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212 Cards in this Set
- Front
- Back
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what are the name of SSRIs? |
Citalopram
Escitalopram Fluoxetine Flyvoxamine Paroxetine Sertraline |
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Name the SNRIs
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Venlafaxine
Descvenlafaxine Duloxetine |
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what are the names of Benzodiazepines used to treat anxiety?
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Chlordiazepoxide
Diazepam Lorazepam Alprazolam Clonazepam |
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what are the name of azapirones used to treat anxiety?
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Buspirone
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what type of drugs other than SSRIs, SNRIs, Benzodiazepines, and Azapirones are used to treat anxiety?
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Beta-blockers: Propanolol
Alpha-2-agonist: Clonidine Antihistamines: hydroxyzine pamoate |
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what type of anti-depressants are used to treat anxiety disorders?
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SSRIs
SNRIs |
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what is the history of anxiolytic pharmacology?
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pre 1960s: anxiety and depression are considered separate treatment entities. Barbiturates used mostly.
1970s/80s: an overlap of treatments for depression and anxiety emerge. BZD main source of treatment Early 1990s: SSRIs developed Late 1990s: Effexor (SNRI) is the first agent approved by the FDA to treat both MDD and GAD |
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what could the medical cause of anxiety be? These should be ruled out before the diagnosis of anxiety is labeled on the patient.
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Hyperthyroidism
Hypoglycemia Cardiac arrhythmias, cardiovascular disease, mitral valve prolapse Hypoparathyroidism Hypoxia Pheochromocytoma |
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What type of substance abuse can produce anxiety symptoms?
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amphetamines
cocaine caffeine intake and withdrawal Alcohol and sedative withdrawal |
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what part of the brain is involved in anxiety?
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amygdala
hippocampus thalamus cerebellum are all involved in the neuroanatomy of anxiety |
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where does the 5-HT pathway originate?
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Dorsal raphe
DR innervates cortex, hypothalamus, thalamus, and limbic system 5-HT mediates behavioral effects in animal models and humans |
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what does 5-HT mediate?
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behavior effects in animal models and humans
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describe the NE model?
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Majority of the NE pathway originates in the Locus Coeruleus
Stimuli NE release stimulation of the sympathetic nervous system NE Receptors |
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what are the two types of NE Receptors?
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alpha-2 adrenergic receptors:
agonist may be anxiolytic and decrease withdrawal symptoms beta-adrenergic receptors: Beta-blockers social phobia performance anxiety |
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what anti-depressant medications are used to treat anxiety disorders?
|
SSRI/SNRI
Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline SNRI: Venlafaxine Desvenlafaxine Duloxetine |
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what are SSRIs/SNRIs?
|
newest treatment option
GOLD STANDARD fewer adverse side effects and safer than older classes of antidepressants (TCA & MAOIs) |
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how long must a patient take a SSRI/SNRI before an anti-anxiety effect is seen?
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onset of anti-anxiety is usually 2-6 weeks
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what are some adverse side effects of SSRI/SNRIs?
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most commonly are GI upsets and sexual dysfunction
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what are some special concerns with administration of SNRIs?
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hypertension
tachycardia glaucoma |
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what is a discontinuation syndrome?
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abrupt discontinuation can causes symptoms:
malaise chills/dizziness muscle aches depression/anxiety electric shock sensations |
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what is serotonin syndrome?
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Restlessness
Hallucinations Loss of coordination Fast heart beat Rapid changes in blood pressure increased body temperature overactive reflexes nausea vomitting diarrhea |
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what is the most commonly prescribed drug worldwide?
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Benzodiazepines
30% of the adult population |
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how can you decrease dependency on benzodiazepines?
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use long acting to decrease dependency
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what are the BZDs? what is their duration of action?
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Alprazolam: short
Chlordiazepoxide: long Clonazepam: long Diazepam: long Lorazepam: short |
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how do BZD worK?
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they work at the GABA receptor:
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what is the pharmacology related to BZD?
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BDZs potentiate GABAnergic inhibition
BDZs cause more frequent openings of the GABA-Cl- channel via a membrane hyperpolarization, and increase the affinity for GABA |
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what are the treatment indications for BZD?
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provide the effective initial treatment of moderate to severe anxiety.
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do BZDs have a slow/rapid onset?
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Rapid onset
provide inital treatment of moderate to severe anxiety |
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what is the preferred short term at lowest dose effective?
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BZD
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what are adverse side effects of BZDs?
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sedation
dizziness nausea hypotension weakness ataxia decreased motor performance syncope dry mouth blurred vision |
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T/F
Dependence to BZDs may develop. |
True
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|
T/F
withdrawal may occur even when discontinuation is not abrupt. |
True
Symptoms include: tachycardia, increased blood pressure, muscle cramps, anxiety, insomnia, panic attacks, impairment of memory and concentration, perceptual disturbances, derealization, hallucinations, hyperpyrexia, seizures. These may continue for months |
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what are the azapirones used for treatment of anxiety?
