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90 Cards in this Set
- Front
- Back
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What is anxiety?
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A subjective feeling of fear accompanied by physical symptoms
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Is anxiety a normal human response?
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Yes, and physicians must be careful when diagnosing patients with one of the anxiety disorders that the patient is not experiencing a normal, physiologic response to a possible threat
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What is the lifetime prevalence of anxiety disorders in men?
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19%
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What is the lifetime prevalence of anxiety disorders in women?
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30%
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What socioeconomic class is most predisposed to anxiety disorders?
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Higher Socioeconomic Class
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List some medical causes of anxiety (7)
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1. Hyperthyroidism
2. Neurologic diseases including brain tumors and multiple sclerosis 3. Vitamin B12 Deficiency 4. Anemia 5. Pheochromocytoma 6. Hypoglycemia 7. Hypoxia |
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List some medications or substances that can induce anxiety (9)
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1. Caffeine
2. Amphetamines 3. Nicotine 4. Cocaine 5. Alcohol or Sedative Withdrawal 6. Mercury or Arsenic Toxicity 7. Antidepressants 8. Organophosphate Toxicity 9. Penicillin or Sufonamides |
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What are the 2 major subtypes of Panic Disorder?
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1. Panic Disorder with Agoraphobia
2. Panic Disorder without Agoraphobia |
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Is there a gender disparity in the diagnoses of panic disorder and agoraphobia?
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Yes
They are more commonly diagnosed in women |
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What is the typical age of onset for Panic Disorder?
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Common in late teens to early 30s
Rarely, onset will be after 40 |
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What do the majority of patients describe as the trigger for their first panic attack?
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Nothing
Approximately 80% of patients cannot pinpoint a trigger for their first attack A panic attack is typically the presenting feature of Panic Disorder |
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What is a common childhood disorder that may predispose to the diagnosis of panic disorder as an adult?
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A history of separation anxiety disorder is seen in 20-50% of patients with an eventual diagnosis of panic disorder
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What are major comorbid psychiatric conditions seen in patients with panic disorder?
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1. Major Depression
2. Substance Abuse 3. Social Phobias 4. Specific Phobias 5. Obsessive-Compulsive Disorder (OCD) |
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DSM-IV Criteria for Panic Attack
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A discrete period of intense fear or discomfort in which 4 of the following symptoms developed acutely and peaked in intensity within 10 minutes of onset:
1. Palpitations or Tachycardia 2. Diaphoresis 3. Sensation of Shortness of Breath 4. Shaking or Trembling 5. Subjective Feeling of Choking 6. Chest Pain or Discomfort 7. Nausea or Abdominal Pain 8. Lightheadedness or Fainting 9. Derealization (Feelings of Unreality) or Depersonalization (Being Detached from Onseself) 10. Fear of Losing Control or Going Crazy 11. Fear of Dying 12. Paresthesias 13. Chills or Warm Sensations |
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What is the course of a typical panic attack?
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They usually last between 20-30 minutes
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Which is more important in establishing the diagnosis of a panic attack: time to peak of symptoms or total length of symptoms?
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Time to Peak of Symptoms
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How often do panic attacks typically occur?
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There is no typical frequency
They may occur many times per day or only a few times per year |
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How is panic disorder diagnosed?
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Panic Disorder is characterized by multiple unexpected panic attacks accompanied by anticipatory anxiety about having additional attacks
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How many patients with panic disorder present to the emergency room?
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With recurrent episodes of chest pain that mimic a myocardial infarction
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What commonly used substances can exacerbate anxiety in patients both with and without panic disorder?
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Caffeine and Nicotine
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What is panic disorder with agoraphobia?
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Anxiety about being in public or a large space in which escape my be difficult or embarrassing or in which help may not be readily available if one were to have an unexpected or situationally predisposed attack.
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What is the differential diagnosis of Panic Disorder?
