Anxiety Disorders

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Generalized anxiety disorder

Things you should know

• Characterized by excessive, uncontrollable and often irrational fear about everyday issues and not about a specific thing or at specific time
• Symptoms have been occurring for more than 6 months.

Symptoms

• More than 6 months of excessive worry
• More days are spent worrying than worry free
• Restless,
• Easy Fatigability
• Muscle tension
• Sleep issues
• Irritability
• Difficulty concentrating
• Nausea and diarrhea
• Chest pain
• Dizziness
• Trembling
• Dry mouth
• Hypervigilance

Treatment

• Cognitive and Behavioural therapy
• Medications
  • SSRIs (Selective Serotonin Reuptake Inhibitors)
    • fluoxetine (Prozac)
    • sertraline (Zoloft)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
    • Duloxetine (Cymbalta)
    • Venlafaxine (Effexor)
  • Tricyclic antidepressants (TCAs)
    • Imipramine (Tofranil)
    • Clomipramine (Anafranil)
  • Benzodiazepines – may be used for short term therapy
    • Alprazolam (Xanax)
  • Pregabalin – Lyrica
  • Gabapentin – Neurontin

Panic Attacks & Panic Disorder

Things you should know

• A panic attack is the a case of extreme anxiety which typically lasts less than an hour.
• Panic disorder is characterized by repeated, unexpected panic attacks and the fear of future panic attacks.

I came in to see my physician assistant today because of…

• Sudden unexpected and overwhelming anxiety lasting about 30 minutes
• Tachycardia
• Palpitations
• Excessive perspiration
• Dizziness
• Shortness of breath
• Sensation of choking
• Chest pain / Discomfort
• Numbness / Tingling
• Chills / Hot flashes
• Uncontrollable fear
• Fear of the next panic attack

Diagnosis

• Unexpected recurrent panic attacks with at least a month of significant behavior change which may or may not include agoraphobia

Treatment

• Psychotherapy
  • Cognitive behavior therapy – teaches a person different ways of thinking, behaving, and reacting to situations that help him feel less anxious and fearful
• Reduction of Caffeine Intake
• Medications
  • Medications
    • SSRIs (Selective Serotonin Reuptake Inhibitors)
      • fluoxetine (Prozac)
      • sertraline (Zoloft)
    • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
      • Duloxetine (Cymbalta)
      • Venlafaxine (Effexor)
    • Tricyclic antidepressants (TCAs)
      • Imipramine (Tofranil)
      • Clomipramine (Anafranil)
    • Benzodiazepines – may be used for short term therapy
      • Alprazolam (Xanax)

Phobias

Things you should know

• A phobia is an overwhelming, persistent and unreasonable fear of an object or situation that poses little real danger but provokes anxiety and avoidance.
• Classifications
  • Social Phobia – fear of other people or social situations such as performance anxiety or fears of embarrassment by scrutiny of others.
  • Specific Phobia – Heights, spiders etc
  • Agoraphobia – a generalized fear of leaving home or a familiar ‘safe’ area.  Typically the fear is that there may be a problem or panic attack and the patient can’t escape or get to safety.
• Patients understand that their fear is not rational

I came in to see my physician assistant today because of…

• Uncontrollable panic, terror or dread when exposed to the source of fear
• Total Fear avoidance
• Anxiety interferes with patient’s daily activities
• Sweating
• Tachycardia
• Difficulty breathing
• A feeling of panic and intense anxiety
• Feeling powerless to control fear
• Anxiety
• In children, possibly tantrums, clinging or crying

Treatment

• Psychotherapy

• Desensitization or exposure therapy – focuses on changing response to the object or situation being feared at and may be helpful for phobias. Gradual, repeated
• Cognitive Behavioral Therapy
• Participant modeling and reinforced practice- Used for children and adolescents, wherein the therapist models for the child how they should respond to their fears and then encourages the child to practice this behavior and reinforces their efforts.
• Medications –
  • SSRIs (Selective Serotonin Reuptake Inhibitors)
    • fluoxetine (Prozac)
    • sertraline (Zoloft)
  • Beta blockers –
    • propranolol
    • labetalol
  • Benzodiazepines – may be used for short term therapy
    • Alprazolam (Xanax)

