Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Anxiety Disorders; Trauma and Stress Related Disorders (Pearls)

ANXIETY DISORDERS
Generalized anxiety disorder
Patient will present as → a 35-year-old female with a complaint of worry which she cannot control for the last year. She tells you that her symptoms daily consisting of sleep disturbances, difficulty concentrating, and irritability. She reports her symptoms started around age 17 but have worsened.

Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)

  • The individual finds it difficult to control the worry.
  • The anxiety is associated with three (or more) of the following six symptoms:
    • Restlessness or feeling keyed up or on edge
    • Being easily fatigued
    • Difficulty concentrating or mind going blank
    • Irritability
    • Muscle tension
    • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
  • The anxiety causes clinically significant distress or impairment
  • The disturbance is not attributable to the physiological effects of a substance or another medical condition
  • The disturbance is not better explained by another mental disorder

Treatments:

  • SSRIs: Paroxetine and escitalopram; SNRIs: Venlafaxine
  • Buspirone is also effective; the starting dose is 5 mg PO bid or tid. However, buspirone can take at least 2 wk before it begins to help.
  • Benzodiazepines (short-term use), beta blockers
  • Psychotherapy
Panic disorder
Patient will present as → a 26-year-old first-year PA student with a medical history significant for GERD comes to your office because of frequent episodes of palpitations. The palpitations are sudden in onset and are accompanied by sweating and a sense that she is going to “pass out.” The episodes typically last no more than 10 minutes, and although the patient feels as if she may pass out, she never has. The episodes first appeared when she started PA school and have increased in frequency to the point where she is afraid to attend lectures out of fear of having an “attack.”

An occurrence of three panic attack (sudden unexpected periods of intense fear or discomfort) episodes in three weeks

  • At least one of the attacks has been followed by one month (or more) of one or both of the following:
    • Persistent concern or worry about additional panic attacks or their consequences
    • A significant maladaptive change in behavior related to the attacks

Treatments:

  • SSRIs: Paroxetine, Sertraline, Fluoxetine
  • Benzodiazepines: for acute attacks (watch for abuse)
  • CBT (relaxation, desensitization, examining behavior consequences)
Phobic disorders Specific phobia (see below)

Social phobia (social anxiety disorder)

  • Marked and persistent (>  6 months) fear of social or performance situations in which one is exposed to unfamiliar people or to possible scrutiny by others
  • Fear of acting in a humiliating or embarrassing way
    • public speaking, initiating conversation, dating, eating in public
  • May coexist with avoidant personality disorder
Specific phobias
Patient case presentation → a lab technician calls to tell you that a 22-year-old man you have sent for a blood draw is very anxious. He says he is terrified of having his blood drawn and almost faints at the sight of the needle.

Excessive and persistent fear of a specific object, situation or activity that is generally not harmful.

  • Lasts for 6 months or more.
  • Patients know their fear is excessive, but they can’t overcome it.
  • These fears cause such distress that some people go to extreme lengths to avoid what they fear. Examples are fear of flying or fear of spiders.

Treat with exposure therapy (first line), teach to relax and try to understand/overcome the fear

  • SSRI + CBT
  • Benzodiazepines (i.e prior to flying)
  • Treat agoraphobia just as GAD with SSRIs and CBT
TRAUMA- AND STRESS-RELATED DISORDERS
Post-traumatic stress disorder The patient has experienced a traumatic event which causes an acute stress reaction. Once the symptoms persist past 1 month it is now considered post-traumatic stress disorder (PTSD)

Treatment:

  • SSRIs are first-line
  • Cognitive Behavioral Therapy (CBT)
  • Prazosin for nightmares
  • Benzodiazepines, if used, should not be continued more than 2 weeks after a traumatic event
Adjustment disorders The disproportionate response to a stressor that would normally be expected (ex. job loss, physical illness) which begin within 3 months of the stressor and end within 6 months after stressor resolved

  • Reaction out of proportion to the stressor or impairs daily functioning

Stressors:

  • Marital conflict
  • Financial conflict
  • Family conflict/parental separation
  • School problems/changing schools
  • Sexuality issues
  • Death/illness in the family

Treatment is psychotherapy

Psychiatry EOR: Persistent depressive disorder (Lecture) (Prev Lesson)
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