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Anxiety, Obscessive-Compulsive, Trauma, Stressor related disorders (CH 5) Flashcards

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1
Q

Anxiety

A

individual’s emotional and physical fear response to perceived threat

Most common form of psychopathology
More frequently in women (2:1 ratio)

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2
Q

Pathologic anxiety

A

symptoms are excessive, irrational, out of proportion to the trigger or without an identifiable trigger

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3
Q

Maladaptive anxiety

A

persists longer and feels more intense than transient, situation anxiety

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4
Q

Anxiety Disorder criteria

A

Symptoms cause clinically significant distress or impairment in social and/or occupational functioning

Not due to physiological effects of substance, medication or medical condition

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5
Q

Major neurotransmitter systems implicated in anxiety

A

Norepinephrine, serotonin, GABA

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6
Q

Treatment guidelines for anxiety

A

based on level of symptom impairment

Psychotherapy for milder presentations

Combination treatment with pharmacotherapy for moderate to severe anxiety

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7
Q

First line pharmacotherapy for anxiety

A

SSRIs (sertraline)

SNRIs (venlafaxine)

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8
Q

Benzodiazepines in anxiety

A

enhance activity of GABA at GABA-A receptor

Work quickly and effectively
Can be addictive - minimize use, duration, dose

Avoid if hx of substance use disorders, particularly etOH

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9
Q

Nonaddicticting anxiolytic alternatives in anxiety

A

diphenhydramine or hydroxyzine

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10
Q

Buspirone in anxiety

A

5-HT1a partial agonist
Non-benzodiazepine anxiolytic

minimal efficacy, only prescribed as augmentation

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11
Q

Beta-blockers in anxiety

A

e.g. propranolol

helps control autonomic symptoms - palpitations, tachycardia, sweating with panic attacks or performance anxiety

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12
Q

TCAs and MAOIs in anxiety

A

consider if first line agents not effective, side effect profile make them less tolerable

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13
Q

Psychotherapy in anxiety

A

CBT examines relationship between anxiety driven cognitions (thoughts), emotions, and behavior

Psychodynamic psychotherapy facilitates understanding and insight into development of anxiety and increases anxiety tolerance

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14
Q

Panic attacks

A

fear response involving an abrupt surge of intense anxiety triggered or occurs spontaneously

Peak within minutes, resolve within half an hour

Pt continues to feel anxious for hours afterwards, can be confused as a prolonged panic attack

Can be experienced with other anxiety disorders, psychiatric disorders and other medical condtions

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15
Q

Mnemonic for panic attack symptoms

A

“Da PANICS”

Dizziness, disconnectedness, derealization (unreality), depersonalization (detached from self)
Palpitations, paresthesias
Abdominal distress
Numbness, nausea
Intense fear of dying, losing control, or “going crazy”
Chills, chest pain
Sweating, shaking, shortness of breath

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16
Q

Panic Disorder

A

Spontaneous, recurrent panic attacks, occur suddenly, “out of the blue” or with with clear trigger

Multiple times per day to few monthly

Debilitating anticipatory anxiety about having future attacks “fear of the fear”

Can lead to avoidance behaviors -> homebound

Greater risk if dx in first relatives
Increased stressors prior to onset, hx of childhood physical or sexual abuse

20-24 yo onset

Chronic course with waxing/waning sxs, relapse with dc of meds

65% have major depression; other comorbid syndromes: anxiety disorders (agoraphobia), bipolar disorder, etoh use disorder

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17
Q

Panic disorder DSM5 criteria

A

Recurrent, unexpected panic attacks without identifiable trigger

One or more panic attacks followed by 1 or more month of continuous worry about subsequent attacks or their consequences, and/or maladaptive change in behaviors (avoidance of possible triggers)

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18
Q

Treatment of panic disorder

A

Pharmacotherapy and CBT most effective

First line: SSRI - sertaline, citalopram, escitalopram

Can switch to TCAs (clomipramine, imipramine) if SSRIs not effective

Benzos (clonazepam, lorazepam) scheduled or PRN, especially as a bridge for other meds to reach full efficacy

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19
Q

Agoraphobia

A

intense fear of being in public places where escape or obtaining help may be difficult

Develops with panic disorder

Chronic course, persistent, rare full remission

Avoidance behaviors become extreme as complete confinement to the home.

