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362 Cards in this Set
- Front
- Back
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Some of the most common of all psychiatric illnesses can manifest initially as physical health states. Often only after extensive, unnecessary assessment & diagnostic evaluation is the pt's problem correctly identified as an
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anxiety disorder
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Anxiety is a very _____ & _____ human reaction to life stressors that motivates an individual to deal with events and emotions
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Anxiety is a very common and normal human reaction to life stressors that motivates an individual to deal with event & emotions
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Cultural differences can affect _______ manifestations of anxiety
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Cultural differences can affect behavioral manifestations of anxiety
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High pathological levels of anxiety interfere with _______, ______, _________, and _______ responses.
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High pathological levels of anxiety interfere with PERCEPTIONS, MEMORY, JUDGEMENT and MOTOR RESPONSES
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LEVEL OF ANXIETY
LEVEL I definition |
Mild
Normative level experience by all; functions to motivate |
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LEVEL I Anxiety
Physiological s/s |
~Vital signs normal
~Pupils constricted ~Minimal increase in muscle tone |
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Level I anxiety
Psychological s/s |
~Perceptual field broadened,
~Heightened awareness of environment |
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Level II Anxiety
Definition |
Normative level experienced by most in response to significant stressors
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Level II Anxiety
Physiological s/s |
~Vital signs normal
~mild increased heart rate ~moderate increase in muscle tone |
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Level II Anxiety
Psychological s/s |
~subjective feeling of tension or worry
~narrowed perceptions |
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Level III Anxiety
definition |
Severe
Pathological level |
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Level III anxiety
Physiological s/s |
~autonomic nervous system triggered
~flight-or-fight response ~Pupils dilated ~Vital signs increased ~Diaphoresis ~Muscles rigid ~Hearing decreased ~Pain threshold increased ~urinary frequency ~Diarrhea |
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Level III anxiety
Psychological s/s |
~Perceptual field greatly narrowed
~Difficulty with problem solving ~Distorted perception of time ~Selective inattention ~Dissociative sensations ~Automatic behavior |
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Level IV Anxiety
Definition |
Panic
Pathological level |
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Level IV Anxiety
Physiological S/s |
Severe sx markedly increased;
~Pt is pale ~hypotensive ~has poor eye-hand coordination ~muscle pains ~marked decrease in hearing ~Dizziness ~Shortness of breath |
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Level IV Anxiety
Psychological s/s |
PANIC
~scattered perceptions ~unable to attend to enviro stimuli ~illogical thinking ~may exhibit hallucinations ~may exhibit delusions |
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Anxiety d/o are the most common group of psychiatric d/o & are characterized by
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**the degree of anxiety experienced by the pt
**the duration & severity of the anxiety **the typical behavioral manifestations of anxiety observed in the pt |
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Anxiety ranges from ______ states to ______ d/o & is accompanied by multiple ______ complaints
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Anxiety ranges from ACUTE states to CHRONIC d/o & is accompanied by multiple SOMATIC complaints
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Individuals most often present 1st in a _________ setting with ______complaints
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Individuals most often present 1st in a PRIMARY CARE setting with NONSPECIFIC PHYSICAL complaints
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Anxiety d/o are often confused w/ _______ & ________ d/o so careful differential diagnostic assessment is essential
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Anxiety d/o are often confused w/ CARDIAC & RESPIRATORY d/o so careful differential diagnostic assessment is essential
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Anxiety d/o have a frequent co-morbidity exists with (3)
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~Substance abuse
~Depression ~eating d/o |
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Time frame of anxiety d/o
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Sx sig impair fxning & occur more days than not for a period of at least 6 months, w the pt reporting little or no volitional control over the sx
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How many specific anxiety d/o are identified in the DSM-IV-TR
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9
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Psychodynamic Theory etiology of anxiety
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Freud
Anxiety initially occurs in response to the stimulation of birth & need of the infant to adapt to the changed environment ~Subsequent anxiety results from intrapsychic conflict ~The process of unconscious repression of sexual drive is at the core of much of the conflict ~Anxiety (consciously perceived) signals the individual of the need to deal with the id-superego conflict |
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Conflict (unconscious) exists between instinctual needs of the id & the superego (conscience);
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Psychodynamic Theory etiology of anxiety
Anxiety (consciously perceived) signals the individual of the need to deal with the id-superego conflict |
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Anxiety (consciously perceived) signals the individual of the need to deal with the id-superego conflict
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The Psychodynamic Theory etiology of
Freud |
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Defense mech are unconsciously used by the individual to deal with the anxiety that results from the conflict (unconscious) that exists between instinctual needs of the id-super ego conflict
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The Psychodynamic Theory etiology of
Freud |
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The behavioral manifestations of anxiety d/o stem from
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the pathological overuse of defense mechanisms
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Interpersonal theory of etiology of Anxiety
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Sullivan
Humans are goal directed toward attainment of satisfaction & security needs Anxiety arises when an individual's needs are unmet Anxiety is 1st experienced in an infant's interactions w/ his or her mother Subsequent anxiety arised because of interpersonal conflict Conflict occurs when an individual perceives his/her needs will not be met because of rejection, feelings of inferiority, or inability to engage w/ significant others Sense of self becomes based on the individual's perception of how others view him/her |
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Anxiety 1st experienced in an infant's interactions with his/her mother
Subsequent anxiety arises because of |
interpersonal conflict
conflict occurs when an individual perceives his/her needs (satisfaction & security) will not be met because of ***rejection ***feelings of inferiority ***inability to engage w/ sig others Interpersonal theory of etiology of Anxiety |
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Sense of self becomes based on a individual's perception of
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how others view him/her
Interpersonal theory of etiology of anxiety |
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Anxiety arises when an individual's needs are unmet
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Interpersonal theory (sullivan)
for etiology of Anxiety |
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Unconscious conflict between id & super ego leads to anxiety
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Psychodymanic theory (freud)
for etiology of anxiety |
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Neurobiological theory of anxiety
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Pathological levels of anxiety (level III & IV) result from neurobiological deficits in normal brain fxning
~deficits are genetically mediated by and involve predominantly the limbic sys, midline brain stem area and sections of the cortex Deficits predispose the individual to abnormal stress responses w/ hyperactivity of autonomic nervous system causing sx such as: ~increased HR ~ increased BP, ~ diaphoresis, ~ papillary dilation, ~ tremors, and ~increased respiratory rate Problem w the HPA axis |
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Pathological level of anxiety results from neurobiological deficits in normal brain fxning
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Neurobiological theory of anxiety
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Neurotransmitters involved in suppressing the HPA axis are
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~serotonin
and GABA |
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In anxiety d/o the _____ may not be able to shut of the response or there may not be enough _____ to stop the fight- or -flight response
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In anxiety d/o the AMYGDALA may not be able to shut off the response (OVERACTIVE AMYGDALA), or there may not be enough CORTISOL to stop the fight-or-flight response
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Neurobiological deficits result in low levels of the NT _______ the chemical responsible for inhibitory responses of neurons and in hight levels of _____ the chemical associated with fight or flight response
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Neurobiological deficits result in low levels of the neurotransmitter GABA (gamma-aminobutyyric acid) the chemical responsible for inhibitory responses of neurons and in high levels of NOREPINEPHRINE , the chemical associated w/ the fight or flight
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Problems w/ the HPA axis
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Neurobiological theory
threat is perceives, & amygdala signals the hypothalamus to secrete CRH (corticotropin-releasing hormone) The amygdala also activates the sympathetic nervous system to start fight or flight the pituitary is stimulated to release adrenocorticotropic hormone (ACTH) The adrenal glands are then stimulated to release cortisol which shuts off the alarm system and restores the body to homeostasis |
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What does Cortisol do r/t anxiety
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which shuts off the alarm system (the fight or flight response from the sympathetic nervous system that was activated by the amygdala and restores the body to homeostasis by metabolic effects
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Neurobiological deficits are genetically mediated by and involve predominantly
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~the limbic system
~midline brain stem area ~sections of the cortex Neurobiological theory of etiology of anxiety |
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Neurobiological deficits predispose the individual to
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Abnormal stress responses with hyperactivity of autonomic nervous system causing sx such as:
~increased HR ~increased BP ~diaphoresis ~papillary dilation ~tremors ~increased RR Neurobiological theory of etiology of anxiety |
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Anxiety d/o are common d/o experienced by
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18.1% of the general US population
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Anxiety d/o are common in girls and women than in boys and men except for
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~OCD
~Social Phobia |
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What age do most anxiety d/o manifest?