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Buspirone (Buspar)
5-HT1A agonist acutely decreases firing in the dorsal raphe nuclei chronically: causes receptor desensitization and inhibition of serotonin release presynaptically. |
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what are the most common side effects related to azapirone (Buspirone)?
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very few
restlessness insomnia headaches some nausea and upset stomach lightheadedness numbness & tingling in extremities |
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why are beta-blockers used in the treatment of anxiety?
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treat autonomic symptoms: palpitations, tachycardia, tremor, blushing, sweating
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what type of anxiety are beta-blockers typically prescribed for?
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anxiety related to performance, special event, speech, presentation
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what are the adverse effects of propanolol?
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lethargy
vivid dreams hallucinations |
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what is the most common alpha-blocker used in treatment of anxiety?
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Catapres (Clonidine)
it is a pre-synaptic, central, alpha-2-agonist main use is hypertension and is not commonly used as anxiolytic except for nicotine/opiod withdrawal has been used in the treatment of panic attack |
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what is a possible adverse side effect of clonidine?
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after protracted use may lead to life threatening hypertensive crisis
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what type of medication would you prescribe for an acute stress disorder?
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BZD: short term for anxiety and insomnia
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what type of anti-anxiety medication is used to treat a generalized anxiety disorder?
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SSRIs/SNRIs: first line
Paxil, Effexor, Cymbalta, Lexapro Busprione: may be effective for patients with mild symptoms Benzodiaziapines: short term use only |
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what type of medication is used to treat OCD?
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SSRIs are first line medication: higher than usual doses may be required
Benzodiasepines: may be helpful during intial treatment |
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what type of drugs are used to treat panic disorder with/without agoraphobia?
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SSRI/SNRI: consider starting at low dose and increasing slowly because patients tend to be sensitive to activation side effects
BZDs: initial treatment of acute symptoms may be tappered as SSRI develops therapeutic effectiveness Useful when rapid control of panic is needed |
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what type of drug is used to treat PTSD?
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SSRIs
for intrusive thoughts and flashbacks, fear, avoidance, anxiety, irritability, and difficulty with concentration Clonidine/beta-blockers: for increased startle reflex |
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what type of medication is used to treat social phobias?
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SSRIs are first line medication
BZDs: short term or intermittently may help patient expose themselves to anxiety producing situations beta-blockers: may be used for autonomic symptoms |
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what type of medication is used to treat specific phobias?
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BZDs: may help patient expose self to phobic situation if needed
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what type of information should be discussed with the patient when using medications to treat anxiety disorders?
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the standard current approach to most anxiety disorders is a combination of cognitive-behavioral therapy with medications, typically SSRI
SSRIs are antidepressants but the chemical change in the brain they produce also helps symptoms of anxiety disorders SSRIs are effective, nonaddictive, and have relatively minor side effects SSRIs require a minimum of 2-6 weeks to become fully effective the medication will be started at a low dose, and then gradually increased until your symptoms improve Some people experience a temporary increase in anxiety as their bodies adjust to the medication If the first SSRI doesn't work for you or produces unwanted side effects another type can be tried It may take time but your physician will work with you to find the medication that works best for you with the least amount of side effects do not abruptly stop taking the medication: talk to your physician about stopping BZDs work immediately but have a high potential for abuse so are used only short term Tell your physician about any side effects you experience |
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describe psychiatric/mental disorders general definition
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health conditions characterized by alterations in thinking, mood, or behavior
associated with distress and/or impaired functioning determined by symptoms not by cause |
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what does mental illness refer to?
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mental illness refers to all diagnosable mental disorders
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what is a psychiatrist?
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DO/MD with psychiatry residency
medication management medical evaluation: medical problems that may be contributing to mental health problems may do some psychotherapy |
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what is a psychologist?
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PhD or PsyD in clinical or counseling psychology
Counseling/psychotherapy psychological testing can prescribe medication in some states/settings if have special training |
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what is the lifetime prevalence of psychiatric disorders in the US?
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Lifetime prevalence of any psychiatric disorder among US adults is 46%
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what is the 12 month prevalence of psychiatric disorders in the US?
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20%
women > men |
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what is the age of onset of all individuals who wil have a diagnosable psychiatric disorder in their lifetime?
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half will meet diagnostic criteria by age 14
75% will occur by age 24 |
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what is the age of onset of anxiety disorders?
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median age of onset: 11
most cases occur between 16-21 |
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what is the average age of substance abuse disorders?
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median age of onset: 20
most cases occur between 18-27 |
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what is the average age of mood disorders onset?
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median age of onset: 30
most cases occur between: 18-43 |
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T/F
Substance abuse disorders are often a consequence of primary mental disorders? |
True
nearly half of those with any mental disorder meet criteria for 2 of more disorders |
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what is the leading cause of disability in the US and worldwide?
