Psychiatry/Behavior Science Blueprint PANCE/PANRE Review

Anxiety Disorders

Generalized Anxiety Disorder (GAD) -Generalized Anxiety Disorder- -Generalized Anxiety Disorder (GAD) is a disorder that presents with excessive worrying that is hard to control, that causes impairment or significant distress, and occurs on most days for at least six months -Other symptoms of GAD include apprehension, increased fatigue, irritability, and muscle tension -Treatment modalities for GAD include: cognitive behavior therapy and SSRI's.

Generalized Anxiety Disorder (GAD) -GAD is associated with increased rates of substance of abuse, post traumatic stress disorder, and obsessive compulsive disorder -Genetic factors appear to predispose patients to the development of GAD -Most patients with GAD present with symptoms other than worrying. Many complain of poor sleep, fatigue, difficulty relaxing, and motor tension. -GAD is considered to be a potential chronic illness but may vary in severity over time -The generalized anxiety disorder 7 inter scale (GAD-7) is used to screen for GAD in primary care

Generalized Anxiety Disorder (GAD) -DSM 5 Criteria for Generalized Anxiety Disorder (GAD) requires the presence of: 1. Excessive worry and anxiety occurring on most days for at least 6 months about a number of events and activities. 2. The patient finds it difficult to control the worry. 3. The anxiety and worry are associated with 3 of the following symptoms: -Restlessness or feeling on edge -Being easily fatigued -Difficulty concentrating -Irritability -Muscle Tension -Sleep Disturbance

Generalized Anxiety Disorder (GAD) 4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social or occupation areas of functioning 5. The disturbance is not attributable to the physiological effects of drugs or alcohol 6. The disturbance is not better explained by another mental disorder.

Generalized Anxiety Disorder (GAD) -First line medications are SSRI's and SNRI's in treatment of GAD -The following SSRI's have been shown to be efficacious: Paxil, Zoloft, Celexa, and Lexapro -SNRI's such as Effexor and Cymbalta have been shown to be effective. -Second line medications are tricyclic antidepressants, benzodiazepines, and some anti-convulsants -Other alternative medications have include certain anti-psychotic medications and Atarax

Panic Disorder -Panic Disorder and panic attacks are discrete episodes of intense worry that begins rapidly and lasts several minutes to an hour. -Patients with panic attacks usually present with somatic symptoms such as chest pain and/or shortness of breath. -With Panic Disorder, patients experience recurrent unexpected panic attacks, and one month or more of either worrying about future attacks, or a significant maladaptive change in behavior related to the attacks

Panic Disorder -Somatic features of panic attacks can include chest pain, tachycardia, headaches, dizziness, faintness, pseudo seizures, and epigastric abdominal pain -Panic disorder has been shown to have a high prevalence among patients with bipolar disorder and alcohol abuse

Panic Disorders -Panic Attack is defined by the DSM 5 as an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during the time 4 or more of the following symptoms occur: 1. Palpitations or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensation of shortness of breath or smothering 5. Feeling of choking

6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded or faint 9. Chills or heat sensations 10. Paresthesias 11. Derealization or depersonalization 12. The fear of losing control 13. Fear of dying

Panic Disorder -Panic Disorder is defined by the DSM 5 as 1. Recurrent unexpected panic attacks 2. At least one of the attacks has been followed by a month or more of one or both of the following: -Persistent worry about panic attacks or the consequences -A significant maladaptive change in behavior related to the attacks 3. The disturbance is not related to the physiologic effects of a substance (medication or illicit drugs) or other medical condition such as hyperthyroidism or cardiopulmonary problems. 4. The disturbance is not better explained by another mental disorder

Panic Disorder -Differential diagnosis of panic disorder includes: somatic symptom disorder, illness anxiety disorder, other mental disorders, stimulant use, and general medical conditions -Several classes of medications have been shown to be effective in panic disorder including: SSRI's, SNRI's tricyclic antidepressants, monoamine oxidase inhibitors, and benzodiazepines. -SSRI's are generally preferred because of their side effect profile and advance reactions with overdosing. -Benzodiazepines have abuse potential and have physiologic dependence. Should be use on as needed basis initially until stable or SSRI. -Psychotherapy may also be helpful

Phobias -A phobia is a anxiety disorder characterized by clinically significant fear of a situation or object that leads to an avoidance of a behavior. -There are 5 main specifiers of specific phobias according to DSM 5 that are based on the nature of the phobic stimulus 1. Animals (Spiders, Insects, and Dogs) 2. Natural Environment (Height, Storms, Water) 3. Blood Injection-Injury (Needles or invasive medical procedures) 4. Situational (Airplanes, Elevators and Closed Spaces) 5. Others (Situations that lead to choking or vomiting, loud sounds, or costume characters)

