Anxiety disorders, OBD, Trauma and stress related disorders

Question 1

what falls under the umbrella of anxiety disorders

Answer 1

panic disorder
social anxiety disorders (social phobia)
specific phobia
agoraphobia
generalized anxiety disorder

Question 2

what is a panic attack

Answer 2

not a DSM-5 diagnosis in and of itself
occur in many psychatric disorders
important: Panic dose not equal anxiety
‘uncued’ or unprovoked
short intense bouts of anxiety
associated with physical symptoms
abates within minutes

Question 3

what is the treatment of panic attack

Answer 3

short term: reassurance, positive self talk, must rule out substance induced or medically induced
Long term: CBT, relaxation techniques

Question 4

what is panic disorder

Answer 4

average age at onset: 20-30 yo
higher prevalence in educated pts
increased risk of suicide
co-occuring depression and SUD

Question 5

what is the etiology of panic disorder

Answer 5

biology: autonomic hyperactivity, some evidence for heritability, heightened sensitivity to somatic symptoms
behavioral: ?conditioned response
Environmental: ?repressed memories/trauma

Question 6

what are characteristics of panic disorder

Answer 6

recurrent, unprovoked panic attacks
characterized by intense fear of another attack
+/- agorphobia

Question 7

what are the treatments for panic disorder

Answer 7

Antidepressants : SSRI (paroxetine), SNRI (venlafaxine)
Benzodiazepines (short term): additctive - alprazolam (xanax), clonazepam, diazepam, lorazepam
CBT and education

Question 8

what are phobias

Answer 8

irrational fear of specific object/situation/place
-disproportionate to the trigger
-consistently present with exposure to trigger
-causes significant distress
-person is usually aware that their fearful reaction is excessive
etiology: poorly understood

Question 9

what are the main types of phobias

Answer 9

specific phobia
social phobia (social anxiety)
Agoraphobia

Question 10

what is specific phobia

Answer 10

a specific thing or situation (spiders, snakes, heights, needles, etc)

Question 11

what is social phobias (social anxiety)

Answer 11

fear of being in a public/social setting
fear centers around potential embarrassment/humiliation

Question 12

what is agoraphobia

Answer 12

fear of public places/places outside of home
fear centers around perceived inability to exit
often co-occuring with panic disorder

Question 13

what are the treatment options for phobias

Answer 13

desensitization: gradually increase exposure
flooding: rapid, intense exposure
CBT
medication (primarily for social anxiety and agoraphobia) - SSRI first line (paroxetine)
- SNRI - venlafaxine also effective
-performance anxiety - propranolol

Question 14

what neurotransmitters are associated with generalized anxiety disorders

Answer 14

Serotonin (5-HT) (excitatory)
Norepinepherine (excitatory)
GABA (inhibitory)

Question 15

what is Generalized anxiety disorder characterized by

Answer 15

overwhelming worry that is excessive or persistent
involves multiple arenas of life: personal health, employment, school, social settings, intimate relationships, financial

Question 16

what is the typical presentation of GAD

Answer 16

chronic fatigue
edginess + restlessness
irritability
difficulty concentrating
difficulty sleeping
muscle tension

Question 17

what is the treatment of GAD

Answer 17

control symptoms, complete abatement is rare
CBT or other psychotherapy
medications such as antidepressants/anxiolytics

Question 18

what medications are used to treat GAD

Answer 18

SSRI: Paroxetine (paxil) and Escitalopram (Lexapro)
SNRI: Venlafaxine (effexor) and Duloxetine (Cymbalta)
BZDs: short course - initiation of SSRI/SNRI or flare symptoms
Buspirone (Buspar): long-acting non-BZD anxiolytic - low abuse potential, takes 3-4 weeks for full effect

Question 19

what is OCD

Answer 19

obsessive-compulsive disorder
obsessions and/or compulsions
typically onset early teens to 20s, most present prior to age 30
impair every day functioning

Question 20

What is the etiology of OCD

Answer 20

Brain anatomy: associated with some neurologic disorder, abnormalities in basal ganglia, prefrontal cortex, caudate nucleus
Neurotransmitters: ?imbalance of serotonin
Genetics: rates higher in pts with + FH, no gene has been identified yet
Environmental: sometimes precipitated by stressful events, PANDAS and streptococcal infections

Question 21

what are obsessions

Answer 21

recurrent, intrusive thoughts
cause significant distress
follow common themes around the world

Question 22

what are compulsions

Answer 22

repetitive, intentional behaviors
aimed at relieving the obsession
cause significant distress
rigid behaviors (must follow certain rules/sequences)

Question 23

what are specifiers for OCD

Answer 23

good insight: pt recognize behaviors/beliefs are likely not true
Poor insight: pt believe their obsessions/compulsions are probably true
absent insight/delusional belief: pt believe the beliefs/behaviors are absolutely true
tic-related: associated with a tic disorder

