Anxiety, Obsessive-Compulsive, Trauma/Stressor Flashcards
(89 cards)
1
Q
What is anxiety?
A
Defined as individual’s emotional & physical fear response to a perceived threat
2
Q
What is pathologic anxiety?
A
Occurs when symptoms are excessive, irrational, out of proportion to the trigger or are without an identifiable trigger
3
Q
What is maladaptive anxiety?
A
Persists longer & feels more intense than transient, situational anxiety
4
Q
What are anxiety disorders?
A
Criteria for most anxiety disorders involve symptoms that cause clinically significant distress or impairment in social and/or occupational functioning
Caused by combo of genetic, biological, environmental, & psychosocial factors
Primary anxiety disorders can only be diagnosed after determining that signs & symptoms are NOT due to physiological effects of substance, meds, or medical condition
Late-onset anxiety symptoms without prior or family psychiatric history should increase suspicion of anxiety caused by another medical condition or substance
Most common form of psychopathology
Lifetime prevalence: women 30%, men 19%
More frequently seen in women compared to men (2:1 ratio)
5
Q
What are the major neurotransmitter systems implicated in anxiety disorders?
A
Norepinephrine (NE)
Serotonin (5-HT)
Gamma-aminobutyric acid (GABA)
6
Q
Treatment of anxiety disorders
A
Based on level of symptom impairment
Consider psychotherapy for milder presentations
Initiating combination treatment w/ pharmacotherapy for moderate to severe anxiety
7
Q
What is the assessment for psychopathology based on?
A
Based on if patient’s symptoms are causing Social and/or Occupational Dysfunction (SOD)
8
Q
Signs & symptoms of anxiety
A
Constitutional:
- Fatigue
- Diaphoresis
- Shivering
Cardiac:
- Chest pain
- Palpitations
- Tachycardia
- Hypertension
Pulmonary:
- Shortness of breath
- Hyperventilation
Neurologic / MSK:
- Vertigo
- Lightheadedness
- Paresthesias
- Tremors
- Insomnia
- Muscle tension
GI:
- Abdominal discomfort
- Anorexia
- Nausea
- Emesis
- Diarrhea
- Constipation
9
Q
Meds & substances that cause anxiety
A
Alcohol (intoxication / withdrawal)
Sedatives, hypnotics, or anxiolytics (withdrawal)
Cannabis (intoxication)
Hallucinogens - PCP, LSD, MDMA (intoxication)
Stimulants - amphetamines, cocaine (intoxication / withdrawal)
Caffeine (intoxication)
Tobacco (intoxication / withdrawal)
Opioids (withdrawal)
10
Q
Medical conditions that cause anxiety
A
Neurologic:
- Epilepsy
- Migraines
- Brain tumors
- MS
- Huntington’s disease
Endocrine:
- Hyperthyroidism
- Thyrotoxicosis
- Hypoglycemia
- Pheochromocytoma
- Carcinoid syndrome
Metabolic:
- Vitamin B12 deficiency
- Electrolyte abnormalities
- Porphyria
Respiratory:
- Asthma
- COPD
- Hypoxia
- PE
- Pneumonia
- Pneumothorax
Cardiovascular:
- CHF
- Angina
- Arrhythmia
- MI
11
Q
Treatment for anxiety disorders
A
PHARMACOTHERAPY First-line: SSRIs, SNRIs Benzodiazepines Nonaddicdting anxiolytic alternatives for PRN use - diphenhydramine, hydroxyzine Buspirone Beta-blockers TCAs & MAOIs
Pharmacologic goal is to achieve symptomatic relief & continue treatment for at least 6 months before attempting to titrate off medications
Medications can reduce symptoms enough so that a patient can participate in therapy
PSYCHOTHERAPY
Cognitive behavioral therapy (CBT)
Psychodynamic psychotherapy
12
Q
SSRI treatment for anxiety disorders
A
E.g. sertraline
Typically take about 4-6 weeks to become fully effective
Higher doses (than used in treating depression) are generally required
13
Q
Benzodiazepines treatment for anxiety disorders
A
Enhance GABA at GABA-A receptor
If patient has cormobid depressive disorder, consider alternatives to benzos as they may worsen depression
Used to temporarily bridge patients until long-term meds becomes effective
Work quickly & effectively, but they all can be addictive
- Minimize use, duration, & dose
Should be avoided in patients w/ history of substance use disorders
Consider nonaddicting anxiolytic alternatives for PRN use = diphenhydramie, hydroxyzine
