Anxiety Disorders Chart

							    ANXIETY DISORDERS: frequently ass. w/ ↑ SES; NT imbalance: ↑NE, ↓GABA, ↓ 5-HT
                               Dz, Dx, description                                                                      Signs/Sx                                                                          Tx
    Panic D/O w/ or w/o Agoraphobia                                                  4 of the Sx: palpitations, ↑ HR, sweating, trembling, feelings of choking,       Mild cases or combo: Cognitive behavioral therapy (CBT) & respiratory
    Dx: Recurrent unexpected attacks of intense terror & fear of impending           SOB, chest pain, N& GI distress, dizzy, derealization, depersonalization,         training: helps pts recognize & overcome desire to hyperventilate
     doom w/ 4 sx peaking within 10 min w/o understanding the trigger/source          fear of dying/going crazy, paresthesias, chills or hot flushes                   For Agoraphobia: exposure desensitization &/or β-blockers
    Lifetime prevalence: 2-5%, 3F>1M, presents in 20s, >50% pts have                Attacks are followed by 1 mo of:                                                  (prophylaxis)
     depression, ↑ risk of suicide, strong genetic component                            o concerns of additional attacks: anticipatory anxiety                             Maintenance: SSRIs (fluoxetine [Prozac], paroxetine [Paxil]): 1st line
    Classifications of Panic D/O:                                                      o implications of the attack, such as fear of having MI or “going crazy”           favorable profile, but rare impotence, insomnia, anorexia, anxiety
      Unexpected Panic Attacks: occur spontaneously w/o trigger                         o Change in behavior related to the attacks (restriction of activities)            TCAs (amitriptyline, desipramine, imipramine [Tofranil], nortriptyline): 2nd line
      Situationally Bound Panic Attacks: occur immediately after exposure to feared  Agoraphobia: anxiety about being in places/situations where escape is                orthostatic hypotension (α block), ↑ QRS duration, dry mouth, blurred
      stimulus (elevator, heights)                                                    difficult/embarrassing. Develops 2˚ to PA occurring in public places                  vision, constipation, urinary retention (anti-cholinergic), confusion, sedation
                                                                                                                                                                            (antihistamine)
      Situationally Predisposed Panic Attacks: occur upon exposure of stimulus but    (trains, bus). Situations are avoided or endured w/ marked distress
                                                                                                                                                                           OD: ♥ arrhythmias; tx w/ bicarbonate
      not necessarily immediately after every exposure                               Clinical progression: PT has a PA while shopping @ a supermarket                     MAOIs (phenelzine, tranylcypromine): 3rd line (severe) most efficacious, but SE!
    May be induced by: hyperventilation, inhalation of CO2                           subsequently develops a fear of entering the supermarket. As the pt                  Serotonin syndrome: (when combo MAOIs w/ SSRIs, meperdine,
    May be exacerbated by: caffeine, nicotine                                        experiences more PAs in different settings  develops a progressive and               pseudoephedrine) hyperthermia, muscle rigidity, altered mental status
    Pt may mistaken panic attack for an MI, and end up at the ER!                    more general fear of public spaces (agoraphobia).                                    Hypertensive crisis: malignant HTN when ingested w/ foods rich in tyramine
    Ass w/: MDD, substance dependence, social & specific phobias, OCD               PANICS: Palpitations, Paresthesias, Abdominal distress, Nausea, Intense               (wine & cheese)
    DDx: CHF, angina, MI, thyrotoxicosis, TLE, MS, pheochromocytoma,                 fear of dying, Chest pain, Chills, Choking, disConnectedness, Sweating,              acute initial tx: Benzos (Clonazepam [Klonopin], Alprazolam [Xanax])
     carcinoid syndrome, other mental D/O, amphetamine, nicotine, cocaine             Shaking, SOB                                                                    Note: takes 2-6 wks for effect
     abuse, alcohol or opiate withdrawal                                                                                                                               Consider panic D/O if medical workup shows no abnormalities. 43% of
                                                                                                                                                                        pts presenting w/ chest pains & normal angiograms were Dx w/ panic D/O
    Specific Phobia Ex: Gamophobia (marriage), Algophobia (pain), Acrophobia          Phobias: MC psychiatric D/O (specific > social), often ass. w/ substance        Behavioral therapy such as systemic desensitization (gradual exposure
    (heights), Agoraphobia (open places)                                               abuse (esp. alcohol)                                                             w/ relaxing/breathing techniques) or flooding + supportive psychotherapy
 Dx: intense fear of specific objects or situations (e.g. snakes, heights,           Lifetime prevalence: 10%, F>M (social), F=M (specific), onset ~ teens           Pharmacotherapy is NOT effective
  animals, blood, death, flying) which may take the form of a PA.                     Pts recognize that fear is excessive. If <18 yo, duration must be ≥ 6 mo.
 Social Phobia (Social Anxiety D/O)                                                   The avoidance or anxious anticipation in the feared situations interferes       SSRIs: Paroxetine [Paxil], Sertraline [Zoloft], 1st line
 Dx: intense fear of social or performance situations or of scrutiny by               w/ functioning or causes distress                                               Benzos: Clonazepam [Klonopin]
  others (public speech). Hypersensitivity to criticism, difficulty being             Etiology: genetics, behavioral (traumatic event), neurochemical                 For social phobia w/ performance anxiety: β-blockers [Propranolol]
  assertive, low self-esteem, inadequate social skills, fear of embarrassment          (overproduction of adrenergic NTs, hence β-blockers as tx)                      Cognitive/behavioral therapies: cognitive retraining, desensitization,
 Less common fears: eating, drinking, writing in public, or use of public restroom.  DDx: Substance induced anxiety D/O (caffeine, amphetamines, cocaine),            relaxation techniques
 Onset usually in adolescence w/ childhood Hx of shyness                              withdrawal of benzos or alcohol, Panic D/O, OCD, Social phobia,                 *Recall: combo of pharmacotherapy + behavioral tx is most effective!