Phobias -Common comorbidities are other anxiety disorders and mood disorders with alcohol dependence -The development of a specific photophobia is influence by a complex interaction of biologic, psychological and social/environmental disorders -Differential diagnosis of phobias include agoraphobia, panic disorder, social anxiety disorder, post traumatic stress disorder, separation anxiety disorder, illness anxiety disorder, and eating disorders

Phobias -The DSM 5 Criteria for Specific Phobia are below: 1. Marked fear about an specific object or situation 2. The phobic object or situation always provokes immediate fear or anxiety 3. The phobic object or situation is actively avoided or endured with an intense fear or anxiety 4. The fear of the anxiety is out of proportion to the actual danger posed by specific object 5. The fear, anxiety or avoidance is typically lasting for 6 months or more 6. The fear caters clinically significant distress or impairment in social, occupational, or other areas of functioning 7. The disturbance is not better explained by the symptoms of another mental disorder including fear and anxiety and avoidance of social situations

Phobias -First line treatment for specific therapy is cognitive behavior therapy that includes exposure treatment -Pharmacotherapy such as benzodiazepines and SSRI's have a limited role of specific phobia but can be used as an adjunct

Post Traumatic Stress Disorder (PTSD) -Post Traumatic Stress Disorder (PTSD) is a complex of somatic, cognitive, affective, and behavior effect of psychological trauma. -PTSD is characterized by intrusive thoughts, nightmares, and flashbacks of past traumatic events, avoidance of reminders of trauma, hyper-vigilance, and sleep disturbance -Many different traumas result in PTSD. Common traumas area as follows: military combat, violent personal assault, natural and man made disasters, severe car accidents, rape, incest, childhood sexual abuse, diagnosis of life threatening illness, severe physical injury, and hospitalization in an intensive care unit

Post Traumatic Stress Disorder (PTSD) -Most patients who experience trauma react to some degree when experience reminders of trauma. Most patients compensate for such intense arousal by attempting to avoid experiences to elicit symptoms.

Post Traumatic Stress Disorder -DSM-5 Criteria for PTSD over the age of six are as follows: 1. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: -Directly experiencing the traumatic event -Witness in person of the event as it occurred to others -Learning that the traumatic event occurred to close family member or friend. Must be violent and accidental. 2. Presence of one of the following intrusion symptoms associated with the traumatic event beginning after the traumatic event occurred -Recurrent, involuntary, and intrusive distressing memories of the traumatic event -Recurrent distressing dreams in which the content and/or affect the dream are related to the traumatic event -Dissociative reactions in which the individual feels or acts as if the traumatic event were recurring

-Intense or prolonged psychosocial distress at exposure to internal or external cures that symbolize or resemble an aspect of the traumatic event -Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic events 3. Persistent avoidance of stimuli associated with traumatic event, beginning after the traumatic event occurred, by one or both of the following: -Avoidance of or efforts to avoid distressing memories, thoughts, or feeling about or closely associated with the traumatic event -Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about closely associated with the traumatic event

4. Negative alterations in cognition and mood associated with the traumatic event beginning or worsening after the traumatic event occurred as evidenced by at least 2 of the following: -Inability to remember an important aspect of the traumatic event -Persistent and exaggerated negative beliefs or expectations about oneself, others or the world -Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself/herself or others -Persistent negative emotional state -Markedly diminished interest or participations in significant activities -Feeling of detachment or estrangement from others -Persistent inability to experience positive emotions

Post Traumatic Stress Disorder 5. Marked alterations in arousal and reactivity associated with traumatic event, beginning or worsening after the traumatic event occurred as evidence by two or more of the following: -Irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects -Reckless or self destructive behavior -Hyper-vigilance -Exaggerated startle response -Problems with concentration -Sleep disturbance 6. Duration of the disturbance is more than 1 month

Post Traumatic Stress Disorder (PTSD) 7. The disturbance causes clinically significant distress or impairment in social, occupational, or other areas of functioning 8. The disturbance is not attributable to physiologic effects of a substance or another medical condition -Treatment of PTSD includes psychotherapy and pharmacotherapy. They often are combined and refractory to treatment. -SSRI's are first line medications for PTSD -TCA's, MAOi's atypical antidepressants, and atypical antipsychotics do not help PTSD

Post Traumatic Stress Disorder -Alpha adrenergic receptor blockers have been shown to reduce nightmares and improve sleep -Benzodiazepines are used to treat the symptoms of anxiety and increased arousal -Medications should be continued for at least 6 months to 12 months