14
Q
Buspirone treatment for anxiety disorders
A
5-HT1A partial agonist
Non-benzodiazepine anxiolytic
Not commonly used due to minimal efficacy & often only prescribed augmentation
15
Q
Beta-blockers treatment for anxiety disorders
A
E.g. Propranolol
May be used to help control autonomic symptoms (e.g. palpitations, tachycardia, sweating) w/ panic attacks or performance anxiety (use the Bs to Block the Ps)
16
Q
TCAs & MAOIs treatment for anxiety disorders
A
May be considered if first-line agents are not effective
Their side-effect profile makes them less tolerable
17
Q
CBT treatment for anxiety disorders
A
Proven effective for anxiety disorders
Examines relationship between anxiety-driven conditions (thoughts), emotions, & behavior
18
Q
Psychodynamic psychotherapy treatment for anxiety disorders
A
Facilitates understanding & insight into development of anxiety & ultimately increases anxiety tolerance
19
Q
What are panic attacks?
A
Type of fear response involving an abrupt surge of intense anxiety which may be triggered or occur spontaneously
Attacks peak within mins. & usually resolve within half an hour
May continue to feel anxious for hours afterwards & confuse this for a prolonged panic attack
Although classically associated w/ panic disorder, panic attacks can also be experienced w/ panic disorder, panic attacks can be experienced with other anxiety disorders, psychiatric disorders, & other medical conditions
20
Q
Symptoms of panic attacks
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
21
Q
What are panic disorders?
A
Characterized by spontaneous, recurrent panic attacks
Attacks occur suddenly, “out of the blue”
May experience panic attacks w/ a clear trigger
Frequency of attacks ranges from multiple times per day to a few monthly
Develop debilitating anticipatory anxiety about having future attacks - “fear of the fear”
- Can lead to avoidance behaviors & become so severe as to leave patients homebound (i.e. agoraphobia)
Smoking is a risk factor for panic attacks
22
Q
Diagnosis & DSM-V criteria of panic disorders
A
Recurrent, unexpected panic attacks without an identifiable trigger
1 or more panic attakcs followed by >=1 month of continuous worry about experiencing subsequent attacks or their consequences and/or maladaptive change in behaviors (e.g. avoidance of possible triggers)
Not cause by direct effects of substance, another mental disorder, or another medical condition
When patient presents w/ panic attack, rule out potentially life-threatening medical conditions (e.g. heart attack, thyrotoxicosis, thromboembolism)
23
Q
Etiology of panic disorders
A
Genetic factors:
- Greater risk if first-degree relative affected
Psychosocial factors:
- Increase incidence of stressors (especially loss) prior to onset of disorder
- History of childhood physical or sexual abuse
24
Q
Epidemiology of panic disorders
A
Lifetime prevalence: 4%
Higher rate in women compared to men (2:1 ratio)
Median age of onset: 20-24 years old
25
Course & prognosis of panic disorders
Panic disorder has chronic course w/ waxing & waning symptoms
- Relapses are common w/ discontinuation of medical therapy
Only minority of patients has full remission of symptoms
Up to 65% of patients w/ panic disorder have major depression
Other comorbid syndromes:
- Other anxiety disorders (especially agoraphobia)
- Bipolar disorder
- Alcohol use disorder
Carefully screen patients w/ panic attacks for suicidality
- They are at an increased risk for suicide attempts
26
Treatment of panic disorders
Most effective: pharmacotherapy & CBT
- First line: SSRIs (e.g. sertraline, citalopram, escitalopram)
- Start SSRIs or SNRIs at low doses & increase slowly because side effects may initially worsen anxiety, especially in panic disorder
- Can switch to TCAs (clomipramine, imipramine) if SSRIs are not effective
- Can use benzodiazepines (clonazepam, lorazepam) as scheduled or PRN, especially until other meds reach full efficacy
27
What is agoraphobia?