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Major depressive disorders
4 or 10 leading causes of disability are psychiatric disorders: 1. major depression 2. bipolar disorder 3. schizophrenia 4. OCD |
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what is the % of burden of disease in the US caused by psychiatric disorders?
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15%
second only to CV conditions MORE than all Cancers |
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describe some of the effects of psychiatric disorders on physical health? depression.
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depression increases risk of developing CAD and increase risk of death in patients with CHD
Women with depression have increase risk for breast cancer depressed patients are 3X more likely to be non-compliant with medical treatment recommendations |
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what is the estimated % of patients seen in PC that have a diagnosable psychiatric disorder?
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11-36%
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_______ and ________ disorders are among the six MC conditions seen in family medicine.
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Anxiety and depression
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what type of physician provides more care for patients with psychiatric disorders than any other provider?
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PCP
23% primary care physician |
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what is the primary role of the PCP in managing psychiatric disorders?
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PCPs are in the prime position to prevent progression of psychiatric disorders by early detection and management. Role in management varies with individuals comfort and interest, but detection and referral is minimum requirement
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What are the challenges in PC with psychiatric disorders?
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Patient presents with somatic complaints
Patients psychiatric symptoms are often mild-moderate PCPs must manage mental and physical health needs Patients attitudes about mental health Personal reactions to patients with mental health problems time constraints |
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T/F
training in detection and management of psychiatric disorders is essential to effective patient care in PC setting |
True
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what is the multiaxial classification system in the DSM-IV used for?
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5 axis system is used to facilitate comprehensive biopsychosocial evaluation
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describe Axis I
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clinical disorders that are the focus of clinical attention
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describe Axis II
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personality disorders and mental retardation
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describe Axis III
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general medical conditions
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describe axis IV
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psychosocial and environmental problems
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describe axis V
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global assessment of functioning
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what is the GAF scale?
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part of Axis V in the DSM-IV
used to assign a number between 0 and 100 to describe the patient's overall current level of functioning |
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if a patient had a GAF score of 60 what does this mean?
|
moderate symptoms
flat affect, occasional panic attacks or moderate difficulty in social, occupational, or school functioning has few friends, conflicts with peers or co-workers |
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if a patient has a GAF score of 50 what does this mean?
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Serious symptoms
(suicidal ideation, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (no friends, unable to keep a job) |
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what is the biopsychosocial model?
|
most widely accepted theory/paradigm
developed by George Engel in 1977, response to biomedical model most medical and psychiatric illnesses are caused by combination of biological, psychological, and social factors |
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what are the theories of the biopsychosocial model?
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Learning theory
Cognitive theory Social cognitive theory Psychoanalytic theory |
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describe the Learning theory.
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Basis for Behavior theory
application of principle of learning to modification of behavior long term change in behavior results from practice or previous experience scientifically based: 1. focused on two types of learning: Classical conditioning Operant conditioning |
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Describe Classical conditioning
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Pavlov's dog
learning an association between stimulus that evokes physiological reflex and new stimulus occurs when: neutral stimulus is repeatedly paired with stimulus that naturally evokes the reflex until the neutral stimulus evokes the reflex |
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what is stimulus generalization?
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conditioned response occur with presentation of stimuli similar to original conditioned stimulus
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what is extinction?
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elimination of pairing of CS and UCS. CR ceases
EX: chemo stops, pt makes several returns to hospital, nausea eventually stops |
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what is counter-conditioning?
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conditioned stimulus paired with new stimulus > incompatible response
ex: if pt with fear of medical situations learns relaxation response > elicits relaxation in medical situations > fear response will diminish |
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what is systemic desensitization and exposure therapy?
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application of counter-conditioning to tx phobias and anxiety
patient learns relaxation and anxiety management skills patient is exposed to situation: 1. through imagination (systemic desensitization) or 2. real life (exposure therapy) and attempts to maintain relaxed after patient can maintain relaxation in one situation patient practices next situation in the hierarchy, process is repeated for each situation in the hierarchy |
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describe an example of hierarchy for elevator phobia for a patient who was raped in an elevator.
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Stand in elevator with door open
stand in elevator with door closed with companion stand in elevator with the door closed alone go up 1 floor in the elevator with companion go up 1 floor alone, etc. |
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what are some examples of classical conditioning in psychiatry?
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modifying health behaviors: smoking cessation difficulties when exposed to stimuli paired with smoking
sleep hygiene: pts with insomnia encouraged to pair sleep onset with relaxing stimuli Fears, phobias, agoraphobia, PTSD |
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describe operant conditioning?
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behavior is function of consequence:
responses followed by + consequences will become more frequent responses followed by - consequences will become less frequent involves voluntary responses |
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describe reward, reinforcement
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positive consequences: reward, reinforcement
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describe punishment
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presentation of adverse negative consequences or removal of + consequences
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what is negative reinforcement?
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removal of adverse stimulus, which strengthens the behavior that caused the adverse stimuli to cease
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what is shaping?