Strong genetic factor - 60%
Onset follows traumatic event

Onset before 35

Comorbid: other anxiety disorders, depressive disorders, substance use disorders

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20
Q

Agoraphobia DSM5 criteria

A

Intense fear/anxiety about more than 2 situaiton d/t concern of difficulty escaping or obtaining help in case of panic or other humiliating sxs

  • outside of home alone
  • open spaces (bridges)
  • enclosed places (stores)
  • public transportation (trains)
  • crowds/lines

Triggering situations cause fear/anxiety out of proportion to the potential danger posed -> endurance of intense anxiety, avoidance, or requiring a companion. True even if pt has medical conditions like IBS -> embarrasing public scenarios

Sxs cause significant social or occupational dysfunction

lasts 6 or more months

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21
Q

Treatment of Agoraphobia

A

CBT and SSRIs (for panic sxs)

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22
Q

Phobia

A

irrational fear -> endurance of anxiety and/or avoidance of the feared object or situation

Develop in wake of a negative or traumatic encounter with the stimulus

Most common psychiatric disorder in women, second in men

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23
Q

Specific phobia

A

an intense fear of a specific object or situation (phobic stimulus)

Mean onset 10 yo

Treatment: CBT

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24
Q

Social anxiety disorder

A

Social phobia
fear of scrutiny by others or fear of acting in a humiliating or embarrassing way, negative evaluation, rejection

Fear may be limited to performance or public speaking

social situations causing significant anxiety may be avoided altogether ->social and academic/occupational impairment

