Tn: Psychiatry - 3/4

Front 1

Define anxiety?

Back 1

• universal human characteristic involving tension, apprehension, or even terror
• adaptive mechanism to warn about an external threat by activating the sympathetic nervous system (flight or fight)
  

Front 2

Physiological manifestations of anxiety?

Back 2

main brain structure involved is the amygdala

NTs involved include 5-HT, cholecystokinin, epinephrine, NE, DA

Front 3

Psychological manifestations of anxiety?

Back 3

One's perception of a given situation is distorted which causes one to believe it is threatening in some way

Front 4

Behavioural manifestations of anxiety?

Back 4

Once feeling threatened, one responds by escaping or facing the situation, thereby causing a disruption in daily functioning

Front 5

When does anxiety become pathological?

Back 5

• Fear greatly out or proportion to risk/severity of threat
• response continues beyond existence of threat or becomes generalized to other similar/dissimilar situations
• social or occupational functioning is impaired
  

Front 6

Five main forms of anxiety disorder?

Back 6

• Panic disorder
• Generalized anxiety disorder
• Phobic disorder
• OCD
• PTSD

Front 7

Medical workup of anxiety disorder? (6)

Back 7

• Physical exam
• CBC
• Thyroid Function Tests
• Electrolytes
• Urinalysis
• Urine drug screening
  

Front 8

Additional screening of anxiety disorder?

Back 8

• Neurological consultation
• chest X-ray
• ECG
• CT
  

Front 9

Systems involved in DDx of anxiety disorders?

Back 9

• CV
• RESP
• Endo
• Metabolic
• Neurologic
• Substance induced
• Other psychiatric disorders
  

Front 10

CV DDx of anxiety disorders?

Back 10

• Post-MI
• Arrhythmia
• Congestive heart failure
• Pulmonary embolus
• Mitral valve prolapse
  

Front 11

RESP DDx of anxiety disorders?

Back 11

• Asthma
• COPD
• pneumonia
• hyperventilation
  

Front 12

Endo DDx of anxiety disorders?

Back 12

• Hyperthyroidism
• Pheochromocytoma
• Hypoglycemia
• Hyperadrenalism
• Hyperparathyroidism
  

Front 13

Metabolic ddx of anxiety disorders?

Back 13

• Vitamin B12 deficiency
• Porphyria
  

Front 14

Neurological ddx of anxiety disorders?

Back 14

• Neoplasm
• Vestibular dysfunction
• Encephalitis
  

Front 15

Substance-induced ddx of anxiety disorders?

Back 15

• Intoxication (caffeine, amphetamines, cocaine, thyroid preps, OTC for colds/decongestants)
  
• Withdrawal (benzos, EtOH)
  

Front 16

Criteria for Panic Disorder mnemonic?

Back 16

STUDENTS FEAR THE 3 C's

Front 17

Criteria for Panic Disorder?

Back 17

STUDENTS FEAR THE 3 Cs

(greater or equal to 4)

Sweating

Trembling

Unsteadiness, dizziness

Depersonalization, Derealization

Excessive heart rate, palpitations

Nausea

Tingling

SOB

Fear of dying, losing control, going crazy

3 Cs: Chest pain, chills, choking

Front 18

Panic attack vs panic disorder?

Back 18

• Panic disorder consists of panic attacks and other criteria
• Panic attack is not a codable disorder and can occur in the context of many different disorders
  

Front 19

Tips starting medication for anxiety?

Back 19

• Start low
• Go slow
• Aim high and explain symptoms to expect prior to initiation of treatment
  

Front 20

Epidemiology of panic disorder?

Back 20

Prevalence: 2-5%

Onset: average late 20s, familial pattern

Front 21

Psychological treatment for panic disorder?

Back 21

CBT

• interoceptive exposure (eliciting symptoms of a panic attack and learning to tolerate the symptoms without coping strategies);
  
• cognitive restructuring (addressing underlying beliefs regarding the panic attacks),
  
• relaxation techniques (visualization, box-breathing)
  

Front 22

Pharmacological treatment for panic disorder?