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reinforcement of behavior approx. desired result
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what is extinction?
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elimination of reinforcement leading to cessation of behavior
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what is an extinction burst?
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during the process of extinction in an operant conditioning model, there may be an initial increase in the rate of responding
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what is the schedule of reinforcement?
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pattern of reinforcement affects the resulting pattern of behavior
behaviors that are reinforced on an intermittent basis are more resistant to extinction than behaviors reinforced on a continuous basis |
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Give some examples of operant conditioning in psychiatry.
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adherence to medical advise
building a positive association with medical care in pediatric patients changing lifestyle behaviors giving advice to parents on managing children's behavior problems children's and adolescent behavior problems in patient psychiatry units |
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what is the cognitive theory in psychiatry?
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focus of importance of thoughts and beliefs in human behaviors and development of psychiatric disorders
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how can the cognitive theory be applicable in the primary care setting?
|
managing chronic disease/medical conditions
coping with anxiety provoking medical procedures |
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T/F
Cognitive therapy is as effective as antidepressant medications in mild/moderate depression |
True
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what is CBT?
|
Cognitive Behavioral Therapy
- combination of cognitive & behavior therapy - focuses on changing behaviors and thoughts - tx is structured, directed, and brief - widely used, efficacy well demonstrated Evidenced based first line tx for: anxiety disorders mood disorders bulimia |
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what is the social cognitive theory?
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social learning theory
modeling, observational learning - people can learn by watching others application: child sx: video of another child going through sx just fine aggressive or violent behaviors: gangs initiation of substance use support groups |
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what is the self-efficacy of the social cognitive theory of therapy?
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confidence is own ability to carry out a behavior (condom use)
important in health risk behavior > increases adherence to medical advise, coping with chronic pain |
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what is the psychoanalytic theory in psychiatry?
|
Freud
current behaviors, emotions, and relationships are deeply influenced by early experiences in important relationships unconscious |
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what is the defense mechanism in the psychoanalytic theory?
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unconscious response to anxiety created by unacceptable impulses or painful feelings that threaten to break into the conscious mind
denial: refusing to acknowledge threatening or anxiety provoking events displacement: redirecting feelings from an original source to a more acceptable substitute |
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what is transference?
|
patient brings feelings from previous relationships to therapeutic encounter
may be occurring when patient responses seem unexpected or out of proportion for the situation - maintain respectful, empathetic approach to patient |
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what is countertransference?
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clinician brings feelings from previous relationships to patient encounter
may be occurring when clinician has strong feelings toward patient |
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what is the classical psychoanalysis therapy?
|
Goal: bring awareness previously unconscious feelings and belief
Structure: patient lies on couch, session 4-5 times/week for 2-3 years Techniques: free association: pt says whatever comes to mind, helps analyst understand unconscious thought process interpretation of transference: pt transfers to analyst thoughts and feelins from early life, analyst interprets to help make conscious for patient Candidates: stable life circumstances, psychologically healthy, motivated by self-understanding rather than symptoms relief, financial resources |
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what is the psychodynamic psychotherapy?
|
based on modifications of Frueds original theories
patient and therapist face each other reviews relationships with parents/significant others but also focuses on current problems helps patient achieve insight into development and persistance of symptoms so can bring about needed change duration is variable |
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Describe the interpersonal psychotherapy
|
focus on: current social functioning and improving interpersonal skills
Goal: improve interpersonal relationships Brief, active Demonstrated effectiveness in treatment of depressed patients |
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describe supportive psychotherapy
|
goal: maintaining or restoring best level of functioning possible
not as change oriented as other psychotherapies based on secure, reassuring, accepting relationships with the therapist therapist provides encouragement and direction as needed Indications: stressful life circumstances, patient with serious chronic illness |
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what is an essential feature of panic disorder?
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recurrent unexpected panic attacks
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what are the characteristics of Panic Attacks?
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discrete periods of intense fear, terror, or sense of impending doom
come on "out of the blue" at least initially accompanied by intense physical sensations (pt goes to ER) symptoms develop abruptly diagnostic criteria require 4 or more symptoms |
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what are the symptoms of a panic attack? how many symptoms are required for a DSM-IV diagnosis?
|
4 symptoms are required
- palpitations, pounding heart, increased heart rate - chest pain or discomfort - sweating - trembling or shaking - SOB or smothering sensation - feelings of choking - nausea or abdominal distress - feeling dizzy, lightheaded, or faint - numbness or tingling - chills or hot flashes - fear of losing control, going crazy, or dying - derealization or depersonalization |
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To actually be diagnosed with a panic disorder what must occur?
|
at least one attack has been followed by one month or more of one or more of the following:
- persistent concern about having additional attacks - worry about implications of an attack or its consequences - a significant change in behavior related to attacks |
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How are patients impaired with Panic disorders?
|
patients with panic symptoms or panic disorder most frequently utilize ER medical services
Patients with panic disorder, particularly with co-morbid depression had a higher risk for suicide attempts, and impairment in social as well as marital functioning |
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when asked what the fear is about, what type of syndromes can the fear be associated with?
