Class 1 Flashcards
(107 cards)
1
Q
Anxiety disorders are highly comorbid with
A
- Other anxiety disorders
- Depression and bipolar disorders
- OCD, PTSD
- Substance use disorders
- Personality Disorders
- ADHD
2
Q
GAD DSM-5 Criteria
A
- Core feature:‘Excessive worry and persistent worrying that is hard to control, causes significant distress or impairment, and occurs on more days than not’
- Accompanied by 3/6:
- Muscle tension
- Fatigue
- Insomnia
- Impaired concentration
- Irritability
- Restlessness or feeling on edge
• At least 6 months
3
Q
Worry
A
- Cognitive process
- Ruminative style
- Future oriented
- Can be phrased as a ‘What if…?’ statement
- In GAD worry is excessive to actual situations, generalized to many subjects and accompanied by tendancy to catastophize
4
Q
Questions to Evaluate for GAD
A
• “Are you someone who worries too much about minor
matters (not only the big things)?”
• “Do other people tell you that you worry too much about too much about things that you don’t need to worry about?”
• “Is it hard for you to put aside the worry to the extent that it interferes with work or family life?”
5
Q
Differential Diagnosis GAD
A
Normal worry or Adjustment disorder
OCD
MDD
6
Q
Tool for GAD
A
GAD-7, non specific
7
Q
Social Anxiety DSM-5 criteria
A
- Marked fear or anxiety about 1 or more social situations in which possible scrutiny by others. (for children, not just adults)
- Fears of being negatively evaluated
- Almost always provoke fear or anxiety
- Avoided or endured with fear or anxiety
- Out of proportion to actual threat
- > 6 months
- Causes impairment
- Not due to drugs or another medical condition
- Not explained by another mental disorder
- If other medical condition present, fear is unrelated or excessive
- Specify if performance only
8
Q
Screening question SAD:
A
Are you very uncomfortable in social situations? E.g. public speaking, asking questions in front of a class, or being at a party or in a meeting.
If “yes”:
• How uncomfortable do you get? Do you get to the point of having a panic attack? Is this anxiety so intolerable that you would go out of your way to avoid any social situations?
9
Q
Tool for SAD
A
Social anxiety disorder test: SPIN Screen
10
Q
Differential Diagnosis SAD
A
Normal: Shyness, Introversion, Performance Anxiety
MDD / Bipolar depression: • Often anxious around people • Usually, worries that people will place demands on them, or have expectations they can’t fill • Anxiety not present outside of depressive episodes
Other anxiety disorders
Autistic spectrum disorder: • Difficulty maintaining relationships • Difficulty understanding TOM, nonverbal communication • Restricted interests, imaginative play
Schizotypal PD: “Excessive social anxiety that does not diminish with familiarity and associated with paranoid fears”
Negative symptoms of Schizophrenia
Schizophrenia prodrome
Body Dysmorphic Disorder: May present as socially anxious, but fear is focused on being judged due to a perceived flaw
11
Q
Panic Disorder DSM-5 Criteria
A
• Recurrent unexpected panic attacks
• >1 month of:
• concern or worry about having panic attacks or their
consequences
• Maladaptive behaviours to avoid panic attacks
• Not due to another mental disorder
- > 4 / 13 peaking in a few minutes and accompanied by intense fear or discomfort
- Cardiac: Palpitations, accelerated heart rate, Chest pain or discomfort
- Derm: Sweating, Chills
- Resp: SOB, Choking
- Neuro: Trembling, Paresthesia, Lightheadedness
- Gastro, Nausea, abdo discomfort
- Psych: Derealization, Fear of losing control / going crazy, Fear of dying
12
Q
Assessment panic disorder
A
- Do you have panic attacks? A panic attack is a surge of anxiety that feels like you are dying, having a heart attack or an asthma attack. You would need to stop what you are doing for 10 minutes or so and calm yourself down.
- What triggers the panic attacks? Do you get attacks “out of the blue”?