Back 22

• SSRIs: fluoxetine, citalopram, paroxetine, fluvoxamine, sertraline
  
• SNRI: venlafaxine
  
• SSRI/SNRIs (start low, titrate up slowly)
  
• anxiety disorders often require treatment at high doses for longer period of time
  
• AVOID bupropion
  
• benzos for short term low dose, regular schedule, long half-life, avoid prn use)
  

Front 23

Panic disorder prognosis?

Back 23

• 6-10 yr post treatment:
  
• 30% well, 40-50% improved, 20-30% change or worse
  

Front 24

clinical course of panic disorder?

Back 24

• Chronic
  
• Episodic with psychosocial stressors
  

Front 25

Criteria A Agoraphobia

Back 25

marked fear or anxiety about two (or more) of the following five situations using public transportation being in open spaces being in enclosed places standing in line or being in a crowd being outside of the home alone

Front 26

Criteria B Agoraphobia

Back 26

the individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms

Front 27

Mnemonic for GAD?

Back 27

BE SKIM

Front 28

Criteria for GAD?

Back 28

Greater than or equal to 3:
BE SKIM

Blank mind

Easily fatigued

Sleep disturbance

Keyed up

Irritability

Muscle tension

Front 29

Epidemiology of GAD?

Back 29

1 yr prevalence: 3-8%;

M:F 1:2

Front 30

When does GAD usually present?

Back 30

early adulthood

Front 31

Three factors for treatment of GAD?

Back 31

• Lifestyle
  
• Psychological
  
• Biological
  

Front 32

Lifestyle treatment for GAD?

Back 32

• caffeine and EtOH avoidance
  
• Sleep hygiene
  

Front 33

Psychological treatment of GAD?

Back 33

CBT including relaxation techniques, mindfulness

Front 34

Biological treatment(s) of GAD?

Back 34

• SSRIs and SNRIs: first line
  
• 2nd line: bupropion (caution due to stimulating effects)
  
• add on benzos (short term, low dose, regular schedule, long half-life avoid prn)
  
• beta-blockers not recommended
  

Front 35

Prognosis of GAD?

Back 35

• Chronically anxious adults become less so with age
  
• Depends on pre-morbid personality functioning, stability of relationships, work and severity of environmental stress
  
• difficult to treat
  

Front 36

Define "specific phobia"

Back 36

marked and persistent fear that is excessive or unreasonable cued by presence or anticipation of a specific object or situation

Front 37

Lifetime prevalence of specific phobia?

Back 37

12-16%;

M:F ratio variable

Front 38

Types of specific phobias?

Back 38

• Animal/insect
  
• Environmnetal (heights, storms)
  
• Blood/injection/injury
  
• Situational (airplane, closed spaces)
  
• Other (loud noise, clowns)
  

Front 39

What is social phobia?

Back 39

Social anxiety disorder:

marked and persistent fear of social or performance siuations in which one is exposed to unfamiliar people or to possibly scrutiny by others

fear he/she will act in a way that may be humiliating or embarassing

Front 40

Lifetime prevalence of social phobia?

Back 40

• 13-16%; 12 month prevalance may be as high as 7%
  
• F>M
  

Front 41

Five diagnostic criteria of phobia disorders?

Back 41

• Exposure to stimulus almost invariable provokes an immediate anxiety response/may present as panic attack
  
• person recognizes fear as excessive or unreasonable
  
• situations are avoided or endured with anxiety/distress
  
• sifnificant interference with daily routine, occupation/social function, and/or marked distress
  
• if person is less than 18 years old, duration is at least 6 mo
  

Front 42

Two main types of treatment for phobic disorders?

Back 42

• Psychological
  
• Biological
  

Front 43

Psychological treatment for phobic disorder?

Back 43

• Cognitive behavioural therapy (focusing on both in vivo and virtual exposure therapy, gradually facing feared situations)
  
• Behaviour therapy (more efficacious than meds)
  

Front 44

Biological treatment for phobic disorders?

