#14 Anxiety H&P.txt

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#14 Anxiety H&P.txt
2012-07-25 11:57:28
Family Med

Family Med
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  1. #14 Anxiety
  2. Differential diagnosis of anxiety disorders
    • Adjustment disorder
    • Organic states
    • Substance abuse disorders
    • Mood disorders
    • Personality disorders
  3. 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
  4. Different anxiety disorders
    • Panic disorder with or without agoraphobia (PDAG)
    • Agorphonia without panic
    • Specific phobia (SP)
    • Social anxiety disorder
    • Obsessive-compulsive disorder
    • PTSD
    • Acute stress disorder (ASD)
    • Generalized anxiety disorder (GAD)
    • Anxiety d/o due to GMC
    • Substance-induced anxiety disorder
    • Anxiety disorder not otherwise specified
  5. 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
  6. 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
  7. 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?"
  8. 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
  9. 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?"
  10. OCD Screening
    • "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
  11. GAD
    • very common
    • excessive uncontrollable worry, muscle tension, fatigue, insomnia, impaired concentration, irritability
    • WHAT IF:
    • Worry
    • Hard-to-control headache
    • Anxiety
    • Tension
    • Insomnia/irritability/irritable bowel
    • Fatigue
  12. PTSD
    • "anything really traumatic or scary happen to you?"
    • "does that affect your life now?"
    • flashbacks, hyperaurousal, avoidance
  13. Baseline Laboratory Investigations in patients with anxiety disorders
    • CBC
    • U/A
    • FBG
    • Fasting lipids
    • 24h CrCl (if Hx of renal disease)
    • Electrolytes, Cr
    • TSH
    • Liver enzymes
    • ECG (>40yrs)
    • serum bilirubin
    • Preg test
    • Urine drug screen
    • Prolactin
  14. Acute treatment
    • -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
  15. 3 types of pharmacologic therapy for anxiety
    antidepressants, anxiolytics, psychotropics to augment antidepressants
  16. 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