
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9
Q

What should be on your differential for panic and other anxiety disorders?

A
  • Angina
  • Cardiac arrhythmias
  • Hypoglycemia
  • Thyrotoxicosis
  • Schizophrenia
  • Mood disorders
  • Drugs: sympathomimetics, caffeine, antipsychotics
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10
Q

What are some examples of specific (simple) phobias? Tx?

A
  • Common phobia in medical setting: MRI
    1. Need to be taken seriously; pt can’t “simply will himself” to tolerate the enclosed space -> if open MRI not suitable, pt has to be sedated
  • Vasovagal (fainting) episodes involving BLOOD, NEEDLES, and injury are also common in medical settings; may or may not be phobias -> may just be a physiological reaction
  • Only need to be treated if they interfere with important activities
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11
Q

What is social anxiety disorder?

A
  • Fear of embarrassment in social situations

- Developmental experiences are important contributing factors

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12
Q

What is the usual portal of entry for panic disorder?

A
  • ER
  • Symptoms are frightening and somatic in nature
  • These pts can be referred to specialties as diverse as pulmonology (SOB), cardio (palpitations), neuro (tingling and numbness), otolaryngologist (choking sensation), gynecologist (hot flashes), gastroenterologist (nausea, abdominal pain), and urologist (frequent urination)
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13
Q

What are the features of agoraphobia?

A
  • Marked, persistent fear or anxiety about 2 or more of the following situations:
    1. Using public transportation
    2. Being in open spaces: parking lots, bridges, marketplaces
    3. Being in shops, theaters, cinemas
    4. Standing in line, or being in a crowd
    5. Being outside of the home alone
  • Often the consequence of undiagnosed, untreated, or under-treated panic disorder
  • NOTE: this fear and avoidance may or may not be accompanied by panic attacks -> if present, both dx’s are given (important bc untreated panic disorder can deteriorate into agoraphobia, which is much more disabling than acute panic disorder)
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14
Q

How is phobia treated?

A
  • SOCIAL: rehearsal, improved competence, facing your fears, Toastmasters International
  • SIMPLE: short-term tx with short-acting BNZ for symptomatic relief (fear of flying, claustrophobia in MRI)
    1. Repeated gradual exposure (systematic desensitization) to feared stimulus for lasting relief, like fear of getting into swimming pool or proximity to cats/dogs
  • AGORAPHOBIAS: gradual exposure (systematic desensitization) + SSRI’s
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15
Q

How might pts with generalized anxiety disorder “slip through the cracks?”

A
  • SOMATIC SYMPTOMS ARE VERY COMMON, and often the chief complaint
  • Pt does not realize connection between anxiety and somatic symptoms, seeking help only for the somatic complaints
  • Inquire and pay attention to any pt’s psychosocial situation when evaluating vague symptoms that don’t seem to make sense
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16
Q

What substances/meds can induce anxiety disorders? How do these commonly present?

A
  • Stimulants: cocaine, methamphetamine, ADHD meds, caffeine
  • Alcohol: mini-withdrawals
  • OTC decongestants and cough syrup
  • PANIC ATTACKS PREDOMINATE
17
Q

What are some medical conditions that can cause anxiety disorders? Dx?

A
  • Endocrinopathies: pheochromocytoma, hyperthyroidism, hypoglycemia
  • Metabolic problems
  • Neuro problems, e.g., vestibular neuritis
  • Dx is made if pt’s medical condition is known to induce anxiety, AND preceded the onset of anxiety
  • NOTE: may be the physician’s job to detect the medical condition, and know that it has been known to precipitate anxiety symptoms
    1. Think about what kind of med conditions (psychiatric and otherwise) can create an anxiety syndrome, incl. palpitations, sweaty palms, SOB, impending feeling of doom, etc.
18
Q

What are the obsessive-compulsive and related disorders? Unifying features?

