PHA 115: Anxiety Disorders
What is important for selective non-benzos that have GABA activity?
Eating will delay absorption by 1 hr
What is the best treatment for phobia?
Exposure Therapy
True or False: Panic disorder is never present in a patient with agorophobia
False
What is pyrophobia?
Fear of fire
What is germophobia?
Fear of germs
What are differential Psychiatric Diagnoses for Panic Disorder?
GAD, PTSD, OCD, Specific/Social phobias, Drug intoxication, Drug withdrawal
Who should you not prescribe Benzos to?
Pts with Hx of Addiction, delirium, and dementia
What is the onset and half life of SA benzos?
Rapid onset, short half life (1-12 hr)
What is an issue with SA benzos?
Rebound insomnia and anterograde amnesia are a problem with these medications
What is detected on an MSE with a patient suffering from panic disorder?
Rumination, difficulty speaking, and impaired memory
How do you treat social anxiety disorders?
SSRIs, Benzos, Venalfaxine (effexor), Buspirone (Buspar), MAOIs, BB, CBT, psychotherapy
What is the first line treatment for Panic Disorder?
SSRIs-Paroxitine (Paxil) with CBT
What is the epidemiology of panic disorder?
1-4%
Panic disorder commonly develops where in a persons lifetime?
25 YO
How many patients with GAD will have panic disorder as well?
25%
What is the ratio of women to men that have GAD?
2:1
What is the half life of LA benzos?
30-100 hours
What is the DSM-5 for panic disorder
4+: palpitations, sweating, trembling/shaking, SOB, chocking, CP/discomfort, nausea, GI, dizziness, lightheadedness, faint, chills, heat sensations, paresthesias, derealization, depersonalization ,fear of losing control, fear of dying with 1 month+ worry off other attacks, maladaptive behavior bc of attacks not associated with substance/medical condition not associated with other mental disorder
What is the peak age of onset for social anxiety disorder?
5-35 YO
What is the peak age for animal, environmental, and blood injection injury type phobias?
5-9 YO
How often does GAD coexist with another mental disorder?
50%
What is the DSM-5 for GAD?
A.Excessive anxiety and worry occurring more days than not for at least 6 months, about several events or activities. B.The individual finds it difficult to control the worry. C.The anxiety and worry are associated with 3 or more of the following: 1.Restlessness or feeling keyed up or on edge. 2.Being easily fatigued. 3.Difficulty concentrating or mind going blank. 4.Irritability. 5.Muscle tension. 6.Sleep disturbances. D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance. F. The disturbance is not better explained by the symptoms of another mental disorder.
What is the DSM-5 for Specific Phobias?
A.Marked fear or anxiety about a specific object or situation. B.The phobia object or situation almost always provokes immediate fear or anxiety. C.The phobic object or situation is actively avoided or endured with intense fear or anxiety. D.The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E.The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more. F.The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G.The disturbance is not better explained by the symptoms of another mental disorder; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations.
What is the DSM-5 for social anxiety disorder?
A.Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. B.The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated. C.The social situations almost always provoke fear or anxiety. D.The social situations are actively avoided or endured with intense fear or anxiety. E.The fear of anxiety is out of proportion to the actual threat posed by the social situations and to the sociocultural contex.t F.The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more. G.The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H.The disturbance is not better explained by the symptoms of another mental disorder. I.If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
How prevalent are phobias?
Affecting 5-10% of US population
What are common psychiatric comorbidities with panic disorder?
Agoraphobia, MDD, social anxiety disorder, generalized anxiety disorder, alcohol/substance abuse disorder, PTSD, OCD
What are long acting benzos often used for?
Alcohol detox
What is panic disorder?
An acute intense attack of anxiety accompanied by the feelings of impending doom characterized by discrete periods of intense fear
What TCAs are recommended for panic disorder?
Anafranil
What TCAs are recommended for agoraphobia?
Anafranil, Tofranil
What are the specificities for Specific phobia?