Intense fear of being in public places where escape or obtaining help may be difficult:
- Bridges
- Crowds
- Buses
- Trains
- Open areas outside the home
Often develops w/ panic disorder
Course of disorder is chronic
Avoidance behaviors may become as extreme as complete confinement to home
28
Diagnosis & DSM-V criteria of agoraphobia
Intense fear/anxiety about >2 situations due to concern of difficulty escaping or obtaining help in case of panic or other humiliating symptoms:
- Outside of the home alone
- Open spaces (e.g. bridges)
- Enclosed places (e.g. stores)
- Public transportation (e.g. trains)
- Crowds / lines
Triggering situations cause fear / anxiety out of proportion to potential danger posed, leading to endurance of intense anxiety, avoidance, or requiring companion
- Holds true even if patient suffers from medical condition (e.g. IBS) which may lead to embarrassing public scenarios
Symptoms cause significant social or occupational dysfunction
Symptoms last >= 6 months
Symptoms not better explained by another mental disorder
29
Etiology of agoraphobia
Strong genetic factor:
- Heritability abut 60%
Psychosocial factor:
- Onset frequently follows traumatic event
30
Course / prognosis of agoraphobia
>50% of patients experience panic attack prior to developing agoraphobia
Onset is usually before age 35
Course is persistent & chronic, w/ rare full remission
Comorbid diagnoses include other anxiety disorders, depressive disorders, & substance use disorders
31
Treatment of agoraphobia
Similar approach as panic disorder:
| - CBT & SSRIs (for panic symptoms)
32
Common domains of social anxiety disorder (social phobia)
Speaking in public
Eating in public
Using public restrooms
33
What is a phobia?
Irrational fear that leads to endurance of anxiety and/or avoidance of feared object or situation
Phobia may develop in wake of negative or traumatic encounters w/ stimulus
34
What is a specific phobia?
Intense fear of specific object or situation (i.e. phobic stimulus)
35
What is social anxiety disorder (social phobia)?
Fear of scrutiny by others or fear of acting in humiliating or embarrassing way
Social situations causing significant anxiety may be avoided altogether, resulting in social & academic / occupational impairment
Substance use & depressive disorders frequently co-occur w/ phobias
36
Diagnosis & DSM-V criteria of specific phobias / social anxiety disorder (social phobia
Persistent, excessive fear elicited by specific situation or object which is out of proportion to any actual danger / threat
Exposure to situation triggers an immediate fear response
Situation or object is avoided when possible or tolerated w/ intense anxiety
Symptoms cause significant social or occupational dysfunction
Duration >= 6 months
Symptoms not solely due to another mental disorder, substance (medication or drug), or another medical condition
Diagnostic criteria for social anxiety disorder (social phobia) are similar to above except phobic stimulus is related to social scrutiny & negative evaluation
- Patients fear embarrassment, humiliation, & rejection
- Fear may be limited to performance or public speaking
37
Epidemiology of specific phobias / social anxiety disorder (social phobia
Phobias are most common psychiatric disorder in women & 2nd most common in men (substance-related is first)
Lifetime prevalence of specific phobia: >10%
Mean age of onset for specific phobia is 10 years old
- Median age of onset for social anxiety disorder is 13 years old
Specific phobia rates are higher in women compared to men (2:1)
Social anxiety disorder occurs equally in men & women
38
Treatment of specific phobias / social anxiety disorder (social phobia
Specific phobia:
- Treatment of choice: CBT
Social anxiety disorder (social phobia):
- Treatment of choice: CBT
- First-line meds, if needed: SSRIs (e.g. sertraline, fluoxetine) or SNRIs (e.g. venlafaxine) for debilitating symptoms
- Benzodiazepines (e.g. clonazepam, lorazepam) can be used as scheduled or PRN
- Beta blockers (e.g. atenolol, propranolol) for performance anxiety / public speaking
39
What are common specific phobias?
Animal - spiders, insects, dogs, snakes, mice
Natural environment - heights, storms, water
Situational - elevators, airplanes, enclosed spaces, buses
Blood-injection injury - needles, injections, blood, invasive medical procedures, injuries
- May experience bradycardia & hypotension --> vasovagal fainting
40
What is selective mutism?
