Anxiety Disorders

syndrome characterized by clinically significant disturbance in an individual'scognition, emotional regulation or behavior that reflects a dysfunction in thepsychological, biological or developmental processes underlying mental functioning

mental disorder according to the Diagnostic and Statistical Manual (DSM) 5 is defined as

Appearance

Attitude

Speech

Mood

Affect

Thought Process

Thought Content

Perception

Cognition

Insight

Judgment

The Mental Status Exam components

Appearance

general appearance and attire, grooming and hygiene

Attitude

cooperative, eye contact

Motor

slowed or agitated movements, medication side effects causing abnormal movements

Speech

rate, tone and volume

Mood

current state of mind, often a direct quote from the patient

Affect

how the patient appears

Reduced range of appearance

What is a blunted or restricted affect

Abrupt changes in appearance

What is a labile affect

Full range

What is considered an appropriate affect

Thought process

the quality of the patient's thoughts

jumping from one idea to the next

What does it mean for someone to be Flight of ideas

illogical shifts between unrelated topics

What does it mean for someone to have Looseness of associations

Tangentiality

thoughts wander from the original goal

Circumstantiality

digression which eventually reaches intended point

Echolalia

echoing of words, mimicking

Neologisms

creation of new words

Clanging

speech based on rhyming

Perseveration

repetition of phrases or words

Suicidality or homicidality

Delusions

Illusions

Derealization

Depersonalization

What is within Thought Content

Delusions

fixed beliefs held in spite in of contrary evidence

Persecutory

A delusion in which the person believes others are trying to cause harm to the patient

Erotomanic

A delusion in which the person believes a person, usually of higher status, is in love with the patient

Grandiose

A delusion in which the person has an inflated sense of self-worth, power, knowledge or wealth

Somatic

A delusion in which the person believes patient has a physical disorder or defect

Illusions

misinterpretation of real events or stimuli

Derealization

feelings of unrealness involving the outer environment

Depersonalization

feelings of being outside one's own body observing events

orientation, memory, attention/calculation and language; 30 is a perfect score

What does the Mini Mental Status Exam (MMSE) or MoCA assess

Insight

the patient's awareness of his/her circumstances

Judgement

the decisions that the patient makes

Deficits in intellectual functioning

Deficits in adaptive functioning

Onset of deficits during the developmental period

What are Intellectual Disability

Neurocognitive disorder

Cognitive decline from a previous level of performance in one or more of the following cognitive domains: Complex Attention, Executive Function, Learning and Memory, Language, Perceptual-Motor or Social Cognition

Dementia (Alzheimers, Lewy bodies)

Traumatic brain injury

Substance or medication use

Medical (HIV, Parkinsons, Prions, Huntington's)

Causes of neurocognitive disorder

a temporary alteration in mental status with a variety of etiologies, many of which are medical

What is delirium

Malingering

Intentional production of false or grossly exaggerated symptoms motivated by external incentives

Cognitive Impairment

Psychosis

Two types of malingering

Test of Malingered Memory (TOMM)

Test for detecting malingered cognitive deficits

Structured Interview of Reported Symptoms (SIRS)

How to test for Malingered psychosis

More frequent in women (2:1 ratio)

Develops at an early age and persist if untreated

Anxiety may be caused by medical conditions

Myocardial infarction

Pulmonary embolism

COPD

Cushing's Disease

Pheochromocytoma

General Characteristics of anxiety disorders

Panic disorder

Recurrent, unexpected panic attacks about which there is persistent concern, can occur with or without agoraphobia

Panic attacks

Discrete period with intense fear often associated with a sense of impending doom, physical symptoms are also common (chest pain, palpitations, shortness of breath, choking or smothering sensations)

Prozac (Fluoxetine)

Paxil (Paroxetine)

Zoloft(Sertraline)

Xanax (Alprazolam)

Klonopin (Clonazepam)

FDA approved treatments of panic disorder

Agoraphobia

Fear using public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd and/ or being outside of the home alone and these situations are avoided (or require a companion or are endured with intense anxiety) due to concern that symptoms will develop

