1What is a group of signs and symptoms that occur together and characterize a particular abnormality or condition?
Syndrome
2What is a disorder of structure or function in a human, especially one that produces specific signs or symptoms?
Disease
3When someone says that they have anxiety, what are they stating?
They have a symptom of awareness of an internal state of "nervousness" and physiological sensations of restlessness, palpitations, and sweating
4What is the etiology of anxiety?
excessive respons in the autonomic nervous system (palpitations, sweating, etc)
neurotransmitters
excessive cortisol production
elevated corticotropin releasing hormone
behavioral conditioning
inadequate neuropeptide Y
inadequate glanin
abnormalities in brain structure
genetics
5What is aplysia?
behavioral conditioning
6What are the common peripheral manifestations of anxiety (autonomic)?
diarrhea
dizziness/lightheaded
hyperhidrosis
hyperreflexia
palpitations
pupillary mydriasis
restlessness
syncope
tachycardia
paresthesia
tremor
upset stomach
urinary symptoms
7What neurotransmitter is responsible for the sense of well-being, memory, and arousal?
Serotonin
8What neurotransmitter is responsible for attentiveness and drive?
norepinephrine
9What neurotransmitter is responsible for calming or slowing of the nervous sysmtem?
GABA
10What neurotransmitter is responsible for focus, pleasure, and movement?
Dopamine
11What neurotransmitters are highly associated with the circadian rhythm?
Adenosine
Melatonin
12What neurotransmitter is highly associated with arousal and wakefulness?
Orexin
13What neurotransmitter is excitatory and is associated with sensations?
glutamate
14What neurotransmitter is responsible for arousal and motivation?
ACTH
15What receptors are associated with panic?
Beta
16What theory explains that anxiety is a signal of danger in the unconscious mind?
Psychoanalytic
17What theory explains that anxiety is a conditioned response to an evironmental stimulus?
Behavioral
18What theory explains that anxiety is a response to a perceived void in meaning or existence?
Existential
19What are some important factor about treating anxiety that the clinician should be aware of and also convey to the patient?
Medication does not change thought process.
Medication assists w/ imbalance of neurotransmitters
Therapy helps with balancing thought process
Lifestyle or environmental changes may be necessary to fully treat anxiety
The pts fundamental needs must be addressed to fully treat anxiety
Managment of anxiety is achieved over time with personal growth
20What is one thing to keep in mind about treatment of anxiety in individuals with a personality disorder?
Often resistent to medication interventions and therapy is a key component
21What are the benefits of utilizing Maslow's hierarchy of needs when using therapy as treatment for patients with anxiety?
Helps to prioritize needs and gives specific areas to target during therapy
Meeting needs lower in the hierarchy are essential before moving to those at the top because unmet needs will impact the treatment
22When considering treatment for specific age groups, what theorist helps to guide potential conflicts that may be evident throughout the lifespan?
Erikson
23What is the primary difference between a fear and anxiety?
Fear=KNOWN threat
Anxiety=UNKNOWN threat or UNCERTAIN future
24What is the primary difference between worry, fear and anxiety?
With an anxiety disorder, the perceived fear is out of proportion with the actual situation
25What diagnosis describes unrealistic worry/tension for no reason?
GAD: generalized anxiety disorder
26What diagnosis describes overwhelming worry in social situations and carries a fear of judgment?
Social Anxiety Disorder
27What diagnosis describes terror striking at random leading to panic attacks?
Panic Disorder
28What diagnosis describes irrational fear of open/crowded places, leaving the home, or being incapable of escape?
Agoraphobia
29What diagnosis describes irrational fear of something that poses no real danger?
Specific Phobia
30What are primary rating scales that can be utilized to assess anxiety?
GAD-7
HAM-A
Zung Self-Rating Scale
31What experiences can contribute to the development of an anxiety disorder by changing brain structure?
Stress
Trauma
Addiction
Diseasse
Nutrition
Hormones
32What medications are used to treat anxiety?
