Student Adjustment, Anxiety, and Depressive Disorders 2.7.25 PDF

Adjustment, Anxiety, Depressive Disorders RYA NE LE ST ER PA -C CLIN ICA L ME DICINE II FE BRUARY 7, 2025 Objectives Adjustment, Anxiety & Depressive Disorders 1.Summarize the epidemiology, clinical features, how diagnosis is established, potential complications, and treatment for the following c...

Adjustment, Anxiety, Depressive Disorders RYA NE LE ST ER PA -C CLIN ICA L ME DICINE II FE BRUARY 7, 2025 Objectives Adjustment, Anxiety & Depressive Disorders 1.Summarize the epidemiology, clinical features, how diagnosis is established, potential complications, and treatment for the following conditions: Adjustment disorder Post-traumatic stress disorder (PTSD) Anxiety disorders: Generalized anxiety disorder Panic disorder Phobias Agoraphobia Obsessive-compulsive disorder (OCD) Depressive Disorders: Major depressive disorder Dysthymia Premenstrual dysphoric disorder Bereavement Adjustment disorder Obsessive Compulsive Disorder Anxiety Disorders Depressive Disorders Major depressive disorder General Anxiety Disorder Persistent depressive disorder Panic Disorder (dysthymia) Phobic Disorder Premenstrual dysphoric disorder Agoraphobia Trauma and Stressor Related Disorders Post Traumatic Stress Disorder Adjustment Disorder  Adjustment Disorder ▪Anxiety or depression (emotional or behavioral symptoms) in reaction to a stress (Criterion A) ▪ Within 3 months of the stressor onset ▪ Must resolve withing 6 months of the termination of the stressor ▪ Out of proportion in regards to severity ▪The stressor happens → anxious or depressed ▪ The individuals response to the stressor is the physical symptoms of anxiety or stress ▪ Can manifest in many ways: sadness, fear, rage, guilt, shame ▪ Acutely: irritability, tension, sleep difficulties ▪If distressing emotional and behavioral responses to stress occur → adjustment disorder ▪ Followed by the major symptom ▪How is this different: ▪ SITUATIONAL – goes away when stressor goes away/adapt ▪ These occur in reactions to an identifiable stress Adjustment Disorder ▪Treatment: ▪ Behavioral: stress reduction, relaxation, mindfulness exercises ▪ Social: ▪ Psychological: ▪ Therapy – focus on coping mechanisms → helps resilience, reinforce ▪ CBT – treats acute stress ▪ Pharmacologic: ▪ Sedatives for acute phases can be use (Lorazepam), for a limited time ▪ Short term SSRI’s ▪Return to function is expected Adjustment Disorder ▪This can be single event (breakup, medical procedure), multiple stressors (marital problems, business problems), recurrent (seasonal issues), or continuous (painful illness) ▪Difference from MDD: you must meet the criteria for MDD ▪Difference from PTSD: timing, severity of stressor Post Traumatic Stress Disorder  Post-traumatic Stress Disorder ▪Characterized by “reexperiencing” a traumatic event and avoidance of events associated with the trauma ▪This is also in children ▪Clinical findings: ▪ Exposure to a traumatic or life-threatening event (actual or perceived) ▪ Flashbacks, intrusive images, nightmares ▪ Avoidance symptoms (withdrawal) ▪ Increased startle and difficulty falling asleep ▪ Overgeneralized associations ▪ Impulsivity, difficulties in concertation, hyper-alertness ▪ Impairs functioning ▪ Fear based, emotional, behavioral, anhedonia, negative cognitions, combination – varying presentation ▪ Symptoms can be brought on or exaggerated by events that are a reminder ▪ Symptoms have to be for at least ONE MONTH  Post-traumatic Stress Disorder ▪Essential to the diagnosis is the symptoms following exposure to one or more traumatic events ▪Presentation can vary – see next slide ▪All have actual/threatened death, injury, sexual violence – but everyone differs in how they were exposed to it ▪ Direct, indirect, witnessed ▪ More long term effects if it was interpersonal and intentional PTSD ▪Individual will make efforts to avoid the thought/memories ▪A lot of negative thoughts or associations often made ▪Arousal and reactivity begin or get worse after the event ▪ Reckless, destructive behaviors, irritable or angry, verbally or physically aggressive, excessive substance abuse, risky sexual activity; jumping at loud noises, over-reactive to threats ▪More the one month, impairment of functioning ▪Symptoms usually begin within the first 3 months of the trauma ▪Can affect long term effects with emotions, relationships PTSD ▪Lots of overlap with