Rare condition characterized by failure to speak in specific situations for at least 1 month, despite intact ability to comprehend & use language
Symptom onset typically starts during childhood
Majority of these patients suffer from anxiety (social anxiety) as mutism manifests in social setting
Patients may remain completely silent or whisper
- May use nonverbal means of communication (e.g. writing, gesturing)
Communication delays or disorders may co-occur, but they would not account for selective mutism
41
Diagnosis & DSM-V criteria of selective mutism
Consistent failure to speak in select social situations (e.g. school) despite speech ability in other scenarios
Mutism is not due to language difficulty or communication disorder
Symptoms cause significant impairment in academic, occupational, or social functioning
Symptoms last >1 month (extending beyond 1st month of school)
42
Treatment of selective mutism
Psychotherapy:
- CBT
- Family therapy
Medications:
- SSRIs for anxiety
43
What are stranger anxiety & separation anxiety?
As part of normal human development, infants become distressed when they are separated from primary caregiver
Stranger anxiety: begins around 6 months & peaks around 9 months
Separation anxiety: emerges by 1 year old & peaks by 18 months
44
What is separation anxiety disorder?
When anxiety due to separation becomes extreme or developmentally inappropriate
Considered pathologic
May be preceded by stressful life event
May lead to complaints of somatic symptoms to avoid school/work
45
Diagnosis & DSM-V criteria of separation anxiety disorder
Excessive & developmentally inappropriate fear / anxiety regarding separation from attachment figures, with at least 3 of the following:
- Separation from attachment figures leads to extreme distress
- Excessive worry about loss of or harm to attachment figures
- Excessive worry about experiencing an event that leads to separation from attachment figures
- Reluctance to leave home, or attend school / work
- Reluctance to be alone
- Reluctance to sleep alone or away from home
- Complaints of physical symptoms when separated from major attachment figures
- Nightmares of separation & refusal to sleep without proximity to attachment figure
- Lasts for >=4 weeks in children / adolescents & >= 6 months in adults
- Symptoms cause significant social, academic, or occupational dysfunction
- Symptoms not due to another mental disorder
46
Treatment of separation anxiety disorder
Psychotherapy:
- CBT
- Family therapy
Medications:
- SSRIs can be effective as an adjunct to therapy
47
What is generalized anxiety disorder (GAD)?
Have persistent, excessive anxiety about many aspects of their daily lives
Often experience somatic symptoms (e.g. fatigue, muscle tension)
- The physical complains lead patients to initially present to PCP
Highly cormorbid w/ other anxiety & depressive disorders
48
Diagnosis & DSM-V criteria of GAD
Worry WARTS:
- Worried
- Wound up, worn out
- Absent-minded
- Restless
- Tense
- Sleepless
Excessive, anxiety/worry about various daily events/activities >= 6 months
Difficulty controlling the worry
Associated >= 3 symptoms:
- Restlessness
- Fatigue
- Impaired concentration
- Irritability
- Muscle tension
- Insomnia
Symptoms are not caused by direct effects of substance or another mental disorder or medical condition
Symptoms cause significant social or occupational dysfunction
Evaluate for caffeine use & recommend significant reduction or elimination
49
Epidemiology / etiology of GAD
Lifetime prevalence: 5-9%
GAD rates higher in women compared to men (2:1)
1/3 of risk of developing GAD is genetic
50
Course / prognosis of GAD
Symptoms of worry begin in childhood
Median age of onset of GAD: 30 years old
Course is chronic, w/ waxing & waning symptoms
Rates of full remission are low
Comorbid diagnoses include other anxiety disorders & depressive disorders
Exercise can significantly reduce anxiety
51
Treatment of GAD
Most effective treatment approach: combo of psychotherapy & pharmacotherapy:
- CBT
- SSRI (e.g. sertraline, citalopram) or SNRI (e.g. venlafaxine)
- Can consider shot-term course of benzodiazepines or augmentation w/ buspirone
- Much less commonly used meds are TCAs & MAOIs
52
What is obsessive-compulsive disorder (OCD)?