mean onset 13 yo

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25
Specific phobias/social anxiety disorder DSM5 criteria
Persistent, excessive fear elicited by specific situation or object, out of proportion to any actual danger/treat Exposure to situaiton triggers immediate fear response Situation or object is avoided or tolerated with intense anxiety Causes significant social or occupational dysfunction Lasts 6 or more months
26
Treatment of Social anxiety disorder
Treatment of choice: CBT First line medications: SSRI (sertraline, fluoxetine) or SNRIs (venlafaxine) for debilitating sxs Benzodiazepines (clonazepam, lorazepam) scheduled or PRN Beta-blockers (atenolol, PRORPANOLOL) for performance anxiety/public speaking
27
Selective mutism
failure to speak in specific situations for at least 1 month, despite intact ability to comprehend and use language Starts in childhood manifests in social settings Pt may remain completely silent or whisper, may use nonverbal communication - writing or gesturing
28
Selective mutism DSM5 criteria
Consistent failure to speak in select social situations (school), despite ability in other scenarios Mutism not due to language difficulty or communication disorder Significant impairment in academic, occupational, social functioning Sxs last longer than 1 mo (beyond first month of school)
29
Treatment of selective mutism
Psychotherapy: CBT, family therapy Medications: SSRIs for anxiety (esp. with comorbid social anxiety disorder)
30
Stranger anxiety
begins at 6 mo, peaks around 9 mo
31
Separation anxiety
emerges by 1 year, peaks by 18 mo
32
Separation anxiety disorder DSM5 criteria
Excessive and developmentally inappropriate fear/anxiety re: separation from attachment figures At least three: 1. separation leads to extreme distress 2 excessive worry about loss of or harm to attachment figures 3. Excessive worry about event that leads to separation from attachment figures 4. Reluctance to leave home, or attend school or work 5. Reluctance to be alone 6. Reluctance to sleep alone or away from home 7. Complaints of physical symptoms when separated 8. Nightmares of separation and refusal to sleep without proximity to attachment figure 9. Lasts more than 4 weeks in children/adolescents, longer than 6 mo in adults 10. sxs cause significant social, academic, or occupational dysfunction
33
Treatment of separation anxiety disorder
Psychotherapy: CBT, family therapy Medications: SSRI as adjunct to therapy
34
Generalized anxiety disorder (GAD)
Persistent, excessive anxiety about many aspects of daily lives Somatic sxs: fatigue, muscle tension -> PCP visit Highly comorbid with other anxiety and depressive disorders Higher in women 1/3 risk is genetic Worry begins in childhood Onset mean 30 yo Chronic course w/ waxing/waning sxs
35
Generalized Anxiety Disorder DSM5 Criteria
Excessive, anxiety/worry about various daily events/activities longer than 6 mo Difficulty controlling worry Associated with 3 or more sxs: restlessness, fatigue, impaired concentration, irritability, muscle tension, insomnia Cause social or occupational dysfunction
36
Treatment of Generalized Anxiety Disorder
Most effective approach psychotherapy combined with pharmacotherapy CBT SSRI (sertraline, citalopram) or SNRI (venlafaxine) Consider short term benzo or augment with buspirone Much less commonly used: TCAs, MAOIs
37
Obsessive compulsive disorder
obsessions and/or compulsions that are time consuming, distressing, and impairing varying degrees of insight Mean onset 20 yo Higher rates in 1st degree relatives with OCD and Tourette's disorder Chronic course, waxes/wanes SI in 50%, attempts in 25% High comorbidity: 75% other anxiety disorders, 60% depressive or bipolar, 30% OCPD and tic disorder
38
Obsessions
recurrent, intrusive, anxiety-provoking thoughts, images, or urges that the patient attempts to suppress, ignore or neutralize by some other thought or action anxiety relieved by compulsions, anxiety increases if resist compulsions
39
Compulsions
repetitive behaviors or mental rituals the patient feels driven to perform in response to an obsession or a rule aimed at stress reduction or disaster prevention. behaviors not realistically linked with what they are to prevent or are excessive
40
Obsessive-compulsive disorder DSM5 criteria
Obsessions and/or compulsions that are time-consuming (>1 hr/day) or cause significant distress or dysfunction
41
Triad of uncontrollable urges
OCD, ADHD, tic disorder first seen in children or adolescents
42
Treatment of Obsessive-compulsive disorder
Utilize combination of psychopharmacology and CBT CBT focuses on exposure and response prevention - prolonged, graded exposure to ritual-eliciting stimulus and prevention of relieving compulsions First line medications: SSRIs (sertraline, fluoxetine) - higher doses Can use most serotonin selective TCA - Clomipramine Can augment with atypical antipsychotics Last resort: severely debilitating cases - psychosurgery (cingulotomy) or ECT (esp if depression present)
43
Body dysmorphic disorder
