Anxiety

Question 1

When is anxiety pathological?

1. Autonomy
2. Intensity
3. Duration
4. Behavior

Answer 1

1. when the person starts having symptoms w/o obvious reasons
2. when the degree of response is out of proportion or causes dysfunction and/or is unbearable
3. when the response lasts longer than expected
4. when the coping mechanisms are not enough and/or patient displays other behaviors that make them dysfunctional

Question 2

General Stats

1. Prevalence of Any anxiety (1 year and lifetime)
2. Prevalence of Simple Phobia (1 year and lifetime)
3. Prevalence of Social Phobia (1 year and lifetime)
4. Prevalence of GAD (1 year and lifetime)

Answer 2

1. about 12%, about 20%
2. about 8% about 12%
3. about 2%, about 5%
4. about 3%, about 5%

Question 3

Comorbidity of Anxiety Disorders

1. What 4 disorders are seen?

Answer 3

1. Depression
2. Personality traits/disorders
3. Substance abuse, pts alleviate symptoms by drinking
4. other anxiety disorder (pts often meet full criteria for other anx. disorders)

Question 4

Genetics of Anxiety Disorders: Panic Disorder

1. twins
2. family members?
3. CO2 challenge

Answer 4

1. higher incidence in MZ vs DZ;
2. higher risk in family members
3. unaffected relatives more likely to have panic attacks with CO2 challenge

Question 5

Genetics of OCD

1. twins
2. risk in 1st degree relatives

Answer 5

1. MZ>DZ

2. approximately 5x increased risk in 1st degree relatives

Question 6

Genetics of GAD

1. twins
2. family risk?

Answer 6

1. results are mixed;

2. may be increased

Question 7

Genetics of PTSD, Social Phobia, Simple Phobias

Answer 7

some genetic contribution, but not well studied

Question 8

Learning and Cognitive Theories of Anxiety

Answer 8

Panic states are learned responses to fearful situations
OR
normal thoughts are interpreted by the patient as dangerous or worrisome, thus increasing anxiety

Question 9

Anxiety Differential Diagnosis (7)

Answer 9

1. Endocrine Dysfunction
2. Drug-related
3. Cardiovascular/respiratory
4. Metabolic Abnormalities
5. Neurological disorders
6. Psychiatric disorders
7. Other (pheochromocytoma, carcinoid)

Question 10

Panic Disorder

1. Describe
2. What follows? for how long?
3. What else may be present?
4. What can it not be?

Answer 10

1. recurrent, unexpected panic attacks
2. at least 1 attack is followed by 1 month of
   - persistent concern about having a subsequent attack
   - worry about implications of the attack or its consequences
   - significant change in behavior related to the attack
3. +/- agoraphobia
4. can’t be better explained by another mental disorder/general medical condition

Question 11

Panic Attack

1. Criteria of acute attack

Answer 11

1. Discrete period of intense fear, discomfort, with at least 4 of the following symptoms, which develop abruptly and reach a peak w/in 10 minutes
   - palpitations, pounding of heart,
   - sweating
   - trembling/shaking
   - sensations of SOB or smothering
   - feeling of choking
   - chest pain/discomfort
   - nausea or abdominal diistress
   - feeling dizzy unsteady, lightheaded or fait
   - derealization, depersonalization
   - fear of losing control/going crazy
   - fear of dying
   - paresthesias
   - chills or hot flushes

Question 12

Agoraphobia

1. Describe
2. What results?
3. What % of panic disorder pts meet agoraphobia criteria?

Answer 12

1. anxiety about being in places or situations from which escape may be difficult or embarassing or in which help may not be available in the event of a panic attack or panic-like symptoms
2. pt avoids situations (restricts travel) or endures situations with marked distress or with anxiety about having a panic attack; may require presence of a companion
3. 1/4

Question 13

Panic Disorder

1. age of onset
2. what do majority of pts have as comorbid illness?
3. course of disease
4. What can remain after panic attacks/symptoms remit?