Characterized by obsessions and/or compulsions that are time-consuming, distressing, & impairing
Obsessions: recurrent, intrusive, undesired thoughts that increase anxiety
- Attempt to relieve this anxiety by performing compulsions
Compulsions: repetitive behaviors or mental rituals
- Anxiety may increase when patient resists acting out compulsion
- Can take form of repeated checking or counting
Have varying degrees of insight
Often initially seek help from PCP & other nonpsychiatric providers for help w/ consequences of compulsions (e.g. excessive washing)
53
Diagnosis & DSM-V criteria of OCD
Experiencing obsessions and/or compulsions that are time-consuming (e.g. >1 hour / daily) or cause significant distress or dysfunction
Obsessions: recurrent, intrusive, anxiety-provoking thoughts, images, or urges that patient attempts to suppress, ignore, or neutralize by some other thought or action (i.e. by performing a compulsion)
Compulsions: repetitive behaviors or mental acts the patient feels driven to perform in response to an obsession or rule aimed at stress reduction or disaster prevention
- Behaviors are not realistically linked w/ what they are able to prevent or are excessive
Not caused by direct effects of a substance, another mental illness, or another mental condition
54
What is the triad of "uncontrollable urges"?
OCD
ADHD
Tic disorder
Usually first seen in children / adolescents
55
Epidemiology of OCD
Lifetime prevalence: 2-3%
Mean age of onset: 30 years old
No gender difference in prevalence
56
Etiology of OCD
Significant genetic component:
- Higher rates of OCD in first-degree relatives & monozygotic twins than in general population
- Higher rate of OCD in first-degree relatives w/ Tourette's disorder
57
Course / prognosis of OCD
Chronic, w/ waxing & waning symptoms
<20% remission rate without treatment
Suicidal ideation in 50%, attempts in 25% of patients
High comorbidity w/ other anxiety disorders (>75%), depressive or bipolar disorder (>60%), obsessive-compulsive personality disorder (up to 32%), & tic disorder (up to 30%)
58
Common patterns of obsessions & compulsions in OCD
Obsession: contamination
Compulsion: cleaning or avoidance of contaminant
O: doubt or harm (e.g. oven)
C: Checking multiple times to avoid potential danger
O: symmetry
C: ordering or counting
O: intrusive, taboo thoughts (e.g. sexual, violent)
C: w/ or w/o related compulsion
59
Treatment of OCD
Utilize combo of psychopharmacology & CBT
CBT:
- Focuses on exposure & response prevention
- Prolonged, graded exposure to ritual-eliciting stimulus & prevention of the relieving compulsion
Meds:
- First-line meds: SSRIs (e.g. sertraline, fluoxetine), typically at higher doses
- Can use most serotonin selective TCA (clomipramine)
- Can augment w/ atypical antispychotics
Last resort:
- In treatment-resistant, severely debilitating cases, can use psychosurgery (cingulotomy) or ECT
60
What is the difference between OCD & OCPD?
OCPD:
- Obsessed w/ details, control, & perfectionism
- Not intruded upon by unwanted preoccupations nor compelled to carry out compulsions
- Do not perceive their symptoms as an issue (ego-systonic)
OCD:
- Distressed by their symptoms (ego-dystonic)
61
What is body dysmorphic disorder?