                                                                                       hypochondriasis, anorexia nervosa, mood & psychotic D/O
 Generalized Anxiety D/O (GAD)                                                        Restlessness, fatigability, difficulty concentrating, irritable, muscle         Venlafaxine [Effexor/XR], SSRIs, Buspirone [BuSpar]: 1st line
 Dx: intense pervasive worry over virtually every aspect of life                      tension, insomnia                                                               Adjunct: long acting Benzos (Clonazepam [klonopin], Diazepam
  (nonspecific) ass. w/ physical manifestations of anxiety for ≥ 6 mo                 Pts “can’t stop worring” about $, jobs, marriage, health, safety of children     [Valium], TCA
 Lifetime prevalence: 5%, 2F>1M, onset early 20s                                     Commonly coexists w/: mood D/O, substance & stress related D/O, 30-             Quit coffee, avoid alcohol, get adequate sleep, exercise
 DDx: substance induced anxiety D/O, Panic D/O, OCD, social phobia,                   50% meet criteria for MDD                                                       Cognitive behavioral therapy w/ emphasis on biofeedback & relaxation
  hypochondriasis, anorexia nervosa, mood & psychotic D/O                             Labs: serum glucose, Ca, phosphate, ECG, thyroid, U tox, catecholamines          techniques
 Acute Stress D/O                                                                     Pt avoids precipitating stimuli via feelings of detachment (emotional           Psychotherapy
 Dx: precedes PTSD, occurs within 1 month of stressor, lasting < 1 mo.                numbing), anhedonia, amnesia, restricted affect, avoids public places &         For short-term insomnia & ↑ arousal: sedative hypnotics
                                                                                       activities. Ex: woman avoids parking lots after being rapped in one             SSRIs: 1st line
 Post-Traumatic Stress D/O
                                                                                      Hyperarousal persists after the traumatic event: ↓ concentration,               Imipramine, Amitriptyline, MAOI: moderately effective
 Dx: Relives events via recollections or nightmares (intense horror/fear),
                                                                                       hypervigilance, exaggerated startle response, insomnia, outbursts of anger      Propranolol, Lithium, anticonvulsants, Buspirone: last line
  reliving of experiences (flashbacks), or distress when exposed to
                                                                                      Sx cause significant distress/impaired occupational/social functioning          Psychotherapy: Exposure or relaxation techniques
  reminders of the traumatic event w/ Sx for > 1 mo.
                                                                                      Survivor guilt: surviving when others have died in war                          Avoid Benzos b/c of ass. w/ substance abuse & PTSD
 Lifetime prevalence: 7%, in soldiers & assault victims: 60%
                                                                                      Personality change, poor impulse control, aggression, ↑ risk of depression,
 Acute (<3mo), Chronic (>3mo), delayed onset (begin 6 mo after stressor)
                                                                                       S/A, anxiety D/O, somatization D/O, suicide
 Obsessive Compulsive D/O (OCD)                                                       Pt recognizes (has insight, in contrast to OC personality D/O, where pt         SSRI’s (↑ dose): Sertraline [Zoloft], Paroxetine [Paxil], Fluoxetine
 Obsession: recurrent thoughts, impulses, or images causing anxiety. Pt               doesn’t) obsessions & compulsions are excessive & unreasonable, and              [Prozac], Citalopram [Celexa], Fluvoxamine [Luvox], 1st line
  realizes it is a product of his/her own mind & tries to suppress them.               pts which to get rid of them (ego-dystonic, in contrast to OCD P/D/O)           TCA (standard dose): Clomipramine [Anafranil]
 Compulsion: repetitive acts pt does in response to relieve anxiety; may             Patterns: contamination followed by washing, doubt followed by                  Others: Lithium, Propranolol, anticonvulsants, and Buspirone
  cause social & occupational impairment                                               repeated checking, symmetry followed by slow performance of a task,             Behavioral therapy: exposure & response prevention (ERP) is prolonged
 Epi: earlier onset M, adolescence / early adulthood, up to 50% of pts w/             intrusive thoughts (sexual or violent) w/ no compulsion                          exposure to the ritual-eliciting stimulus and prevention of the relieving
  Tourette’s D/O have OCD, but only 5% of OCD pts have Tourette’s                     OCD pts often initially seek help from nonpsychiatric Drs. For ex, they          compulsion (e.g., the patient must touch the dirty floor w/o washing
 Etiology: abnormal regulation of 5-HT, genetics, trigger                             may visit a dermatologist complaining of skin problems on their hands            hands), desensitization, or flooding
 Ass. w/ MDD, drug abuse to ↓ stress; eating & anxiety D/Os, OCD P/D/O                (related to their frequent hand washing).                                       ECT or surgery (cigulotomy): refractory cases
 Adjustment D/O development of maladaptive emotional/behavioral sx                    stressful event is NOT life threatening (such as a divorce, death of a loved    Supportive psychotherapy
 in response to identifiable stressor within 3 mo after event and ends ½ yr           one, or loss of job) as opposed to PTSD in which it is.                          Group therapy
 after event has terminated. NOTE: NOT considered anxiety D/Os!!!                     Subtypes w/: depressed mood, anxiety, disturbance of conduct                    Pharmacotherapy for ass. Sx (insomnia, anxiety, depression)
 Epi: 2F>M, triggered by psychosocial factors                                         (aggression), combos of the above