Anxiety d/os, trauma and stress-related d/os

Question 1

What are the major mediators of sx of anxiety d/os?

Answer 1

Norepinephrine
Serotonin
Dopamine
GABA

Question 2

Etiology of GAD

Answer 2

Psychoanalytic, behavioral, and existential theories
Increased sympathetic tone
Slow adaptation to repeated stimuli
Excessive response to moderate stimuli
Excessive ans sustained cortisol secretion
Corticotropin-releasing hormone
Low NPY
Low galanin
Genetics
Increased activity in the septohippocampal pathway

Question 3

DSM-5 criteria for panic d/o

Answer 3

Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following sx occur:
-Palpitations, pounding heart, or accelerated heart rate
-Sweating
-Trembling or shaking
-Sensations of SOB or smothering
-Feelings of choking
-CP or discomfort
-Nausea or abdominal distress
-Feeling dizzy, unsteady, light-headed or faint
-Chills or heat sensations
-Paresthesias
-Derealization or depersonalization
-Fear of losing control or going crazy
-Fear of dying
At least one of the attacks has been followed by 1 mo or more of one or both of the following:
-Persistent concern or worry about additional panic attacks or their consequences
-A significant maladaptive change in behavior related to the attacks

Question 4

Etiology of panic d/o

Answer 4

Autonomic imbalance
Decreased GABA
Allelic polymorphism of the COMT gene
Increased adenosine receptor function
Increased cortisol
Diminished benzodiazepine receptor function
Disturbances in serotonin, serotonin transporter and promoter genes, NE, dopamine, cholecystokinine and interleukin 1-beta
Chronic hyperventilation and carbon dioxide receptor hypersensitivity
Genetics

Question 5

Etiology of panic d/o- other theories

Answer 5

Serotonergic model
Catecholamine model
Locus coeruleus model
Lactate model
Neuroanatomic model involving amygdala, hypothalamus, and brainstem centers
Cognitive theory

Question 6

Workup for panic d/o

Answer 6

Serum electrolytes to exclude hypokalemia and acidosis
Serum glucose to exclude hypoglycemia
Cardiac enzymes in pts suspected of acute coronary syndromes
Serum hemoglobin in pts with near syncope
TSH in pts suspected of hyperthyroidism
Urine tox screen for amphetamines, cannabis, cocaine and phencyclidine
D-dimer assay to exclude pulm embolism

Question 7

Tx for panic d/o

Answer 7

CBT, with or without pharmacotherapy is tx of choice
Other psychological tx modalities
Educate pt regarding the importance of longer-term pharm management with SSRIs
Only provide benzos in very limited quantities to emphasize the emergency aspect of them

Question 8

ED management of panic d/o

Answer 8

Pts with CP, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or Fowler position
Educate the pt that their sx are neither from a serious medical condition nor from a psychotic d/o
Pts may require frequent reassurance and explanation

Question 9

What are second line meds for panic d/o after SSRIs?

Answer 9

TCAs, such as imipramine or clomipramine may be considered for the management of panic disorder if an SSRI is not suitable or if there is no improvement after a 12-wk course of SSRI tx

Question 10

What is a good med choice in panic d/o for pts with complicated medical regimens or for those who are concerned with drug interactions?

Answer 10

Citalopram and escitalopram

Question 11

What is suggested for use in panic d/o with co-occurring depression?

Answer 11

Fluoxetine

Question 12

What is usually prescribed in panic d/o to help improve with sleep?

