Psychres Differential Diagnosis of Anxiety Disorders

7/30/2019 Psychres Differential Diagnosis of Anxiety Disorders

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Differential Diagnosis of AnxietyDisorders


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Objectives

Define anxiety and be able to identify

when it goes from being normal to being

pathological

Become familiar with the major anxiety

diagnoses, including diagnostic criteria,

prevalence, onset, typical course and

treatment


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Define Anxiety

Miriam-Webster Medical Dictionary

1. a: a painful or apprehensive uneasiness of mindusually over an impending or anticipated ill b: a causeof anxiety = NONPATHOLOGICAL

2. an abnormal and overwhelming sense ofapprehension and fear often marked by physiologicalsigns (as sweating, tension, and increased pulse), bydoubt concerning the reality and nature of the threat,and by self-doubt about one's capacity to cope with it= PATHOLOGICAL


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Anxiety Definition

Features of Pathological Anxiety Autonomy: no or minimal recognizable

environmental trigger

Intensity:exceeds the patients capacity tobear discomfort

Duration: the symptoms are persistent ratherthan transient

Behavior: anxiety impairs coping andresulting in disabling behavioral strategiessuch as avoidance or withdrawal


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Anxiety Definition

Manifestations of Anxiety Physical symptoms: related to autonomic

arousal (elevated pulse or resp rate, physical

tension, nausea, sweating) Affective Symptoms: ranging from mild

edginess to severe terror

Behavior: avoidance or compulsions

Cognitions: worry, apprehension,obsessions, and thoughts about emotional orbodily damage


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Workup

Dont forget medical workup! Especially if historynot typical, if family history negative, in absenceof stressors, in older patient, or unusual physicalsx/signs

Possible medical causes: Hyperthyroidism

Carcinoid

Hyperparathyroidism Pheochromocytoma

Hypoglycemia

Substance intoxication or withdrawal


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DSM-IV-TR Anxiety Disorders

Panic Disorder (with or withoutAgoraphobia)

Generalized Anxiety Disorder

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

Acute Stress Disorder

Social Phobia

Specific Phobia


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Panic Attack

Associated with many different anxiety disorders(Panic D/O, GAD, Phobias, etc and can be seen inMDD as well)

Discrete period of intense fear or discomfort, with 4(or more) symptoms onset suddenly and reach apeak in 10 minutes

SYMPTOMS:

Palpitations

Sweating

Shaking

Shortness of breath Choking

Chest pain Nausea

Dizziness/Feeling Faint Derealization or depersonalization

Fear of losing control or going

crazy Fear of dying

Paresthesisas

Chills or hot flushes


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Panic Disorder

Criteria:

Recurrent Unexplained Panic Attacks

After at least one attack, 1+ month of at

least one symptom:

1. Worry about more attacks2. Worry about what the attack means or

what will happen after (e.g.. Having an

MI, going crazy)

3. A significant change of behavior related

to attacks Not due to substances/medical

condition, or a different anxiety disorder


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Panic Disorder and Agoraphobia

Agoraphobia literally means fearof the marketplace

DSM Criteria:1. Anxiety about being in places from which

escape might be difficult or embarrassing ifthey felt panicky

2. These situations are then avoided orendured with marked distress (or only witha companion)

3. Not better accounted for by another

anxiety disorder (e.g. specific phobia formalls or social phobia)

Agoraphobia is highly overlappingwith Panic D/O


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Panic Disorder

Lifetime prevalence Panic 3.5%, Agoraphobia 5.3%

Prevalence per Year Panic 2.3%, Agoraphobia 2.8%

2:1 female: male ratio Typically onset in 20s (79% before age 30)

Usually wax and wane over time80% havereoccurence, but 70 % have remissions

50% will also have depression, 20% will have alcohol

abuse Treatment Medication (SSRIs, MAOIs, short term

benzos, beta-blockers) and Therapy (CBT, behavioralcomponent needed for agoraphobia)


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Criteria: Excessive anxiety and worry, more days

than not, for 6+ months, about morethan one topic

Cannot control the worry

With 3 or more of the followingsymptoms (1 in kids): Restlessness

Easily fatigued

Difficulty concentrating

Irritability

Muscle tension Sleep Disturbance

Not due to another anxiety d/o

Not due to another anxiety disorder,substances or medical condition


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Lifetime Prevalence 5.1%, 1 year Prevalence 3.1%

2:1 female: male ratio

Typical onset in adolescent-20s, although can occur atany time

Course is prolonged with fluctuations in symptoms andup to 25% may develop panic at follow-up