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Adolescence
& Early childhood |
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Risk factors for anxiety d/o
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Genetic loading
***a 1st degree relative of an individual w. panic is up to 8x more likely than the general pop to develop panic d/o ***if a 1st degree relative of an individual developed panic d/o before age 20 that person is up to 20x more lekely than the general population to develop panic d/o Another risk factor for anxiety d/o is limited range of coping skills |
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a 1st degree relative of an individual w. panic is up to ___x more likely than the general pop to develop panic d/o
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a 1st degree relative of an individual w. panic is up to 8x more likely than the general pop to develop panic d/o
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Common indicators of PATHOLOGICAL levels of anxiety indicative of underlying anxiety d/o
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~anxiety is perceived as out of the control of the individual
~anxiety does not respond, even momentarily to conscious suppression ~more pervasive anxiety overlaps into all spheres of fxning ~anxiety is pronounced, distressing & of long duration ~Anxiety is unlinked & not seen as caused by life events ~anxiety is accompanied by somatic complaints which is more uncommon in normal anxiety levels ~anxiety interferes w/ ** social ** occupational ** recreational activities **ADLs |
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when anxiety interferes with:
(4) is is an indicator of pathological level or anxiety indicative of underlying anxiety d/o |
1) Social activities
2) occupational activities 3) ADLs |
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anxiety + somatic complaints
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is an indicator of pathological level or anxiety indicative of underlying anxiety d/o
more uncommon to have somatic complaints with normal anxiety levels |
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What psychometric can be used to establish & monitor the pt's anxiety level over time
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Use standardized rating scales such as the Hamilton Rating Scale for Anxiety (HAM-A)
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Assess for dysfunctional and self-medicating strategies in anxious pts
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~Substance use or abuse
~increased caffeine us ~increased nicotine use |
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Assess for psychological sx of anxiety
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~fear of dying, losing one's mind or a sense of unreality
~belief that he/she is very ill w/ no finding to support belief ~narrowed perceptions ~limited eye contact ~thought content exhibiting increased worry |
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Physical exam findings of anxiety
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Anxiety manifests in many physical ways:
~pupillary dilation ~tachycardia ~increased muscle tone ~headaches ~HTN ~motor restlessness ~Diaphoresis ~palpitations, often w/ tightness of chest ~GI problems ~dizziness or light headedness |
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Common mood for anxiety d/o
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Tense
nervous worried |
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Common affect for anxiety d/o
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anxious
worried |
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Common speech patterns observed in anxiety d/o
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~over-productive
~Rapid ~distractible speech patterns ~thought blocking |
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Common appearance observed in anxiety d/o
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~Psychomotor reslessness
~fidgeting ~tremors ~inability to sit still ~hand-wringing |
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Common thought process observed in anxiety d/o
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~overall organized
~goal directed ~redirectable |
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Common thought content observed in anxiety d/o
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~Thematic for worry
~mild perseveration on topics of concern |
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Common memory observations in anxiety d/o
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~impaired short-term & immediate memory
~Forgetful |
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Common concentration observation anxiety d/o
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~inattentive
~decreased concentrations |
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Common judgement & insight observed in anxiety d/o
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Judgement: poor judgment for self-welfare
Insight: limited insight |
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Baseline labs to obtain in anxiety d/o
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TO r/o metabolic causes or unidentified conditions
~CBC ~chemistry profile ~thyroid fxn tests ~B12 level Drug toxicity screening |
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In some cases pt may have labs reflecting compensated respiratory _____
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In some cases, pt may have labs reflecting compensated RESPIRATORY ALKALOSIS:
**decreased carbon dioxide level **decreased bicarbonate levels **normal pH |
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Cardiovascular medical conditions that may mimic anxiety d/o
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CHF
~Mitral valve prolapse ~Myocardial infarct ~Arrhythmia especially tachcardic arrhythmias ~Pulmonary embolism ~Coronary artery disease |
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Respiratory medical conditions that may mimic anxiety d/o
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~Asthma
~chronic obstructive pulmonary d/o ~Pneumonia |
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Endocrine medical conditions that may mimic anxiety d/o
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~hyperthyroidism
~hyperparathyroidism ~Cushing's disease |
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Neurological medical conditions that may mimic anxiety d/o
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~seizure d/o
~transient ischemic attack ~Cerebral vascular accident ~encephalitis ~CNS neoplasm |
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Metabolic medical conditions that may mimic anxiety d/o
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~hypoglycemia
~vitamin B deficiency ~porphyria |
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Substance abuse or dependency medical conditions that may mimic anxiety d/o
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~Intoxication w/ CNS stimulants (cocaine, amphetamines, caffeine)
~withdrawal from CNS depressants ( EtOH, marijuana) |
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Pharm MGMT of anxiety
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Most of the meds known to improve sx of anziety act on the GABA system
SSRI BNZs TCAs Non-BNZ |
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Selective serotonin reuptake inhibitors SSRIs to treat anxiety
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~considered 1st line agents for chronic anxiety d/o
~Action on 5HT system & indirectly on GABA system ~Carry no risk of dependency ~Cannot be used prn ~clean sife-effect profile ~take time to reach sx control (usually 3-4 wks) ~best when combined with psychotherapy |
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Benzodiazepines (BZNs)
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~potentiate the effects of GABA
~rapid onset of action ~can be used prn ~limit to lowest possible dose & short-term use if possible, as long term use may lead to ***tolerance ***dependence ***memory impaired ***depression Use should be limited to period of excessive sx, period of high stress or in unremitting sx contraindicate in pt w/ hx of substance dependence Effective but carry high risk for addictiion |
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Advantages to using
Klonopin (clonazepam) Valium (diazepam) |
Benzos w/ longer 1/2 life require less frequent dosing, have less severs withdrawal and have less rebound anxiety
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Advantages of benzo w/ short 1/2 lives
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~less daytime sedation
~less drug accumulation ~quick onset of action ~useful for tx of insomnia |
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Disadvantages of benzo w/ short 1/2 life
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~require more frequent dosing
~have more severe withdrawal ~haver more rebound anxiety ~increased risk of additction |
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TCAs in anxiety d/o
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***Effective but have dirty side-effect profiles
***Side effects often affect compliance |
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Non-benzo anxiolytics
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Buspar (buspirone)
Gabitril (tiagabine) Neurontin (gabapentin) Usually adjunctive use w/ other pharm agent |
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Buspirone
Trade Dose SE |
Non-benzo anxiolytics
Buspar 20-60mg/d SE: Dizziness Insomnia Tremors Akathisia Stomach upset Dry mouth Helpful adjunct for anxiety |
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Tiagabine
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Gabitril
4-56mg/d SE: Dizziness somnolence stomach upset tremors dry mouth Helpful adjunct for anxiety |
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Gabapentin
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Non-benzo anxiolytics
Neurontin 300-3600mg/d SE: Ataxia decreased coordination Sedation disequilibrium Used for anxiety neuropathic pain fibromyalgia and as an anti-craving medication |
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Comorbidities of Anxiety d/o
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~Anemia
~cardiac d/o esp in pt's w. dysrhythmias ~endocrine d/o **cushing's disease **hyperthyroidism **hypoglycemia ~plumonary conditions **COPD **Asthma **pulmonary embolism **pneumothorax ~adverse med rxn ~mood d/o ~substance abuse relate d/o |
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Adverse med rxn w/ anxiety d/o
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~Caffeine
~nicotine ~anticholinergics ~antihistamines ~antipsychotics ~steroids ~bronchodilators ~anesthetics |
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Chronic anxiety is wearing on the body; therefore assess for effects on the
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Cardiovascular sys
~perform a general assessment for a healthy lifestyle |
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Pt w/ anxiety should be seen initially how often to titrate meds?
