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Psychiatry > Anxiety and Adjustment Disorders > Flashcards

Anxiety and Adjustment Disorders Flashcards

1
Q

What is anxiety?

What are some autonomic symptoms of anxiety?

A
  • The subjective experience of fear and its physical manifestations
  • Autonomic symptoms
    • Palpitations
    • Perspiration
    • Dizziness
    • Mydriasis
    • GI disturbances
    • Urinary urgency & frequency
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2
Q

What is the etiology of anxiety disorders?

A
  • Combination of genetic, environmental, biological and psychosocial factors
  • Neurotransmitter disturbances
    • Increased NE
    • Decreased GABA & serotonin
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3
Q

Anxiety disorders

Women: ___%

Men: ___%

(High/Low) socioeconomic groups

A
  • Women: 30% lifetime prevalence
  • Men: 19% lifetime prevalence
  • Higher socioeconomic groups
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4
Q

What are the 9 primary anxiety disorders?

A
  • Panic disorder
  • Agoraphobia
  • Specific and social phobias
  • Obsessive-compulsive disorder
  • Posttraumatic stress disorder
  • Acute stress disorder
  • Generalized anxiety disorder
  • Anxiety disorder secondary to general medical condition
  • Substance-induced anxiety disorder
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5
Q

What at 8 medical causes of anxiety disorders?

A
  • Hyperthyroidism
  • Vitamin B12 deficiency
  • Hypoxia
  • Neurological disorders
    • Epilepsy, brain tumors, MS
  • Cardiovascular disease
  • Anemia
  • Pheochromocytoma
  • Hypoglycemia
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6
Q

What are the 10 medication or substance-induced anxiety disorders?

A
  • Caffeine intake and withdrawal
  • Amphetamines
  • Alcohol and sedative withdrawal
  • Other illicit drug withdrawal
  • Mercury or arsenic toxicity
  • Organophosphate or benzene toxicity
  • Penicillin
  • Sulfonamides
  • Sympathomimetics
  • Antidepressants
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7
Q

How long do panic attacks last?

Are they provoked?

A
  • Often peak in several minutes and subside within 25 minutes
  • Rarely last >1 hour
  • Attacks unexpected or provoked by triggers
  • “Sudden rush of fear”
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8
Q

What is the DSM IV criteria for a panic attack?

A

Discrete period of intense fear and discomfort that is accompanied by at least 4 of the following:

  • Palpitations
  • Sweating
  • Shaking
  • Shortness of breath
  • Choking sensation
  • Chest pain
  • Nausea
  • Light-headedness
  • Depersonalization (feeling detached from oneself)
  • Fear of losing control or “going crazy”
  • Fear of dying
  • Numbness or tingling
  • Chills or hot flushes
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9
Q

What is the DSM IV criteria for panic disorder?

A
  • Spontaneous recurrent panic attacks with no obvious precipitant
  • At least 1 of the attacks has been followed by a minimum of 1 month of the following:
    • Persistent concern about having additional attacks
    • Worry about the implications of the attack (“Am I out of control?”)
    • A significant change in behavior related to the attacks (avoid situations that may provoke attacks)
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10
Q

How should panic disorder by specified?

A

with or without agoraphobia

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11
Q

How do panic attacks related to panic disorder present?

How often do they occur?

A
  • 1st panic attack unexpected
  • Physical symptoms
    • Tachycardia, sweating, SOB
  • Extreme fear w/o understanding the source
  • May sense impending death or harm
  • Attacks on average 2x/week
  • 20-30 min long
  • Common: anticipatory anxiety
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12
Q

What is the etiology of panic disorder?

A
  • Biological, genetic & psychosocial factors
  • Dysregulation of the autonomic nervous system, CNS & cerebral blood flow
  • Increased NE
  • Decreased serotonin & GABA
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13
Q

What are some examples of panic-inducing substances?

A
  • Hyperventilation or its treatment (inhalation of CO2/breathing in & out of a paper bag)
  • Caffeine
  • Nicotine
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14
Q

Panic disorder

  • Lifetime prevalence
  • Female vs. Male
  • Genetics
  • Age of onset
A
  • Lifetime prevalence: 2-5%
  • 2-3x more common in females than males
  • Strong genetic component
    • 4-8x greater risk if 1st degree relative affected
  • Onset: late teens to early thirties (avg 25)
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15
Q

What are 4 conditions frequently associated with both panic disorder & agoraphobia?

