Distinguished future physicians welcome to Stomp on Step 1 the only free videos series
that helps you study more efficiently by focusing on the highest yield material.
I’m Brian McDaniel and I will be your guide on this journey through Anxiety Disorders.
This is the 3rd video in my playlist covering Psychiatry and we are going to review things
like Generalized Anxiety Disorder, PTSD, Phobias & Panic attacks.
Anxiety is uncontrolled fear, nervousness and/or worry about trivial or non-existent
things.
It is an unpleasant fear of future events that are unlikely to occur.
Some patients have insight and realize that their uneasiness is illogical, but that does
not alleviate symptoms.
A certain level of anxiety is considered normal in many situations, but frequent anxiety or
anxiety that inhibits function is pathologic.
During anxiety sympathetic nervous system activation can result in physical symptoms
such as Palpitations, Tachycardia, Shortness of breath, Muscle tension, Restlessness, Lack
of focus, Sweating or chills and Changes in sleeping pattern.
In order to make a diagnosis of anxiety, one must rule out other potential causes of these
symptoms.
The differential diagnosis for anxiety includes other psychiatric disorders, cardiac abnormalities
(such as myocardial infarction or valvular disease), endocrine disorders (like hyperthyroidism)
and respiratory disease (such as asthma or Pulmonary Embolism).
Substances such as street drugs and prescribed medications must also be ruled out as a potential
cause of the symptoms.
We are going to hold off on discussing most of the different treatment options for anxiety
until a later video that will cover all of pharmacology for the psychiatry section.
That video will cover things like SSRIs, anxiolytics and cognitive behavioral therapy which can
be used to treat anxiety disorders.
However, during this video I will mention a couple treatment options that are used for
specific anxiety disorders.
We will start our discussion with Generalized Anxiety Disorder or GAD.
You can see here in the top right corner I give GAD a high yield rating of 2.
For those of you who aren’t familiar with the High Yield Rating it is a scale from 0
to 10 that gives you an estimate for how important each topic is for the USMLE Step 1 Medical
Board Exam.
GAD is a prolonged period of near constant anxiety.
Their anxiety is not linked to a specific item, person, or situation (AKA it isn’t
a phobia).
They usually worry about a wide variety of things including school/work performance,
finances, health, friends and/or family members.
Their anxiety is “generalized” across many situations.
Their anxiety frequently presents with “physical” symptoms and may be severe enough to impair
function.
A Panic Attack is sudden onset period of extremely intense anxiety accompanied by numerous signs
and symptoms of anxiety.
The attack is often associated with a sense of impending doom.
These “episodes” usually last 10 to 30 minutes and are disabling.
The patient returns to their normal level of function soon after the panic attack.
They may be brought on by an inciting event or be completely unprovoked.
I’d like to stop here for a moment to clarify the difference between generalized anxiety
disorder and a panic attack.
GAD can be thought of as a constant moderate level of anxiety while panic attacks are short
periods of severe anxiety.
Panic Disorder is recurrent panic attacks that are unprovoked and have no identifiable
trigger.
The onset of these anxiety episodes is unpredictable.
Patients may be relatively asymptomatic between attacks, but often have anxiety about having
more attacks.
Their fear is related to the panic attacks themselves rather than a particular external
stimuli.
This differentiates Panic Disorder from Panic Attacks that are caused by things like phobias.
Agoraphobia is anxiety related to open spaces and/or crowded places.
These people are afraid of being helpless or embarrassed in a situation that is difficult
to “escape” from.
This often leads to avoidance of such experiences and in severe cases these people never leave
their homes.
Agoraphobia is most closely related to Panic Disorder.
In this situation patients fear having an unexpected panic attack in a place where they
may be embarrassed in front of other or help may not be available.
However, agoraphobia can be the result of other psychiatric disorders such as specific
phobia.
Specific Phobia is an excessive amount of anxiety related to a specific situation or
item that interferes.
Common examples include fear of heights, spiders or medical injections.
These individuals can be relatively asymptomatic in the absence of exposure to what they fear.
Some individuals will adapt quite well and you won’t even know they have a phobia because
they are good at avoiding the exposure.
For example, somebody afraid of heights may move to an area with no mountains or high
rise buildings.
Specific phobia can lead to a panic attack.
However, these attacks only occur as a result of exposure to what they fear.
They will not have panic attack in the absence of external stimuli.
This differentiates it from panic disorder where the individual will have unprovoked
panic attacks.
In extreme cases specific phobia can lead to Agoraphobia.
For example, if somebody is deathly afraid of spiders they may never want to leave their
house.
Treatment can include Exposure Therapy.
Here the patient creates a hierarchy of fears and is exposed to them in order of increasing
level of fear.
So a person who is afraid of heights will start with standing on a step stool and then
slowly work their way up to using an elevator and going to the top of a sky scraper.
By taking “baby steps” patients are often able to do things they would have never been
able to without the process.
In certain situations benzos may be used if the feared stimuli is infrequent and unavoidable.
For example, somebody who is afraid of flying but only takes a few flights a year may be
well controlled with benzos on an as needed basis.
Social Anxiety Disorder (AKA Social Phobia) is anxiety in social situations such as public
speaking, eating in public or using public restrooms.
This usually includes an intense fear of scrutiny and judgment from others.
These patients may be relatively asymptomatic if they can avoid being the center of attention.
Social Phobia can be thought of as a Specific Phobia where the fear is related to social
situations.
However, despite the similarities the two disorders are separate diagnoses in the DSM.
In extreme cases it can lead to panic attacks.
Beta blockers are sometimes used on an as needed basis for “performance anxiety”
of “stage freight”.
For example, if a person has to give a big presentation you can give a beta blocker about
30 minutes before the meeting in order to block some of the sympathetic signals.
They will still have the anxiety, but because the physical symptoms of anxiety are blunted
they won’t realize they are anxious.
Obsessive-Compulsive Disorder is anxiety and intrusive thoughts that drive the patient
to unusual repetitive actions called Compulsions.
The compulsions temporarily relieve the anxiety in some patients while others feel like they
“just have to” do their rituals.
Common compulsions include counting their steps, repetitively washing hands, preoccupation
with certain numbers and rituals such as opening and closing doors repetitively.
The patient often realizes that their fears and compulsions are irrational, but there
remains a lack of control.
OCD should not be confused with the similar sounding Obsessive Compulsive Personality
Disorder (OCPD).
There are some similarities between the two as both can include a preoccupation with things
like order, cleanliness and organization.
However, OCDP patients usually lack the “classic” compulsions found in OCD.
OCD patients also have insight, while OCPD patients do not.
In OCD they view their thoughts and behaviors as abnormal, unwanted and distressing.
In OCPD they view their way of thinking as normal and beneficial.
They don’t realize they have a disorder.
We will discuss OCPD in much more detail in a later video covering personality disorders.
If you would like to skip ahead to that video you can click on this orange box here
Post-traumatic Stress Disorder is anxiety related to a traumatic experience that may
include flashbacks, nightmares and avoidance of certain triggers that remind them of the
experience.
These patients may also have hyperarousal where they have an amplified response to external
stimuli such as loud noises.
Classically the trauma is experiencing or witnessing a life threatening event or sexual
assault.
Symptoms must be present for more than a month in order to make a diagnosis of PTSD.
If these same symptoms last for less than a month the patient would more correctly be
diagnosed with Acute Stress Disorder.
That brings us to the end of this video.
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The next video in the psychiatry section is going to cover Malingering, Somatoform Disorder
& Factitious Disorder.
If you would like to be taken directly to that video you can click on this black box
here.
Thank you so much for watching and good luck with the rest of your studying