Posttraumatic stress disorder (PTSD)

Things you should know

• PTSD is seen in people who have experienced or perceived a life threatening event
• Possible traumatic events
  • Combat exposure
  • Childhood neglect and physical abuse
  • Sexual assault
  • Physical attack
  • Threat of death

I came in to see my physician assistant today because of…

• Re-experiencing symptoms
  • Flashbacks—reliving the trauma over and over, including physical symptoms such as sweating and tachycardia
  • Nightmares

• Avoidance Symptoms
  • Staying away from places, events, or objects that are reminders of the experience
  • Feeling emotionally numb
  • Feeling strong guilt, depression, or worry
  • Losing interest in activities that were enjoyable in the past
  • Having trouble remembering the dangerous event

• Hyperarousal symptoms
  • Being easily startled
  • Feeling tense or edgy
  • Having difficulty sleeping, and/or having angry outbursts

Diagnosis

• Diagnostic criteria for PTSD:
  • Duration of symptoms for more than 1 month
  • Exposure to a traumatic event
  • Persistent re-experiencing of the event
  • Persistent avoidance and emotional numbing
  • Persistent symptoms of increased arousal not present before (hypervigilance, hyper startle reflex)
  • Feeling of detachment from other people
  • Significant Impairment

Treatment

• Psychotherapy
  • Cognitive Behavioral Therapy
    • Exposure therapy
      • Helps people face and control their fear by exposing them to the trauma they experienced in a safe way.
      • Uses mental imagery, writing, or visits to the place where the event happened.
    • Cognitive restructuring.
      • Helps people make sense of the bad memories.
      • The therapist helps people with PTSD look at what happened in a realistic way.
    • Stress inoculation training
      • Tries to reduce PTSD symptoms by teaching a person how to reduce anxiety.
  • Eye Movement Desensitization and Reprocessing
    • EMDR combines exposure therapy with a series of guided eye movements that helps process traumatic memories and change the reaction to traumatic memories.
  • Interpersonal Psychotherapy
• Medications
  • SSRIs (Selective Serotonin Reuptake Inhibitors)
    • fluoxetine (Prozac)
    • sertraline (Zoloft)
  • Benzodiazepines – may be used for short term therapy
    • Alprazolam (Xanax)
  • Tricyclic antidepressants
    • Amitriptyline
  • Alpha-adrenergic antagonists
    • Prazosin-helps relieve or reduce nightmares
    • Clonidine – can be helpful with startle, hyperarousal, and general autonomic hyperexcitability
  • Anti-convulsants, mood stabilizers, anti-aggression agents
  • Serotonin antagonists
    • Cyproheptadine – aids in sleep disorders and nightmares
  • Beta blockers
    • Propranolol  – to reduce hyperarousal symptoms, including sleep disturbances
• Exercise, Sports and Physical Activity
  

  Study Tip

  Begin with the end in mind.  This is one of Dr. Stephen Covey’s 7 habits of highly effective people.  They plan backwards.  You decide in advance what you want to achieve and you figure out your plan from end to beginning.
  For example you decide you want to cover all 14 topics in detail.  You then decide how you will cover those topics.  What books you will use and how long each topic should take.  etc

  Key terms and Ideas

  • How long does a typical panic attack last?
    • Most end by 30 minutes but may be as long as an hour
  • What is the most common traumatic event leading to PTSD in women?
    • Rape / sexual assault
  • How do you use benzodiazepines for treating anxiety disorders?
    • Use them cautiously and only short term.
  • Name two SSRIs.
    • fluoxetine (Prozac)
    • sertraline (Zoloft)

 

<< Click here to get 23 Psych questions straight from my book, The Final Step >>