- Give me an example of one of the panic attacks
13
Q
Panic disorder tool
A
Panic disorder severity scale
14
Q
DDx Panic attacks
A
- MI
- Arrhythmia
- Asthma attacks
- Vertigo
- Stroke, seizure
- Hypoglycemia
- Drugs/caffeine/stimulants
- Zebras – e.g. endocrine tumors
15
Q
Ddx Panic disorder
A
Other anxiety disorders, panic attacks should be untriggered
16
Q
Agoraphobia criteria
A
- Marked fear or anxiety about ≥2 of the following:
- Using public transportation
- Being in open spaces
- Being in enclosed spaces
- Standing in line or being in a crowd
- Being outside alone
• Fear due to fear of being unable to escape, having a panic attack or being incapacitated or embarrassed
• Almost always provoke fear or anx, out of proportion to
danger
- Situations actively avoided or require a companion
- > 6 months
17
Q
Onset GAD
A
Young adulthood* always a worrier until mid 2os, 30s had to go off on their own= overwhelmed = increase anxiety, consult
18
Q
Panic Disorder onset
A
Young adulthood
19
Q
Agoraphobia onset
A
adulthood
20
Q
Social Anxiety Disorder onset
A
Childhood
21
Q
Separation Anx onset
A
Childhood
22
Q
Selective Mutism onset
A
Childhood
23
Q
Specific Phobia onset
A
Childhood
24
Q
Separation Anx onset time
A
> 1 mo kids
>6 mo adult
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Illness Anxiety Disorder criteria
* Classified under Somatic Symptom Disorders
* Worry about having or acquiring a serious illness
* Somatic symptoms are absent or mild
* High level of health anxiety
* Maladaptive behaviors
* >6 months
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Depression with Anxious Distress criteria
* Major Depressive Disorder
* ≥ 2 of the following
* Keyed up or tense
* Restless
* Difficulty concentrating because of worry
* Fear that something awful may happen
* Feelings of losing control
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Depression with Anxious Distress is associated with
Associated with higher suicide risk, longer duration of illness, poorer response to treatment
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x % of people with MDD have anxious distress
70%
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CBT Techniques for Anxiety Disorders
* Exposure hierarchies
| * Cognitive restructuring
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The Cycle of Fear and Avoidance
Anxiety = feared consequence = anticipatory anxiety = avoidance = reinforcement of fear = anxiety
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Exposure Therapy - Metaphors
* The Bee Trap
* The Horror Movie
* The Swimming Pool
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Cognitive Techniques for Worrying
* Helpful vs. unhelpful worry:
* Is there something that can be done about this in the next 24 hrs? -> If so, stop worrying and start acting.
* Likelihood questions:
* What is the worst case scenario? What is the best case scenario?
* How likely are each?
* Importance Questions:
* If the worst case scenario happens, can you deal with it?
* How important do you think this will be 5 years from now?
* Acceptance of Uncertainty
* We do things every day that are potentially dangerous: Driving, crossing the street, eating at restaurants, smoking
* We can never predict what will happen in life
* People usually consider their greatest accomplishments to be how the overcame adversity
* Life would be boring if we could always predict the future and nothing bad every happened
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First-line for all anxiety disorders
SSRIs / SNRIs
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SSRIs/ SNRIs start
low go slow, especially panic, GAD
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In resistant depression + chronic pain, Rx
SNRIs > SSRIs, not
| proven for anxiety disorders
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SSRIs / SNRIs how many weeks full benefit
12-16 weeks
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SSRIs / SNRIs maintain
1 year after remission
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Benzodiazepines
• Effective alone or in combination with SSRIs/SNRIs for GAD, SAD, Panic.
• Regular, intermediate acting (e.g. clonazepam tid, lorazepam tid or qid) preferred over PRN less misuse. as needed = take as much as i need.
