in today's video we are going to be talking about anxiety disorders this is brought to you by dirty medicine before i get into today's video if you like what i'm doing on this channel you want to give back you want to support dirty medicine and my quest to provide free medical education please consider clicking the join button you can find that join button on my channel home page on the bottom of every video and also as a link as the first link in the description of any video when you click join you'll become a dirty medicine member and in exchange for providing secure monthly financial support to my channel in the form of 4.99 a month you'll get some cool perks one you'll get the dirty medicine logo after your name so whenever you post publicly on my channel everybody will know that you're a dirty medicine member two you'll get access to the locked section of my channel which is under the community tab right now i'm polling members asking them what topic they'd like the next video to be but in the future they might get access to exclusive content now let's get into today's video we are talking about anxiety disorders which means that we're going to be talking about everything that you see on this slide generalized anxiety disorder adjustment disorder panic disorder specific phobia agoraphobia social anxiety disorder post-traumatic stress disorder and obsessive-compulsive disorder these are all a lot of different psychiatric disorders but they all are considered anxiety disorders so let's go through them one at a time as we go i'll point out what's very important for you to know and where relevant i'll give you a really cool mnemonic to memorize something that you need to know for usmle or comlex so let's get started with generalized anxiety disorder now as many of you know if you've been studying the psychiatry section of your textbooks you know that the timeline is very very high yield so in generalized anxiety disorder the timeline is six or more months the symptoms include excessive worry irritability fatigue tension decreased concentration and restlessness so you think about your anxious friend who constantly is worrying excessively about doing poorly in school chances are they have a lot of these symptoms now of note these symptoms are not associated with a specific person or an event and this is important this is actually very high yield because in generalized anxiety disorder the person is not worried about a specific thing the worrying is just generalized as the disease or the disorder implies it is generalized so it's not specific worry about a specific thing and therefore in a question stem on usmle or complex if they give you somebody with symptoms of anxiety but those symptoms are all specific to one singular event chances are it's not generalized anxiety disorder the treatment for generalized anxiety disorder is ssris snris and cbt which stands for cognitive behavioral therapy so you might see that written out on an exam as an answer choice as psychotherapy or the test writer could be much more specific and write cognitive behavior therapy both of those terms are used interchangeably it would be akin to writing antidepressants or ssri so you're just getting a little bit more specific when you write cbt now something that gives medical students a really tough time is comparing and contrasting generalized anxiety disorder with adjustment disorder and people don't quite understand what adjustment disorder is so i want to simplify this and make it stupid and simple so adjustment disorder how does it work well there's some triggering event so some event happens which causes mood symptoms another question for deciding whether or not this is adjustment disorder is asking yourself assuming that you're the physician how long have these mood symptoms been going on since the triggering event and the answer to that question really guides you clinically because if the event and the subsequent mood symptoms have only lasted up to six months meaning basically up to the last day in the fifth month that's adjustment disorder but as soon as those symptoms go beyond the six-month mark so now you're at 6.0 months or greater if they're still having those mood symptoms in response to the triggering event that's generalized anxiety disorder so it's extremely high yield for us emily and complex to understand that some event happens it causes mood symptoms and when i write mood symptoms i'm referring to either anxiety symptoms or depression symptoms and then those symptoms will last either up to six months and therefore it's adjustment disorder or 6.0 months and beyond and therefore it automatically converts to generalized anxiety disorder so you need to understand that six month timeline if the symptoms are still going on then what was previously called adjustment disorder is now converted to generalized anxiety disorder so let's go through this with a stupid example let's say that a man gets a divorce as a result of his divorce he has constant worrying he's very irritable he's just not pleasant to be around now the question is how long do those symptoms go on for and let's assume in this example that he has gotten that divorce three months ago and therefore these symptoms have only been going on for three months therefore we would kind of go to the left side of this flow diagram and therefore we would diagnose him with adjustment disorder we would not call this generalized anxiety disorder because these symptoms have not been going on for at least six months so very very high yield know the timeline and although generalized anxiety disorder technically is not symptoms to a specific event if it's an adjustment disorder it can be converted into the generalized anxiety disorder assuming that those symptoms go on for more than six months even though those symptoms are related or follow a specific triggering event so high yield summary here we go generalized anxiety disorder red on the left and adjustment disorder will be blue on the right side of this slide the timelines gad six plus months adjustment zero to five months gad no specific event adjustment disorder follows a specific event generalized anxiety disorder you treat with ssris and cbt adjustment disorder you treat with cbt and ssris and i switched the order there because technically you don't really need to treat adjustment disorder but if there is going to be pharmacotherapy then it will be ssris or snris but typically you want to start with psychotherapy which is why i put cbt first now how do you remember this right you're struggling to fit all of this information into the very precious amount of brain space you have left you're feeling exhausted you're thinking to yourself dirty i want to be a vascular surgeon why the hell do i care about psychiatry well let's give you a mnemonic then so