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MEDICAL
--Myocardial Infarction --Angina --COPD --CHF --Pheochromocytoma --Other Cardiac, Pulmonary or Endocrine Disorders PSYCHIATRIC --Depressive Disorder --Phobic Disorders --OCD --PTSD SUBSTANCE --Cocaine --Nicotine --Caffeine --Alcohol or Opiate Withdrawal |
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How is panic disorder treated in the acute setting?
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Symptomatically with Anxiolytics, typically Benzodiazepines such as Lorazepam (Ativan)
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What risk is associated with initial pharmacologic treatment of panic disorder?
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Benzodiazepine Dependence
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How is panic disorder treated over the long-term?
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Tapered benzodiazepine dose (to avoid dependence) after initiation of long-term selective serotonin/norepinephrine reuptake inhibitor (SS/NRI) therapy
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How is treatment of panic disorder with SS/NRI different than treatment for depression?
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Panic disorder is treated with higher doses of SNRIs
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What is the typical length of treatment with SNRIs for panic disorder?
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These medications should be taken for 8-12 months as relapse of panic disorder is common
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What is an important side effect of SNRIs that should be explained to patients beginning to take them for panic disorder?
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Patients may report anxiety, insomnia, and increased frequency of panic attacks upon initiation of SNRI therapy
This tends to resolve within the first week of treatment |
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What is the best nonpharmacologic treatment for panic disorder?
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Cognitive Behavioral Therapy (CBT) has been shown to be as effective as pharmacologic treatment
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What is a common activity during which social anxiety disorder becomes apparent?
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Public Speaking
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DSM-IV Criteria for Social Anxiety Disorder
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1. Persistent and excessive fear of social or performance situations
2. Exposure to the situation results in immediate anxiety 3. The patient recognized that the fear is excessive or unreasonable 4. The avoidance or anticipation of the precipitating situation significantly interferes with the patient's routine 5. The fear is not due to a general medical condition, substance induced or due to another psychiatric disorder including panic attacks |
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How is Social Anxiety Disorder treated?
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High-dose SNRIs, CBT, Psychodynamic Therapies have been shown to have some benefit
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How would one distinguish between social anxiety disorder and avoidant personality disorder?
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Social Anxiety Disorder involves an unreasonable fear of embarrassment and humiliation in social or performance situations
Avoidant Personality Disorder involves fear of rejection in social situations |
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What is a phobia?
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An irrational fear that leads to avoidance
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DSM-IV Criteria for Specific Phobia
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1. Persistent and excessive fear of a specific situation or thing
2. Exposure to the situation or thing results in immediate anxiety 3. The patient recognizes that the fear is excessive or unreasonable 4. The avoidance or anticipation of the precipitating situation or thing significantly interferes with the patient's routine 5. The fear is not due to a general medical condition, substance induced or due to another psychiatric disorder including panic attacks |
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What are some common specific phobias?
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--Fear of flying
--Fear of blood --Fear of snakes --Fear of heights |
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What is the gender disparity for diagnosed specific phobia?
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Estimated to be twice as common in women as men
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How are specific phobias treated?
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Achieve habituation or elimination of the fear response through systemic desensitization and supportive psychotherapy
Pharmacologic treatments have yet to show benefit |
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What is systemic desensitization?
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Gradually exposing patient to the feared situation while teaching relaxation techniques
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How do some patients "self-treat"?
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As with many other anxiety disorders, some patients will choose to drink alcohol to "lessen" their anxiety
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What is Obsessive-Compulsive Disorder (OCD)?
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The presence of obsessions and/or compulsions that produce discomfort or impairment
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When is the most common age of onset for OCD?
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Early Adulthood
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Are women affected more than men in OCD?
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No
Both genders are equally affected |
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The occurrence of what other mental disorder in a first-degree relative predisposes a person to OCD?
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Tourette Disorder
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What is the etiology of OCD?
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GENETIC
--More common in patients who have first-degree relatives with OCD PSYCHOSOCIAL --the onset of OCD can be triggered by stressful events in up to 60% of patients |
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What is the physiologic basis of OCD?