Reduce CBT: cause problems with learning, don’t become as anxious when exposed, don’t learn how to overcome
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Benzodiazepines +
Rapid onset of action, anticonvulsant, sedating, relatively
| safe in OD
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Benzodiazepines -
falls, impaired driving, impaired cognition, reduces CBT
| effectiveness, W/D anxiety, 1/3 can get addicted
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Pregabalin
• Binds to subunit of voltage sensitive calcium channels
leading to decreased release of neurotransmitters including glutamate
• Better absorbed than gabapentin at higher doses
• Approved in Canada as anticonvulsant, for fibromyalgia, and neuropathic pain treatment
• Side effects: dizziness, drowsiness, weight gain, rare edema
• Rare reports of abuse/misuse
Trouble tolerating it BID
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Pregabalin GAD
300-600 mg divided bid
| monotherapy and as augmentation with SSRI nonresponders
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Pregabalin SAD
600 mg divided bid
| monotherapy
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Quetiapine XR GAD
• quetiapine XR (150-300 mg) effective in multiple RCTs
• similar efficacy compared to SSRIs
• Not effective in augmentation or in treatment resistant patients
when they're bipolar and anxious and you don't want them to become hypomanic
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Quetiapine XR SAD
quetiapine XR benefit on some secondary outcome measures in one RCT (i.e. SPIN and CGI), but not on the main outcome (BSPS)
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Quetiapine XR +
Sedating, antidepressant, low risk of manic switch
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Quetiapine XR -
Weight gain, metabolic s/e
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Mirtazapine
effective for most anxiety disorders
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Buspirone
good side effect profile, but clinical experience suggests poor efficacy
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TCAs
can be effective, but no evidence of superiority compared to SSRIs
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MAOIs
may have a role in some resistant cases, especially established for SAD
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Vortioxetine
helps anxiety associated with MDD. Mixed data for GAD. Low incidence of sexual side effects.
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Silexan
(lavender oil), improves anxiety and sleep. Well tolerated and not addictive.
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Obsessions
• Recurrent and persistent thoughts, impulses, or
images experienced as intrusive and cause marked
anxiety
• Attempts to suppress or ignore or to neutralize them
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Characteristics of Obsessions
* Intrusive - unintended and against one's will
* Unacceptability - annoyance, unpleasantness or distress
* Subjective resistance - urge to suppress through cognitive control strategies, avoidance or compulsions
* Uncontrollability
* Ego-dystonicity - inconsistent with respect to core values
56
Compulsions
• Repetitive behaviors or mental acts in response to an
obsession or rules applied rigidly.
• Aimed at preventing or reducing distress or preventing
some dreaded event.
• Could not realistically neutralize or prevent whatever
they are meant to address or clearly excessive.
• Not performed for pleasure, but may reduce anxiety.
57
OCD Criteria DSM-5
* Obsessions and/or Compulsions
* Time consuming (>1hr) or marked distress or significantly interfere with functioning
* Not a result of the direct physiologic effects of a substance or a general medical condition.
* Not better explained another mental disorder
* Specifiers: Insight - Good, fair, poor, absent
* Tic related
58
Questioning about OCD
• Screening Question:
• "Do you have symptoms of an obsessive-compulsive disorder, such as needing to wash your hands all the time because you feel dirty, constantly checking things, or
having annoying thoughts pop into your head over and over?"
• If "yes", then check if uncomfortably driven: When you check to make sure the door is locked, do you feel like you really have to check it, and that if you didn't you'd feel very uncomfortable?
• Establish interference with activities and/or distress:
• How many times do you check the door usually? Is it just once or twice or do you have to check it 10 or 20 times to be satisfied that it's locked? How much time do
you spend checking
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OCD Phenomenology
```
• Contamination - Washing/Cleaning
• Pathological doubt - Checking
• Symmetry/"Just right" - Arranging
• Harm/Sexual thoughts - Neutralizing (praying,
touching, counting etc..)