A
  • Major depression (40-80%)
  • Substance dependence (20-40%)
  • Social & specific phobias
  • Obsessive-compulsive disorder
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16
Q

Differential diagnosis for panic disorder

Medical

A
  • Cardiac
    • CHF, angina, MI
  • Endocrine
    • Thyrotoxicosis, pheochromocytoma, carcinoid syndrome
  • Neuro
    • Temporal lobe epilepsy, MS
  • Pulmonary
    • COPD
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17
Q

Differential diagnosis for panic disorder

Mental

A
  • Depressive disorders
  • Phobic disorders
  • Obsessive-compulsive disorders
  • Posttraumatic stress disorder
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18
Q

Differential diagnosis for panic disorder

Drug

A
  • Amphetamine
  • Caffeine
  • Nicotine
  • Cocaine
  • Hallucinogen intoxication
  • Alcohol or opiate withdrawal
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19
Q

What is the prognosis for patients with panic disorder?

A
  • 10-20% continue to have significant symptoms that interfere with daily functioning
  • 50% continue to have mild, infrequent symptoms
  • 30-40% remain free of symptoms after treatment
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20
Q

What drugs are used to treat panic disorder?

When are they used?

How long are they used for?

A
  • Benzodiazepines
    • Acute initial treatment of anxiety
    • Dose should be tapered with SSRI intro
  • SSRIs
    • Maintenance
    • Paroxetine, sertraline
    • 2-4 weeks to become effective
    • Treatment for 8-12 months
    • Relapse common
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21
Q

What are some alternatives to drugs for panic disorder?

A
  • Relaxation training
  • Biofeedback
  • Cognitive therapy
  • Insight-oriented psychotherapy
  • Family therapy
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22
Q

Why start SSRIs at low dose and increase slowly?

A
  • Activation side effects
  • Anxiety symptoms that mimic those of panic
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23
Q

In agoraphobia patients, ___% have coexisting panic disorder.

A

50-75%

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24
Q

What is the DSM-IV criteria for agoraphobia?

A
  • Anxiety about being in places or situations from which escape might be difficult, or in which help would not be readily available in the event of a panic attack
  • The situations are either avoided, endured with severe distress, or faced only with the presence of a companion
  • These symptoms cannot be better explained by another mental disorder
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25
Q

What are the typical fears of agoraphobia?

A
  • Being outside the home alone
  • Being on a bridge or in a crowd
  • Riding in a car, bus or train
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26
Q

What is an example of the relationship between panic attacks and agoraphobia?

A

Clinical progression

  • A person who has a panic attack while shopping in a large supermarket subsequently develops a fear of entering that supermarket.
  • As the person experiences more panic attacks in different settings, he or she develops a progressive and more general fear of public spaces (agoraphobia)
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27
Q

How is agoraphobia treated?

A
  • SSRIs are first-line treatment
  • Behavioral therapy
  • As coexisting panic disorder is treated, agoraphobia usually resolves
  • When not associated with a panic disorder, agoraphobia is chronic and debilitating
28
Q

phobia vs. specific phobia vs. social phobia

A
  • Phobia - irrational fear that leads to avoidance of the feared object or situation
  • Specific phobia - strong, exaggerated fear of a specific object or situation
  • Social phobia - fear of social situations in which embarrassment can occur (social anxiety disorder)
29
Q

What are some common specific phobias?

A
  • Fear of animals
  • Fear of heights
  • Fear of blood or needles
  • Fear of illness or injury
  • Fear of death
  • Fear of flying
30
Q

What are some common social phobias?

A
  • Speaking in public
  • Eating in public
  • Using public restrooms
31
Q

What is the DSM-IV criteria for specific phobias?

A
  • Persistent excessive fear brought on by a specific situation or object
  • Exposure to the situation beings about an immediate anxiety response
  • Patient recognizes that the fear is excessive
  • The situation is avoided when possible or tolerated with intense anxiety
  • If person is under age 18, duration must be at least 6 months
32
Q

What is the DSM-IV criteria for social phobia?

A
  • Same as specific phobia
  • Except that the feared situation is related to social settings in which the patient might be embarrassed or humiliated in front of other people
33
Q

What are the most common mental disorders in the United States?

A

Phobias

34
Q

Phobias

  • ___% of the population
  • Specific vs. Social
  • Age of onset
A
  • 5-10% of the population (some report 25%)
  • Specific >> Social
  • Onset at early as 5 for blood, as old as 35 for situational fears
  • Average age for social phobias: mid-teens
35
Q

Men vs. Women for social & specific phobias

A
  • Specific phobia
    • Women 2x more than men
  • Social phobia
    • Women = men
36
Q

How do genetics play a role in the etiology of phobias?