Answer 13

1. late teens-20s
2. another Axis I psychiatric diagnosis
3. varies: 1/3 recover; 1/2 have mild impairment, <20% have major impariment; may wax/wane over time
4. anticipatory anxiety

Question 14

Panic Disorder:

1. What is an indicator of poor prognosis?
2. Higher risk of what?
3. Higher risk of what in depressed pt?

Answer 14

1. severity of initial panic, agoraphobic symptoms, duration of illness prior to treatment, comorbid depression, history of parental separation, high interpersonal sensitivity, personality disorders, being single are predictors of poorer prognosis
2. stroke, CV death;
3. increased suicide risk

Question 15

Panic Disorder Biology

1. What NTs are involved? (3)
2. May be caused by an abnormally sensitive what? where?
3. Higher serum conc of what has been linked to developing PD?

Answer 15

1. GABA, NE, Serotonin
2. fear network; amygdala
3. lead

Question 16

Panic Disorder Treatment

1. Pharmacotherapy
2. What else?
3. What doesn’t tend to work?

Answer 16

1. SSRIs, SNRIs, Benzodiazepines *short term
2. Cognitive Behavioral Therapy (changing what person thinks and changing what a person does to improve how he/she feels)
3. Psychodynamic approaches

Question 17

Generalized Anxiety Disorder

1. Describe
2. Criteria/Symptoms
3. What does it cause?
4. What can it not be due to?

Answer 17

1. excessive anxiety and worry occuring more days than not for at least 6 months, about a number of events
2. 3 of the following:
   - restlessness or feeling keyed up or on edge
   - easily fatigued
   - difficulty concentrating or mind going blank
   - irritability
   - muscle tension
   - sleep disturbance
3. significant distres or impairment in social, occupational, or other important area of functioning
4. general medical condition, mood disorder, or substance

Question 18

GAD

1. onset
2. course
3. comorbidity rate
4. increased risk of what?
5. What does not induce panic attacks in GAD pts?

Answer 18

1. early, often in childhood
2. chronic; less waxing and waning; does not seem to reced in late life; may worsen
3. 90% comorbid with other psychiatric disorders
4. Cardiac events
5. CO2 challenge

Question 19

Treatment of GAD

1. Pharmacotherapy

Answer 19

1. SSRIs, SNRIs, TCAs, Buspirone (only thing its approved for), Benzodiazepines

Question 20

Obsessive Compulsive Disorder

1. What does pt have?
2. What has pt realized?
3. What do symptoms cause?
4. If another disorder is present, are obsessions/compulsions limited to it?
5. What can it not be due to?

Answer 20

1. either obsessions or compulsions (or both)
2. that obsessions/compulsions are excessive/unreasonable
3. marked distress, time consuming, affect functioning, or relationships
4. no
5. effects of medication or drug abuse

Question 21

1. Define Obsessions
2. What does pt attempt to do?
3. What does pt recognize?
4. What are these worries NOT?

Answer 21

1. recurrent and persistent thoughts, impulses, or images experienced as intrusive and inappropriate and causing marked anxiety or distress
2. ignore, suppress, or neutralize
3. that obsessions are not imposed
4. not worries about “real life” problems (bills)

Question 22

1. Define Compulsions

2. What are these compulsions aimed at?

Answer 22

1. repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
2. preventing or reducing distress or preventing some dreaded event or situation; not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

Question 23

1. Common Obsessions

2. Common Compulsions

Answer 23

1. aggressive, contamination, symmetry/exactness, somatic, hoarding/saving, religious, sexual, miscellanoues (may have more than 1)
2. Checking, washing, repeating, ordering/arranging, counting, hoarding, miscellaneous (>40% have more than 1 type)

Question 24

OCD Epidemiology

1. onset
2. what makes it worse?
3. Course
4. Other conditions w/ which it co-occurs

Answer 24

1. bimodal: early (12-14) and in 20s; unusual after 50 and rare after 65
2. pregnancy and post-partum period
3. waxes and wanes, lifelong
4. Panic disorder; depression, tourette’s, substance dependence, anorexia, schizophrenia

Question 25

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep Infection (PANDAS) 1. what is it? 2. how is it different from idiopathic OCD? 3. Where do both OCD and PANDAS have pathology in brain? 4. Limited to strep?

