134: Anxiety and Obsessive-Compulsive Disorders

Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 134 and today we’re going to be talking about anxiety and obsessive compulsive disorders.

Alright, so what I’m going to have to do probably is at the end of Psych is go through and do a big review where we compare and contrast all of these diseases. Because what we’re going to do today is we’re going to lay down some groundwork, but we’re not going to have enough to create some real solid comparisons, the things we need for exam day. We’ll build them out as we go, for sure. But I think what I’m going to do is set up a, maybe like a final review for psych where we do a big compare and contrast and look into the different diseases, how you’d look at those for questions, that kind of thing. So that should be a really fun way to wrap this up. Big news this week. This show is obviously coming out a little bit late this week.

On Saturday is the opening of registration for the 33 Days to Pass the PANCE program for the September cohort. I’m really excited about this. I’ve been putting a lot of work into some things in the background. That’s why this show is a little late this week. And I’ve been talking with a lot of students who are struggling and looking for ways to improve their scores. Students who are struggling on the rotation exams, students who have failed the PANCE multiple times and not seen their scores move despite 90 days of studying with another course and then another 90 days of studying with another course and so on and so on. And I go into why we’re going to take care of that.

But two big things. One is if you’re listening to this on August 14th when I’m releasing it and recording it tomorrow, the 15th at 8 p.m., I’m going to be doing a live Q&A about the 33 Days program. Just make sure and see if it fits for you for this cohort, maybe the next one. Actually emailed someone today and said, Hey, I think maybe you should push this back a little bit. I have one more person to reach out to. And I’m going to have the same comment to them that I think the September cohort just isn’t going to fit for them. But anyway, if you want to come tomorrow night, 8pm at physicianassistantexamreview.com/q&a for Q&A, and that’ll get you into the Zoom call at 8pm if you’re interested.

If you already know that you want to participate in the September cohort, physicianassistantexamreview.com/33. You can get all the information that you want about the program and you can register there starting on Saturday morning at 9 a.m.

All right, so let’s go ahead and jump in to our priming questions for today’s topics. Number one, what is the minimum duration of symptoms to diagnose generalized anxiety disorder? Length of symptoms is going to be a major way that we discern different diseases, right? So, what is the minimum duration of symptoms to diagnose generalized anxiety disorder? Number two, what is the typical maximum duration of a panic attack? What’s the typical maximum duration of a panic attack? Which type of therapy is considered first line for specific phobias?

Which type of therapy is considered first line for specific phobias? Name two SSRIs commonly used in the treatment of anxiety disorder. Name two SSRIs commonly used in the treatment of anxiety disorder.

All right, let’s go ahead and jump in with generalized anxiety disorder to start with. This is excessive, or GAD, right? This is excessive, uncontrollable worry about everyday issues. Duration greater than six months. I feel like I know lots of people with this. Symptoms occur more days than not. The clinical presentation here, it goes along with our definition, right?

You have restlessness, you have fatigue, you have muscle tensions, irritability, difficulty concentrating. You may get some somatic manifestations like nausea, diarrhea, chest pain, dizziness, dry mouth. These people may have trouble sleeping at night, right? Because they’re so concerned about all these daily events and the things going on. Lab studies and physical exam findings. Obviously for psych, we’re not going to have a ton of physical exam findings for most of these. It’s really going to be just, if someone comes in with restlessness, fatigue, muscle tension, sleep disturbances, irritability, and difficulty concentrating, well, we have to rule out some other things, right?

So our labs and studies are going to be to rule out things like thyroid disorders or cardiac conditions, physical things, right? So we have to consider those as we’re working this up. Treatments and management. Well, the first line here is going to be SSRIs, so fluoxetine, sertraline, and then SNRIs, duloxetine, and venlafaxine. Not sure about that one. I haven’t had to do names of drugs in a long time, I feel like, so I haven’t screwed this up too badly. Second line would be something like pregabalin or gabapentin, CBT in support of psychotherapy, and then we get to benzodiazepines for short-term only, right?

Very short-term. Then we move into panic disorders, right? So recurrent unexpected panic attacks, fear of future attacks lasting greater than one month. So again, our timeframes are relevant. Our timeframes are important. Clinical presentation, sudden onset of anxiety, typical peaks in minutes and duration of less than one hour. Palpitations, chest pain, dizziness, shortness of breath, choking sensation, numbness, tingling, fear of dying or losing control.