A
  • Fear of seeing blood may be associated with an inherited, exaggerated vasovagal response
  • 1st degree relatives of patients w/ social phobias 3x more likely to develop the disorder
37
Q

How do behaviors play a role in the etiology of phobias?

A
  • Phobias may develop through association with traumatic events
  • Ex: people who were in a car accident may develop a specific phobia for driving
38
Q

How do neurochemical components play a role in the etiology of phobias?

A
  • Overproduction of adrenergic NTs may contribute to anxiety symptoms
  • Ex: performance anxiety is often successfully treated with beta blockers
39
Q

What is the treatment for specific phobias?

A
  • Pharmacological treatment NOT effective
  • Systemic desensitization
  • Supportive psychotherapy
  • Short course of benzos or beta blockers may be used to control autonomic symptoms
40
Q

What is systemic desensitization?

A

Gradually expose patient to feared object or situation while teaching relaxation and breathing techniques

41
Q

What is the treatment for social phobias?

A
  • SSRIs
    • Paroxetine (Paxil)
  • Beta blockers
  • Cognitive & behavioral therapies
42
Q

What is the definition of an obsession?

A

A recurrent or intrusive thought, feeling or idea

43
Q

What is the definition of a compulsion?

A

A conscious repetitive behavior linked to an obsession that, when performed, functions to relieve anxiety caused by the obsession

44
Q

What are the definitions of insight and ego-dystonic in the context of OCD?

A
  • Insight
    • Patients are generally aware of their problems and realize that their thoughts and behaviors are irrational
  • Ego-dystonic
    • Symptoms cause significant stress in their lives, patients with they could get rid of them
45
Q

What is the DSM-IV criteria for Obsessive-compulsive disorder?

A

Either obsessions or compulsions as defined below:

  • Obsessions
    • Recurrent & persistent intrusive thoughts or impulses that cause marked anxiety and are not simply excessive worries about real problems
    • Person attempts to suppress the thoughts
    • Person realizes thoughts are product of his or her own mind
  • Compulsions
    • Repetitive behaviors that the person feels driven to perform in response to an obsession
    • The behaviors are aimed at reducing distress, but there is no realistic link between the behavior and the distress
  • The person is aware that the obsessions and compulsions are unreasonable and excessive
  • The obsessions cause marked distress, are time consuming or significantly interfere w/ daily functioning
46
Q

What are the 4 common patterns of obsessions & compulsions?

A
  • Obsessions about contamination followed by excessive washing or compulsive avoidance of the feared contaminant
  • Obsessions of doubt (forgetting to turn off the stove, lock the door) followed by repeated checking to avoid potential danger
  • Obsessions about symmetry followed by compulsively slow performance of a task (eating, showering, etc)
  • Intrusive thoughts with no compulsion. Thoughts are often sexual or violent.
47
Q

OCD

  • Lifetime prevalence: ___%
  • Age of onset
  • Men vs. Women
A
  • Lifetime prevalence: 2-3%
  • Onset in early adulthood
  • Men = Women
  • Rate higher if 1st degree relatives w/ Tourette’s
48
Q

OCD is associated with…

A
  • Major depressive disorder
  • Eating disorders
  • Other anxiety disorders
  • OCD personality disorder
49
Q

What are the 3 common etiologies of OCD?

A
  • Neurochemical
    • Abnormal regulation of serotonin
  • Genetic
    • Rates higher in 1st degree relatives and monozygotic twins than the general population
  • Psychosocial
    • Onset triggered by a stressful life event in 60% of patients
50
Q

OCD

___% show significant improvement w/o treatment

___% have moderate improvement

___% remain significantly impaired or experience worsening of symptoms

A

30% show significant improvement w/o treatment

40-50% have moderate improvement

20-40% remain significantly impaired or experience worsening of symptoms

51
Q

What pharmacologic treatment is used for OCD?

A
  • SSRIs are the first line of treatment
    • Higher than normal doses may be required
  • TCAs (clomipramine)
52
Q

What behavioral treatments are used for OCD?

A
  • Best outcomes achieved with behavioral therapy and drugs are used simultaneously
  • Exposure & response prevention (ERP)
    • Prolonged exposure to the ritual-eliciting stimulus and prevention of receiving compulsion
  • Relaxation techniques employed to help the patient manage the anxiety that occurs when the compulsion is prevented
53
Q

What is considered “last resort” for treatment of OCD?