Answer 25

1. acutely developing syndrome in children (b>g) w/ ADHD like smptoms, mild depressions, nighttime fears, separation anxiety, tics, and OCD 2. early age of onset, rapid onset, history of remissions and exacerbation, history of strep throat, family hx of autoimmune disorders 3. basal ganglia 4. no; Pediatric Acute-Onset Neuropsychiatric syndrome (PANS)

Question 26

Causes of OCD

Answer 26

1. increase of glucose metabolism in an orbitofrontal-striatal (caudate and putamen)-thalamic circuit 2. autoimmune response to strep infection 3. injury to orbitofrontal-striatal-thalamic circuit

Question 27

Pharm Treatment of OCD 1. DOC 2. 2nd line option 3. What are doses like?

Answer 27

1. SSRIs 2. Clomipramine 3. often higher

Question 28

Psychotherapeutic Treatment of OCD (2)

Answer 28

1. Exposure and Response Prevention Treatments | 2. Cognitive Therapies without ERP component

Question 29

Post Traumatic Stress Disorder 1. What has pt experienced? 2. pt's response? 3. 3 other symptoms

Answer 29

1. pt experienced, witnessed, or was confronted with an event that involved actual or threatened death/serious injury or a threat to physical integrity to self or others; 2. intense fear, helplessness, or horror 3. Pt reexperiences event 4. avoids stimulus associated with trauma 5. Pt becomes hyper-aroused

Question 30

Acute Stress Disorder 1. Criteria 2. What other symptoms are present? 3. Time course

Answer 30

1. occurs w/in 4 weeks of traumatic event and lasts at least 2 days w/ remission within 4 weeks 2. dissociative symptoms, including sense of numbing, detachment, or absence of emotions, reduced awareness of surroundings, and feelings of depersonalization and derealization 3. onset w/in 3 months; duration less than 6 months

Question 31

PTSD 1. course 2. quality of life 3. more likely to develop what?

Answer 31

1. varies, but most have chronic, unrelenting course 2. lowered quality of life; two-fold mortality risk at 16 year follow-up 3. dementia

Question 32

PTSD predictors 1. gender 2. others (5)

Answer 32

1. female gender 2. victims of assaultive violence (sexual trauma, domestic violence) 3. interpersonal trauma 4. prolonged or repeated exposure 5. higher HR in 1st month after trauma 6. Childhood trauma 7. separation from parents during childhood 8. history of psychiatric illness (esp depression and anxiety) 9. Personality traits/disorders (borderline, dependent, antisocial, paranoid) 10. ASD may be a risk factor 11. high religiosity may confer less vulnerability to development of PTSD

Question 33

PTSD Psychotherapies (5)

Answer 33

1. CBT 2. Exposure Therapy 3. Imagery Rehearsal Therapy for Nightmares 4. Eye Movement Desensitization and Reproccessing (EMDR)- works w/ milder traumas 5. Anger management training

Question 34

PTSD Pharmacotherapy 1. overall goal 2. what else must be managed? 3. drugs

Answer 34

1. augment effects of psychotherapy 2. other related symptoms (affective lability, nightmares, insomnia) 3. SSRIs, Sertraline, paroxetine

Question 35

Social Phobia (Socail Anxiety Disorder) 1. Describe 2. age of onset 3. good prognosticators

Answer 35

1. marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. pt fears he will act in a way that will be humiliating or embarassing 2. adolescence to early adulthood; chronic symptoms 3. onset after age 11, higher levels of education, fewer confounding psychiatric and medical diagnoses

Question 36

Specific Phobias 1. Describe 2. course 3. 4 types

Answer 36

1. marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation; phobic stimulus predictably elicits an anxiety response and pt experiences significant distress or functional impariment 2. chronic w/o treatment, but generally less severe 3. Animal, Natural environment, Blood-Injection-Injury, Situational

Question 37

Treatment of Phobias 1. Social 2. Performance anxiety 3. Specific Phobias

Answer 37

1. SSRIs 2. short acting benzodiazepine or propranolol 3. medications not used; other therapy