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weekly or biweekly to titrate meds initially
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Anxiety Pt teaching should include
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risk
benefits potential se of med tx sx of anxiety ~tell fact that d/o are chronic illnesses ~estab relapse plan for all all pts |
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F/U of anxiety pt assess for
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If pt is taking benzos monitor for potential dependence
~if pt is taking SSRIs monitor for common se & adverse effects ~assessment for suicidality ~bx of frequent comorbidity w/ MDD assess frequently for depression levels using standardized psycho metrics (Zung self-rating anxiety scale, hamilton rating scale for anxiety, Yale-brown obsessive compulsive scale) ~med should be combo w/ therapy to reach ma control of sx ~Pts need encouragement to continue tx especially after initial sx relief occurs |
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Standardized rating scales for anxiety d/o
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~Zung self-rating anxiety scale
~Hamilton rating scale for anxiety (HAM-A) ~Yale-brown obsessive-compulsive scale |
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Panic d/o description
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Panic d/o is experienced as discrete episodes or attacks w/ sudden onset of:
*intense apprehension *fearfulness *terror *often associated w/ sense of impending doom May be dx w/ or w/o agoraphobia ~attacks occur w/o warning & in the ABSENCE OF ANY REAL DANGER ~attacks build to a peak of intensity w/in a short, self-limiting time, usually w/in 10 mins of onset |
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Panic d/o is more common in which sex
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WOMEN
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Diagnostic criteria of panic d/o
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Discrete episode in which pt experiences 4 or more of the following sx, having a SUDDEN onset and peaking w/in 10 mins of onset
**paresthesias **chills or hot flushing **fear of losing control or of going crazy **fear of dying **SOB or smothering sensation **palpitations, pounding, or accelerated HR **chest pain, tightness or discomfort **sweating **trembling or shaking **nausea or abdominal distress After 1st attack, persistent concern over: ***having another attack ***or a sig behavioral change r/t attack |
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with high somatic sensations, pt often sensitive to ________ or ______
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With high somatic sensations, pt often sensitive to NEW SOMATIC EXPERIENCES or PERCEPTIONS
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Pt often intolerant of or concerned w. common se of med tx
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Panic d/o
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Pt discouraged or ashamed about failure to control emotions and over concern about dying when no other pathology identified
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Panic d/o
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In 2/3 of cases, MDD occurs 1st followed by _______ d/o sx
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Panic d/o
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in 1/3 of cases panic d/o sx precede _______ sx
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MDD
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3 characteristic types of panic d/o
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pt presentation is defined by relationship between onset of attack and presence or absence of triggers for attacks
TYPE 1; UNCUED TYPE 2; CUED TYPE 3; SITUATIONALLY CUED |
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TYPE 1 PANIC D/O
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uncued
no associated internal or external trigger experienced as spontaneous or out of the blue attack may over time become cued or situationally cued or may, less commonly remain uncued NOTE; RECURRENT, UNEXPECTED, UNCUED ATTACKS ARE REQUIRED FOR INITIAL FULFILLMENT OF DSM-IV-TR DIAGNOSTIC CRITERIA FOR PANIC D/O. IF INITIAL ONSET IS NOT THIS TYPE, CONSIDER AN ALTERNATIVE DX (PHOBIA, PTSD, GAD) |
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uncued attack
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type 1 panic d/o
no associated internal or external rigger experienced as spontaneous or "out of the blue" attack |
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What is needed for initial fulfillment of DSM-IV-TR diagnostic criteria of panic d/o?