Generalized anxiety disorder

Persistent and excessive anxiety and worry

Lexapro (Escitalopram)

Paxil (Paroxetine)

Effexor(Venlafaxine)

Benzodiazepines

Buspar (Buspirone)

FDA approved treatments of generalized anxiety disorder

Social phobia

Marked and persistent fear of social or performance situations in which embarrassment may occur and exposure to such situations causes anxiety

Paxil (Paroxetine)

Zoloft (Sertraline)

DA approved treatments of social phobias

Posttraumatic stress disorder

Exposure to a traumatic event accompanied by intrusive thoughts, avoidance, cognitive/ mood changes and increased arousal

Zoloft (Sertraline)

Paxil (Paroxetine)

FDA approved treatments of PTSD

Obsessions

persistent, intrusive thoughts that cause distress

Compulsions

repetitive actions which decrease anxiety (washing hands, counting telephone poles, checking the locks)

Prozac (Fluoxetine)

Paxil (Paroxetine)

Zoloft (Sertraline)

Luvox (Fluvoxamine)

Anafranil (Clomipramine)

FDA approved treatments of OCD

Avoidant Personality Disorder

wish for social contact, but fear humiliation

Dependant Personality Disorder

submissive and clinging behavior; excessive need to be cared for by others; often taken advantage of; belittle themselves

Obsessive-Compulsive Personality Disorder

preoccupation with orderliness, perfectionism and control; loses major point of activity in details; perfectionism; inflexible morality and ethics; unable to discard worthless objects; reluctant to delegate; miserly spending; rigidity

non-addictive, lack of cognitive impairment, relatively safe inpregnancy (except Paxil)

Advantages of antidepressants

slow onset, side effect profile (nausea, diarrhea/constipation,sexual dysfunction, headache, dry mouth, sedation/agitation), may be a problemin overdose (TCA's are cardiotoxic)

Disadvantages of antidepressants

SSRIs

_____ may initially increase anxiety, generally requires higher doses than used to treat depression

♦ Prozac (Fluoxetine)

♦ Zoloft (Sertraline)

♦ Paxil (Paroxetine)

♦ Celexa (Citalopram)

♦ Lexapro (Escitalopram)

♦ Luvox (Fluvoxamine)

What are the SSRIs

TCAs

_____ act at multiple receptors, "dirty drugs," many are anti-cholinergic

Effexor (Venlafaxine)

Cymbalta (Duloxetine)

What are the SNRIs

NE uptake inhibition varies with dose

MOA of Effexor (Venlafaxine)

NE uptake inhibition does not vary with dose

MOA of Cymbalta (Duloxetine)

5-HT1A agonist

Buspar (Buspirone)

Buspar (Buspirone)

What has drug-drug interactions uncommon, relative lack of side effects, questionable efficacy

Indural (Propranolol)

Beta Blocker most useful for social phobia (public speakingin particular) as it decreases the physical symptoms that occur with anxiety (increased HR and BP)

Vistaril (Hydroxyzine)

Benadryl (Diphenhydramine)

useful in disorders for their mild sedative effect, non-addictive

Xanax

Short acting Benzodiazepines

Long acting Benzodiazepines

effective, rapid onset

Advantages of benzos

depression, dependence (withdrawal can be lethal), disinhibition(especially in the elderly), ataxia, contraindicated in pregnancy

Disadvantages of benzos

• Wellbutrin (Bupropion)

• Steroids

• Thyroid supplementation

• Stimulants

Medications that worsen anxiety

therapy and medications

_____ is thought to be best treatment for anxiety

Cognitive Behavioral Therapy (CBT)

short term therapy that helps patientsidentify their faulty beliefs and the behavior associated with them

Exposure therapy

patients must confront and remain in contact with the objector situation that they fear

Psychosurgery

Used for severely incapacitating, treatment refractory OCD

Anterior cingulotomy

Psychosurgery is most often where

Anterior cingulotomy

placement of bilateral lesions in theanterior cingulate under stereotactic guidance