Answer 12

Paroxetine, mirtazapine, and TCAs

Paroxetine is category D

Question 13

DDx of panic d/o: cardiovascular dz

Answer 13

Anemia
Angina
CHF
Hyperactive beta-adrenergic state
HTN
Mitral valve prolapse
MI
Paradoxical atrial tachycardia

Question 14

DDx of panic d/o- pulm dz

Answer 14

Asthma
Hyperventilation
Pulmonary embolus

Question 15

DDx of panic d/o- neurological dz

Answer 15

Cerebrovascular dz
Epilepsy
Huntington's dz
Infection
Meniere's dz
Migraine
Multiple sclerosis
TIA
Tumor
Wilson's dz

Question 16

DDx of panic d/o- endocrine diseases

Answer 16

Addison's
Carcinoid syndrome
Cushing's syndrome
DM
Hyperthyroidism
Hypoglycemia
Hypoparathyroidism
Menopausal d/os
Pheochromocytoma
PMS

Question 17

DDx of panic d/o- drug intoxications

Answer 17

Amphetamine
Amyl nitrite
Anticholinergics
Cocaine
Hallucinogens
Marijuana
Nicotine
Theophylline

Question 18

DDx of panic d/o- drug withdrawal

Answer 18

Alcohol
Antihypertensives
Opiates and opioids
Sedative-hypnotics

Question 19

DDx of panic d/o- other conditions

Answer 19

Anaphylaxis
B12 deficiency
Electrolyte disturbances
Heavy metal poisoning
Systemic infections
SLE
Temporal arteritis
Uremia

Question 20

Duration of pharmacotherapy for panic d/o

Answer 20

8-12 mos

Question 21

Acrophobia

Answer 21

Fear of heights

Question 22

Agoraphobia

Answer 22

Fear of open places

Question 23

Ailurophobia

Answer 23

Fear of cats

Question 24

Hydrophobia

Answer 24

Fear of water

Question 25

Claustrophobia

Answer 25

Fear of closed spaces

Question 26

cynophobia

Answer 26

Fear of dogs

Question 27

Mysophobia

Answer 27

Fear of dirt and germs

Question 28

Pyrophobia

Answer 28

Fear of fire

Question 29

Xenophobia

Answer 29

Fear of strangers

Question 30

Zoophobia

Answer 30

Fear of animals

Question 31

Theories of phobias

Answer 31

Classic conditioning Operant conditioning Learning theory Psychodynamic theories of displacement, projection, and avoidance Counterphobic attitudes In specific phobia, the pairing of a specific object or situation with the emotions of fear and panic Genetic factors

Question 32

DSM-5 criteria for specific phobia

Answer 32

Marked fear or anxiety about a specific object or situation The phobic object or situation almost always provokes immediate fear or anxiety The phobic object or situation is actively avoided or endured with intense fear or anxiety The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context The fear, anxiety, or avoidance causes is persistent, typically lasting for 6 mos or more

Question 33

Tx of specific phobia

Answer 33

``` Behavior therapy: models Systemic desensitization Imaginal flooding Virtual therapy Exposure therapy Insight-oriented psychotherapy ```

Question 34

Neurochemical factors in social anxiety disorder

Answer 34

Adrenergic theory: pts with performance phobias may release more NE or epi, both centrally and peripherally Dopaminergic dysfunction

Question 35

DSM-5 criteria for social anxiety disorder

Answer 35

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others The individual fears that he or she will act in a way or show anxiety sx that will be negatively evaluated The social situations almost always provoke fear or anxiety The social situations are avoided or endured with intense fear or anxiety The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context The fear, anxiety, or avoidance is persistent, typically lasting 6 mos or more

Question 36

Workup for social anxiety disorder

Answer 36

Basic labs to screen for comorbid conditions such as anemia, low ferritin levels, and hypothyroidism

Question 37

DDx considerations for social anxiety d/o

Answer 37

``` Appropriate fear and normal shyness Agoraphobia Panic d/o Avoidant personality d/o Major depressive d/o Schizoid personality d/o ```