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Both abnormal regulation of serotonin and dysregulation in the basal ganglia-thalami-cortical circuit have been implicated
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Define and differentiate obsessions and compulsions
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Obsessions
--Recurrent, repeated intrusive thoughts, ideas or images --The Patient attempts to suppress these thoughts and recognizes that they may be irrational Compulsions --Repetitive conscious mental acts or ritual behaviors that a person feels driven to perform in response to an obsession --The patient recognizes that the behaviors are excessive and irrational --These rituals are generally disruptive and interfere with a person's daily activities --Performing the ritual temporarily relieves the anxiety |
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How is OCD diagnosed?
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Patients exhibit either obsessions or compulsions
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What percentage of OCD patients exhibit both obsessions and compulsions?
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75%
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Do patients with OCD have insight into their disorder?
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Yes, patients usually recognize that they have irrational fears that they wish to get rid of
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What are some examples of compulsions?
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Excessive hand washing, checking locks, turning light switches on and off, counting things, skin picking (dermatillomania), hair plucking (trichotillomania), nail biting (onychophagia) and hoarding
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How are obsessions of OCD distinct from delusions?
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The obsessions of OCD are experienced by patients as ego-dystonic
For example, a person with no history of violence has repeated thoughts of harming women and cause then significant distress |
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How is OCD different from obsessive-compulsive personality disorder (OCPD)?
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OCPD is an Axis II diagnosis that pertains to patients who are overly obsessed with details and orderliness and generally do not perceive themselves to have a problem (poor insight)
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What is the typical course of OCD?
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Generally chronic with only about one-third of patients showing significant improvement
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How is OCD treated?
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Pharmacologic treatment combined with behavioral psychotherapy
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What is the pharmacologic treatment of OCD?
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SNRIs at higher doses than those used for the treatment of depression and other disorders
Tricyclic antidepressants (TCAs), specifically Clomipramine (Anafranil), have also shown some efficacy |
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What is behavioral therapy conducted?
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Exposure to ritual-eliciting situations and prevention of the resulting compulsions
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What surgical procedure has been used in the treatment of intractable OCD?
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Anterior Cingulotomy
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What is PTSD?
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The response to a traumatic or stressful life event in which the patient re-experiences the event, avoids similar situations or reminders and may experience hyperarousal or emotional blunting
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Is the response immediate or delayed in PTSD (in relation to the inciting event)?
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It can be either immediate or delayed (ie, up to years after the initial traumatic event)
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What are examples of people who may have PTSD?
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War veterans, rape victims, mugging victims
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DSM-IV Criteria for PTSD?
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1. The person experiences an event that involved death, serious threat to life or bodily harm that was experienced with intense fear, horror or hopelessness
2. The traumatic event is persistently re-experienced in dreams or flashbacks 3. There is repeated avoidance of the stimuli associated with the trauma 4. Persistent symptoms of increased arousal including hypervigilance, insomnia, irritability and so on 5. Symptoms persist for at least 1 month and cause distress or impairment in functioning |
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What are the common comorbid conditions in patients with PTSD?
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1. Substance Abuse
2. Depression |
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How is PTSD generally treated?
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A combination of pharmacologic and behavioral therapy
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What drugs are used in the treatment of PTSD?
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1. SNRIs
2. MAOIs 3. TCAs 4. Benzodiazepines 5. Mood Stabilizers |
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What medications, if used in the acute period following exposure to trauma, have been found to reduce the severity of PTSD symptoms over the long-term?
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Beta-Blockers
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What are some behavioral therapies that have shown efficacy?
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1. Exposure Therapy
2. Group Therapy 3. CBT 4. Eye Movement Desensitization and Reprocessing (EMDR) 5. Psychodynamic Therapy |
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What is EMDR?