Patients are preoccupied w/ body parts that they perceive as flawed or defective, having strong beliefs that they are unattractive or repulsive
Though their physical imperfections are either minimal or not observable, patients view them as severe & grotesque
Spend significant time trying to correct perceived flaws w/ makeup, dermatological procedures, or plastic surgery
62
Diagnosis & DSM-V criteria of body dysmorphic disorder
Preoccupation w/ 1 or more perceived defects or flaws in physical appearance that are not observable by or appear slight to others
Repetitive behaviors (e.g. skin picking, excessive grooming) or mental acts (e.g. comparing appearance to others) are performed in response to appearance concerns
Preoccupation causes significant distress or impairment in functioning
Appearance preoccupation is not better accounted for by concerns w/ body fat / weight in an eating disorder
63
Epidemiology of body dysmorphic disorder
May be slightly more common in women than men
Prevalence elevated in those w/ high rates of childhood abuse & neglect & first-degree relatives w/ OCD
Higher prevalence in dermatologic & cosmetic surgery patients
Mean age of onset: 15 years old
64
Course / prognosis of body dysmorphic disorder
Onset is usually gradual, beginning in early adolescence
Symptoms tend to be chronic
Surgical / dermatological procedures are routinely unsuccessful in satisfying patient
High rate of suicidal ideation & attempts
Comorbidity w/ major depression, social anxiety disorder (social phobia), & OCD
65
Treatment of body dysmorphic disorder
SSRIs and/or CBT
| - May reduce obsessive & compulsive symptoms in many patients
66
Diagnosis & DSM-V criteria of hoarding disorder
Persistent difficulty discarding possessions, regardless of value
Difficulty is due to need to save the items & distress associated w/ discarding them
Results in accumulation of possessions that congest/clutter living areas & compromise use
Hoarding causes clinically significant distress or impairment in social, occupational, or other areas of functioning
Hoarding is not attributable to another medical condition or another mental disorder
67
Epidemiology / etiology of hoarding disorder
Unclear lifetime prevalence, but point prevalence of significant hoarding is 2-6%
Unclear gender preference
Hoarding 3x more prevalent in older population
Individuals w/ hoarding often report stressful & traumatic events preceding onset of hoarding
Large genetic component, w/ 50% of individuals w/ hoarding having a relative who also hoards
68
Course / prognosis of hoarding disorder
Hoarding behavior begins in early teens
Hoarding tends to worsen
Usually chronic course
75% of individuals have comorbid mood (MDD) or anxiety disorder (social anxiety disorder)
20% of individuals have comorbid OCD
69
Treatment of hoarding disorder
Very difficult to treat
Specialized CBT for hoarding
SSRIs can be used, but not as beneficial unless OCD symptoms are present
70
Diagnosis & DSM-V criteria of trichotillomania (hair-pulling disorder)
Recurrent pulling out of one's hair, resulting in hair loss
Repeated attempts to decrease or stop hair pulling
Causes significant distress or impairment in daily functioning
Hair pulling or hair loss is not due to another medical condition or psychiatric disorder
Usually involves scalp, eyebrows, or eyelashes, but may include facial, axillary, & pubic hair
71
Epidemiology / etiology of trichotillomania
Lifetime prevalence: 1-2% of adult population
More common in women than men (10:1 ratio)
Onset usually at time of puberty & frequently associated w/ stressful event
Site of hair pulling may vary & specific hair textures may be preferred
Etiology may involve biological, genetic, & environmental factors
Increased incidence of comorbid OCD, MDD, & excoriation (skin-picking) disorder
Course may be chronic w/ waxing & waning periods
- Adult onset is generally more difficult to treat
72
Treatment of trichotillomania
Treatment includes:
- SSRIs
- Second-generation antipsychotics
- N-acetylcysteine
- Lithium
Forms of CBT (e.g. habit reversal training) are best-evidenced psychotherapy
73
Diagnosis & DSM-V criteria of excoriation (skin-picking) disorder
Recurrent skin picking resulting in lesions
Repeated attempts to decrease or stop skin picking
Causes significant distress or impairment in daily functioning
Skin picking is not due to a substance, another medical condition, or another psychiatric disorder
74
Epidemiology / etiology of excoriation disorder
Lifetime prevalence: 1.4% of adult population
>75% of cases are women
More common in individuals w/ OCD & first-degree family members
75
Course / prognosis of excoriation disorder
Skin picking begins in adolescence
Course is chronic, w/ waxing & waning periods if untreated
Comorbidity w/ OCD, trichotillomania, & MDD
76
Treatment of excoriation disorder
Similar to that for trichotillomania
Specialized types of CBT (e.g. habit reversal training)
SSRIs have also shown some benefit
77
What is posttraumatic stress disorder (PTSD)?
Characterized by development of multiple symptoms after exposure to 1 or more traumatic events:
- Intrusive symptoms (e.g. nightmares, flashbacks)
- Avoidance
- Negative alterations in thoughts & mood
- Increased arousal
Symptoms last for at least 1 month
May occur immediately after trauma or w/ delayed expression
78
What is acute stress disorder?