Question 38

Pharmacotherapy for the tx of social anxiety d/o

Answer 38

``` SSRIs BZDs Venlafaxine Buspirone Severe cases- irreversible MAOIs SAD associated with performance situations: Beta-adrenergic receptor antagonists Short or immediate-acting BZD ```

Question 39

Psychotherapy for social anxiety d/o

Answer 39

Cognitive retraining Desensitization Rehearsal during sessions Homework assignments

Question 40

Research and hypotheses with GAD- biological factors

Answer 40

GABA and serotonin neurotransmitter systems Occipital, basal ganglia, limbic system, and frontal cortex NE, glutamate, cholecystokinin systems Genetic studies EEG abnormalities in sleep

Question 41

Psychosoical factors in GAD

Answer 41

CBT theory- pts with GAD respond to incorrectly and inaccurately perceived dangers. The inaccuracy is generated by selective attention to negative details in the environment, by distortions in information processing, and by an overly negative view of the person's own ability to cope Psychoanalytic school- anxiety is a symptom of unresolved, unconscious conflicts

Question 42

DSM-5 criteria for GAD

Answer 42

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 mos, about a number of events or activities The individual finds it difficult to control the worry The anxiety and worry are associated with three or more of the following six sx, with at least some sx having been present for more days than not for the past 6 mos: Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance

Question 43

Workup for GAD

Answer 43

``` CBC CMP Thyroid function UA Urine drug screen When CNS d/o suspected: EEG, LP, or CT When cardiac d/o suspected: EKG To r/o infection: RPR, LP, or HIV test ABG to exclude hypoxemia or metabolic acidosis ```

Question 44

Tx of GAD

Answer 44

``` CBT Short-term BZD use Buspirone Venlafaxine Sertraline, citalopram or paroxetine- better SSRI choices for high anxiety ```

Question 45

Psychological theories of PTSD

Answer 45

Psychodynamic- the trauma has reactivated a previously quiescent, yet unresolved psychological conflict Cognitive-behavioral: Affected persons cannot process or rationalize the trauma that precipitated the disorder Two phases: Classic conditioning Instrumental learning

Question 46

Biological factors of PTSD

Answer 46

Altered function in the noradrenergic system Opioid system hyperregulation Hyperregulation of the HPA axis- low plasma and urinary free cortisol, blunted ACTH Structural changes in the amygdala

Question 47

DSM-5 criteria for PTSD: exposure

Answer 47

Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: Directly experiencing the traumatic event(s) Witnessing, in person, the event(s) as it occurred to others Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend,the event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to averse details of the traumatic event(s)

Question 48

DSM-5 criteria of PTSD: intrusion sx

Answer 48

``` Presence of one or more of the following intrusion sx associated with the traumatic event(s), beginning after the traumatic event(s) occurred: Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) ```

Question 49

DSM-5 criteria of PTSD: persistent avoidance

Answer 49

Persistent avoidance of stimuli associated with the traumatic event(s) beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

Question 50

DSM-5 criteria for PTSD: negative alterations in cognitions and mood

Answer 50

Negative alterations in cognition and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: Inability to remember an important aspect of the traumatic event(s) Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world Persistent, distorted cognitions about the cause or consequences of traumatic event(s) that lead to the individual to blame himself/herself or others Persistent negative emotional state Markedly diminished interest or participation in significant activities Feelings of detachment or estrangement from others Persistent inability to experience positive emotions

Question 51

DSM-5 criteria for PTSD: marked alterations in arousal and reactivity

Answer 51

Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects Reckless or self-destructive behavior Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance

Question 52

DSM-5 criteria for PTSD: duration

Answer 52

Duration is more than 1 mo

Question 53

Self-report scales for PTSD

Answer 53

``` Distressing Events Questionnaire PTSD checklist for DSM-5 Screen for Posttraumatic Stress Sx Trauma Symptom Checklist-40 Trauma Symptom Inventory ```

Question 54

Pharmacotherapy for PTSD

Answer 54

``` SSRIs first line Buspirone Imipramine and amitriptyline MAOIs Trazodone Anticonvulsants Clonidine and propranolol ```

Question 55

Psychotherapy for PTSD

Answer 55

``` Exposure therapy Teaching pt stress management methods Behavior therapy Cognitive therapy Hypnosis EMDR ```