panic and depressive disorders – 75% ▪Association with alcohol and substance abuse ▪Primary care PTSD Screen or PTSD Checklist ▪Tx: ▪ Psychotherapy = improvement in symptoms ▪ What to be able to adapt to the experience, “master” it ▪ Often alongside substance abuse treatment and/or marriage counseling ▪ Pharmacotherapy: ▪ SSRI’s = ONLY MEDICATIONS APPROVED FOR PTSD ▪ Improve depression, panic attacks, sleep disruption, startle responses ▪ NO BENZO’s ▪Many patients have chronic symptoms Anxiety Disorders GENE RALIZED ANXIE TY DISORD ER, PANIC D ISORDER, PHOBIC DISORDE RS Things that pertain to all ▪These are NOT a result of another physical disorder, psychiatric disorder, or drug/substance abuse ▪Not limited to an adjustment disorder ▪Persistent anxiety/fear AND behavioral effects, with somatic symptoms ▪People may use the terms stress, fear, anxiety with lots of overlap ▪The key here is that these are true psychological and somatic components ▪ Because the two features reinforce each other, anxiety can be self generating → worsen ▪ Avoidance of the trigger also triggers anxiety ▪Will become chronic in many people  General Anxiety Disorder ▪Very common, more common than dementia and depression in the older population ▪ Poorer quality of life ▪Feature is excessive anxiety and worry about a number of event or activities ▪ OUT OF PROPORTION ▪ Routine life circumstances ▪Dx: ▪ The anxiety symptoms or somatic complaints are present more days than not for at least 6 months ▪ Can be associated with a number of different activities ▪Usually long standing, sometimes difficult to treat GAD: how to distinguish from non GAD ▪GAD: ▪Non pathological anxiety: ▪ Worries are excessive ▪ Perceived as more manageable worries ▪ Worries interfere with psychosocial functions ▪ No excessive ▪ More distressing, pervasive, no precipitants ▪ Can put off these worries if something else is ▪ Longer duration more important ▪ Greater range of worries ▪ Everyday worries less likely to be accompanied ▪ Distressed about the constant worry by symptoms ▪ Restlessness, on edge, “stressed” ▪ Impairs some everyday functioning Mean age of onset = 35 Most people say they have felt anxious their whole life GAD ▪Tx ▪ Pharmacologic: Antidepressants SSRI’s and SNRI’s = first line **** ▪ SSRI: escitalopram, paroxetine ▪ SNRI: venlafaxine, duloxetine ▪ 2-4 week delay they take effect ▪ Behavioral: ▪ Often used with medication ▪ Relaxation techniques, desensitization, imagery, exercise ▪ Psychological: **** ▪ Cognitive behavioral therapy – FIRST LINE psychotherapy for anxiety disorders ▪ Cognitive component = examining the thoughts with the fear → finding a behavioral technique to give exposure to the patient ▪ Group therapy ▪ Acceptance and commitment therapy ▪ Social: ▪ Peer support ▪ Social modifications  Panic Disorder ▪Panic attacks ≠ panic disorder ▪In panic disorder, panic attacks are recurrent, unpredictable episodes of intense anxiety with physiologic effects ▪Panic disorder: when panic attacks are accompanied by a chronic fear of the recurrence of an attack or a behavior is adapted to avoid the potential trigger ▪Familial component ▪Onset under 25 ▪Female to make 2:1 ▪Patients will often undergo conditions emergent to their symptoms (heart attack, hypoglycemia) ▪GI symptoms are commonly associated (n/v, pain, constipation, diarrhea) ▪Really affects their lives → agoraphobic, depresses, hypochondriacal ▪ Depression and suicide are risks ▪ Alcohol abuse and dependence on sedatives results from self treatment ▪Average age of onset in US is 20-24 Panic Disorder ▪Panic attack ▪Recurrent and unexpected ▪ No obvious trigger – “out of the blue” ▪These can be frequent or in bursts – varies ▪Have to have a full symptom panic attack to have the diagnosis ▪Have worry about future panic attacks and attempt to avoid situations where they could occur Panic Disorder ▪Tx: ▪ Pharmacologic: antidepressants are first line (SSRI’s, SNRI – venlafaxine) ▪ Benzo’s early on along with antidepressants (why), then wean off ▪ Behavioral: ▪ Often used with medication ▪ Relaxation techniques, desensitization, imagery, exercise ▪ Psychological: ▪ Cognitive behavioral therapy – FIRST LINE psychotherapy for anxiety disorders ▪ Cognitive component = examining the thoughts with the fear → finding a behavioral technique to give exposure to the patient ▪ Group therapy ▪ Acceptance and commitment therapy ▪ Social: ▪ Peer support ▪ Social modifications  Phobic Disorder ▪DSM V = Specific phobia ▪Common to have more than one ▪Must have a fear/anxiety to a particular situation or object = stimulus ▪To diagnose – response much be intense/severe ▪ Amount may vary to the proximity ▪ Response can take the form of full or limited panic attack ▪Simple or Social phobias ▪ Agoraphobia – intense fear with common situations – more to come ▪Active avoidance of it the situation  Phobic Disorder ▪Response of the anxiety/fear is OUT OF PROPORTION to the actual danger it poses or more intense than necessary ▪ They might recognize that its out of proportion ▪The fear or anxiety must be present for at least 6 months ▪Likely heighted arousal in anticipation of or during exposure ▪Can stem from a traumatic event or witnessed event or panic attack ▪ Most don’t know why they have the phobia ▪ Most develop before the age of 10 Phobic Disorder ▪Tx: ▪ Pharmacologic: antidepressants are first line (SSRI’s, SNRI – venlafaxine) ▪ Gabapentin is an options ▪ Specific phobias: BB ▪ Behavioral: ▪ Often used with medication ▪ Relaxation techniques, desensitization, imagery, exercise ▪ Psychological: ▪ Cognitive behavioral therapy – FIRST LINE psychotherapy for anxiety disorders ▪ Cognitive component = examining the thoughts with the fear → finding a behavioral technique to give exposure to the patient ▪ Group therapy ▪ Acceptance and commitment therapy ▪ Social: ▪ Peer support ▪ Social modifications  Agoraphobia ▪The fear or anxiety has to be triggered by exposure to a wide range of situations ▪ At least 2 of the 5 ▪ Something terrible might happen ▪ Panic like symptoms are any of they symptoms listed in panic attack criteria ▪Amount of fear can vary with closeness and with anticipation or in the presence of the fear ▪Can have partial or full panic attack symptoms ▪Happen with every exposure, exposures are avoided or require some adaptation (C and D) ▪ Might be so severe they are homebound ▪Out of proportion to actual danger and context ▪Lasts at least 6 month and causes significant distress ▪More common in women, 1-7% of adolescents and adults ▪Usually persistent and chronic, complete remission is rare unless treated Obsessive Compulsive Disorder  OCD ▪In a category of OCD and related disorders (not an anxiety disorder) ▪Irrational idea or impulse interferes into the patients awareness ▪2 components = characteristic symptoms ▪ Obsession: distressing thought/repetitive thought/persistent thoughts ▪ They are not pleasant, they are intrusive, unwanted, and cause distress ▪ Compulsion: repetitive action/rituals, feel driven to perform these ▪ Can have one or both ▪ They are typically related, but can be unrelated, unrealistic or excessive ▪The person is often aware of these (what is this called), they know that are not logical, they want to resist them, but anxiety gives in ▪ Anxiety is alleviated by the ritual OCD ▪Must take up to at least one hour a day, or cause clinically significant distress or impairment = Criterion B ▪ This separate OCD from normal fear ▪ Distress/impairment can be manifested in avoidance (public places for fear of germs) ▪The severity of the obsession and compulsion can be mild or severe ▪They can have a sensory phenomenon before the compulsion: ▪ Things just aren’t right, things seem wrong, incomplete ▪Lots of overlap – OCD spectrum ▪Correlation with major depression (2/3) ▪Young, divorced, separated, unemployed ▪ Average onset is 19.5 years ▪Usually chronic if untreated OCD ▪Tx: ▪ Pharmacologic: ▪ SSRI and clomipramine (TCA) ▪ Behavioral: ▪ Exposure and response ▪ Psychological: ▪ CBT – works well with exposure and response ▪ Social: ▪ Support system in place ▪ Can really affect their ability to lead a normal life ▪ Procedures: ▪ Transcranial magnetic stimulation ▪ Deep brain stimulation Depressive Disorders Major Depressive Disorder ▪Depression is common ▪ Up to 30% of primary are visits – higher in females ▪ At any age – peak in the 20’s ▪ Course is variable ▪ Can be the final expression of underlying issues: ▪ Categories/types of depressive disorders: ▪ Adjustment disorder with depressed mood ▪ Depressive disorders ▪ Major depressive disorder ▪ Persistent depressive disorder (dysthymia) ▪ Premenstrual dysphoric disorder ▪ Bipolar disorder ▪ Mood disorders secondary to illness and medication ▪Changes will affect the persons ability to function ▪ Focus on timing and duration to set the