Lecture 1 - Anxiety & OCD

What is a good recommendation for psychopharmacotherapy?

Start low and tritrate slow

What is the DSM-V-TR?

The Diagnostic and Statistical Manual of Mental Disorders 5th edition to help classify diseases

What are important components of psychiatric history taking?

- Gather presenting symptoms (mood changes, panic attacks, anxiety, hallucinations, etc.)

- Assess patient insight into condition and impact on ADLs

- Social History

What are collaterals?

Individuals that can advocate for patient and speak on their conditions/situation

What are the 6 general components of the Mental Status Examination (MSE)?

1) Appearance and Behavior

2) Speech and Language

3) Mood

4) Thoughts and Perception

5) Cognitive Function

6) Higher Cognitive Functions

What is the most common type of psychotherapy?

Cognitive Behavioral Therapy (CBT)

When does anxiety become a disorder?

When it 1) interferes with psychosocial functioning or 2) causes significant distress to the patient

What is generalized anxiety disorder (GAD)?

General state of persistent, uncontrollable worrying that last longer than 6 months

What are the clinical manifestations of GAD?

- Persistent, uncontrollable worrying about everyday activities and responsibilities

- Hyperarousability

- Muscle Tension

- Sleeping difficulties

- Difficulty concentrating

Is GAD more common in men or women?

women

How is GAD diagnosed?

- Physical exam with attention to MSE, thyroid, skin, neuro and abdominal exam

- No neuro imaging or lab studies needed

What is the management for GAD?

1) Psychotherapy (ex.CBT)

2) Pharmacotherapy (ex. SSRIs and SNRIs)

- SSRIs: paroxetine (Paxil), escitalopram (Lexapro), citalopram (Celexa), sertraline (Zoloft)

- SNRIs: Venlafaxine (Effexor), duloxetine (Cymbalta)

Can benzodiazepines be used to treat GAD?

- Yes but only acutely, not long-term

- Not first line therapy

What are side effects of BZDs?

- Sedation

- Confusion

- Memory problems

- Seizures (if stopped abruptly)

What is panic disorder?

Short, lasting panic attacks with fear of recurrent ones for at least one month

What is the difference between panic attack and panic disorders?

Panic Attack - singular episode that can be triggered or untriggered

Panic Disorder - experience of recurrent, spontaneous attack for at least 1 month of worry about future attacks (fear of the attacks happening + worry about the effects)

What are the clinical manifestations and symptoms of panic disorders?

- Recurrent and spontaneous panic attacks

- Fever of further attacks

- SOB

- Rapid HR

- Palpitations

- Dizziness

- Feeling hot or cold

- Feeling of choking

- Nausea

What is agoraphobia?

Fear of being in places or situations where you cannot leave

How are panic disorders diagnosed?

- Clinically/PE

- No lab or neuroimaging needed

What is the management for panic attacks?

Mild: CBT alone

Moderate/Severe:

first line combo therapy: (CBT+SSRIs)

2nd line: (CBT+SNRIs)

- Med options include SSRIs (ex. Paroxetine, sertraline, fluoxetine, citalopram, escitalopram)

SNRIs: venlafatine

What are potential complications of panic disorders?

Major Depression (common comorbid disorder)

What are the two categories of phobias?

- Specific Phobias - fear of a specific thing (seen in about 5-10% of population)

- Social phobia - social anxiety disorder (seen in about 3% of population)

What is a specific phobia?

irrational fear of a specific object or situation such as heights, spiders, needles and small spaces

What is social phobia?

fear of social situations such as public speaking, using public restrooms, eating in public, performing, etc.

What is the difference between social phobia and separation anxiety in children?

Social phobia - child not wanting to go to school or in public, even with parent

Separation anxiety - child not wanting to go to school or public place without parent; may be overly clingy

How are phobias diagnosed?

- Physical Exam

- Neuroimaging and lab studies are not necessary

How are phobias managed?

- Psychotherapy such as CBT (preferred)

- Beta Blockers such as propanolol

What is obsessive-compulsive disorder (OCD)?

a disorder characterized by unwanted repetitive thoughts (obsessions), that lead to an actions to calm the obsession(compulsions)

What are OCD examples (what pt can have)?

- Obsessions - 1) contamination fears and pathological doubt/false memory

- Compulsions - checking and decontamination rituals + reassurance seeking

What are common comorbid conditions with OCD?

Tic disorders

Tourette Syndrome

schizotypal

How is OCD diagnosed?

- Hx and Physical

- No neuroimaging or labs needed

What is the management for OCD?

- Combination therapy (psychotherapy and pharmacology such as SSRIs) is preferred management as 1/4 of patients are refractory to mono therapy

CBT: ERP: exposure and response prevention

Meds: SSRIs + TCA

What is the difference in pharmacological treatment effects of OCD vs. other psychiatric disorders (ex. Depression/anxiety)?

- Takes longer in OCD to see medication effects (approximately 12 weeks)

- High doses may be needed in OCD compared to depression/anxiety

What is the theme of Body Dysmorphia Disorder (BDD)?

Imagined Ugliness

What are the clinical manifestations of BDD?

- Preoccupation w/ one or more perceived defects or flaws in physical appearance

- Associated with repetitive behaviors (pt. May spend hours looking in the mirror, camera, etc.)

- Causes functional impairment and significant distress

How is BDD diagnosed?

- Hx and PE

- No labs or imaging needed

What is the management for BDD?

- SSRIs

- CBT

- Tx from dermatologist and plastic surgeons are rarely effective and can worsen conditions

What can happen with patients with BDD?

High rates of suicidal ideations and attempts