|
social performance > SAD
Traumatic memories > PTSD obsessive > OCD unexpected > PD |
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what are patients with panic attacks found to often have occurring in their lives?
|
have a history of recent stressful life events
may have recently separated from loved ones show excessive apprehension about own health have chronic pattern of subtle hyperventilation |
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what are some common fears in panic disorder?
|
fear of dying
fear of going crazy fear of having a heart attack fear of suffocating fear of having a brain tumor fear of doing something uncontrollable or becoming hysterical |
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what should give you a high index of suspicion that your patient may be suffering from a panic disorder?
|
average of 10+ visits before being correctly diagnosed
individuals with panic attacks have an average of 37 visits a year to their doctor patient is commonly present to ER of those with chest pain, 16-25% have panic disorder rule out other medical conditions/other etiological factors that create panic symptoms |
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what questions should you ask when screening a patient for a panic disorder?
|
have you ever had a panic attack where you felt a sudden rush of intense anxiety or fear?
have attacks ever occurred "out of the blue"? do you have strong fears of certain places or situations or do you avoid certain situations because of your fears? Has anyone in your family ever had similar symptoms or problems with anxiety? |
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When a patient has a suspected panic disorder, what co-morbidities should you suspect?
|
lifetime prevalence of major depression in 60-90% in persons with panic disorders
about 33% to 50% of patients with panic disorder are depressed when presenting for treatment be alert to increased risk for suicide be alert for possible substance use |
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what other medical conditions may be present with panic disorder?
|
IBS
migraine respiratory illness |
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what are the steps in patient education of treatment of panic disorder?
|
show you understand the frightening nature of the attacks.
- assure the patient that the attacks are "real" - symptoms of panic attack represent real physiolgoical changes in the body - anxiety producing thoughts contribute to the maintenance of panic over time - panic attacks can develop during times of increased stress |
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how should you help a patient hand panic?
|
advise the patient they may feel a desire to avoid the situation in which the attack occurred or to avoid being alone
- explain how avoidance of these situations can reinforce or strengthen fear explain that isn't your body's "false alarm" going off! |
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how should you advise a patient to handle a panic attack?
|
best approach is to let it happen
don't fight it it is frightening but will be over in a few moments attacks are self-limiting |
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what are the patients treatment options for panic disorder?
|
medication: SSRI/SNRI
Psychotherapy combination of medication and CBT |
|
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what is the best treatment option for panic disorder?
|
Combination of medication and CBT
- lifestyle management as indicated CBT may involve exposure therapy, which introduces exposure to feared sensation in a gradual manner |
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what does the CBT part of therapy for panic disorder focus on?
|
deconditioning the patients bodily responses
- may involve exposure to cues which elicit panic - address fearful thoughts that promote panic - breathing re-training |
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what is agoraphobia?
|
anxiety about being in situations where:
escape might be difficult or embarrassing or help might not be available in the event of a panic attack the situations are avoided or endured with marked distress |
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what is the course of panic disorders with agoraphobia?
|
often begins with initial panic attack
fear further develops via: conditioning and generalization can see increase constriction of activities; in severe case individuals may become house bound over time situationally bound panic attacks may become more common than unexpected ones |
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what are treatment options for panic disorder with agoraphobia?
|
medication
cognitive behavioral therapy - exposure therapy involves exposure to feared situation in gradual manner face fear and going out on their own combination of medication and CBT |
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How do you educate your patient about panic disorder with agoraphobia?
|
reassure and educate about panic attacks
if agoraphobia is in its early stages: - set up gradual exposures that become increasingly difficult as person achieves success success is not necessarily defined by the absence of symptoms at first, but rather by the doing of the exposure Explain that avoidance strengthens fears and erodes confidence in ability to handle situation |
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what is anxiety?
|
a natural and universal emotion. It alerts us to danger or threat and has an adaptive function.
- it helps to meet the challenges of life - moderate levels enhance performance while too little or too much anxiety hinders performance |
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what are the components of anxiety?
|
Physiological
Affective Cognitive Behavioral |
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how do you distinguish when anxiety becomes a clinical problem?
|
anxiety lies on a continiuum
must consider context |
|
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what helps distinguish when anxiety becomes problematic?
|
duration/persistence of symptoms
intensity of symptoms controllability: the content of worry is often similar to normal worry safety behaviors/rituals impact on functioning or marked distress (must affect you in a meaningful way) |
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anxiety is the most common mental health problem. what is the lifetime prevalence?
|
lifetime prevalence is ~29% of population will have an AD at some point in lifetime
Course tends to be chronic and recurrent effective treatments are available reduction in symptoms and even remission |
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how do patients commonly present with anxiety in primary care setting?
|
patients often present with somatic complaints
|
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T/F
Patients with identified medical conditions may develop anxiety disorder secondary to a medical problem |
True
|
|
|
what is the Etiology of anxiety disorders?