All of those go into effect here. For our labs and studies, it’s going to be similar, right? So this is a clinical diagnosis, so we’re not really going to be doing a whole lot of imaging here, but you might do an ECG and labs to exclude other things for, again, like cardiovascular issues, like thyroid issues, and so on. Treatment and management. Again, the first line is going to be SSRIs, fluoxetine, sertraline, SNRIs. Second line is going to be something like clomipramine or imipramine, CBT, benzodiazepines for short term, very short term. I also came across reduced caffeine intake.

Might be a good idea for all of these.

Okay, after that, under anxiety disorders, we have phobias. So I pulled this apart. What I did was I did anxiety disorders and obsessive compulsive disorders, right? But anxiety disorders is short, right? It’s quick. Like all we have is generalized anxiety disorder, panic disorder, and phobias. So we can move right through.

There’s not a ton, ton to know in this particular section, which is great.

So let’s hit on phobias. What’s a phobia? So think for just a minute. You can come up with an idea here. We can all picture this in our heads. And this is a major key to studying and understanding, right? So we did generalized anxiety disorder.

You should be able to picture that in your head, what those patients kind of look like. Then we did… Where were we? I’m scrolling through my notes and I’m a little lost. Panic disorder. We should have some idea what that looks like. It is a little bit heavier, right?

We have more like palpitations, dizziness, shortness of breath, choking sensation. So, it’s a little more intense, lasting greater than a month, right? And so, they’re on and off episodes, less and greater than a month. Then we move into phobias. These are persistent, and here’s the key term, unreasonable fear triggered by specific objects or situations causing avoidance. This is where you get like arachnophobia, right? Fear of spiders.

Wow. What’s the agoraphobia? Isn’t that fear of going outside wide open spaces? Is that what I’m thinking? Am I screwing this up? Either way, fear of a specific trigger that’s unreasonable that creates an avoidance situation. Clinical presentation would be immediate anxiety or panic response upon exposure to that situation.

And the patient knows it’s irrational. That’s part of the key here, right? Is the patient knows that it’s completely irrational. The other key, and this goes along with a lot of your psych diagnoses, this behavior also interferes with daily life. So they have trouble doing the things that they would do during the normal day because of this fear. Lab studies and imaging. Clinical diagnosis based on patient history, right?

We’re not going to be imaging a whole lot here again. Treatment and management. First line is exposure therapy. So systematic desensitization. So we’re going to expose people to their fears. And hopefully at some point they start to realize that this, what was the word I used? Unreasonable.

Fear is unreasonable because they won’t have any actual problem with it. CBT, beta blockers like propranolol or labetalol for situational anxiety. So this would be like test-taking anxiety. I’ve definitely seen people who will take labetalol before an exam to sort of calm their nerves and get them into a good situation. I don’t think that’s the best choice, but I think for some people it is helpful. Benzodiazepines, again, short-term, you’re not going to want that before an exam. That might not go so well.

But that brings us to the end of phobias.

Next, we have obsessive-compulsive disorder, OCD. This is the presence of obsessions, compulsions, or both causing significant distress or impairment. Again, the key is significant distress or impairment in their daily lives. Obsession is intrusive, repetitive thoughts. So some of us have that during exams, right? Or when we’re studying. Maybe about ourselves.

A compulsion is a repetitive behavior performed to reduce anxiety. So I had a good friend who would go back in and check to make sure the stove was off before he left like 10, 15 times. That’s a compulsion. He’s trying to reduce anxiety. He had trouble leaving his house because he was so anxious about it. So he was compelled to go back in and check the stove. Treatment and management first line is going to be high dose SSRIs.

I’m not going to butcher names again, although these are a little easier. Sertraline and fluoxetine, maybe. Then we have CBT and with exposure response prevention. I noticed I didn’t tell you what CBT is. Cognitive behavioral therapy, definitely a mainstay of treatment for all of these. And most of us, I think, can picture obsessive compulsive disorder. We have a pretty good idea of what that looks like.

At least, I don’t know, maybe I had some more exposure to it than a lot of people. But when I was in PA school, I felt like that was one of the few psych diagnoses I could really wrap my head around and hold on to.

Okay, a couple of different things I want to touch on before we move on. The difference between generalized anxiety disorder and panic disorder is the duration and the pattern of the symptoms, like we said, so how long they go on for. Generalized anxiety disorder is greater than six months. I’m lost in my notes again. Panic disorder is greater than one month, but it also has to do with the sudden onset of the anxiety attacks, which is less than an hour, right, with the panic disorder. So those time frames are going to matter. The other thing we talked about just a second ago is the pattern of behavior, the symptoms, right?

