Anxiety Disorder

PTSD types of traumas

war related activity assault or rape natural disaster (hurricane, flood and earthquake) witnessing serious violence accident destruction of home or community child or domestic abuse

Stages: Management of Anxiety Disorder

Initiation/acute (12 weeks): initiate psychotherapies. If necessary, initiate SSRIs. Benzodiazepines may be useful for short-term. stabilization: After 12-18months, Discontination of med can be attempted with close follow up Maintenance: Respond to relapses with rapid re-intiation of tx.

Benzodiazepines duration of action

Longer Half-lives: Advantages are less frequet dosing, less variation in plasma concentration, less severe withdrawal. Disadvantages drug accumulation, daytime sedation, and daytime psychomotor impairment. shorter halflives: Advantages:no drug accumulation and less daytime sedation. Disadvantages are more frequent dosing, earlier and more severe withdrawal syndromes, and rebound insomnia.

Four Levels of Anxiety

MILD-alert ad preceptual field is increased. Increased motivation and learning MODERATE- focuses only on immediate concern perceptual field narrows SEVERE-Focuses on specific detail only and unaware of what is in surroundings. Tunnel Vision PANIC-loss of control, dissociation,shock,dread and terror

Benzodiazpines are used for acute anxiety and agitation

MOA: potentate the fx of GABA, inhibitng neurotransmission in limbic system and cortex. anti anxiety fx in 30-60mins use lowes possible effective dose for shortest possible period of time

PTSD epidemiology

Male to female, 1:1 prevalence 16% all ages; can show up months/years later etiology=catastrophe related prognosis=chronic and episodic symptoms must last more than one month.

OCD additions DSM-5

OC hoarding disorder OC animal hoarding disorder excoriation (skin picking) childhood changes to be covered later in the semester (separation anxiety)

Phobia

irrational dread of and compelling desir toa void a specific object situation or activity charactrized by extreme anxiety and panic when exposed to the specific object and situation

Relationship w/neuro function

locus coeruleus (NE porduction excess) amgydala and hippocampus (limbic system)-center for emotion and memory

ANS (sympathetic nervous system activation)

peripheral flight/figh noradrenergic NE symtpoms include increased HR, RR, skin sweat, tremor and pupil dilation

Hoarding Disorder

persistent difficulty discarding or parting with possessions, regardless of their actual value difficulty is d/t perceived need to save items and due to distress associated with discarding them to0 difficult to discard results in accumulation of possessions that congest and clutter active living areas and compromise their intented use causes clinically significant distress or impairment in social,occupation or other areas of functioning

PTSD

psychological and physiological response to any extreme stressor

Panic Disorder

recurrent unexpected panic attacks and at least one of the attacks has been followed by at least 1 month of one or more of the following 1.persistent concernabout having additional attacks 2. worry about the implications of the attack or its consequences 3. a significant change in behavior r/t to attacks

AD epidemiology

30% of the US pop has an AD and it's rsiing it is thought that 17 and 18% of Iran and Afghanistan vets have PTSD GAD or depression. this represents 4 x the pop Anxiety disorders are the most common psychiatric disorder in children and teens

Dx criteria for PTSD

An acute acquired mental disorder that can occur soon after trauma or can have a delayed onset of more than 6 months after trauma referred to as acutre stress disorder when symptomatic during te first 4 weeks after trauma may not necessarily progress to PTSD the associated trauma must be an event that is outside the range of normal human experience and would be seriously disturbing to anyone helplessness and horror

Treatment of OCD

Behavior modification CBT meds (SSRI) psychotherapy

Medications to decrease NE production at locus coereleus

Clonidine (alpha 2 agonist)

Management of Benzodiazepines

Common side fx: drowsiness, fatigue, depression,dizziness, ataxia, slurred speech, weakness, forgetfulness Risk for injury (falls,accidents) especially in elderly: avoid alcohol or other CNS depressants otc drugs may potentiate actions. driving should be avoided until tolerance develops Deficient knowledge pt teach-do not use to treat minor stresses of everyday life. do not discontiune abruptly. take w/food if GI upset does occur. report symptoms of urinary incontinence. discontinue during pregancny and breast feeding

Adverse fx associated with SSRI

Common: Anxiety, agitation, akathisia, insomnia, nausea, diarrhea, sexual dysfunction Serotonin syndrome (excess serotonin) Serotonin Discontinuation syndrome Most side fx will pass. May need to add Bupropion for sexual dysfunction or switch to another agent.