SSRIs: Celexa, Lexapro, Zoloft, Paxil, Prozac, Luvox
SNRIs: Effexor, Cymbalta, Pristiq,Fetzima,
NDRIs: Wellbutrin (not usually used for anxiety alone)
SMS: Viibryd, Trintellix
SARIs: Serzone, Trazodone (used mostly for sleep)
NASSAs: Remeron
Tricyclics: amytriptiline, doxepin, nortriptyline (helps w/ nerve pain), clomipramine (used for OCD)
MAOIs: not often used; need to know how to taper off to switch
33What are the main side effects of antidepressants?
Head
Stomach
Sexual
34What 2 medications may help to combat the sexual side effects associated with antidepressant use?
Buspar
Wellbutrin
35What antidepressant group can be used to treat premature ejaculation?
SSRI
36How many days should the clinician suggest to "fight through" the side effects when starting an antidepressant?
4-5 days because most resolve within this timeframe as the body adjusts
37What is the parameter for a prolonged QT in males?
450
38What is the parameter for a prolonged QT in females?
470
39What symptoms may be associated with a prolonged QT?
Fainting, palpitations, seizures, fatigue, dizziness, irregular heartbeat, and may lead to cardiac arrest
40What is the typical dose for citalopram?
10-40mg
41What is the max dose of citalopram for an elderly pt?
20mg
42What is one drawback of using citalopram?
Prolonged QT
43What are some advantages of using citalopram?
Well tolerated
Few drug interactions
44What is the typical dose for escitalopram?
5-20mg
45What is the max dose of escitalopram for elderly pt?
10mg
46What is the typical dose for fluoxetine?
10-80mg
47What is one disadvantage of fluoxetine?
> drug to drug reactions
48What is one advantage about the half life of fluoxetine?
Long so no need to taper off the dose
May be good for patients that aren't compliant
49What is one disorder aside from depression/anxiety that fluoxetine is helpful at treating?
Eating disorders
50What is the typical dose for sertraline?
25-200mg
51What is one disorder aside from depression/anxiety that sertraline if helpful at treating?
OCD
52What SSRI can often "ramp up" bipolar symptoms?
sertraline
53What is the preferred SSRI for treating OCD?
fluvoxamine
54What is the typical dosing of fluvoxamine?
50-300mg at HS or BID
55What are disadvanatages of fluvoxamine?
> drug to drug interactions
sedating
56What is the typical dose of paroxetine?
10-50mg at HS
57What are the disadvantages of paroxetine?
> drug to drug interactions
> risk of birth defects
> side effects r/t cognition & sexual disfunction
58What SSRI has the least impact on QT prolongation?
paroxetine
59What is the typical dose of venlafaxine?
37.5-375mg AM
60When stoppping venlafaxine, what should the clinician tell the patient?
Must slowly taper off of it and expect significant w/d symptoms ("brain zaps")
61What is the typical dose of desvenlafaxine?
50-150mg AM
62What is the typical dose of duloxetine?
20-120mg AM or BID
63How should most antidepressants be stopped?
Taper
-reduce by 50% every 3-4 days
64When restarting an antidepressant, how should this be approached?
Increase the dose every 4-7 days until prior target dose is achieved
65What is the typical dose for buspirone?
5-60mg BID (AM & Dinner)
66What is the advantage of Viibryd?
Antidepressant w/ antianxiety effect (Buspar + SSRI effect)
67What benzo has the shortest half life?
Lorazepam
68What benzo is the most "addictive"?
alprazolam (Xanax)
69What benzo is best at treating panic?
clonazepam
70What benzo is approved for insomnia?
temazepam
71What is important to remember about Valium?
Long half life (100+ hours)
72What medication is best for alcohol withdrawal?
Librium
73Why are benzos not a good choice for long-term treatment of anxiety?
Over time, tolerance develops and as the concentration of the drug drops, anxiety increases. Therefore, treatment then becomes treatment for the dependence symptoms and not really the anxiety.
74What is the equation for changing benzos using the equivalent ratios?