Diagnosed in patients who experience major traumatic event & suffer from similar symptoms as PTSD, but for a shorter duration
Onset of symptoms occurs within 1 month of the trauma & symptoms last for less than 1 month
79
Diagnosis & DSM-V criteria of PTSD & acute stress disorder
PTSD: TRAUMA
- Traumatic event
- Reexperience
- Avoidance
- Unable to function
- Month or more of symptoms
- Arousal increased
Exposure to actual / threatened death, serious injury, or sexual violence by directly experiencing or witnessing the trauma
Recurrent intrusions of re-experiencing event via memories, nightmares, or dissociative reactions (e.g. flashbacks); intense distress at exposure to cues relating to trauma; or physiological reactions to cues relating to trauma
Active avoidance of triggering stimuli (e.g. memories, feelings, people, places, objects) associated w/ trauma
At least 2 of following negative cognitions / mood:
- Dissociative amnesia
- Negative feelings of self/others/world
- Self-blame
- Negative emotions (e.g. fear, horror, anger, guilt)
- Anhedonia
- Feelings of detachment / estrangement
- Inability to experience positive emotions
At least 2 of the following symptoms of increased arousal / reactivity:
- Hypervigilance
- Exaggerated startle response
- Irritability / angry outbursts
- Impaired concentration
- Insomnia
Symptoms not caused by direct effects of substance or another medical condition
Symptoms result in significant impairment in social or occupational functioning
Presentation differs in children <7 years of age
80
PTSD vs. acute stress disorder
PTSD:
- Trauma occurred at any time in the past
- Symptoms last >1 month
Acute stress disorder:
- Trauma occurred <1 month ago
- Symptoms last <1 month
81
Epidemiology / etiology of PTSD
Lifetime prevalence of PTSD: >8%
Higher prevalence in women, most likely due to greater risk of exposure to traumatic events
- Rape
- Other forms of interpersonal violence
Risk factor:
- Exposure to prior trauma, especially during childhood
82
Course / prognosis of PTSD
Usually begins within 3 months after trauma
Symptoms of PTSD may have dealyed expression
50% of patients have complete recovery within 3 months
Symptoms tend to diminish w/ older age
80% of patients w/ PTSD have another mental disorder (e.g. MDD, bipolar disorder, anxiety disorder, substance use disorder)
83
Treatment of PTSD & acute stress disorder
PHARMACOLOGICAL
- First-line antidepressants: SSRIs (e.g. sertraline, citalopram) or SNRIs (e.g. venlafaxine)
- Prazosin (alpha1-receptor antagonist): targets nightmares & hypervigilance (for Ptsd, use PrazoSiN to Stop Nightmares)
- May augment w/ atypical (second-generation) antipsychotics in severe cases
- Addictive meds (e.g. benzo) should be avoided in treatment of PTSD because of high rate of comorbid substance use disorders
PSYCHOTHERAPY
- Specialized forms of CBT (e.g. exposure therapy, cognitive processing therapy) = thoughts, feelings, & meanings of event are revisited & questioned
- Supportive & psychodynamic therapy
- Couples / family therapy
84
What is adjustment disorder?
Adjustment disorders occur when behavioral or emotional symptoms develop after a stressful life eent
85
Diagnosis & DSM-V criteria of adjustment disorder
Development of emotional / behavioral symptoms within 3 months in response to an identifiable stressful life event. These symptoms produce either:
- Marked distress in excess of what would be expected after such an event
- Significant impairment in daily functioning
- Stressful event is not life-threatening (e.g. divorce, death of loved one, or loss of job)
Symptoms are not those of normal bereavement
Symptoms resolve within 6 months after stressor has terminated
Stress-related disturbance does not meet criteria for another mental disorder
Subtypes: symptoms are coded based on predominance of either depressed mood, anxiety, mixed anxiety & depression, disturbance of conduct (such as aggression), or mixed disturbance of emotions & conduct
86
Epidemiology of adjustment disorder
Very common (5-20% of patients in outpatient mental health clinics)
May occur at any age
87
Etiology of adjustment disorder
Triggered by psychosocial factors
88
Prognosis of adjustment disorder
May be chronic if stressor is chronic or recurrent
Symptoms resolve within 6 months of cessation of stressor
89
Treatment of adjustment disorder
Supportive psychotherapy (most effective)
Group therapy
Occasionally pharmacotherapy is used to treat associated symptoms (insomnia, anxiety, or depression) in time-limited fashion