Back 44

• SSRIs/SNRIs
  
• Beta blockers or benzos in acute situations
  

Prognosis: chronic

Front 45

Obsessive compulsive disorder diagnosis? (it's own thing)

Back 45

• Either obsessions or compulsions, or both
  
• time consuming
• significant distress
• not attributable to the physiological effects
• disturbance is not better explained by symptoms of another mental disorder

Front 46

What are obsessions?

Back 46

1. recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress

2. the individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. by performing a compulsion)

Front 47

What are compulsions?

Back 47

1. repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying,counting, repeating words silently) that the individual feels driven to perform inresponse to an obsession or according to rules that must be applied rigidly

2. the behaviors or mental acts are aimed at preventing or reducing anxiety or distress, orpreventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

Front 48

Epidemiology of OCD?

Back 48

• 12 mo prevalance 1.1-1.8%
  
• females affected at slightly higher rates than males
• Rate of OCD in first degress relatives is higher than in the general population
  

Front 49

Is OCD acute or chronic?

Back 49

Chronic and refractory

Front 50

What is the mnemonic to remember criteria for PTSD?

Back 50

TRAUMA

Front 51

Two main modes of treatment of OCD?

Back 51

• CBT
  
• pharmacotherapy
  

Front 52

Describe CBT for OCD?

Back 52

Exposure with response prevention (ERP) - involves exposure to feared situations with addition of preventing the compulsive behaviours, cog strategies include challenging underlying beliefs

Front 53

Pharmacotherapy for OCD?

Back 53

SSRIs/SNRIs, clomipramine, adjunctive risperidone

Front 54

What is the criteria for diagnosing PTSD?

Back 54

• Traumatic event
  
• Re-experience the event
  
• Avoidance of stimuli associated with the trauma
  
• Unable to function
  
• More than a month
  
• Arousal increased
  

+ negative alterations in cognition andmood

Front 55

Epidemiology of PTSD?

Back 55

• Prevalence in general population: 8.7%
  
• Men's trauma is most commonly combat /physical assault
  
• Women's trauma is usually physical or sexual assault
  

Front 56

Three main modes of treatment for PTSD?

Back 56

• CBT
  
• Biological
  
• Eye movement desensitization and reprocessing (EMDR)
  
• challenge dysfunctional beliefs

Front 57

CBT treatment for PTSD?

Back 57

• Exposure therapy
  
• Challenge dysfunctional beliefs
  
• Emotional regulation techniques
  

Front 58

Biological treatments for PTSD?

Back 58

• SSRIs
  
• Benzodiazepines (for acute anxiety)
  
• Adjunctive atypical antipsychotics (resperidone, olanzapine)
  

Front 59

Criteria C agoraphobia

Back 59

the agoraphobic situations almost always provoke fear or anxiety

Front 60

Eye movement desensitization and reprocessing (EMDR) for PTSD?

Back 60

experimental method of reprocessing memories of distressing events by recounting them while using a form of dual attention stimulation such as eye movements, bilateral sound, or bilateral tactile stimulation

Front 61

Complications from PTSD?

Back 61

• Substance abuse
  
• relationship difficulties
  
• Depression
  
• Impaired social and occupational functioning disorders
• personality disorders

Front 62

Criteria D agoraphobia

Back 62

the agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety

Front 63

Criteria E agoraphobia

Back 63

the fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context

Front 64

Criteria F agoraphobia

Back 64

the fear, anxiety, or avoidance is persistent, typically lasting for ≥6 mo

Front 65

Criteria G agoraphobia

Back 65

the fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Front 66

Criteria H agoraphobia

Back 66

if another medical condition is present, the fear, anxiety, or avoidance is clearly excessive

Front 67

Criteria E agoraphobia

Back 67

the fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder and are not related exclusively to obsessions, perceived defects or flaws in physicalappearance, reminders of traumatic events, or fear of separation

Front 68

Note: is agoraphobia diagnosed irrespective of PD?

Back 68

Yes: If an individual’spresentation meets criteria for panic disorder and agoraphobia, both diagnoses should beassigned

Front 69

What is acute stress disorder?

Back 69

• May be a precursor to PTSD

• Similar symptoms to PTSD

• Symptoms persist 3 d after a trauma until 1 mo after the exposure