|
Genetic studies: risk of getting an anxiety disorder is increased among family members of probands
patients do not inherit the disorder but inherit the vulnerability to anxiety Environmental factors: important in the expresion of anxiety disorder Neurobiology: various brain regions and NT are implicated |
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what are the common medical dDx of anxiety?
|
hypoglycemia
hyperthyroidism cardiac dysfunction |
|
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what are the common psychiatric dDx of anxiety?
|
substance use
drug or alcohol withdrawal adjustment disorder with anxiety psychotic disorders other anxiety disorders major depression |
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what are the frequent co-morbidities with anxiety?
|
substance abuse
depression other anxiety disorders |
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what must you rule out in order to diagnose anxiety?
|
underlying medical conditions
medication use substance use other psychiatric disorders |
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what is one of the most common anxiety disorders?
|
Generalized anxiety disorder
|
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what are the DSM-IV features of GAD?
|
excessive anxiety and worry
more days than not at least 6 months, about the number of events or activities difficult to control the worry |
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what do worries in GAD focus on?
|
worries focus on various matters such as health, finances, job
worry is out of proportion to the situation; unwarranted |
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what is the general course of GAD?
|
occurs in children, adolescents, and adults
usual onset in early adulthood more common in females chronic but fluctuating course typically exacerbated during times of stress common disorder in the elderly |
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what are the impacts of GAD?
|
compared to patients with common medical illnesses such as DM or CHD patients with GAD tend to have poorer functioning in social and physical spheres
|
|
|
what is the presentation of GAD in the PCP setting?
|
likely to focus on somatic complaints
do not spontaneously present themselves as "worriers" often do not connect their feelings of worry, somatic symptoms, and life stress may present with a number of associated symptoms |
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what are the co-morbid conditions seen in other anxiety disorders?
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often co-morbid with other anxiety disorders:
social phobia Specific phobia panic disorder major depression substance abuse, PTSD, OCD |
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what is the GAD-7 screening tool?
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used in evaluation of GAD
over the last 2 WEEKS how often have you been bothered by the following problems: 1. feeling nervous, anxious, or on edge 2. not being able to stop or control worrying 3. worrying to much about different things 4. being so restless that it is hard to sit still 5. trouble relaxing 6. becoming easily annoyed or irritable 7. feeling afraid as if something awful might happen Score of 8 of more is used to cut point for possible identified case |
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what is the GAD-2 subscale?
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further assessment of GAD after GAD-7 screening tool has been used.
over the last 2 WEEKS how often have you been bothered by the following problems: 1. feeling nervous, anxious, or on edge 2. not being able to stop or control worrying Score of 3 or more is used as cut-point for possible identified cases and further assessment may be needed |
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what should be considerations for treatment of GAD?
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it is important not to trivialize the patients worries
explain the nature of anxiety - normal and adaptive emotion - provide reassurance Consider treatment options: - medications - psychotherapy - lifestyle modification |
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what is the first line of therapy in GAD?
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Cognitive behavioral therapy is the first line treatment in anxiety disorders
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what does CBT focus on in treatment of GAD?
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reducing physiological arousal
modifying anxiety producing thoughts learning adaptive coping skills |
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describe generalized anxiety disorder
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excessive worry day-to-day theme
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describe panic disorder/agoraphobia
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fear of fear
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describe the definition of specific phobia
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fear of particular object
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describe the definition of social anxiety disorder
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fear humiliation/embarrassment
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describe obsessive compulsive disorder
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fears focus on certain themes (obsessions) which are temporarily relieved by rituals (compulsions)
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describe what occurs in a specific phobia
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marked or persistent fear
- cued by presence or anticipation of specific object or situation exposure typically provokes immediate anxiety which may be panic person recognizes fear is excessive, unreasonable situation is avoided or endured with distress fear interferes significantly with functioning or there is marked distress about having the phobia |
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what are some subtypes of a specific phobia?
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animal type: onset usually in childhood
natural environment type: thunderstorm, water, heights, usually childhood onset Blood-injection-injury type: sight of blood, injections, strong vasovagal response, often produces fainting, highly familial, individuals may avoid medical care Situational: tunnels, elevators, bridges, driving, usually onset in childhood, as well as in mid-20s other: choking, vomiting |
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what are developmentally appropriate fears in children?
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fear of strangers
age 3 to 6 developmentally appropriate fears include fear of animals, insects, the dark |
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what are the basic components of CBT for treating a specific phobia?
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psychoeducation about anxiety
anxiety management coping skills exposure to feared situations cognitive therapy: to correct misconception and/or distort beliefs that contribute to anxiety/fear |
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describe CBT steps for specific phobias.
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exposure therapy
real-life exposure graduated fashion |
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how would systemic desensitization be used in treatment of a specific phobia?
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imaginal exposure
graduated fashion flooding |
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describe the hierarchy of treatment of an animal phobia.