So generalized anxiety disorder is not quite as powerful. You’re going to use benzodiazepines extremely cautiously. They’re only for short term to avoid dependency. The typical panic attack is usually less than 30 minutes and rarely greater than one hour. Most common traumatic event leading to PTSD in women is sexual assault, which looks like it creeped into my notes from last time. And then again, the common SSRIs are fluoxetine and sertraline. So, fluoxetine is Prozac, sertraline is Zoloft.

And I’m going to apologize. I’m also a little distracted. I’m recording because things have been so crazy. I’m recording this in the afternoon. My family’s home, running through the house, slamming doors, yelling at each other. So it’s all good here. If you can hear background noise, everyone’s fine.

Things are going great. But sometimes that’s how it rolls, right? Sometimes you get it done when you can get it done.

Okay, perfect. So what I want to talk about today is for our study tip, now that we got through our OCD and our anxiety disorder is to talk a little bit about anxiety. Anxiety is a major, major factor when it comes to taking the PANCE, when it comes to taking end-of-rotation exams, when it comes to end-of-curriculum exams, when it comes to dealing with your preceptors, when it comes to dealing with your attendings, when it comes to dealing with your faculty, it plays a huge role. None of us think as well, none of us function as well when we are anxious. I had a great mentor, a plastic surgeon who was teaching me from day one in the OR. And one of the things he taught me was the more relaxed you are, the better job you do. So he pushes for his rooms to be light and joking and people to be having fun.

Not that you’re not paying attention, that you’re not focused, but he never wants to yell at people because he knows they do worse, right? When they tighten up. Same thing happens in your exams. When you’re yelling at yourself during your exam or before and telling yourself how dumb you are and what a bad test taker you are, you tighten up. You don’t think as well. You don’t make as good conclusions. You don’t reach.

You’re not nimble. You’re not agile. You become very robotic. You become where you’re overworking, things don’t go well. So that’s something I always try to point out to even, you know, one good example is my son learning to drive, he’s 16, right? He’s got his permit. So when you’re overthinking, when you’re over gripping the wheel, when you’re overworking, you’re not good.

It has to be kind of natural, has to kind of flow. And that’s very much how I view test taking. So, fighting anxiety is a major cornerstone to what I teach in a 33 Days program, but in general for surviving high stakes exams is, you have to get into a state where you can trust yourself, where you can function, where you can work, and get the information that you know out of your head and out of the paper. Because all the information in your head is great, but that doesn’t help anyone. It doesn’t get you the grades. What gets you the grades is putting it down on the paper and getting the right answers. So what I recommend strongly for dealing with anxiety, especially things like testing anxiety, but even slides into some of these other realms is creating routines for yourself, right?

You can outwork anxiety. You can outwork it. You can train yourself so that when you look and you can say, oh, I’m such an idiot, I’m such a bad test taker. And then you’re like, wait, that’s not true. I’ve done all this work. I’ve done all these things. I’m studying all the time.

I’m doing this. I’m getting these grades. So you can prove it to yourself. But that takes foundational work. That takes work every single day. And the best way to go about that is consistency. So it’s daily work where you can demonstrate you’re putting in the time and the effort and getting the results.

That’s how you beat anxiety. There’s a whole nother way. There’s a whole lots of stuff. And we go into deep, deep on this in the 33 Days program to take people who have their ego shattered a little bit after failing the PANCE. But even during PA school, you just get beat up all the time, right? It’s test after test after test, and you’re just exhausted. And that very bright-eyed, excited student who hit the ground running on day one by midway through clinical years just doesn’t feel as confident like themselves anymore.

We spent a lot of time rebuilding that, not handing it to you, because it can’t be handed to you, can’t be given to you. But we show you how to rebuild it. There’s so many techniques. But again, you can come up with this a lot on your own. You don’t have to join that program to do it. We’ve talked about enough here where you can start to think about how to create that for yourself.

All right, let’s get into our priming questions and answer these. And then we’ll do our PANCE questions, our new section, and then we will wrap it up for today. What is the minimum duration of symptoms to diagnose generalized anxiety disorder? What’s the minimum duration of symptoms to diagnose generalized anxiety disorder? Six months. What’s the typical maximum duration of a panic attack? Less than one hour.

Which type of therapy is considered first line for specific phobias? Exposure therapy, systematic desensitization. Systematic desensitization. Name two SSRIs commonly used in the treatment of anxiety disorders. Fluoxetine, Prozac, and sertraline, Zoloft.