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Recurrent
Unexpected Uncued attacks If initial onset is not this type consider an alternative dx (Phobia, PTSD, GAD) |
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Type 2 Panic d/o
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Cued
occurs immediately and invariably on exposure to or in anticipation of a situational cue or trigger |
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attack occurs immediately and invariably on exposure to or in anticipation of a situational cure or trigger
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Type 2: Cued Panic d/o
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Type 3 panic d/o
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Situationally cued panic d/o
similar to cued (attack occurs immediately and invariably on exposure to or in anticipation of a situational cure or trigger) but is NOT immediate and not invariably cued to trigger |
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attack occurs (not immediate and not invariably) on exposure to or in anticipation of a situational cue or trigger
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Type 3: situationally cued panic d/o
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Type of panic d/o determined by assessment of
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~pt's focus of anxiety
~type & # of attacks ~# of situations avoided by pt ~level of anxiety experience between panic attacks |
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Nonspecific _____ related complaints during panic episodes often bring pt into tx
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Cardiac
****chest pain ****numbness ****SOB Nonspecific physical exam findings especially when pt not experiencing panic attack |
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MSE findings in panic d/o
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findings very pronounced during panic episodes & less pronounced during nonpanic periods
High level of anticipatory anxiety between panic episodes |
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Diagnostic & lab findings in panic d/o
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None specific
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Differential dx panic attack
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R/o gen med conditions known to produce similar sx including
***hyperthyroidism ***hyperparathyroidism ***Pheochromocytosis ***vestibular dysfxn ***seizure d/o ***cardiac arrhythmias such as supraventricular tachycardia (SVT) ***Use of CNS stimulants including ~~~~~~cocaine ~~~~~~amphetamines ~~~~~~caffeine ***Panic attacks w/ another anxiety d/o such as PTSD or phobias ***separation anxiety disorder ***avoidance behavior in delusional d/o ***consider gen med d/o if 1st episode panic attack sx occur after age 45 or panic sx are atypical |
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Atypical panic sx
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consider dx of general med d/o
***vertigo ***loss of consciousness ***incontinence ***headache ***slurred speech ***amnesic pattern after attacks |
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Consider a gen med d/o diagnosis instead of panic IF
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1st episode panic attack sx occurs after age 45
or Panic sx are atypical: **headache **slurred speech **amnesic pattern after attacks **vertigo **incontinence **loss of consciousness **vertigo |
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Panic d/o is differentiated from other anxiety conditions by
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~sudden onset of attack
~discrete, self-limiting nature of sx ~paroxysmal sx profile ~level III-IV anxiety sx w/ somatic sx that are experienced as distressing & severe by the pt |
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Pharm MGMT of Panic d/o
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~SSRI
~Benzo (usually used for short-term sx control) ~Buspar effective as an adjunct to an antidepressant ~other non-benzo anxiolytic meds used as adjuncts |
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NON-pharm mgmt of panic d/o
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~CBT
~Individual or group therapy ~exposure therapy ~relaxation therapies |
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COmmon co-morbidities of Panic d/o
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~frequent w MDD
~estimated between 10% and 65%, depending on source: ****social phobia ****OCD ****substance abuse |
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Agoraphobis is characterized by
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~avoidance of places or situations from which escape may be difficult or embarrassing or in which help may not be available in the event of perceived need such as a panic attack
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THe anxiety in this d/o usually leads to avoidant behavior that impairs and individual's ability to carry out responsibilities of daily living
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Agoraphobia
also impairs and individual's ability to travel & to work |
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Feel better & report less significant concerns w/ anxiety when accompanied by a trusted companion
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AGORAPHOBIA
the decrease in anxiety when with trusted person assists in differential dx |
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Is not an independently coded DSM-IV dx & is always dx in relationship to presence or absence of panic d/o
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Agoraphobia
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Agoraphobia most commonly occurs in conjunction w/ _____ d/o & is labeled as _________
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panic d/o
is labeled : panic d/o w/ agoraphobia |
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For pt to be dx panic d/o w/ agoraphobia they must meet the criteria for
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Panic d/o and must experience agoraphobic anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of a panic attack
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If agoraphobia is experienced w/o panic d/o the anxiety d/o is labeled?
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Agoraphobia w/o hx of panic d/o
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Diagnostic criteria for agoraphobia
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~presence of agoraphobic anxiety r/t fear of developing panic-like sx
~never met criteria for panic d/o ~avoidant behavior as a result of the agoraphobic anxiety |
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Agoraphobia pharm mgmt
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~SSRIs
~benzos for short term use |
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Nonpharm mgmt of agoraphobia
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~CBT
~supportive group therapy ~desensitization therapy |
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In Specific phobias there is a
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clinically significant level of marked and persistent fear that is clearly observable and is by pt perception, clearly r/t specific objects or situations
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In specific phobias in adults but not in kids there exists
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the conscious recognition that the fear is excessive or unreasonable
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In specific phobias in kiddos the degree of insight
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to the unreasonable nature of the fear increases as age increases
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Risk factors for specific phobias
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TRAUMATIC PAST EXPOSURE
**having been bitten by dog, having choked on food etc OBSERVATION OF ANOTHER'S TRAUMA **seeing others be bitten by dog, seeing others choke on food EXCESSIVE INFORMATIONAL TRANSMISSION **repeated graphic parental warnings of dangers of certain events or situations GENETIC LOADING **fam member w/ specific phobia **blood-injection subtype phobia most familial **subtype aggregation patterns noted w/in familites (e.g. if an individual's 1st degree relative has animal subtype specific phobia the risk is highest for him or her to develop animal subtype |
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Genetic influence of specific phobias
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**fam member w/ specific phobia
**blood-injection subtype phobia most familial **subtype aggregation patterns noted w/in familites (e.g. if an individual's 1st degree relative has animal subtype specific phobia the risk is highest for him or her to develop animal subtype |
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Children manifest fear and anxiety as what kind of behaviors?
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crying
freezing tantrums excessive clinging This is seen in hx of kiddos with specific phobias (aka simple phobias) |
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Most familial subtype specific phobia
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blood-injection subtype phobia
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subtype aggregation patterns noted w/in families for what d/o
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Specific phobia
What this means: if an individual's 1st degree relative has animal subtype specific phobia the risk is highest for him or her to develop animal subtype |
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Simple phobias aka
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specific phobias
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Specific phobias aka
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Simple phobias
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The content of phobias can vary with ....
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Culture
ethnicity age |
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Kids normatively express a transient fear of animals and other natural objects phobic dx should occur only when
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accompanied by sig functional impairment,
such as full avoidance of school r/t fear of encountering a spider |
|
|
history of exposure to a certain feared object or situation, which immediately provokes the onset of clinically sig levels of anxiety
|
Think specific phobias!!
This anxiety may fit the criteria for cued panic attack the level of anxiety is directly r/t how physically close the object or situation is to the person & the degree to which escape from the object or situation is possible |
|
|
Level of anxiety is directly r/t how physically close the object or situation is to the person
|
Specific phobias
AND level of anxiety is directly r/t the degree to which escape from the object or situation is possible |
|
|
Individual engages in avoidance behavior to prevent rxn to object or situation or endures object or situation w. dread
|
SPECIFIC PHOBIAS
avoidant behavior is distressful and has implications for social, recreational, or occupational or school fxning |
|
|
5 common subtypes of specific phobias
|
Situational
Natural environment Blood injection injury animal other |
|
|
a phobia to one object or situation in a subclass predisposes an individual to
|
another phobia w/in the same subclass
e.g. fear of rats increases the risk for fear of spiders |
|
|
Can an individual experience more than one subtype of phobia at time?