Criteria for GAD

Excessive anxiety and worry on more days than not for at least 6 months about a number of evtns or activiies (school and work) the worry is difficult to control ans has at least three of these feeling resltess keyed up or on edge easily fatigued difficulty concentrating mind going blank muscle tension irritabilty sleep disturbance

Symptoms:PTSD

Flashbacks-intrusive reexperiencing of event Generalized anxiety-sympathetic nervous system stays aroused emotional numbness,avoidance of places or images that remind the person of the traumatic event (no more pleasure) nightmares, hypervigilance, increased startle angry outbursts, irritability and aggression

SSRI

Fluoxetine (Prozac,Sarafem): 20-80mg/day for depression and anxiety disorders; 60-80mg/day fluvoxamine (luvox) 100-300mg/day for OCD; 100-200mg/day for depression. paroxetine (paxil)-20-60mg day Setraline (zoloft)- 50-200mg/day Citalopram (Celexa)-20-60mg/day Escitalopram (lexapro) 10-20mg/day

Anxiety Disorders

Generalized Anxiety Disorder Panic Disorder Specific PHobias obsessive compulsive disorder acute stress disorder post traumatic stress disorder

Social Phobia (Epidemiology)

High familial incidence onset inteensoa condition is chronic and thoigh severity may fluctuate w/stress and life demands

Excoriation (Skin Picking)

Recurrent skin picking resulting in lesions repeated attempts to stop or decrease behavior causes cliinically significant distress or impairment in social, occupation or other areas of functioning

Autonomic Hyperactivity (GAD)

SOB, smothering feeling tachycardia cold clammy hands dry mouth, difficulty swallowing, lump inthroat nausea,diarrhea,abdominal pain chills or hot flashes

Panic Attack

a discreet episode of intense fear/discomfort with at least 4 of the following symptoms which develop abruptly and reach a peak within 10 minutes 1. palpitations, pounding heart or increased HR 2.Sweating 3. Trembling or shaking 4. Shortness of breath and or choking 5. Chest pain or discomfort 6. Nausea or abdominal distress 7. Feeling dizzy,unsteady, lightheaded or faint 8. de-realization or depersonalization 9. fear of losing conrol or going crazy 10. Paresthesia (tingling, tickling, burning skin) 11. chills or hot flashes

Serotonin Discontinuation syndrome

agitation,nausea, disequilibrium and dysphoria. Taper is advised

Phobia categories

animal type (includes insects) natural environment type (storms, heights and water) blood injection type(seeing blood, injection o other invasive procedures) Situational type (public tranportation, tunnels, bridges, elevators, flying driving or enclosed places) other tpes (fear of situations that might lead to choking, vomiting, contracting an illness, avoidance of loud sounds or costumed characters ex. clowns)

Medications that act directly at the level of the amygdala

antidepressants-SSRIs increase serotonin. Tricyclic (serotonin and NE reuptake inhibition) Benzodiazepines-GABA agonist

Discontinuation of Benzodiazepines

b/c risk of physical dependence long term use should be carefully monitored. the drugs should be tapered at discontinuation discontinuation syndromes depend on the length of time on drug, dosage taken, rate of taper and half life. the higher the dose the shorter the half life,the moe severe the withdrawal symptoms. Withdrawal symptoms include: anxiety, nervousness, diaphoresis, restlessness, irritability, fatigue, light headedness, tremor, insomnia, weakness risk for seizures and death

Tx PTSD

cbt-trauma focused SSRIs, anti-anxiet meds family support and education watch closely for heavy drinking and drug abuse watch closely major depression and suicide risks

