Anxiety Disorders; Trauma- And Stress-Related Disorders

Question 1

Generalized anxiety disorder (GAD)

Answer 1

• excessive anxiety or worry a majority of days for at least a 6 month period
• about various aspects of life
• not episodic (panic disorders), situational (phobias), nor focal
• MC in females
• onset= early 20s

Question 2

GAD- symptoms

Answer 2

• 3 or more:
  
  • fatigue
  • restlessness
  • difficulty concentrating
  • muscle tension
  • sleep disturbance
  • irritability
  • shakiness
  • HA
• not due to medical illness

Question 3

GAD- management

Answer 3

• medication:
  
  • antidepressants:
    
    • SSRIs (paroxetine, escitalopram)
    • SNRIs (venlafaxine)
  • buspirone (buspar)- stimulates serotonin receptors and blocks dopamine receptors
    
    • may take several weeks before improvement
    • does not cause sedation*
    • SE= nausea, RLS, extrapyramidal symptoms, dizziness
  • benzodiazepines (short-term use only)
  • beta blockers
  • TCAs
• psychotherapy: CBT

Question 4

Panic disorder

Answer 4

• 2-3x MC in women

- onset= before age 30

Question 5

Panic disorder- criteria

Answer 5

• recurrent, unexpected panic attacks* (at least 2)
  
  • may or may not be related to a tigger
  • sudden in onset, peaks within 10 minutes, lasts <60 minutes
• at least 1 must occur for at least 1 month:
  
  • panic attacks often followed by concern about future attacks
  • worry about implication of attacks (losing control)
  • significant change in behavior related to attacks
• at least 4 of 13 typical symptoms of panic
• symptoms not due to substance use, medical condition, or other mental disorder
• +/ agoraphobia- anxiety about being in places or situations from which escape can be difficult
  
  • now seen as separate entity

Question 6

Panic attack- symptoms

Answer 6

• dizziness
• trembling
• choking feeling
• paresthesias
• sweating
• SOB
• CP/discomfort
• chills or hot flashes
• fear or losing control
• fear of dying
• palpitations, increased HR
• nausea or abdominal distress
• depersonalization or derealization

Question 7

Panic disorder- management

Answer 7

Long-term

• medication:
  
  • first line= SSRIs* (paroxetine, sertraline, fluoxetine)
    
    • SNRIs (venlafaxine)
• psychotherapy: initial therapy in mild cases
  
  • CBT- focuses on thinking and behavior (realization, desensitization, examining behavior consequences

Acute attack

• first line= benzodiazepines (alprazolam, clonazepam, lorazepam)*
  
  • watch for dependence or abuse

Question 8

Phobic disorders

Answer 8

?

Question 9

PTSD

Answer 9

• MC in young adults
  
  • men= combat experience and urban violence
  • women= rape or assault

Question 10

PTSD- criteria

Answer 10

• exposure to actual or threatened death, serious injury, or sexual violence via:
  
  • direct experience of traumatic event
  • witnessing event in person
  • learning event happened to someone close (family member or friend)
  • experiencing extreme or repeated exposure to aversive details of traumatic event (first responders collecting human remains during 9/11)
• presence of 1 or more intrusion symptoms after event that may lead to significant distress or impairment in function (occupational, social, or other areas):
  
  • re-experiencing: >1 month* as…
    
    • repetitive recollections (distressing dreams)
    • dissociative reactions (flashbacks)
    • ^^leading to physiologic distress and/or physiologic reactions
  • avoidance of stimuli associated with event (reminders)
  • negative alterations in condition and mood:
    
    • inability to remember an important aspect of event
    • persistent exaggerated beliefs (world is unsafe)
    • horror, guilty, anger, shame, disinterest in activities
  • arousal and reactivity:
    
    • angry outbursts, irritable behavior, reckless or self-destructive behaviors, hypervigilance sleep disturbances, concentration issues, exaggerated startle response

Question 11

PTSD- management

Answer 11

• medication:
  
  • antidepressants:
    
    • first line= SSRIs* (paroxetine, sertraline, fluoxetine)
    • TCAs (imipramine)
    • MAOIs
    • trazodone may be helpful for insomnia
• psychotherapy: CBT, individual or group counseling

Question 12

Acute stress disorder

Answer 12

• similar to PTSD, but…
  
  • symptoms last <1 month*
  • onset= within 1 month of event
• management:
  
  • counseling/psychotherapy
  • if persistent -> treat at PTSD

Question 13

Specific phobias

Answer 13

• persistent (>6 months) intense fear/anxiety of…
  
  • specific situation (heights, flying)
  • object (pigeons, snakes, blood)
  • place (hospital)
• fear out of proportion to any real danger
• phobic object or situation is actively avoided or endured with intense fear or anxiety
• everyday activities must be impaired by distress or avoidance

Question 14

Specific phobias- management

Answer 14

• childhood phobias may disappear or lessen with age
• treatment of choice= exposure/desensitization therapy
• medication:
  
  • short-term benzodiazepines and beta blockers can be used in some patients