|
Yes
|
|
|
Situational Type
|
specific phobia subtype
cued by specific situations **eg include driving, enclosed spaces, tunnels or bridges & flying *Most common adult form *In elderly people, fear of closed-in situations most common *Bimodal peak of onset *****1st peak, childhood *****2nd peak, mid-20s |
|
|
Situational type phobia peak of onset
|
1st peak, childhood
2nd peak, mid-20s |
|
|
Most common adult form of phobia
|
situational type of phobia
(cued by specific situations) e.g. include driving, enclosed spaces, tunnels or bridges, and flying |
|
|
In elderly people this is the most common phobia
|
situational type specifically: fear of closed-in situations
|
|
|
Fear of tunnels
|
situational type of phobia
cued by specific situations |
|
|
Fear of flying
|
situational type of phobia
cued by specific situations |
|
|
Fear of driving
|
situational type of phobia
cued by specific situations |
|
|
Fear of enclosed spaces
|
situational type of phobia
(most common in elderly people) cued by specific situations |
|
|
Natural environment type phobia
|
fear cued by objects in the natural environment;
e.g. storms lightning, water, heights 2nd most common adult form Onset usually during childhood |
|
|
Natural environment type phobia onset
|
Onset usually during childhood
|
|
|
2nd most common adult form of phobia
|
ear cued by objects in the natural environment;
e.g. storms lightning, water, heights |
|
|
Fear of heights
|
Natural environment type phobia:
fear cued by objects in the natural environment; |
|
|
Fear of storms
|
Natural environment type phobia:
fear cued by objects in the natural environment; |
|
|
Fear of lightning
|
Natural environment type phobia:
fear cued by objects in the natural environment; |
|
|
Fear of water
|
Natural environment type phobia:
fear cued by objects in the natural environment; rabies :) |
|
|
Blood-injection-injury type
|
specific phobia cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure
***3rd most common adult form ***Highly familiar subtype **Strong vasovagal component that con produce other somatic sensations |
|
|
Highly familiar subtype phobia
|
BLOOD-INJECTION-INJURY TYPE PHOBIA;
specific phobia cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure |
|
|
strong vasovagal component that can produce other somatic sensations
|
this is in blood-injection-injury type phobia
**may exacerbate underlying cardiac or respiratory d/o **Person often presents w/ fainting as CC **experiences paroxysmal tachycardia & HTN followed by decelerations of HR & drop in BP **Clinical presentation & disease natural hx similar to panic d/o w agoraphobia |
|
|
3rd most common adult form of phobia
|
Blood-injection-injury type phobia
cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure |
|
|
Highly familiar subtype
|
Blood-injection-injury type phobia
cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure |
|
|
Animal type phobia
|
Specific phobia
fear cued by animals or insects e.g. rats, snakes, spiders 4th most common adult form Onset usually during childhood |
|
|
Specific phobia
fear cued by animals or insects |
Animal type phobia
|
|
|
4th most common adult form of phobia
|
Specific phobia
fear cued by animals or insects e.g. rats, snakes, spiders |
|
|
Onset of Animal type phobia
|
onset usually during childhood
Specific phobia fear cued by animals or insects e.g. rats, snakes, spiders |
|
|
Other type phobia
|
fear cued by range of other stimuli
e.g. include fear of choking, fear of vomiting and fear of a specific illness In kids often manifests as fear of loud sounds or costumed characters |
|
|
In kids often manifests as fear of loud sounds or costumed characters
|
Other type phobia
|
|
|
How does other type phobia manifest in kids?
|
n kids often manifests as fear of loud sounds or costumed characters
|
|
|
Fear of vomiting
|
fear cued by range of other stimuli
e.g. include fear of choking, fear of vomiting and fear of a specific illness |
|
|
fear of a specific illness
|
fear cued by range of other stimuli
e.g. include fear of choking, fear of vomiting and fear of a specific illness |
|
|
Fear of vomiting
|
fear cued by range of other stimuli
e.g. include fear of choking, fear of vomiting and fear of a specific illness |
|
|
Differential dx for specific phobia
|
Avoidance behavior in:
PTSD OCD separation anxiety d/o psychotic d/o |
|
|
5 common subtypes of phobias
|
~situational
~natural environment ~blood injection injury ~animal ~other |
|
|
Pharmacological mgmt specific phobia
|
~SSRI
~TCAs ~short term use of Benzos |
|
|
Nonpharm mgmt specific phobia
|
~CBT
~BIofeedback ~desensitization therapy |
|
|
~CBT
~BIofeedback ~desensitization therapy is tx for what |
Nonpharm mgmt specific phobia
|
|
|
~SSRI
~TCAs ~short term use of Benzos |
Pharmacological mgmt specific phobia
|
|
|
Social anxiety (phobia) d/o
|
~rates are equal for the genders
~anxiety levels often are sufficient to fit criteria for situationally boards panic attack |
|
|
How common is social anxiety d/o
|
the disorder has an estimated 3-13% prevalence rate among US population
by comparison MDD 5% of population (only 50% ppl seek tx) |
|
|
Social anxiety d/o is
|
a marked & persistent fear of social or performance situations in which embarrassment may occur
Anxiety levels often are sufficient to fit criteria for a situationally bound panic attack |
|
|
Social phobia should be dx only if
|
Sx persist for longer than 6 mo
|
|
|
onset for social phobia
|
Onset is in the mid-teens
Often following stressful or humiliating experience and tends to remit w/ age some degree of social anxiety is common and normative in adolescence |
|
|
Diff dx for social anxiety is assisted by
|
the awareness that individuals w/ social phobia DO NOT feel better or experience decreased anxiety when accompanied by a trusted companion
|
|
|
DO NOT feel better or experience decreased anxiety when accompanied by a trusted companion
|
Social anxiety
|
|
|
Common descriptive features of social anxiety
|
~hypersensitivity to criticism
~negative self-evaluation ~sensitivity to rejection ~low self-esteem ~inferiority feelings ~lack of assertiveness ~protracted anticipatory anxiety may occur days or weeks before the feared social situation ~Levels of subjective distress & impaired functioning can be significant & have been associated w/ suicidal ideation |
|
|
protracted anticipatory anxiety may occur days or weeks before the feared social situation
|
Common descriptive features of social anxiety
|
|
|
lack of assertiveness
|
Common descriptive features of social anxiety
|
|
|
inferiority feelings
|
Common descriptive features of social anxiety
|
|
|
sensitivity to rejection
|
Common descriptive features of social anxiety
|
|
|
Negative self-evaluations
|
Common descriptive features of social anxiety
|
|
|
hypersensitivity to criticism
|
Common descriptive features of social anxiety
|
|
|
Levels of subjective distress & impaired functioning can be significant & have been associated w/ suicidal ideation
|
Common descriptive features of social anxiety
|
|
|
Physical exam findings in social anxiety d/o
|
~sweating
~tremors ~palpitations ~muscle tension ~diarrhea ~blushing |
|
|
Pharm mgmt for social anxiety d/o
|
~SSRI
~Benzo (for short term use) ~Beta blockers **use for discrete-episode relief **e.g before having to attend a scheduled social fxn **do not use in performance anxiety of athletics |
|
|
Non-pharm mgmt for social anxiety d/o
|
~CBT
~exposure therapy ~relaxation therapy |
|
|
~CBT
~exposure therapy ~relaxation therapy |
Non-pharm mgmt for social anxiety d/o
|
|
|
~SSRI
~Benzo (for short term use) ~Beta blockers **use for discrete-episode relief |
Pharm mgmt for social anxiety d/o
|
|
|
OCD is the
|
presence of anxiety-provoking obsessions or compulsions that fxn to reduce the individual's subjective anxiety level