All right, perfect. All right, let’s try something a little bit tougher and move on to PANCE-style questions. Which of the following is considered first-line pharmacotherapy for generalized anxiety disorder? Which of the following is considered first-line pharmacotherapy for generalized anxiety disorder? This one’s pretty straightforward. Looks a little like a priming question. You have A, alprazolam, which is Xanax, B, fluoxetine, which is Prozac, C, propranolol, which is Inderal, and D, haloperidol, which is Haldol.

So it’s basically like our priming questions, except you have answer choices, so it’s a little easier. Which of the following is considered first-line pharmacotherapy for generalized anxiety disorder? Our answer here is SSRI, so it’s going to be fluoxetine. That’s our only SSRI, right? So again, this is pretty straightforward stuff. This question isn’t trying to fool you. There’s nothing to look at here, nothing to worry about.

But I found that a lot of students who don’t do well on the PANCE come back and tell me that they really struggle with these straight-line questions, that they spend so much time in question banks that give you deep, deep, thorough dives, that when they got to these short ones, they just felt like they didn’t have a foundation and didn’t feel like there was anything to pull apart or look for answers. You either knew it or you don’t. And I said, yeah, that’s 100% the truth, right? That’s why I love flashcards. That’s why I wrote The Final Step. That’s why I think this stuff is so important. But some of the question banks out there don’t have these single line, straightforward questions for you to practice.

So I think it’s important, even though they seem easy, I’m surprised that people do struggle with them. So pay attention. Number two, a 28-year-old, and this one’s going to be slightly more complex. A 28-year-old man reports repeated episodes of intense dizziness, chest discomfort, sweating, and choking sensation that occur spontaneously and without warning. Between episodes, he feels persistent anxiety about when the next episode might happen. What’s the most likely diagnosis? A, generalized anxiety disorder, B, panic disorder, C, post-traumatic stress disorder, or D, specific phobia.

Again, not super complicated, but I want you to see how the question is written more than I need you to really dial in the information. You start out wondering if this might be a cardiovascular problem, but you can have a 28-year-old man. So a cardiovascular problem with intense dizziness, chest discomfort, and sweating, it’s a bit of a stretch. It’s possible, but that might not be your first thought. And then when it specifically brings up anxiety, you start to slide into that direction, right? So in this case, we’re talking about panic disorder. Or this is going to be B, panic disorder.

And it’s because it’s recurrent spontaneous attacks, plus that persistent worry about future attacks is classic for a panic disorder. Why isn’t it, and this is just as important, why isn’t this generalized anxiety disorder? Right? I think most of us can tell it’s not specific phobia. He’s not talking about spiders. He’s not talking about anything in particular. It’s probably not post-traumatic stress disorder, because again, you would need something in there.

You would need him having been a soldier. You would need him having had a sexual assault. You would need him having some, something, you know, witnessing a murder. You would need something really solid in there to cause post-traumatic stress disorder. It’s probably not going to fit, maybe, but unlikely. So the two you’re really down to are generalized anxiety disorder and panic disorder. So why isn’t it generalized anxiety disorder?

What are you looking for, for that to be the case? Well, one, it’s slightly less intense symptoms, right? So it’s muscle tension, irritability, difficulty concentrating. It’s not choking, sweating, dizziness, right? The other thing is timeframe. What was the timeframe for generalized anxiety disorder? Well, it was greater than six months.

And there’s nothing in here to say that. Right? So we’re going to be looking at a panic disorder. That’s really going to be the two main differences there.

All right, fantastic. Well, that was a ton of fun. I really like going through the PANCE questions. I want you to let me know if you’d like that. That was, I thought, very, very valuable. That’s really going to be it for today. So, I’m going to sign off there and just, I don’t know if you can hear my kids running around in the background, but we’re going to call it a day that if you’re interested in learning more about controlling anxiety, if you’re interested in learning more about PANCE questions, how to break them down, how to function with them, how to get higher scores in your test with the information you already have, or how to study better, definitely come check out physicianassistantexamreview.com/33 for information on 33 Days to Pass the PANCE.

If you have questions on it, certainly reach out to me. Like I said, I’m doing that Q&A tomorrow night, maybe one on Sunday. Let me know what you’re thinking. Let me know where you’re at, and we can definitely talk about if this program makes sense for you or not.

All right. Take care. Have a great weekend, and I will talk to you next week. Registration opens on Saturday. So, if you’re interested, we only have 40 seats. Oh, that’s something important to point out. We only have 40 seats.

So, if you’re interested, get in quick.