Overall felt to be milder disorder than panic ordepression, with only 10% of anxious patients seen by

psychiatrists diagnosed with GAD Treatment: Primarily therapy (CBT, behavioral) but meds

(benzos, beta blockers) when symptoms particularly bad,+/- SSRI, Buspar if chronically symptomatic


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Obsessive-Compulsive Disorder

Prevalence of 2-3% in General population

Onset typically teens to early 20s (only 5% onset afterage 35)

Common obsessions: aggression, contamination,

symmetry, sexual, hoarding, religious, somatic Key differential diagnosis feature: obsessions are ego-

dystonic but recognized as their own thoughts

Roughly equal male to female, although may have slightfemale predominance, but 75% of childhood onset in

males Typically chronic course and difficult to treat

Treatment: Medications (high dose SSRIs,clomipramine) and therapy (exposure with responseprevention)


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Post Traumatic Stress Disorder Criteria:

1. Person experienced a traumaticevent with actual or threateneddeath, injury, or threat to personalintegrity, about which they felt fearand helplessness

2. Persistently re-experienced through(1 or more) Intrusive recollections

Recurrent dreams of event

Flashbacks (feeling as if reliving

experience) Intense distress at exposure to cues of

event

Physiological reactivity to cues of event


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Post Traumatic Stress Disorder3. Avoidance of Stimuli associated with event (3 or more)

Efforts to avoid thoughts, feelings or conversations about the event Efforts to avoid activities, places or people that provoke memories of

event

Inability to recall important aspects of the event

Diminished interest or participation in usual activities

Feeling estranged from others

Restricted range of affect Sense of foreshortened future

4. Symptoms of increased arousal (2 or more) Difficulty falling or staying asleep

Irritability or anger outbursts

Difficulty concentrating

Hypervigilance Exaggerated startle response

5. Symptoms occur for more than one month (if for less than 1 month,consider Acute Stress Disorder)

6. Causes significant distress or functional impairment


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Post Traumatic Stress Disorder

Prevalence: 0.5% in men, 1.2% in women,lifetime prevalence up to 8%

Can occur at any age (kid burn pts up to 80%PTSD at 1 year, only 30% in adults)

Traumatic events: For men, most due to combat.For women, most likely physical assault or rape.

Treatment: Medications (antidepressants,buspar, mood stabilizers, betablockers, benzos,

antipsychotics) and therapy (individual, CBT,group)


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Social Phobia

Criteria: Persistent fear of one or more social or

performance situations where he/she willbe around unfamiliar people, where he orshe fears acting in a way to that will behumiliating or embarrassing

Exposure to feared situation causesanxiety (possibly a panic attack)

He/she recognizes fear is excessive orunreasonable

The feared situation is avoided and this

avoidance/anxiety has functionallimitations

Duration > 6mo (in adults)

Not due to other anxiety d/o, medicalillness, or substances


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Social Phobia

Prevalence between 3-13%

Female > male in community samples, male >female in clinical samples

May be limited (performance anxiety) orgeneralized

Onset either in late adolescence or in earlychildhood

Tends to develop slowly but is chronic but

fluctuating Treatment: Medications (SSRIs, MAOIs, benzos,

beta blockers) and therapy (CBT, behavioral)


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Specific Phobias

Criteria: Persistent fear that is excessive or

unreasonable caused by the

presence of anticipation of a specific

object or situation

Exposure to the feared thingprovokes anxiety (possibly PA)

The phobic situation is avoided or

endured with intense distress

The avoidance, anticipations or

distress cause functional impairment Duration > 6 months in adults

Not due to other anxiety d/o, medical

illness, or substances


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Specific Phobias

Types of Phobias

Animal type (snakes, spiders)

Natural Environment type (heights, storms)

Blood-injection-injury type (highly family

associated and strong vasovagal response)

Situational Type (flying, driving, elevators)

Other type (vomiting, choking, hypochondria,clowns)


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Specific Phobias

Lifetime prevalence 10-25%

Onset most often in childhood (especiallyanimals, natural, blood-injection-injury types).Situational phobias have a bimodal distribution:

1 peak in childhood and 1 in mid 20s. May spontaneously remit, few come to

psychiatric attention (on 2-3% of psych pts)

Treatment: Exposure based interventions

(systematic desensitization, flooding andparticipant modeling), may also need meds(SSRI, MAOI, benzos)

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Psychres Differential Diagnosis of Anxiety Disorders