|
|
|
Obsession
|
recurrent & persistent thought, impulse, images that are experienced & that cause anxiety & distress
Experienced as intrusive & inappropriate Ego-dystonic experience in which a pt feel the content of obsession is alien to their belief structure & not the kin of common thought, impulse, or image he/she usually experiences |
|
|
recurrent & persistent thought, impulse, images that are experienced & that cause anxiety & distress
|
Obsession
|
|
|
The thought is the
The behavior is the |
obsession
compulsion |
|
|
thought experienced as intrusive & inappropriate
|
Obsession
|
|
|
Ego-dystonic experience in which a pt feel the content of thought is alien to their belief structure
|
Ego-dystonic experience in which a pt feel the content of obsession is alien to their belief structure & not the kin of common thought, impulse, or image he/she usually experiences
|
|
|
not the kin of common thought, impulse, or image he/she usually experiences
|
ego-dystonic experience in which a pt feels the content of obsession is alien to their belief structure
|
|
|
compulsion
|
repetitive behaviors or mental actions such that an individual feels driven to perform in response to an obsession
|
|
|
OCD occurs more in which gender
|
rates are equal in men and women
Except for OCD and social anxiety (phobia), anxiety d/o are more common in girls and women than in men and boys |
|
|
Anxiety d/o are more common in girls and women than in men and boys
What are the exceptions? |
OCD & social anxiety (phobia)
|
|
|
Diagnostic criteria OCD
|
~presence of EITHER obsession OR compulsion
~The individual recognizes that the obsession or compulsion is excessive or unreasonable The obsession or compulsion is causing marked distress, is time-consuming or interferes w. normal daily activity |
|
|
Common obsession include
|
~repeated thoughts about contamination, dirt, or germs
~Repeated doubts, such as having hit someone w a car or having left an oven on or garage door open w/o evidence ~need to have things in a specific order, with marked distress when that order is disturbed ~aggressive or horrific impulses ~Sexual imagery |
|
|
Sexual imagery
|
Common obsession include
|
|
|
aggressive or horrific impulses
|
Common obsession include
|
|
|
need to have things in a specific order, with marked distress when that order is disturbed
|
Common obsession include
|
|
|
Repeated doubts, such as having hit someone w a car or having left an oven on or garage door open w/o evidence
|
common obsession
|
|
|
Repeated thoughts about contamination
|
common obsession
|
|
|
Obsessions usually do not involve
|
real-world worries such as concern over finances
|
|
|
An individual with this d/o recognizes that the thought are a product of his/her own mind
|
OCD
An individual recognizes that the thought, impulse or images are a product of his or her own mind |
|
|
An individual attempts to _____or ____ thoughts, impulse, or images
|
An individual attempts to IGNORE or SUPPRESS thought, impulse, or images or to override them with other thoughts or actions in OCD
|
|
|
Individuals often ____ in which content of obsession may be encountered. Give examples
|
Individuals often AVOID SITUATIONS in which the content of obsession may be encountered
e.g. avoiding public restrooms to avoid contamination |
|
|
Common compulsions include
|
~Repetitive actions, usually behavioral and often called rituals
~Level III anxiety level (pathological level, ANS triggered, fight or flight response, pupils dilated, vital signs increased, muscles rigid, diaphoresis, hearing decreased, pain threshold increased, urinary frequency, diarrhea) common behaviors include: **handwashing **excessive cleaning **checking to see (e.g. if the lights are turned off, the stove is turned off, or the doors are locked) **ordering behaviors Common mental actions: **counting **silently repeating words **praying |
|
|
**counting
**silently repeating words **praying |
Common mental actions of compulsions
|
|
|
Common mental actions of compulsions
|
**counting
**silently repeating words **praying |
|
|
common behaviors of compulsions include
|
**handwashing
**excessive cleaning **checking to see (e.g. if the lights are turned off, the stove is turned off, or the doors are locked) **ordering behaviors |
|
|
**handwashing
**excessive cleaning **checking to see **ordering behaviors |
Common behaviors of compulsions
|
|
|
excessive cleaning
|
Common behaviors of compulsions
|
|
|
checking to see
|
Common behaviors of compulsions
|
|
|
ordering behaviors
|
Common behaviors of compulsions
|
|
|
handwashing
|
Common behaviors of compulsions
|
|
|
Differential dx for OCD
|
~body dysmorphic d/o
~eating do ~trichotillomania ~hypochondriasis ~obsessive-compulsive personality d/o ~tic or stereotypic movement d/o |
|
|
trichotillomania
|
Trichotillomania is hair loss from repeated urges to pull or twist the hair until it breaks off. Patients are unable to stop this behavior, even as their hair becomes thinner. Symptoms usually begin before age 17.
|
|
|
~body dysmorphic d/o
~eating do ~trichotillomania ~hypochondriasis ~obsessive-compulsive personality d/o ~tic or stereotypic movement d/o |
Differential dx for OCD
|
|
|
Physical exam findings on OCD
|
~Nonspecific
~dermatitis often present r/t excessive hand washing or overuse of caustic cleaning agents ~Hypochondriasis & somatic fixation common |
|
|
Dermatitis often present r/t excessive hand washing or overuse of caustic cleaning agents
|
Physical exam findings on OCD
|
|
|
Hypochondriasis & somatic fixation common with what d/o
|
OCD
|
|
|
Praying
|
a common mental action of compulsion
|
|
|
Common co-morbidities of OCD
|
~major depression
~eating d/o ~other anxiety d/o |
|
|
Pharmacological mgmt of OCD
|
SSRIs (Fluvoxamine/Luvox)
TCAs (clomipramine/anafranil approved for OCD) |
|
|
Fluvoxamine/Luvox indicated for
|
it is an SSRI indicated for OCD
(I don't think technically approved for depression |
|
|
clomipramine/anafranil approved for
|
TCA
approved for OCD, and everything else TCAs are approved for |
|
|
Can kids have OCD
|
~yes, common in childhood, usually w. prepubertal onset
~More common in boys than girls ~washing, checking and ordering the most common behavioral manifestations Common comorbidities in kids w/ OCD *learning d/o *disruptive behavioral d/o *tourette's syndrome Associated w. kids w. group A beta-hemolytic streptococcal infections (scarlet fever, strip throat) |
|
|
Group A beta-hemolytic streptococcal infections are associated w/
|
(scarlet fever, strip throat)
OCD |
|
|
Common comorbidities in kids w/ OCD
|
~Learning d/o
~Disruptive behavioral d/o ~Tourette's syndrome |
|
|
~Learning d/o
~Disruptive behavioral d/o ~Tourette's syndrome are common comorbidities in kids w/ |
OCD
|
|
|
Most common behavioral manifestations in kids
|
washing
checking ordering |
|
|
Older adults w/ OCD
|
~more obsessions than compulsions usually present
~obsessive content characteristically about dying ~compulsions characteristically about washing & cleaning |
|
|
This OCD populations compulsions characteristically about washing & cleaning
|
Older adults
|
|
|
This OCD populations obsessive content characteristically about dying
|
Older adults
|
|
|
THis OCD populations more obsessions than compulsions usually present
|
Older adults
|
|
|
clomipramine/anafranil approved for
|
TCA
approved for OCD, and everything else TCAs are approved for |
|
|
Differential dx for OCD
|
~body dysmorphic d/o
~eating do ~trichotillomania ~hypochondriasis ~obsessive-compulsive personality d/o ~tic or stereotypic movement d/o |
|
|
trichotillomania
|
Trichotillomania is hair loss from repeated urges to pull or twist the hair until it breaks off. Patients are unable to stop this behavior, even as their hair becomes thinner. Symptoms usually begin before age 17.