Current Daily Dose x (Desired/Equivalent Dose Current)=Daily Dose of Desired
Ex. 6mg lorazepam x (10mg diazepam/2mg lorazepam)=30mg diazepam daily
75What are the recommendations for stopping benzos?
Taper needs to be over >2 weeks but < 6mo
76How should you proceed with switching to a longer acting benzo when trying to eliminate benzo use altogether?
Reduce by 50% over 2-4 weeks (switch half way through)
Maintain dose for 1-2 months w/ long acting option
Reduce by 25% every 2 weeks until eliminated
77What is one benefit of using longer acting benzos?
Less addiction
Less withdrawal side effects when tapering off them
78What population should not receive long acting benzos?
Elderly
79What are some off label adjunct medications that can help with anxiety control?
Trazodone
Beta Blockers
Antihistamines
Clonidine
Prazosin
Gabapentin
Seroquel (anxiety w/ agitation)
**short term: benzos, baclofen (<2 wks)
80What medications are a good adjunct for reducing panic attacks?
Beta Blockers: propranolol
81What patients should avoid use of propranolol or other beta blockers?
H/O COPD/Asthma
82What hydroxizine is actually the one approved for anxiety?
Hydroxizine pamoate
83What is clonidine used to treat?
Break through anxiety
Nightmares
ADHD
Withdrawals
84What is the best non-pharamacological treatment for treating anxiety?
Therapy
85How do you know that treatment for anxiety is working?
Evaluate w/ screening tool
Discuss improvement in: daily function, relationships, self-care, and less need to see the provider
86What should the clinician do if progress is not being made with controlled substances?
Drug screen
Serum drug level
Consider stopping high risk meds and trying something else
87What diagnosis is is characterized by intrusive thoughts, rituals, preoccupations and compulsions?
OCD
88What term defines a recurrent, intrusive thought, feeling, idea or sensation?
Obsession
89What term defines conscious, standardized, recurrent behavior?
Compulsion
90True or False: A patient with OCD understands the irrationality of both the obsession and compulsion.
True
91Compulsive actions may be an attempt to alleviate _______ associated with the obsession.
anxiety
92Obsessions and/or compulsions are time consuming and significantly interfere with ______.
Functioning
93OCD is linked to:
Serotonin dysregulation
Altered functioning in neurocircuitry between orbitofrontal cortex, caudate and thalamus
Significant genetic component
94Explain why Some learning theorists suggest that obsessions are conditioned stimulus.
A neutral stimulus becomes associated w/ fear or anxiety through respondant conditioning
The neutral stimulus begins to heighten anxiety or discomfort when encountered
95How are compulsions developed?
The behaviors or compulsions are active avoidant strategies that sometimes serve to alleviate anxiety from obsessions
These avoidant strategies then become learned patterns of compulsive behavior
96What is the difference between OCD and having a obsessive compulsive personality disorder?
Obsessive compulsive personality disorder has an obsessive focus on details, perfectionism, and symmetry
97What are the psychodynamic factors that contribute to OCD?
Maintaining symptomatology for secondary gains
Accommodation by relatives, thus reinforcing behavior
Interpersonal difficulties and environmental stressors increase the patient’s anxiety, thus increasing symptomatology
98What is the DSM-5 criteria for diagnosing OCD?
Presence of obsessions, compulsions, or both
Obsessions are time consuming (more than 1 hour per day)
99What are the most common clinical features in a patient with OCD?
Obsession of contamination, accompanied by compulsions of washing or avoidance of contamination
Obsession by pathological doubt, accompanied by compulsion of checking
Obsession by intrusive thoughts without compulsions
Need for symmetry or precision, accompanied by compulsion to be slow and methodical
Other less common patterns include religious obsessions, compulsive hoarding, hair pulling, nail biting and masturbation
100New onset OCD in older adults should alert the clinician to consider what differential diagnosis?
Neurological abnormalities
101What are the treatment options for OCD?
