#14 Anxiety H&P.txt
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Differential diagnosis of anxiety disorders
- Adjustment disorder
- Organic states
- Substance abuse disorders
- Mood disorders
- Personality disorders
DDx of anxiety disorders
- 1) Adjustment disorder: identifiable stressor causing Sx, Sx within 3 months on stressor, resolves within 6 months.
- nervousness, worry, jittery
- children - fear of separation from major figures
- 2) Organic disorders: hyperthyroidism (tremulousness, palpitations), dementia, stimulants (coffee, amphetamines)
- 3) Substance use disorders: withdrawal of benzodiazepines or alcohol, stimulant use, caffeine, marijuana
- 4) Mood disorders - often with depression
- 5) Personality disorders - often Cluster B with severe anxiety Sx at time of instability
Different anxiety disorders
- Panic disorder with or without agoraphobia (PDAG)
- Agorphonia without panic
- Specific phobia (SP)
- Social anxiety disorder
- Obsessive-compulsive disorder
- Acute stress disorder (ASD)
- Generalized anxiety disorder (GAD)
- Anxiety d/o due to GMC
- Substance-induced anxiety disorder
- Anxiety disorder not otherwise specified
Screening for panic disorder:
- -sudden unexpected episodes of panic/fear
- -avoidance or hesitation to approach situations expected to bring on the symptoms (crowds, enclosed spaces, etc.)
- -must cause significant distress or impairment of function
Screening for agoraphobia
- - avoidance of crowds, lines, bridges, going outside alone, travelling on bus, etc. or need to have a companion as a safe person
- -rarely completely housebound
Screening for Social anxiety disorder
- -shy person?
- fear of embarrassment or negative evaluation by others
- very early onset, childhood or adolescence
- "In general, are you overly anxious or concerned about embarrassing or humiliating yourself while doing things in front of people or interacting with others?"
Mini-SPIN for Dx of SAD
- During the past week: not at all (0) to extremely (4)
- 1) fear of embarrassment causes me to avoid doing things or speaking to people
- 2) avoid activities in which I am the centre of attention
- 3) being embarrassed or looking stupid are among my worst fears
- Score 6+ strongly suggests SAD
Screening for Specific phobia
- -most prevalent anxiety disorder
- -underdiagnosed b/c managed by avoidance
- "Do any of the following make you anxious or fearful?"
- animals, snakes, insects
- heights, storms, being near water
- sight of blood, getting a needle
- enclosed spaces, flying, elevators
- "Does this fear interfere with your life?"
- "Do you experience repeated unwanted thoughts that you cannot easily control?"
- "Do you feel compelled to carry out repetitive acts, such as washing, counting or checking?"
- > 1 hour of time per day, impaired fxn or distress
- very common
- excessive uncontrollable worry, muscle tension, fatigue, insomnia, impaired concentration, irritability
- WHAT IF:
- Hard-to-control headache
- Insomnia/irritability/irritable bowel
- "anything really traumatic or scary happen to you?"
- "does that affect your life now?"
- flashbacks, hyperaurousal, avoidance
Baseline Laboratory Investigations in patients with anxiety disorders
- Fasting lipids
- 24h CrCl (if Hx of renal disease)
- Electrolytes, Cr
- Liver enzymes
- ECG (>40yrs)
- serum bilirubin
- Preg test
- Urine drug screen
- -benzodiazepines for short term relief if severe onset or exacerbation with marked dysfxn
- -stop alcohol and caffeine
- -self help techniques
- F/U in 2 weeks
3 types of pharmacologic therapy for anxiety
antidepressants, anxiolytics, psychotropics to augment antidepressants
Antidepressants for anxiety
- SSRIs and SNRIs are effective for panic disorder, social anxiety disorder, OCD, PSTD and GAD
- 1st line: SSRIs and SNRIs
- 2nd line: TCAs, Novel action(NaSSA), RIMA.MAOIs
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