|
|
|
Can kids have OCD
|
~yes, common in childhood, usually w. prepubertal onset
~More common in boys than girls ~washing, checking and ordering the most common behavioral manifestations Common comorbidities in kids w/ OCD *learning d/o *disruptive behavioral d/o *tourette's syndrome Associated w. kids w. group A beta-hemolytic streptococcal infections (scarlet fever, strip throat) |
|
|
~body dysmorphic d/o
~eating do ~trichotillomania ~hypochondriasis ~obsessive-compulsive personality d/o ~tic or stereotypic movement d/o |
Differential dx for OCD
|
|
|
Group A beta-hemolytic streptococcal infections are associated w/
|
(scarlet fever, strip throat)
OCD |
|
|
Physical exam findings on OCD
|
~Nonspecific
~dermatitis often present r/t excessive hand washing or overuse of caustic cleaning agents ~Hypochondriasis & somatic fixation common |
|
|
Common comorbidities in kids w/ OCD
|
~Learning d/o
~Disruptive behavioral d/o ~Tourette's syndrome |
|
|
~Learning d/o
~Disruptive behavioral d/o ~Tourette's syndrome are common comorbidities in kids w/ |
OCD
|
|
|
Dermatitis often present r/t excessive hand washing or overuse of caustic cleaning agents
|
Physical exam findings on OCD
|
|
|
Most common behavioral manifestations in kids
|
washing
checking ordering |
|
|
Physical exam findings for OCD
|
Nonspecific
Dermatitis often present r/t excessive hand washing or over use of caustic cleaning agents Hypochondriasis & somatic fixation common |
|
|
Dermatitis often present r/t excessive hand washing or over use of caustic cleaning agents
|
Physical exam findings for OCD
|
|
|
Common comorbidities of OCD
|
~major depression
~eating d/o ~other anxiety d/o |
|
|
~major depression
~eating d/o ~other anxiety d/o |
Common comorbidities of OCD
|
|
|
Pharmacological MGMT of OCD
|
SSRIs (Luvox/fluvoxsmine approved for OCD)
TCAs (clomipramine/anafraniil approved for OCD) |
|
|
Non-Pharm MGMT OCD
|
CBT
Behavioral therapies |
|
|
Kiddos and OCD
|
~Common in childhood, usually w/ prepubertal onset
~More common in boy than girls ~Washing, checking & ordering the most common behavioral manifestations ~Common comorbidities in kid **learning d/o **Disruptive behavioral d/o **Tourette's syndrome Associate in children w/ Group A beta-hemotolytic streptococcal infections (e.g. scarlet fever, strep thoat) |
|
|
Group A beta-hemotolytic streptococcal infections are associated w/
|
OCD
|
|
|
OCD in kids more common in which sex
|
more common in boys than girls
|
|
|
Common comorbidities in kids w/ OCD
|
~learning d/o
~disruptive behavioral d/o ~Tourette's syndrome |
|
|
Older adults w/ OCD have
|
~more obsessions than compulsions usually present
~Obsessive content characteristically about dying ~compulsions characteristically about washing and cleaning |
|
|
compulsions characteristically about washing and cleaning
|
Older adults w/ OCD
|
|
|
Obsessive content characteristically about dying
|
Older adults w/ OCD
|
|
|
more obsessions than compulsions usually present
|
Older adults w/ OCD
|
|
|
Group A beta hemolytic streptococcal infections
|
scarlet fever, strep throat
associated w/ kids w/ OCD |
|
|
Anxiety d/o are more common in women than men
EXCEPT |
OCD & social anxiety (phobia0
|
|
|
Most common behavioral manifestations in kids w/ OCD
|
~washing
~checking ~ordering |
|
|
Washing, checking, ordering
|
Most common behavioral manifestations in kids w/ OCD
|
|
|
PTSD is the _______ of an extremely traumatic event accompanied by sx of _______ ____ and ______ of stimuli associate with the trauma
|
PTSD is the REEXPERIENCING of an extremely traumatic event accompanied by sx of INCREASED AROUSAL and AVOIDANCE of stimuli associated w/ the trauma
|
|
|
common experienced trauma includes
|
~Military combat
~violent personal assault such as robbery or rape ~Kidnapping or hostage situation ~Terrorist attack ~torture ~prolonged sexual abuse ~natural or human-made disasters |
|
|
Common witnessed trauma includes
|
~observing the death of or sig injury to another
~unexpectedly witnessing any of the above traumas ~learning of the sudden or unexpected death of or sig injury to a family member or close friend |
|
|
Risk factors for PTSD
|
Genetic loading
**Assumed to have strong genetic etiological component & tends to run in families **Experienced trauma or witnessed trauma **hx of major depression in 1st degree relative r/t increased risk of developing PTSD |
|
|
Can sx of PTSD predate exposure to trauma
|
NO
|
|
|
Presenting sx & hx can be delineated as one of 3 subtypes of PTSD
|
Acute
Chronic Delayed onset |
|
|
Acute PTSD
|
Duration of sx less than 3 months
|
|
|
Chronic PTSD
|
Sx lasting 3 months or longer
|
|
|
Delayed onset PTSD
|
@ least 6 months between traumatic event and the onset of sx
|
|
|
Duration of sx less than 3 months
|
Acute PTSD
|
|
|
@ least 6 months between traumatic event and the onset of sx
|
delayed onset PTSD
|
|
|
Sx lasting 3 months or longer
|
Chronic PTSD
|
|
|
DSM time frame PTSD
|
Sx for 1 month or longer
|
|
|
Diagnostic criteria PTSD
|
(Sx for 1 month or longer)
~Exposure to a traumatic event ~The traumatic event is persistently reexperienced in one or more of reexperiencing sx ~3 or more avoidance sx ~2 or more increased arousal sx |
|
|
Reexperiencing sx
|
Need one or more for dx PTSD
~recurrent & intrusive distressing recollection of the event, including images, thoughts, and perceptions **may be experienced as flashbacks **rare cases involve dissociative states lasting hours to days ~recurrent distressing dreams (nightmares) about the event ~acting or feeling as if the traumatic event were recurring ~intense psychological distress @ exposure to cues that symbolize or resemble aspects of the traumatic event ~Physiological reactivity on exposure to cues that symbolize ore resemble aspects of the traumatic event |
|
|
Physiological reactivity on exposure to cues that symbolize ore resemble aspects of the traumatic event
|
Re-experiencing sx of PTSD
|
|
|
intense psychological distress @ exposure to cues that symbolize or resemble aspects of the traumatic event
|
Re-experiencing sx of PTSD
|
|
|
acting or feeling as if the traumatic event were recurring
|
Re-experiencing sx of PTSD
|
|
|
recurrent distressing dreams (nightmares) about the event
|
Re-experiencing sx of PTSD
|
|
|
recurrent & intrusive distressing recollection of the event, including images, thoughts, and perceptions
|
Re-experiencing sx of PTSD
|
|
|
PTSD criteria broke down
|
Traumatic event
3+ avoidance sx 2+ increased arousal sx 1+ reexperience sx |
|
|
How many reexperience sx needed to dx PTSD?
|
1+ reexperience sx
|
|
|
How many avoidance sx needed to dx PTSD?
|
3+ avoidance sx
|
|
|
How many increased arousal sx needed to dx PTSD?