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touching a dog: 100 SUDS
standing close to a dog: 95 SUDS standing a distance from a dog: 85 SUDS seeing a dog on leash in neighborhood: 75 SUDS hearing a dog barking: 70 SUDS Seeing a dog on tv: 50 SUDS Seeing a picture of a dog: 40 SUDS |
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what is a social phobia disorder?
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marked and persistent fear of social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
- the individual fears that he/she will at in a way that will be humiliating or embarrassing - exposure to the feared social situation almost invariably provokes anxiety |
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what are the essential features of social phobia?
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the person recognizes that the feat is excessive or unreasonable
- fear social/performance situations are avoided or endured with intense anxiety - the avoidance, anxious anticipation, or distress interfere with functioning or there is a marked distress about having the phobia |
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describe some fear eliciting situations in social anxiety disorder
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1. public speaking
2. writing in public 3. use of public restrooms 4. eating in public 5. socializing 6. interacting with authority figures |
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in the treatment of social phobias what is the process used in CBT?
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psychoeducation
exposure to feared situations - in a graduated, hierarchical fashion Cognitive therapy - to correct misconception and/or distorted beliefs that contribute to anxiety/fear Social skills training: particularly when social skills deficits/excesses are present |
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at some point in the progression of OCD what is recognized?
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at some point the obsessions or compulsions are recognized as excessive or unreasonable.
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what is the DSM-IV criteria for obsession?
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recurrent persistent:
thoughts impulses images experienced as: intrusive and inappropriate, anxiety provoking attempts made to suppress or neutralize by: thought action |
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what is the obsession criteria for DSM-IV?
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the obsession are recognized as a product of ones own mind
they are not simply excessive worries about real-life problems obsessions are focused on certain themes |
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what is the functional relationship between obsession and compulsion?
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obsession produces anxiety
compulsion decreases anxiety |
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what is the 4th most common cause of psychiatric disorder?
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OCD
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describe onset and course of OCD.
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usual onset in adolescence or early adulthood
relationship of onset/exacerbation to stress onset may be associated with stress symptoms exacerbated by stress course is chronic - symptoms wax and wane - some may have remission of symptoms for extended periods 5-10 year delay to diagnosis |
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T/F
Children demonstrate age appropriate behaviors during development that "mimic" OCD |
True
-bedtime rituals, magical thinking (step on a crack) these can be thought as normative phenomena consider the severity, content, and timing in discriminating normal phenomena from OCD symptoms |
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what does PANDAS stand for?
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pediatric auto-immune neuropsychiatric disorder with streptococcus (GABHS)- onset of exacerbation of symptoms follows infection
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what do the ritualistic patterns do for a patient with OCD?
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ritualistic behaviors provide short term relief from obsessive thought
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describe the washers of OCD.
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most common type
fear of contamination preoccupation with cleanliness common contaminants include dirt, germs, feces, cancer, AIDS, pesticides rituals can include ritualistic handwashing, excessive use of toiletries, use of disinfectants and excessive cleaning |
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what are the "Checkers" in OCD?
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Doubt they have performed an activity satisfactorily
checking is done in an effort to avert disaster commonly checked items: stove, oven, faucets, iron, windows, locks, route driven, homework, paperwork |
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what are the "Orders" in OCD?
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uncomfortable with asymmetry
distressed by the lack of orderliness compulsions driven by a sense that "it doesn't feel right" |
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define the "repeaters" in OCD.
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repeat action or thought repeatedly in order to feel comfortable or in attempt to prevent something bad from happening
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define the "hoarders" in OCD
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avoid throwing away objects, even if no longer needed
keep objects in the event that they might be needed some time in the future can result in severely limited space as objects accrue in home |
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what are the characteristics of the "harming obsessionals" in OCD?
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fear they may hurt their child or another
person has no wish to harm other person but is afraid they may do so person often avoids individual or will try to avoid being alone with individual |
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define the "pure obsessional" in OCD
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these patients do not have ritualistic activity
disorder is characterized by obsession only not associated with an activity that ameliorates the obsessive thought more difficult to treat |
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what are co-morbidities associated with OCD?
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depression
substance abuse other anxiety disorders risk for suicide |
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list some dDx associated with OCD.
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OCPD: rigid controlling, perfectionist, excessively devoted to work/productivity
Depression: obsession vs. rumination Tourettes disorder: chronic motor and vocal tics Trichotillomania: hair pulling Psychosis: overvalued idea vs. psychosis |
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describe the non-psychiatric presentation of OCD
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presenting problems:
red, chapped hands repeated request for tests without indication postpartum OCD concerns regarding poisoning, cancer, AIDS parental concern over child's behavior reports from family member concern about abnormal features |
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what are the mainstay treatments for OCD?
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Pharmacotherapy
Cognitive behavior therapy Family education |
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how do you detect OCD in PC patients?