preoccupied with body parts perceived as flawed or defective strong beliefs that they are unattractive or repulsive imperfections either minimal or not observable, but pt views as severe and grotesque Spend significant time trying to correct flaws, make up, derm procedures, plastic surgery risk: child abuse/neglect, first degree relatives with OCD Mean onset 15 Gradual course in early adolescence, tends to be chronic high rater of SI and attempts Comorbids: major depression, social anxiety disorder, OCD
44
Body dysmorphic disorder DSM5 criteria
Preoccupation with one or more perceived defects or flaws in appearance, not observable by or appear slight to others repetitive behaviors (skin picking, excessive grooming) or mental acts (compairing appearance to others) in response to appearance concerns Significant distress or impairment of functioning
45
Treatment of body dysmorphic disorder
SSRIs and/or CBT reduce obsessive compulsive sxs
46
Hoarding disorder DSM5 criteria
Persistent difficulty discarding possessions, regardless of value need to save the items, distress associated with discarding them Accummulation of possessions -> congest/clutter living areas and compromise use significant distress or impairment in social, occupational, or other areas of functioning
47
Hoarding disorder
3x more prevalent in older population Stressful and traumatic events precede onset Large genetic component begins early teens, tends to be women Chronic course 75% have MDD or anxiety disorder (social anxiety) 20% have OCD
48
Treatment of hoarding disorder
specialized CBT for hoarding | SSRIs not beneficial unless OCD sxs present
49
Trichotillomania DSM5 criteria
Recurrent pulling out of one's hair, resulting in hair loss Repeated attempts to decrease or stop Significant distress or impairment in daily functioning Usually involves scalp, eyebrows, eyelashes, facial, axillary, and pubic hair
50
Trichotillomania
more common in women (10:1) onset puberty, associated with stressful event Site of hair pulling vary, texture preference Increased OCD, MDD, and excoriation disorder Chronic course w/ waxing/waning periods. Adult onset more difficult to treat
51
Treatment of trichotillomania
SSRIs, second gen antipsychotics, N-acetylcysteine, or lithium CBT - habit reversal training
52
Excoriation (skin picking) disorder DSM5 criteria
Recurrent skin picking resulting in lesions Repeated attempts to decrease or stop Significant distress or impairment in daily functioning
53
Excoriation disorder
3/4 women More common with OCD and first degree relatives begins in adolescence chronic course w/ waxing/waning if untreated Comorbid: OCD, trichotillomania, MDD
54
Treatment of Excoriation disorder
CBT - habit reversal training | SSRIs some benefit
55
PTSD
development of multiple sxs after exposure to one or more traumatic events Intrusive symptoms: nightmares, flashbacks Avoidance Negative alterations in thoughts and mood Increased arousal Sxs last at least 1 month and occur immediately after or with delayed expression (usually within 3 mo) 80% have other mental disorder: MDD, bipolar, anxiety, substance use
56
Acute Stress Disorder
major traumatic event -> sxs similar to PTSD for shorter duration Onset of sxs within 1 month of trauma, last less than 1 month
57
PTSD/Acute Stress Disorder DSM5 Criteria
Exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing or witnessing the trauma Recurrent intrusions of reexperiencing the event via memories, nightmares, or dissociative reactions (flashbacks); intense distress at exposure to cues relating to trauma; or physiological reactions to cues relating to trauma Active avoidance of triggering stimuli (memories, feelings, people, places, objects) associated with the trauma At least two negative cognitions/mood: dissociative amnesia, negative feelings of self/other/world, self-blame, negative emotions (fear, honor, anger, guilt), anhedonia, feelings of detachment/estrangement, inability to experience positive emotions At least two increased arousal/reactivity: hypervigilance, exaggerated startle response, irritability/angry outbursts, impaired concentration, insomnia Significant impairment of social or occupational functioning Presentation differs in kids under 7 yo
58
Treatment of PTSD - pharmacological
First line: SSRIs (sertraline, citalopram) or SNRIs (venlafaxine) Prazosine - a1 receptor antagonist - targets nightmares and hypervigilance augment with atypical (2nd gen) antipsychotics in severe cases
59
Treatment of PTSD - psychotherapy
CBT - exposure therapy, cognitive processing therapy supportive and psychodynamic therapy couples/family therapy
60
Adjustment disorders
behavioral or emotional sxs after stressful life event Chronic if stressor is chronic or recurrent, resolves within 6 months of cessation of stressor Subtypes: depressed mood, anxiety, mixed anxiety/depression, disturbance of conduct (aggression), mixed disturbance of emotions and conduct
61
Adjustment disorders DSM5 criteria
emotional or behavioral sxs within 3 months in response to identifiable stressful life event producing: - marked distress in excess of what would be expected after such event - significant impairment in daily functioning sxs not those of normal bereavement resolve within 6 months after stressor terminated
62
Treatment of adjustment disorder
``` Supportive psychotherapy (most effective) Group therapy ``` Occasionally tx associated sxs: insomnia, anxiety, depression in time-limited fashion

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