A

Electroconvulsive therapy (ECT)

Surgery (cingulotomy)

54
Q

What is the DSM-IV criteria for PTSD?

A
  • Having experienced or witnessed a traumatic event (war, rape, natural disaster). The event was potentially harmful or fatal, and the initial reaction was fear or horror
  • Persistent reexperiencing of the event (dreams, flashbacks, recurrent recollections)
  • Avoidance of stimuli associated with the trauma (avoiding location or difficulty recalling details)
  • Numbing of responsiveness (limited range of affect, feelings of detachment or estrangement from others, etc)
  • Persistent symptoms of increased arousal (difficulty sleeping, outbursts of anger, exaggerated startle response, difficulty concentrating)
  • Symptoms must be present for at least 1 month
55
Q

What are the comorbidities and prognosis of PTSD?

A
  • High incidence of associated substance abuse and depression
  • 1/2 patients remain symptom free after 3 months of treatment
56
Q

How is PTSD treated?

A
  • Pharmacological
    • TCAs - imipramine & doxepin
    • SSRIs, MAOIs
    • Anticonvulsants (for flashbacks & nightmares)
  • Other
    • Psychotherapy
    • Relaxation training
    • Support groups, family therapy
57
Q

What is the DSM-IV criteria for acute stress disorder?

A
  • Reserved for patients who experience a major traumatic event but have anxiety symptoms for only a short duration
  • Symptoms must occur w/i 1 month of the trauma
  • Last for a maximum of 1 month
  • Symptoms similar to PTSD
58
Q

PTSD vs. Acute Stress Disorder

A
  • PTSD
    • Event occurred at any time in the past
    • Symptoms last >1 month
  • Acute Stress Disorder
    • Event occurred <1 month ago
    • Symptoms last <1 month
  • Both are treated the same
59
Q

What is the DSM-IV criteria for generalized anxiety disorder?

A
  • Excessive anxiety & worry about daily events and activities for at least 6 months
  • It is difficult to control the worry
  • Must be associated with at least 3 of the following:
    • Restlessness
    • Fatigue
    • Difficulty concentrating
    • Irritability
    • Muscle tension
    • Sleep disturbance
60
Q

Generalized Anxiety Disorder

  • Lifetime prevalence: ___%
  • Women vs. Men
  • Age of onset
A
  • Lifetime prevalence: 45%
  • GAD is very common in the general population
  • Women 2x more likely to have GAD than men
  • Onset usually before age 20
  • Many patients report lifetime of “feeling anxious”
61
Q

What is the clinical presentation of a patient with GAD?

A
  • Most patients do not initially seek psychiatric help
  • Most seek out a specialist because of their somatic complaints that accompany this disorder, such as muscle tension or fatigue
62
Q

GAD

  • Etiology
  • Comorbidities
  • Prognosis
A
  • Biological & psychosocial
  • 50-90% have a coexisting mental disorder
    • Major depression
    • Social or specific phobia
    • Panic disorder
  • Chronic, with lifelong fluctuating symptoms in 50% of patients; the other half fully recover w/i several years of therapy
63
Q

How is GAD treated?

A
  • Pharm
    • Buspirone
    • Benzodiazepines (clonazepam, diazepam)
      • Taper ASAP due to risk of dependence
    • SSRIs
    • Venlafaxine (extended release)
  • Other
    • Behavioral therapy
    • Psychotherapy
64
Q

What is the DSM-IV criteria for adjustment disorders?

A
  • Development of emotional or behavioral symptoms w/i 3 mo after a stressful life event. These symptoms produce either:
    • Severe distress in excess of what would be expected after such an event
    • Significant impairment in daily functioning
  • The symptoms are not those of bereavement
  • Symptoms resolve w/i 6 mo after stressor has terminated
65
Q

What are the subtypes of adjustment disorders?

A

Coded based on predominance of either depressed mood, anxiety, disturbance of conduct (such as aggression) or combinations of the above

66
Q

Adjustment disorders

  • Prevalence
  • Females vs. Males
  • Age of onset
A
  • Very common
  • Females 2x more than males
  • Most frequently diagnosed in adolescents
67
Q

What is the etiology and prognosis of adjustment disorders?

A
  • Triggered by psychosocial factors
  • May be chronic if stressor is recurrent
  • Symptoms resolve w/i 6 mo of cessation of stressor (by definition)

Psychiatry (18 decks)

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