Animal Type, Natural Environment, Blood-injection-injury type, situational type, other (choking, loud sounds, costume characters)
____________ disorders make up the most common group of psych disorders?
Anxiety
What are benzodiazapines used for?
Anxiolytic, antiasmodic, anticonvulsant, sedative-hypnotic
What are differential Medical Diagnoses for Panic Disorder?
Asthma, PE, MI, Hypoglycemia, hyperthyroidism, phenochromocytoma, CNS neoplasm, seizure disorder, vestibular dysfunction
What are other treatments for phobias?
Behavior, insight oriented, virtual, supportive, family therapies or hypnosis Beta-blockers (propranolol) and benzos
What is an immediate relief for panic attacks?
Benzodiazepines-Xanax, Klonopin, Ativan
What causes substance induced anxiety?
Caffeine, Cocaine, Amphetamine
Why are LA benzos not recommended for sleep?
Cause sedation into the next day
What are peripheral manifestations of anxiety?
Diarrhea, dizziness, light headedness, hyperreflexia, palpitations, pupil mydriasis, hyperhidrosis, restlessness, syncope, tachycardia, tremors, tingling in extremities, GI issues, urinary hesitancy, urinary frequency, urinary urgency
What are long Acting benzos?
Diazepam (Valium) Chlordiazepoxide (Librium)
What are adverse reactions for non-benzo GABA meds?
Drowsiness, Ataxia, Dizziness, Mild cognitive deficits, Antegrade amnesia, tolerance and dependence, confused speech, dyspnea, hyporeflexia
What are other anxiety disorders?
Due to medical conditions, substance induced, mixed anxiety/depressive disorders
What medical conditions are known to cause anxiety?
Hyper/Hypothyroidism, Hypoparathyroidism, Vitamin B12 deficiency, Pheochromocytoma (hormone secreting tumor in adrenal glands), Hypoglycemia
Intermediate benzos are effective _________, but can have residual effects the next morning
Hypnotics
What are selective non-benzos used for?
Insomnia
What benzos have the quickest onset via IM route?
Lorazepam (Ativan) and Midazolam (Versed)
What are intermediate acting Benzos?
Lorazepam (Ativan), Clonazepam (Klonopin), Alprazolam (Xanax),Temazepam (Restoril)
What are differential diagnoses for agoraphobia?
MDD, Schizophrenia, Paranoid personality disorder, dependent personality disorder, and medical conditions that cause anxiety or depresion
What is the DSM-5 for Agorophobia?
Marked anxiety of 2 or more: 1.Using public transportation 2.Being in open spaces 3.Being in enclosed spaces 4.Standing in line or being in a crowd 5.Being outside of the home alone Avoids going out for panic situation provokes anxiety Fix: D.The agoraphobic situation are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E.The fear or anxiety is out of proportion to the actual danger. F.Typically lasting 6 months or more. G.Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H.If another medical condition is present, the fear, anxiety, or avoidance is excessive. I.Can not be explained in another mental disorder.
What is different about benzos vs non-benzos?
Non-benzos have selective sedative effects without muscle relaxant and anticonvulsive effects
What are clinical features of agoraphobia?
Patients avoid situations in which it would be difficult to obtain help may need accompaniment may refuse to leave home
How do treat agorophobia?
Pharmacotherapy: Benzo, SSRI, TCA Psychotherapy: supportive, insight-oriented, behavior, cognitive, and virtual
What MAOIs are recommended for panic disorder?
Phenelzine (nardil)
What SSRI is recommended for agoraphobia?
Prozac
What is the treatments recommended for GAD?
Psychotherapy, benzos, SSRIs, Buspirone (Buspar), Venlafaxine (effexor), TCAs, BB
Where does agoraphobia stem from?
Secondary to traumatic event
What are differential diagnoses for phobias?
Substance use, CNS tumor, Cereb Vascular disease, schizo, panic disorder, agoraphobia, avoidant personality disorder, OCD, hypochondriasis, social phobia, and paranoid personality disorder
What are physical signs of a panic attack?