SSRIs
All SSRIs available in the US have been approved by the FDA for the treatment of OCD
Higher doses are often necessary for beneficial effects
Clomipramine:
First drug approved by the FDA for the treatment of OCD
Most selective for serotonin re-uptake of all tricyclics and tetracyclics
Other drugs:
For unresponsive patients, augment with buspirone, mood stabilizers or SGAs
Other options include Effexor and MAOIs, especially Nardil
Best clinical outcomes occur when pharmacotherapy is used in combination with behavioral therapy
102What therapy is best for treating OCD?
Behavioral: Exposure and response prevention
Other behavioral approaches include:
desensitization
thought stopping
flooding
implosion
aversive conditioning
103How does the clinician know if current treatment for OCD is helping?
Good prognosis indicated by:
good social and occupational adjustment,
presence of a precipitating event,
episodic nature of symptoms
104What prognositc factors are linked to poor prognosis with a pt w/ OCD?
Indicated by:
yielding to, rather than, resisting compulsions
childhood onset
bizarre compulsions
need for hospitalization
co-existing MDD
delusional beliefs
presence of a personality disorder (particularly schizotypal)
105What is BDD?
Preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment
Diagnostic criteria stipulates that patient performs compulsive behaviors such as mirror checking, excessive grooming or comparing self to others
106What is hoarding disorder?
Characterized by acquiring and not discarding things deemed to be of little or no value, resulting in excessive clutter of living spaces
Driven by an excessive fear of losing items that the person believes will be useful in the future
Diagnostic criteria includes significant distress and impairment in functioning due to hoarding. Specifiers relate to insight. Delusions about hoarded items may be present
107What is different about hoarding in comparrison to OCD?
Worsens over time
108What is trichotillomania?
Repetitive hair pulling, leading to variable hair loss
Focused pulling: intentional to control unpleasant personal urges or sensations
Automatic pulling: Occurs outside the person’s awareness
109What is excoriation?
Compulsive and repetitive picking of the skin
Cause is unknown
Diagnostic criteria requires recurrent skin picking resulting in skin lesions and repeated attempts to decrease or stop picking
Skin picking must cause clinically relevant distress or impairment in functioning
110What is the best treatment for hoarding disorder?
CBT
111What is one treatment option for excoriation?
Naltrexone
112
What is the result of chronic anxiety?
>negative thinking; catastrophic in nature
113Define a panic attack.
Acute, intense attack of anxiety accompanied by a feeling of impending doom
114What is a common behavior associated w/ a panic disorder?
Avoidance behavior or anticipatory anxiety that another panic attack will occur
115To fully diagnose a panic disorder, how long should symptoms be present?
1 mo of intense worry following 1 attack
116To fully diagnose argoraphobia, how long should symptoms be present?
>6mo
117What are the symptoms associated with GAD?
Excessive anxiety/worry
Difficulty controlling/managing worry
Restlessness
Fatigue
Poor concentration
Irritability
Muscle tension
Insomnia
118What medical diagnoses can cause anxiety or panic?
Thyroid dysfunction (hypo or hyper)
pheochromocytomas
hypoglycemia associated w/ insulinomas
seizure disorders
vestibular dysfunction
neoplasm
medications or illicit substances
arrhythmias
COPD
asthma
119What symptoms if present may indicate a medical problem vs a mental disorder?
ataxia
alerterations in consciousness
loss of bladder control
late in life onset
120What is the treatment for agoraphobia?
Behavioral therapy
121What medications are not recommended for first-line treatment of anxiety?
antipsychotics
anticonvulsants
122What medications are not recommended for treating social anxiety disorder?
tricyclic antidepressants
quetiapine
123What is the timeframe for maintenance treatment for anxiety?
at least 6 mo
124What type of therapy promotes the goal of increasing the pt's development of insight into psychological conflicts that if left unresolved can manifest into symptomatic behavior?
Insight-oriented
125What anxiety disorder has a proportionate number of men and women that are affected?
Social anxiety
126What anxiety disorder does not show clear findings of amygdala hyperactivty that is often associated with other anxiety disorders?
GAD