A
  • All involve RECURRENT, UNWANTED INTRUSIVE THOUGHTS, and usually the pt knows the thoughts are not logical -> irresistible need to act on these thoughts reduces anxiety
  • OCD
  • Body dysmorphic disorder
  • Hoarding disorder
  • Hair-pulling disorder: trichotillomania
  • Skin-picking disorder: excoriation
19
Q

What are some of the common obsessions in OCD?

A
  • Aggression
  • Contamination
  • Symmetry
  • Sexual
  • Hoarding
  • Religious
  • Somatic
  • > 50% have multiple
20
Q

What is the takeaway for the anxiety disorders?

A
  • Anxiety and panic are COMMON SYMPTOMS in the medical setting
  • A thorough BIO-PSYCHO-SOCIAL HX, combined with a thorough med assessment, will reveal the source
  • Problem may be psychiatric illness, situational factors, medical problems, adverse drug effects, or a combo
21
Q

What are mood disorders?

A
  • Unusually intense and persistent mood (usually depression, elation, irritability, dyscontrol) that compromises self-care, adaptive functioning, ability to effectively cope with life’s duties, and impairs interpersonal relationships
22
Q

What are the 5 common mood disorders?

A
  • Bipolar
  • Cyclothymic
  • Major depressive episode
  • Persistent depressive disorder (cyclothymia)
  • Premenstrual dysphoric disorder
23
Q

What is bipolar disorder?

A
  • Seen as a bridge between psychotic disorders and depressive disorders, in terms of symptomatology, family history, and genetics
24
Q

What are the features of bipolar I disorder?

A
  • Classic “manic depression”
  • Full-blown MANIA is a psychotic disorder: pt loses contact with reality, exhibiting severely impaired judgment
  • Vast majority of bipolar pts experience at least one major DEPRESSIVE EPISODE in their lifetime, in addition to mania
  • NOTE: manic symptoms can be caused by drugs and medical conditions, e.g., stimulants, hyperthyroidism, CNS diseases, Cushing’s -> MEDICAL CAUSES MUST BE RULED OUT
25
Q

What are the features of bipolar II disorder?

A
  • Distinct period of abnormally or persistently elevated, expansive, or irritable mood (HYPOMANIA), and abnormal or persistently INC activity or energy, lasting AT LEAST 4 CONSECUTIVE DAYS, and present most of the day, nearly every day
  • Pt must also have a hx of MAJOR DEPRESSION that lasted at least 2 WEEKS
  • Pt’s “up” episodes may actually be experienced as (+), with heightened energy, creativity, and productivity, also thought to be “within the normal range” -> but, their alternation with recurrent depressions causes significant IMPAIRMENT and DISTRESS
  • NOTE: rapid mood swings are very common in pts with borderline personality disorder, but they do not last nearly as long -> much quicker, and more dependent upon what happened during the day
26
Q

What are the features of cyclothymic disorder?

A
  • Rapidly alternating mood states, occurring for AT LEAST 2 YEARS, but never meeting criteria for hypomania, major depression, or mania
  • Each episode lasts for SEVERAL DAYS
  • Looks like borderline personality disorder, but borderline pts’ mood swings are more rapid and situation-dependent
    1. Pts may meet criteria for both diagnoses
  • NOTE: chaotic life circumstances, self-injurious behavior, and a history of abuse may be more prominent in BPD than in pt with cyclothymic disorder
27
Q

What are the features of major depressive disorder (episode)? How is this similar to/different from bereavement?

A
  • Persistent sadness that impairs daily function, and is out of proportion (intensity and duration) to life events
  • NOTE: intense sadness after bereavement is not abnormal and comes over the pt in waves; most people recover without psych help -> bereavement can, however, morph into major depression, in which case it would be tx’d as such
    1. If pt does not get back on their feet, and gets worse and worse, you may be dealing with major depression -> if pt gradually improves, and tendency is toward getting better, pt may be experiencing bereavement, which is NOT a mental illness
28
Q

What are the features of persistent depressive disorder?

A
  • Aka, dysthymia
  • Low mood for 2 OR MORE YEARS
  • Never without symptoms
  • Causing clinically significant impairment or distress
  • Think of EEYORE: world always problematic, and unable to look on the bright side
29
Q

What are the features of premenstrual dysphoric disorder?