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It involves the patient recalling and visualizing the traumatic experience while making repeated eye movements
EMDR has been found to be equally effective to pharmacotherapy and exposure therapy in multiple RCTs and meta-analyses |
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Is "debriefing" found to be effective in reducing the development of PTSD?
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No
Multiple studies have found that debriefing, which involves encouraging the recollection of the traumatic even for the sake of emotional processing, may increase the risk of PTSD and depression |
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What medication has been found to be effective in reducing the nightmares associated with PTSD?
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Prazosin
(Minipress, Vasoflex, Pressin) |
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What is Acute Distress Disorder?
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A disorder similar to PTSD where the patient has exhibited symptoms for only a short duration
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How would Acute Stress Disorder be diagnosed?
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Symptoms are identical to those in PTSD but the inciting event must have occurred less than 1 month ago, and symptoms must have been present for less than 1 month
As in PTSD, the response to the traumatic event must cause impairment in functioning |
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What happens if the symptoms of Acute Stress Disorder persist for more than 1 month?
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The diagnosis of PTSD is usually made
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How is Acute Stress Disorder treated?
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Same as for PTSD
Also Brief Supportive Psychotherapy can be used |
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What is Generalized Anxiety Disorder (GAD)?
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GAD is characterized by excessive and uncontrollable worry about life circumstances accompanied by hyperarousal
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What percentage of patients with GAD are diagnosed with another anxiety disorder during their lifetime?
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80%
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What gender, age, ethnicity and socioeconomic group are most predisposed to GAD?
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Young to middle aged, nonwhite females in lower socioeconomic classes
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How much more commonly is GAD observed in women as compared to men?
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Approximately twice as common in women
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DSM-IV Criteria for Generalized Anxiety Disorder (GAD)
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1. Excessive worry or anxiety about several life events or activities for at least 6 months
2. Difficulty controlling the worry 3. At least 3 of the following symptoms are present when anxious --Muscle tension --Easy fatigability --Restlessness --Irritability --Difficulty falling or staying asleep --Difficulty concentrating 4. The worry must be out of proportion to the likelihood or impact of feared events 5. Symptoms are not attributable to other medical or psychiatric conditions |
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Upon interviewing patients with suspected GAD, what do they generally report regarding their life?
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Many patients report being anxious for as long as they can remember
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What is the most effective therapeutic approach to GAD?
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A combination of pharmacologic therapy with psychotherapy (especially CBT)
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What medications are shown to be beneficial in the treatment of GAD?
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1. Buspirone (BuSpar, a nonbenzodiazepine anxiolytic)
2. Benzodiazepines 3. High-dose SNRIs |
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What is the best nonpharmacologic treatment for GAD?
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Cognitive Behavioral Therapy (CBT) had been shown to be as effective as pharmacotherapy for GAD
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If a history of alcohol abuse exists, what medications should be avoided?
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Benzodiazepines
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Are adjustment disorders considered anxiety disorders?
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Technically they are not
Adjustment disorders describe maladaptive responses to stressful life events |
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DSM-IV Criteria for Adjustment Disorders
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1. The development of emotional or behavioral symptoms within 3 months of a life stressor and the cessation of these symptoms within 6 months after the stressor has passed
2. The symptoms produce distress out of proportion to the stressor and cause social impairment |
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How is the course of an adjustment disorder useful in differentiating it from other anxiety and mood disorders?
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Symptoms of adjustment disorder resolve within 6 months after termination of the stressor(s)
If symptoms persist, think of an anxiety disorder, PTSD or mood disorder |
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What are the different subtypes of adjustment disorders and how are they classified?
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Classification is based on the predominant symptoms: depressed mood, aggressive conduct, anxiety, and so on
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What is the gender predominance for adjust disorders?
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Females are affected twice as often as males, but it should be noted that the overall prevalence of adjustment disorders in the population is quite low
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How are adjustment disorders treated?
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Supportive Psychotherapy
Pharmacotherapy for the associated symptoms is also effective |