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be alert for possible signs of OCD
Clues: red/chapped hands, many request for reassurance, avoiding things, repeated HIV testing Patients are usually embarrassed by obsession/compulsions and may be ashamed and unlikely to disclose problems approach with sensitivity |
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what are some recommendations for managing OCD in the PC setting?
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screen for anxiety and depression, which is commonly co-morbid '
provide basic education about the disorder, and discuss the role that rituals have in reinforcing obsessive compulsive symptoms many resources are available for patients referral to mental health professional |
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describe the spectrum of reactions to traumatic stress.
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Normal reactions: generally persists for 1-2 weeks and do not cause significant impairment of functioning
Acute stress syndrome: cause clinically significant distress or impairment in functioning and last up to one month PTSD: causes clinically significant distress or impairment in functioning and last longer then one month |
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what are some recommendations to help adults cope with recent traumatic stress?
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education about traumatic stress
expect time for healing and recovery ask for support from people who can give it communicate your experience and feelings in ways that are comfortable take care of health - minimize alcohol, drugs, and caffeine Engage in relaxing, comforting activities postpone major life decisions if possible |
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what are the diagnostic criteria for PTSD?
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- the person has been exposed to a traumatic event in which both of the following were present:
1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or threat to the physical integrity of self or others the person's response involved intense fear, helplessness, or horror |
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what are some examples of medically related traumatic events that could cause PTSD?
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surviving a life threatening acute medical event
being diagnosed with life-threatening illnesses learning about the serious injury, unexpected death, or diagnosis of a life threatening illness of a loved one Awareness during anesthesia Invasive/painful medical procedures |
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what are the diagnostic criteria for PTSD?
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The traumatic event is persistently re-experienced
Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness Persistent symptoms of increased arousal not present before event duration of disturbance is more than one month the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning |
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what does the mnemonic for diagnosis of PTSD stand for?
DREAMS |
Emotionally Detached
Re-experience the event EVent: actual/threatened death/serious injury, involved intense fear, helplessness, or horror Avoidance of reminders of the event Month in duration Sympathetic hyperactivity or hyper-vigilance |
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what are the associated features of PTSD in children under 6?
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clinging to parents
regression to early behaviors physical symptoms frightening dreams without recognizable content reenactment of trauma |
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what are the associated features of PTSD in children age 6-11?
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guilt feeling
repetitive play in which aspects of the trauma are expressed School performance declines Irritability Aggression |
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what are the associated symptoms of PTSD in adolescents?
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rebellious, risk taking behavior
withdrawal pretending not to care substance abuse depression self injury |
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who are the highest rates of PTSD found in?
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survivors of human malevolent acton
- rape - military combat - prisoners of war |
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what are the biological findings associated with PTSD?
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Chronic autonomic hyperarousal
- increased heart rate and blood pressure - cortisol level lower than normal - epinephrine and norepinephrine higher than normal - physiologically and hormonally people with PTSD tend to react to minor stimuli and stressors as emergencies Extreme physiological reactions to trauma related stimuli slower habituation to stressful stimuli |
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what are the neurobiological findings associated with PTSD?
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decrease of volume of hippocampus and increased metabolic activity in limbic regions, especially the amygdala
- may help explain disturbance of emotional memory |
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what co-morbid disorders are associated with PTSD?
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about 80% of PTSD patients have co-morbid psychiatric disorders
- most common: depressive disorders anxiety disorders substance abuse related disorders bipolar disorders |
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what is the role of denial in PTSD?
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common response is to deny the effects of the trauma in order to protect self from awareness of the reality
- patient may smile as talk about trauma, dismiss its significance - if a perpetrator was involved pt. may defend perpetrator or justify perpetrators behavior |
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what is dissociation of trauma?
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a disconnection in the usually integrated function of consciousness, memory, identity, or perception of the environment
- mild dissociation: getting lost in book or movie, daydreaming, spacing out |
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what are the effects of traumatic stress on physical health?
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increased physical symptoms
increased rate of chronic health conditions higher rates of utilization of medical services increased health risk behaviors can impair recovery from medical conditions |
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how do you screen for PTSD in PC?
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ask questions: in your life have you had any experiences that was so frightening, horrible, or upsetting that in the PAST MONTH, you:
1. have had nightmares about it or thought about it when you did want to? 2. tried hard not to think about it or went out of your way to avoid situations that remind you of it? 3. were constantly on guard, watchful, or easily startled? 4. felt numb or detached from others, activities, or your surroundings? If YES, to 3 or more - determine whether patient has had a traumatic experience 2. assess for effects on patients life 3. determine whether traumatic events are ongoing in pts life |
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what is one step in patient education in patients with PTSD?
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although it is natural and common to avoid reminders of the trauma, not talking about it is associated with the development of physical and mental health problems
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how is PTSD treated?
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Psychotherapy is a first line treatment
Pharmacotherapy REfer to mental health professional or support group Patients who are hesitant to participate in treatment for trauma may be more willing to seek treatment for a co-morbid condition |