SSRI indications

depression, OCD, panic disorder, social anxiety disorder, PTSDm eating disorder, borderline personality disorder. pharmacokinetics: therapeutic fx may take 3-6weeks for depression and 12-16weeks for OCD observe for activation of unknown or known bipolar disorder and or suicidal ideation. inform parents and guardian of this risk so they can help observe child or adolescent patterns

Serotonin Syndrome (excess serotonin)

diarrhea, restlessness, extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium,coma and possible death

Agoraphobia

fear of going out of the house alone,being alone, being in a crowd, standing in line or traveling on buses or trains pervasive avoidance of these type of situations anticipatory anxiety inhibits activity some become unable to go out of their homes

Social Phobia

fear of scrutiny and judgement worry about looking foolish or being embarassed fear of being with ppl performance anxiety associated features often include hypersensitivity to criticism, negative evaluation or rejection. Difficulty being assertive, low self esteem, underachievement less friendships and social support

Phobia epidemiology

higher incidence in women 2:1 onset generally in childhood or early adolescence high familial incidence fear of public speaking is the most prevalent phobia persons lifestyle often is altered to avoid exposure to the situation or object treatable with desensitization therapy and CBT

Generalized Anxiety Disorder

higher incidence in women 2:1. Onset in childhood though commonly dx in adulthoot etiology: genetic, biochemical and learned prognosis: chornic but manageable lifetime prevalence rate 5% and 25% of those with GAD have co morbid dx

AD Similar presentation

hyperthyroidism cardiac respiratory compromise drug/alcohol intoxication or withdrawal

HPA Axis activation

hypothalamus secretes CRF.CRF binds to receptors on pituitary to release ACTH. ACTH stimulates synthesis and release of glucocorticoids at the adrenal cortex.

Epidemiology of PD

incidence in women 2-3times higher onset most common b/w late adolescene and mid-thirties 3-5% lifetime prevalance 10-30% rate in general medical settings etiology and genetic

Benzodiazepines

long acting benzodiazepines treat anxiety disorders, seizures, ETOH withdrawal: Clonazepam (klonopin)18-50hrs. Diazepam (Valium) 20-80hrs Intermediate acting benzodiazepines commonly treat anxiety symptoms: Alprazolam (Xanax)- 6-27hrs. Lorazepam (Ativan) 10-20hrs short acting benzodiapeines treat sleep onset insomnia and may be used for preoperative anesthesia (triazolam-halcion) 1.5-3hrs

PD tx

medications-anxiolytics short term. SSRI long term supportive psychotherapy (1 on 1) using deep breathing using self talk cognitive bevhaior training CBT

Obsessive Compulsive disorder

obsessions persistent thoughts ideas, images that are intrusive, inappropriate and cause marked distress compulsion-reptitive behavior or mental acts designed to prevent or reduce anxiety

Physical Symptoms (Social Phobia)

often expereiences the folowing when exposed to the situation: blushing stammergin sweating stomach upset racing heart complete panic.

Dx criteria (OCD)

recurrent, persisten, inappropriate thoughts that result in anxiety or distress attempts to neutralize with some other thought or action or suppress/ignore symptoms recognizes that the thoughts their own, unreasonable, excessive and likely to conceal. rigid adherence to rules, behavior patterns that decrease anxiety obsession or compulsions consumer greater than 1 hr/day

Neurotransmitter involved in inhibition response

serotonin g-aminobutyric acid (GABA)

Non-benzo management of anxiety (may be indicated if abuse potential is present)

serotonin partial agonist-Buspirone (Buspar) usual dose: 20-30mg day. therapeutic effects may take 4 weeks. no physiological dependence beta blockers- propranolol (inderal) useful for performance anxiety where tremor might be a problem. 10-20mg bid or tid

OCD epidemiology

strikes men and women equally (higher in boys during childhood) onset at any age but usually as adolescent (males) and early adulthood (females) 30% onset in children etiology-genes, serotonin dysfunction comorbid with depression and other anxiety disorder

SSRIS are first line tx for chronic anxiety

symptoms association with panic disorder, phobias, social anxiety disorder and ocd (therapeutic effects may take 3-4weeks)