```
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Tool OCD
YBOCS
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Differential diagnosis OCD
• Rumination in MDD: Themes of regret, self-worth, injustice Congruent with negative mood
• Worry in GAD: Everyday (somewhat) realistic concerns
• E.g. Getting into a car accident vs. having run
someone over and not notice, Absence of time consuming compulsions (though will sometimes need to check)
* OCD vs psychosis: Obsessions recognized as own thoughts, Obsessions usually highly stereotyped, Need to neutralize obsessions
* OCD vs suicidal/homicidal ideation: Thoughts are ego-dystonic and cause anxiety, Accompanied my neutralizing compulsions
* OCD vs OCPD: In OCPD, thoughts are ego-syntonic, They see others as not holding high enough standards
* OCD vs pedophilic disorder: In pedophilia they will almost always engage in behaviors at some point. If not, they will often engage in compensatory behaviors as an outlet
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Pharmacotherapy OCD
• All SSRIs and clomipramine have shown efficacy
• High doses are more effective
• Long durations required (up to 12 weeks)
• No convincing data that any one agent is better than
another
• In practice, citalopram is often avoided due to HC warning
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OCD: About of patients will respond to monotherapy
| with SSRI
40-60%
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OCD: Augmentation with may help treatment resistant
| cases
antipsychotics and glutamate modulating medications
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OCD: Antipsychotics
• Risperidone (2-4 mg), aripiprazole (10-15 mg),
haloperidol (2-5 mg) have strongest evidence
• Quetiapine and olanzapine have mixed data
• Paradoxically, some patients with schizophrenia can
have de novo or worsening of OCD symptoms with
SGAs, especially clozapine
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Glutamate modulating drugs OCD
* Lamotrigine 100-200 mg
* Memantine 10 mg bid
* N-actylcysteine 1200 mg bid
* Topiramate 50-200 mg (for compulsions)
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Inclusion criteria neurosurgery OCD
usually 3 antidep, 2 aug strategies, specialized CBT
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Neurostimulation OCD
◦ rTMS (e.g. SMA), deep TMS (vmPFC, ACC)
Place for TMS in OCD algorithm not entirely clear
◦ DBS
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Neuroablation OCD
◦ RF ablation
◦ Stereotactic radiosurgery (gamma knife)
◦ MRgFUS
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Psychotherapy OCD
• CBT / BT - exposure and response prevention
combined with cognitive techniques
• Home visits
• Family involvement (prevent family from helping with rituals)
• May be more effective than SGA augmentation for SSRI resistant cases
• Supportive and psychodynamic not effective
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Cognitive Techniques OCD
* Normalization of obsessions: Intrusive thoughts along lines of obsession themes are common in general population. Becomes pathological due to importance and meaning attached to the thoughts (e.g. If I have the thought of drowning my baby, it means I’m a horrible person)
* Role of neutralization: Attempting to suppress the thought makes it occur more often (e.g. “Don’t think of a pink elephant!”). Goal is to have patient “do nothing” in response to obsession.
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Exposure and Response Prevention
• The most important CBT technique
• Patient places self in situation where obsession is
triggered and resists urge to complete compulsion
• Patient monitors thoughts and emotions during the
exercise
• Can be used to challenge faulty beliefs
73
BDD DSM-V Criteria
* Preoccupation with one or more perceived defects or flaws in physical appearance that is not observable or appears slight to others (not evident at a conversational distance)
* At some point, individual has performed repetitive behaviors or mental acts in response to concerns
* The preoccupation causes clinically significant distress or impairment
* The appearance preoccupations are not restricted to concerns with body fat or weight in an eating disorder
74
BDD specifiers
* Muscle dysmorphia (“Megarexia”)
* Believe that their body is not sufficiently lean or muscular
* Compulsively diet and exercise
* Often use AAS
* BDD by Proxy
* Preoccupied by appears of a family member (usually child) or partner
• Level of insight
75
• BDD patients spend on average x h per day thinking about their appearance or engaging in compensatory behaviors.