A
  • Pt suffers combo of symptoms in the WEEK B4 MENSES, which may include: marked affective lability, irritability, anger, interpersonal conflicts, feeling on edge, anxiety, depression, over-eating, food cravings, sleep problems, feeling overwhelmed and out of control
  • Must have lasted for the BETTER PART OF A YEAR, and symptoms must disappear shortly after onset of menses, and not just be an exacerbation of ongoing interpersonal conflicts
  • Must be measured prospectively by keeping a DAILY DIARY, for at least 2 SYMPTOMATIC MONTHS
    1. If pts not motivated to keep diary, you may wonder if you are dealing with a generally unstable person instead of this specific disorder
  • Easily over-diagnosed
30
Q

How can you easily “screen” pts for mood disorders?

A
  • In mood disorders, like most other psych disorders, chief complaint may be “medical,” not psychological:
    1. No energy, can’t sleep, or sleeping too much; can’t eat, or eating too much; aches and pains, digestive problems, can’t concentrate, can’t remember things
  • ASK about life events, crises, challenges, and mood symptoms
  • ASK about personal and family history of mood and anxiety disorders
  • Rule out obvious medical causes, but don’t hunt for “zebras”
31
Q

How can you treat depression?

A
  • Hopeful, optimistic tone
  • Assess severity of depressive syndrome, not forgetting to acknowledge potential cultural difference
  • Extensive psych probing should not be attempted when pt is deeply depressed
  • ASSESS SUICIDAL RISK, and reassess frequently
  • Treat moderate-severe depression aggressively with somatic therapy:
    1. Severely depressed or suicidal pts may need to be hospitalized and outpatients may need frequent (bi-weekly), brief (10-15 min) contacts for support and med mgmt until their depression lifts
    2. Most pts need at least 16-20 wks of maintenance meds, then trial of DEC or discontinuing med -> re-start if symptoms come back, and consider chronic tx
  • Clinician should look for psychosocial stressors, and counsel on coping mechanisms, if relevant
  • Clinician should help pt learn to abandon negative attitudes via CBT or other psychotherapeutic techniques
32
Q

What is the tx for mania?

A
  • Somatic tx to aggressively tx manic symptoms ASAP, and follow-up closely with pt as mania “breaks” to determine whether subsequent depression is emerging
  • After mania, pts should receive maintenance med, and may take mood stabilizer for many years, or chronically to prevent relapses
  • Advise about importance of SLEEP HYGIENE
  • Even when pts are stable, F/U regularly to ensure compliance and to monitor blood levels (if applicable)
  • Most pts require supportive psychotherapy to help them cope with devastating consequences of manic episodes
  • Provide family members with psych support and educational materials
  • Tell pts the “good side” of their illness -> its association with CREATIVITY and high achievement
33
Q

What % of pts who receive an antidepressant will markedly improve? How long should drug trials last?

A
  • 65-70%
  • Drug trials should last 4-8 weeks
  • NOTE: can also boost effectiveness by augmenting treatment with another drug, like beta-blockers, anti-psychotics, triiodothyronine
34
Q

When might you tx with MAOI’s?

A
  • Atypical depression: involves several specific symptoms, including increased appetite or weight gain, sleepiness or excessive sleep, marked fatigue or weakness, moods that are strongly reactive to environmental circumstances, and feeling extremely sensitive to rejection
35
Q

What should you monitor for in every pt on antidepressants?

A
  • Suicidal thoughts
36
Q

How should antidepressants be discontinued?

A
  • Gradually
37
Q

What are some alternative therapies for depression (non-pharmacological)?

A
  • Electroconvulsive therapy (ECT)
  • Repetitive transcranial magnetic stimulation (rTMS)
  • Vagal nerve stimulation (VNS)
  • Psychotherapy
  • Biofeedback
  • Relaxation Training
  • Deep Breathing/Yoga
  • Mindfulness Meditation

Psych (11 decks)

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