Tachycardia, hyperventillation, palpitations, syncope, dyspnea, and sweating
Which best describes agoraphobia? a) patients avoid difficult situations in which it would be difficult to get help b) fear of spiders c) PTSD following a tour with the army d) Fear of grass and things outside
a
What is xenophobia?
fear of foreigners
What is Acrophobia?
fear of heights
What is hydrophobia?
fear of water
What is agorphobia?
fear or anxiety regarding places from which escape might be difficult; often follows a traumatic event
What are differentials for social anxiety disorder?
fear, normal shyness, agoraphobia, panic disorder, avoidant personality disorder, major depressive disorder, schizoid personality disorder
True or False: Benzos are lipid soluble
True
True or False: Phobias are more common among women than men
True
True or False: Women are 2-3 times more affected with panic disorder than men.
True
True or False: anxiety has life saving qualities
True
True or False: those with recent divorce or separation have a higher likelihood of experiencing panic disorder.
True
What are other additive medications that can be used when treating panic disorder?
Venalfaxine (Effexor) and Buspirone (Buspar)
What populations is agorophobia more common in?
Women and Elderly
What benzodiazepines are recommended for agoraphobia?
Xanax and Ativan
What are selective non-benzos that have GABA activity?
Zolpidem (Ambien), Zaleplon (Sonata), and Eszopiclone (Lunesta)
What are the clinical features of phobias?
arousal of severe anxiety when exposed to situation/objects or when patients anticipate exposure Results in panic attack Pt avoids stimulus
What is somatic anxiety?
bodily sensations associated with nervousness like muscle tension, sweating, and nausea
What is psychic anxiety?
cognitive and emotional part of anxiety
What are the clinical features of panic disorder?
completely spontaneous, patients dont have a source to the fear, episodes of confusion and difficulty concentrating, anticipatory anxiety, concerns of death
Prevalence of anxiety ___________ with higher socioeconimic status.
decreases
What is needed to diagnose a specific phobia?
development of intense anxiety, even to the point of panic, when exposed to the feared object.
What benzos have the quickest onset via oral route?
diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), triazolam (Halcion), and estazolam (ProSom)
What is generalized anxiety disorder?
difficult to control, Excessive worry and anxiety that is out of proportion to the impact of the event or circumstance that is the focus of the worry
Normal anxiety is __________ occompanied by ANS symptoms
diffuse, unpleasant, vague apprehension
What is pathological anxiety?
disabling and maladaptive
What is a specific phobia?
excessive fear of a specific object, circumstance, or situation
What is Ailurophobia?
fear of cats
What is claustrophobia?
fear of closed spaces
What is Cynophobia?
fear of dogs
What do short acting benzos used for?
hypnotics to induce sleep.
What is the onset of generalized anxiety disorder?
late adolescence/early adulthood; can be seen later in adulthood
What is the peak age for situational type phobias?
mid 20s-like agoraphobia
All benzos are absorbed after _______________ and reach peak within _______________.
oral admin; 30 min to 2 hours
What are comorbidities with social anxiety disorder?
other anxiety disorders, mood disorders, substance-related disorders, and bulimia nervosa
If a patient has liver dysfunction what are the recommended benzos?
oxazepam, temazepam or lorazepam
What are differentials for GAD?
panic disorder, OCD, PTSD, phobias, neuro/endo/metabolic/med related disorders
What would distinguish a patient from having GAD versus mixed anxiety-depressive disorder?
presence of subsyndromal symptoms of both anxiety and depression and the presence of some autonomic symptoms
What is social anxiety disorder?
social phobia, fear of social situations, fear of embarrassing themselves in social settings.
Usually the first panic attack is __________________, and occasionally follows a simulus, lasting _______________________.
spontaneous; min to hours
How long does it take to establish a steady state with long acting benzos?
up to 2 weeks
When does the concern of social anxiety/self-consciousness become social anxiety disorder?
when the anxiety either prevents an individual from participating in desired activities or causes marked distress during activities
What are short acting Benzos?
•Oxazepam (Serax) •Triazolam (Halcyon) •Midazolam (Versed)