Question 24

what are the non-pharmacologic treatments for OCD

Answer 24

behavioral therapies (Exposure to stimuli and prevention of response, desensitization, flooding, implosion therapy, conditioning, thought stopping)
support groups

Question 25

what medications can be used to treat OCD

Answer 25

only 50-60% show improvement with only meds
first line: SSRI’s or Clomipramine
All SSRI’s are indicated for OCDs, fluvoxamine
Clomipramine is more serotonergic TCA - very sedating

Question 26

What is body dysmorphic disorder

Answer 26

preoccupation with perceived physical flaw or “ugliness”
significant associated ‘embarrassment’
appears excessive to those around the patient
often involves a facial characteristics

Question 27

what are common symptoms of Body dysmorphic disorders

Answer 27

compulsive mirror checking
compulsive grooming
comparing to others
soliciting reassurance

Question 28

What are common symptoms of body dysmorphic disorder

Answer 28

CBT
SSRI are pharmacologic treatment of choice
if delusional, addition of anti-psychotic may help
many will have surgical interventions (not recommended)

Question 29

What is Tricholotillomania

Answer 29

‘hair pulling disorder’ - one of the body focused repetitive behaviors (BFRB) - nail biting, skin picking
F»M
may involve any site: scalp, eyelashes, eyebrows, body hair, axillary hair, pubic hair

Question 30

what is the treatment of trichotillomania

Answer 30

habit reversal: conditioning and barriers
CBT
? hypnosis
Medications: SSRI and Clomipramine (TCA)

Question 31

what can hoarding be associated with

Answer 31

OCD, GAD, Major Depression, Personality disorder, neurologic disorders, dementia

Question 32

what are the specifiers of hoarding

Answer 32

Accompanied with excessive acquisition
good or fair insight
poor inside
absent insight/delusional beliefs

Question 33

what is the treatment of hoarding

Answer 33

CBT
SSRI
Enlisting personal organizers/family and friends - cleaning up alone NOT helpful

Question 34

what are stressor-related disorders

Answer 34

PTSD
adjustment disorder

Question 35

what is adjustment disorder

Answer 35

normal human response to stressor
symptoms begin within 3 months of the stressor onset
symptoms can cause significant distress or impairment in functioning

Question 36

what are the treatment options for adjustment disorders

Answer 36

mainstay is psychotherapy (individual or group)
+/- support groups
+/- psychosocial interventions
adjunctive medications for symptomatic treatment

Question 37

What are risk factors of PTSD

Answer 37

age (younger = greater risk)
history of psychiatric illness
level of social support
proximity to stressor or event
severity and duration of stressor
low socioeconomic status
FH of depression

Question 38

what is the typical presentation of PTSD

Answer 38

W>M
highest prevalence in young adults
can develop acutely or be delayed
often associated with other psychiatric disorders
increased risk of suicide

Question 39

what is the etiology of PTSD

Answer 39

disruption in Neurotransmitters (NE, DA, 5-HT)
other physiologic disruptions (noradrenergic dysfunction, endogenous opioids, benzodiazepine receptors)
Endocrine dysfunction (disruption of the HPA axis, cortisol dysfunction)

Question 40

what is PTSD characterized by

Answer 40

exposure to a significant stressful event - event is not a normal human experience
reliving the trauma (thoughts/dreams)
avoiding triggers associated with the event
emotional changes
hyper-reactivity

Question 41

what are specifiers of PTSD

Answer 41

with dissociative symptoms (depersonalization or derealization)
with delayed expression(>6 months after event)

Question 42

What is the tool used to assess PTSD

Answer 42

PCL-5
PC-PTSD-5

Question 43

what is the treatment for PTSD

Answer 43

psychotherapy (CBT, hypnosis, exposure therapy, eye movement desensitization and reprocessing, group therapy/support groups)
Medications: SSRI first line (paroxetine (paxil) and sertraline (zoloft))
prazosin for nightmares
BZDs for acute anxiety (short term)

Question 44

what is dissociation

Answer 44

a response to significant stress
unconscious defense mechanism
processing related to the event is separate from the rest of your cognitive process
episodes last several days, weeks or months

Question 45

What is depersonalization

Answer 45

feeling as though you’re looking at yourself from the outside
feeling as though you aren’t yourself
feeling like you’re living a dream
feeling like you’re not in control of yourself

Question 46

what is derealization

Answer 46

feeling disconnected from your environment
feeling completely emotionally cut off
seeing your surroundings differently
distorted perception of time

Question 47

what is dissociative amnesia

Answer 47

most common dissociative disorder
W>M
patient unable to recall a specific memory, usually traumatic
other cognitive functional remains intact
symptoms terminate abruptly

Question 48

what is dissociative fugue

Answer 48

subtype of dissociative amnesia
inability to recall one’s past - presumption of new identity
classically involves travel away from home
symptoms abate abruptly
patient are able to recall pre and post-fugue events
dont have any memories of the fugue itself