disorders apart  MDD ▪Mood, psychological, and cognitive symptoms ▪Major factors: ▪ Anhedonia ▪ Withdrawal from activities ▪ Feelings of guilt ▪Others: ▪ Inability to concentrate ▪ Cognitive dysfunction ▪ Anxiety ▪ Chronic fatigue ▪ Feelings of worthlessness ▪ Somatic complaints ▪ Loss of libido ▪ Thoughts of death ▪ Insomnia ▪ Anorexia/weight loss ▪ constipation MDD ▪Diurnal symptoms ▪Can also be associated with psychosis, paranoia, somatic delusions, hallucinations ▪Subsets of major depression - FYI: ▪ Major depression with atypical features ▪ Melancholic major depression ▪ Major depression with seasons (seasonal affective disorders) ▪ Major depression with peripartum onset MDD ▪How do we know? ▪ Can’t be a symptom or a cause of another disorder or illness ▪ Other behavioral health DO ▪ Thyroid ▪ Brain tumor ▪Suicide is the most important/significant complication ▪ Rates in ages 15-35 are rising ▪ Recent event might trigger ▪ If thinking about it more than one hour a day = high risk ▪Assess with: ▪ Hamilton scale ▪ Montgomery-Asberg scale ▪ QIDS-SR 16 MDD – diagnosis ▪Period of at least 2 weeks, which there is either depressed mood* of loss of interest/pleasure in all or nearly all activities* for most of the day, every day = ESSENTIAL for DX ▪ Bereavement ▪All need 4 additional symptoms during the same 2 weeks (3-9) ▪These symptoms must be new or worsened from baseline ▪ Almost every day, for most of the day during the episode ▪Must have significant distress or impair functioning, Criterion B MDD ▪Who is at risk: ▪ Adverse childhood experiences, income, education, racism, gender ▪ Genetics ▪ Other disorders – medical and mental health related ▪High mortality rate, most of which is by suicide – “died by suicide” Dysthymia/PDD ▪Essential feature is depressed mood that is present for most of the day, for more days than not, for at least 2 years ▪Chronic depressive disturbance ▪ Early and insidious onset ▪ Sadness, loss of interest and withdrawal (2 yrs) ▪ Sad, down in the dumps ▪ Milder but longer acting than MDD, but effects as great or greater ▪Major depression can precede this and major depressive episodes may occur during ▪Because this is chronic, they may seem like their normal ▪Elevated risk of suicidal outcomes Premenstrual Dysphoric Disorder (PMDD) ▪Symptoms during the luteal phase of menstrual cycle ▪ Mood lability, irritability, dysphoria, anxiety = essential features (during pre-menstrual phase) ▪ Behavioral and physical symptoms ▪ REPEATEDLY ▪ Symptoms are comparable to other disorders but the timing/duration is not ▪ Symptoms must have an adverse effect on work or social functioning  Treatment of Depressive Disorders ▪If depression is mild → psychotherapy ▪If there is a true suicidal risk → hospitalization ▪Meds: ▪ SSRI, SNRI, bupropion, trazadone: for all types of depression – typical and atypical ▪ Well tolerated, larger safety profile ▪ Serotonin syndrome ▪ TCA ▪ More variability, narrower safety profile and OD risk ▪ Anticholinergic effects, arrhythmias, seizure threshold ▪ MAO inhibitors ▪ Third line ▪ Lots of restrictions and interactions ▪ Stimulants ▪Any history of med us is helpful ▪Titrate up and monitor for side effects and SI every 2 weeks; wash out period between meds ▪Increased suicidality risk Treatment of Depressive Disorders ▪Electroconvulsive therapy ▪ For severe depression ▪ Use if meds contraindicated or refractory to meds, suicidality ▪ SE: Memory disturbance and headache ▪Phototherapy ▪Transcranial magnetic stimulation – electromagnetic impulses ▪Psychological: ▪ Therapy, CBT, mindfulness-based therapy ▪ Assists with coping, negative thoughts, distortions, increase awareness, self esteem etc. ▪Social: ▪ Social services (ETOH and substance abuse), day treatment, support groups ▪Behavioral: ▪ Desensitization, family therapy, exercise Bereavement Bereavement ▪Experience of losing a loved one by death ▪ Triggers a response that is very similar to MDD – many features overlap ▪The difference is: ▪ Bereavement: the grief is feelings of loss/emptiness ▪ Decreases over time, may come in waves about thoughts of the loss of the loved one ▪ MDD: persistent depressed mood, diminished ability to experience pleasure ▪ Depressed mood is persistent, NOT tied to thoughts ▪Normal grief – 12 months ▪ Complicated grief longer than 12 months with associated features Questions: References and sources unless otherwise noted: ◦ CMDT ◦ DSV-5-TR