3 to 8 hours
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Clinical Features BDD
* Mean involvement of 5 body parts
* Face, skin, hair, genitals most common
* Often concerns about body symmetry or muscularity
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BDD treatment pharmaco
* SSRIs and clomipramine at high doses for long duration (12-16 weeks) most effective
* No evidence that presence of "delusion" requires treatment with antipsychotic. Instead, implies a more severe form of BDD
* Only 22% of patients who tried SRI had a “minimally adequate” trial
* Open studies suggest potential benefit from buspirone + SSRI, SGAs +SSNRI
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BDD psychotherapy
• Often requires motivational interviewing (exploring pros + cons of change)
• Exposure and response prevention
• Perceptual retraining – nonjudgmentally describe their entire body in a mirror for 5 min from an arm`s length away
• Identify maladaptive beliefs: "As long as I have this deformed nose, no one will love me and I will
never be happy"
• -> “Even if my nose is deformed, I can still live a meaningful life. There is more to a person than their outward appearance.”
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Communicating with BDD Patients Don't
* Say that there is “nothing wrong with them”
* Reassure them that they “look good”
* Suggest other abnormalities in their appearance that they did not mention themselves (“e.g. I don’t see acne but you have a little scar on your chin”)
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Communicating with BDD Patients DO
* Explain that you do not perceive the “flaws”
* Explain that you are concerned that they have a “body image problem” that will not benefit from surgery
* Empathize with their distress and suffering
* Explain what BDD is and that it is a treatable mental health problem
81
DSM-5 criteria hoarding disorder
* Persistent difficulty discarding or parting with possessions, regardless of actual value
* Perceived need to save items and distress associated with discarding them
* Accumulation and clutter preventing normal use of space unless others intervene
* Clinically significant distress or impairment
* Not due to GMC
* Not part of another mental disorder
* Specifers:
* With excessive acquisition
* Insight – good, fair, poor, absent
82
Differential Dx hoarding
* Medical causes of pathological hoarding
* Dementia, especially FTLD
* Brain injuries (TBI, stroke, etc.)
* Psychiatric
* Substance dependence
* Part of OCD (hoarding to prevent catastrophic outcomes)
* Severe depression (related to anergy)
* Schizophrenia (related to delusions)
* OCPD
• Normal collecting
83
Assessing for Hoarding
* Do you find it difficult to discard or part with possessions?
* Do you have a large number of possessions that congest and clutter the main rooms in your home?
* Home visit is helpful
* Photos of home
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Hoarding tool
hoarding rating scale
| clutter image rating
85
Hoarding D/O vs OCD
* Phenomenology
* Thoughts related to hoarding are not intrusive, distressing or stereotyped
* Thoughts do not trigger rituals to neutralize them
* Distress occurs primarily when faced with possibility of discarding
* Most patients with hoarding disorder do not have other OCDsymptoms
* Neurobiology
* Cortico-striato-thalamic hyperactivity NOT seen in hoarding disorder
* Instead have hypoactive Anterior Cingluate (ACC) activity, an area involved in decision making
* Hoarding seen with mesial frontal lesions
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Treatment hoarding
* Poor outcomes with traditional CBT for OCD
* Better outcomes with specifically designed CBT
* Help patients to develop more healthy attachment to objects
* Inclusion of home visits for “extreme clean-up”
* SSRIs have mixed data
* In OCD trials, hoarding was predictor of poor outcomes
* Other studies show similar response in hoarding disorder patients to OCD patients
87
Normal anxiety:
Insidious, subjective, emotional response to a stressor that is unknown. Apprehension, tension or uneasiness from anticipation of danger.
88
Fear:
Sudden, intellectual appraisal of a know stimulus
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Pathological anxiety:
Pathological if interferes with social and occupational functioning, achievement of desired goals/ emotional comfort
90
Prevalence GAD and panic
3-4%
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Most prevalent anx dis
specific phobias: 25%,
92
Prevalance SAD, more common in, course
13%, W, lifelong
93
Prevalance OCD
2-3%
94
Anxiety disorders: More common in women or men?
women
95
Impacts of anxiety disorders
Decrease work productivity, increased use of healthcare services. Increased risk for suicide.