|
2+ increased arousal sx
|
|
|
Avoidance sx
|
Need 3+ to dx PTSD
~persistent avoidance of stimuli associated w. the traumatic event and numbing of responsiveness ~efforts to avoid talking about or thinking about traumatic event ~avoidance of activities, places or people that arouse recollections of traumatic event ~inability to recall important aspects of event ~marked decreased interest or participation in activities ~feeling of detachment or estrangement from others ~restricted range of affect ~sense of foreboding and of shortened future, or premature death, or no expectation for success or happiness |
|
|
sense of foreboding and of shortened future, or premature death, or no expectation for success or happiness
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
restricted range of affect
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
feeling of detachment or estrangement from others
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
marked decreased interest or participation in activities
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
inability to recall important aspects of event
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
avoidance of activities, places or people that arouse recollections of traumatic event
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
efforts to avoid talking about or thinking about traumatic event
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
persistent avoidance of stimuli associated w. the traumatic event and numbing of responsiveness
|
Avoidance sx Need 3+ to dx PTSD
|
|
|
Increased arousal sx
|
Need 2+ to dx PTSD
~difficulty falling asleep ~irritability or outburst of anger ~difficulty concentrating ~hypervigilance ~exaggerated startle response |
|
|
Difficulty falling asleep
|
Persistent sx of increased arousal
2+ needed to dx PTSD |
|
|
irritability or outburst of anger
|
Persistent sx of increased arousal
2+ needed to dx PTSD |
|
|
Difficulty concentrating
|
Persistent sx of increased arousal
2+ needed to dx PTSD |
|
|
hypervigilance
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Persistent sx of increased arousal
2+ needed to dx PTSD |
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exaggerated startle response
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Persistent sx of increased arousal
2+ needed to dx PTSD |
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Sx of PTSD
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reexperiencing
increased arousal avoidance Sx causing sig distress or impairment in the ability to carry out activities of daily fxning Sx usually occur w/in 3 mo of trauma Duration of sx highly variable |
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Sx of PTSD usually occur w/in
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3 mo of trauma
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Duration of PTSD sx
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Highly variable
~sx remitting w/in 3 moths in 1/2 cases ~common waxing and waning of sx r/t internal and external cues that resemble the trauma |
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PTSD Sx wax and wan r/t
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internal and external cues that resemble the trauma
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Differential dx for PTSD
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~adjustment d/o
~brief psychotic d/o ~acute stress d/o ~intrusive thoughts of OCD |
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Physical exam findings PTSD
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~nonspecific
~increased rates of somatic complaints ~insomnia frequently cc on presentation for evaluation ~distractability in motor tasks ~measurable increased autonomic fxning **tachycardia **diaphoresis **pupilary dilation **increased startle response **increased RR |
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Insomnia frequently CC on presentation for evaluation
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PTSD
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~nonspecific
~increased rates of somatic complaints ~insomnia frequently cc on presentation for evaluation ~distractability in motor tasks ~measurable increased autonomic fxning |
Physical exam findings PTSD
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PTSD pt may demonstrate some ______ findings during ______ episode
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PTSD pt may demonstrate some PSYCHOTIC findings during FLASHBACK episodes
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PHARMACOLOGICAL MGMT OF PTSD
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SSRIs
TCAs Benzos Antipsychotics during episodes of flashbacks |
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NonPharmacological MGMT of PTSD
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~CBT
~Supportive group therapy ~relaxation therapies ~eye movement desensitization and reprocessing |
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Common comorbidities of PTSD
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~Major depression
~dysthymia ~substance abuse or dependence |
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PTSD age of onset
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PTSD Can occur at ANY age including childhood
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Kiddos and PTSD
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~expression of fear and horror occurs in disorganized or agitated behavior
~repetitive play behaviors show themes or aspects of trauma ~frightening dreams but w/o recognized content are common |
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repetitive play behaviors show themes
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repetitive play behaviors can also show aspects of trauma as well as themes of trauma in kids w/ PTSD
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Frightening dreams w/o recognized content are common in
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kids w/ PTSD
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disorganized or agitated behavior is
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expression of fear and horror in kids w/ PTSD
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GAD def
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excessive worry
apprehension or anxiety about events or activities occurs more days than not for a period of at least 6 months *pt finds it hard to control the anxiety *no clear link exists for the anxiety to life events or stressors *worry and anxiety interfere w/ ADLs ~nature & focus of worry shift frequently ~a pattern of waxing and waning of sx exists Sx worsen as life events stress the individual |
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Onset of GAD
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usually by age 20
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GAD and gender
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more frequent in women than in men
2/3rds of pts are female |
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No clear link exists for the anxiety to life event or stressors.....
what d/o |
GAD
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The nature & focus of worry shift frequently in ...?
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GAD
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Risk factors for GAD
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Genetic loading w/ familial patern of transmission
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Anxiety and worry are out of proportion to the actual likelihood or impact of the feared event
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GAD
In hx individuals report subjective distress caused by the constant worry but do not always describe the worry as excessive |
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Excessive anxiety & worry last for more days than not for at least 6 months
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GAD
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Differential dx for GAD
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~PTSD
~adjustment d/o w/ anxiety ~obsessions in OCD ~anxiety associated w/ another d/o such as hypochondriasis or social phobia |
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~PTSD
~adjustment d/o w/ anxiety ~obsessions in OCD ~anxiety associated w/ another d/o such as hypochondriasis or social phobia |
Differential dx for GAD
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Physical signs of anxiety include
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*muscle tension
*generalized muscle ache & soreness *Tremors *twitching *subjective complaints of shakiness *SOB *autonomic hyperarousal signs *tachycardia *increased RR *dizziness *numbness *easily fatigued, ofen experienced as activity intolerance *muscle tension & increased tone *sleep disturbance |
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Physical exam findings of GAD
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~nonspecific
~Associated w/ other health states **Irritable bowel syndrome **migraine & other headache d/o ~physical signs of anxiety *muscle tension *generalized muscle ache & soreness *Tremors *twitching *subjective complaints of shakiness *SOB *autonomic hyperarousal signs *tachycardia *increased RR *dizziness *numbness *easily fatigued, ofen experienced as activity intolerance *muscle tension & increased tone *sleep disturbance |
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Common mood states GAD
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~anxious
~feeling keyed up or on edge ~irritability |
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Pharmacological MGMT of GAD
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~SSRIs
~Buspar ~benzos as prn agents |
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~SSRIs
~Buspar ~benzos as prn agents |
Pharmacological MGMT of GAD
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Nonpharmacological MGMT of GAD
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~Good candidates for therapy as single-tx modality
~CBT ~relaxation therapies ~stress MGMT ~supportive counseling |
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~Good candidates for therapy as single-tx modality
~CBT ~relaxation therapies ~stress MGMT |
Nonpharmacological MGMT of GAD
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Common comorbidities of GAD
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~Mood d/o
~other anxiety d/o ~substance-related d/o |
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Anxiety is common in kids but
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it is important to assess normal vs. pathological levels
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In kids anxiety is manifested
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in excessive worry over competence,
quality of performance in school or work or other activities |
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excessive worry over competence,
quality of performance in school or work or other activities |
How anxiety is manifested in kids
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Common worry in kids
often manifests as anxiety over |
punctuality or natural catastrophes such as earthquakes or war
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Anxiety in kids often accompanied by
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~overly conforming behavior
~perfectionist self-expectations ~excessive seeking of approval of others ~need for frequent reassurance about performance |
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need for frequent reassurance about performance
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Often accompanies anxiety in kids w/ GAD
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excessive seeking of approval of others
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Often accompanies anxiety in kids w/ GAD
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perfectionist self-expectations
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Often accompanies anxiety in kids w/ GAD
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overly conforming behavior
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Often accompanies anxiety in kids w/ GAD
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