96
Etiology of anxiety
Cell bodies of origin for the serotonin pathways lie within the raphe nuclei located in the brain stem. Serotonin is thought to be decreased in anxiety disorders. Cell bodies for norepinephrine originate in the locus ceruleus. Norepinephrine is thought to be increased in anxiety disorders. GABA is the major inhibitory neurotransmitter in the brain. It is involved in the reduction and slowing of cellular activity. It is synthesized from glutamic acid, with vitamin B 6 as a cofactor. It is found in almost every region of the brain. GABA is thought to be decreased in anxiety disorders (allowing for increased cellular excitability).
Hereditary, genetic, learned beahviors
HPA axis: stress= cortisol = increased arousal, vigilance, focused attention, memory formation, inhibition of the growth and reproductive system containment of the immune response
Stressors = neurophysiological changes
Childhood trauma
Temperament: behavioural inhibition
97
Areas of the brain affected by anxiety disorders and the symptoms that they mediate include the following:
* Amygdala: Fear; particularly important in panic and phobic disorders
* Hippocampus: Associated with memory related to fear responses
* Locus ceruleus: Arousal
* Brainstem: Respiratory activation; heart rate
* Hypothalamus: Activation of stress response
* Frontal cortex: Cognitive interpretations
* Thalamus: Integration of sensory stimuli
* Basal ganglia: Tremor
98
How does anxiety affect thinking, perception, learning, and attention?
By biasing attention, anxiety alters what we are conscious of, and in turn, the way we experience reality. More difficult to learn, attention is focused on threat, heightened senses focused on the threat but everything else falls away. Thought process is distorted. Selective attention. Decrease concentration, reduced ability to make recall associations. Brain fog, senses decreased. Feelings of unreality.
99
Comorbid with OCD
Depression, SUD, social anxiety, GAD, panic disorder, eating disorder, tics, personality disorder, specific phobia, tourette’s
100
OCD onset, men or women, course
Adolescence, early adulthood. The onset of symptoms for about 50 to 70 percent of patients occurs after a stressful event, such as a pregnancy, a sexual problem, or the death of a relative. Equally common among men and women. Chronic. +Single.
101
Separation anxiety criteria
He or she experiences excessive or unwarranted fear or anxiety due to separation from whoever he or she is attached to, as demonstrated by 3 (or more) of the following:
Regular excessive distress when separated from home or from certain individuals.
Regular excessive worry about losing these individuals or about them being harmed.
Regular worry about experiencing an unfortunate event (such as getting lost or ill) that causes separation from their attachment figures.
Persistent reluctance or refusal to go anywhere or do anything out of fear of separation.
Persistent reluctance or refusal to sleep away from home or from the attachment figures.
Frequent nightmares about separation.
Frequent complaints of physical symptoms, such as headaches or nausea, when he or she is separated from attachment figures or anticipating this separation.
The individual’s fears and anxiety are persistent, lasting at least 4 weeks in children and adolescents and at least 6 months or longer in adults.
This separation fear or anxiety causes clinically concerning distress or impairment in important areas of life.
The individual’s excessive fear of separation cannot be attributed to another mental disorder.
102
Other disorders linked to not willing to go to school
Social anxiety, ADHD, oppositional disorder, conduct disorder
103
Describe the typical developmental milestones expected to be achieved by a 10 year old.
Separation anxiety should be resolved, focused on being with peers, gaining skills, Erikson: industry vs inferiority should be looking for autonomy
104
What biopsychosocial factors are predisposing to the development of childhood anxiety?
Temperament: behavioral inhibition to the unfamiliar, over attachment to the mother, overprotecting mother, transferring fear and anxiety through modeling, genetic
105
SAD will probably present first for
probably first present for depression, SUD.
106
CBD
small studies, public speaking SAD = some benefit, one dose of 300 mg, otherwise no evidence
107
OCD with suicidal thoughts:
0% want to actually kill themselves