adjustment disorder is a just zero to five months all right adjustment disorder is a just zero to five months so this will help you remember that the adjustment disorder only lasts up to five months and if it goes six or more you convert it to gad all right done we've knocked off the first two anxiety disorders you're well on your way to being the next freud now let's talk about panic disorder panic disorder has a timeline of one or more months and the symptoms are pretty obvious it's your friend who has panic attacks what's a panic attack well with the panic attacks you're going to get things like palpitations shortness of breath hyperventilation a feeling or sense of impending doom or death for whatever reason that's the biggest buzzword that shows up on usmle and comlex impending doom impending death these patients just feel like they're gonna die because they can't catch their breath their heart is racing they start to sweat they're uncomfortable you know if you've ever seen someone have a panic attack this is truly truly a scary thing to watch um tachycardia so all of these symptoms these are what the layperson refers to as a panic attack now what makes it panic disorder is that the patient has either fear worry or in some way changes their behavior and that's all related to the fear of having another attack so it's it's interesting because it's not necessarily the panic attack itself that is the debilitating part of this disorder i mean certainly don't get me wrong a panic attack sucks and if you've ever seen someone have one it looks awful but what makes this panic disorder is that the patient is fearful of having another panic attack usually in a public situation where he's constantly about having that next panic attack or in some way modifies or changes their behavior to accommodate this idea of what if i have another panic attack so for example patients might not want to take public transportation because they don't want to have a panic attack on the bus or on the train and that's panic disorder now as far as treatment goes there's there's two options here one is maintenance treatment right this is like the long-term treatment the this is what you would put the patient on to hope that you would be curing or treating the panic disorder and that would be either ssris or snris plus therapy but there's also a board of treatment so if someone is past the point of being able to stop the panic attack and now they're having their full-blown panic attack you want to abort that panic attack with a benzo okay and you see the picture here of tony soprano who suffered from panic attacks all right we've talked about panic disorder now let's talk about some phobias so we'll start with specific phobia the timeline for specific phobia is six or more months and the symptoms are an intense fear of a specific object okay so these are your things like people that are scared of spiders people that are scared of blood people that are scared of heights these are specific phobias the phobia is specific to one specific object or thing now these are almost always ego dystonic which means the person is aware of this and the person doesn't like this so ego dystonic means the person dislikes the problem or the mental illness that they have the treatment for specific phobia is systematic desensitization which is a fancy way of saying that we're going to expose you to the phobia and over time we're going to give you more and more and more exposure until you're comfortable with it so this is the way that you you know if someone has a fear of clowns first you show them a clown glove and then you show them clown pants and then you make them squeeze a clown nose and then you expose them to a clown and then you put them in a movie theater full of clowns right that's systematic desensitization that's the treatment for specific phobia that's a form of therapy so you could see the answer written on usmle or complex as psychotherapy but it's a very niche type of therapy and that's known as systematic desensitization so definitely know that now related to specific phobia is agoraphobia and if you were a kid and watched hey arnold this is stoop kid so stoop kid's afraid to leave his stoop agoraphobia is the irrational fear of either public spaces or crowds closed spaces public trans or standing in line lines in general so agoraphobia is just people are scared to go out in public and because of this the way that agoraphobia is depicted in movies and tv shows is people that are scared to leave their home because as it gets more severe people are so worried about all of these things that not only do they want to stay home and never leave their home but it becomes a panic disorder because they start to have panic attacks when they think about what it might be like to go out in public to ride the bus to stand in line at an amusement park so agoraphobia for usmle or comlex you should know is incredibly comorbid with panic disorder now there are a lot of phobias and you've probably heard just throughout your life you know blank phobia blancophobia and those words are hard to keep straight so for your purposes for us emily and comelex the way to remember what agoraphobia means is i don't want to go anywhere a go should remind you of agoraphobia and i don't want to go anywhere i don't want to a go anywhere will remind you that those with agoraphobia typically just want to stay home all day because they fear public spaces so that's agoraphobia the last related disorder in this category is social anxiety disorder now this used to be called social phobia but this is a specific fear of embarrassment in social situations and if you watched the movie elf the character that was played by zoe deschanel she had a fear of singing in public spaces so there's that one scene where she's singing the christmas carol in the shower and she tells will ferrell's character the elf that she doesn't like to sing in public and then lo and behold she overcomes this social anxiety disorder at the end of the movie where she sings the christmas carol bringing christmas cheer and and launching santa's sleigh back into the air so this is social anxiety disorder it's the specific fear of embarrassment in social situations the treatment here is pretty interesting you can maintenance treatment is ssris and therapy specifically cognitive behavior therapy but for the performance subtype and what i mean by performance is people that don't like things like public speaking or giving a presentation you actually can treat with beta blockers and just reduce their sympathetic drive to get them more comfortable and again just like panic disorder abortive treatment would be with benzos so that's social anxiety disorder if we take a look back at our progress thus far in this video you guys are killing it you're well on your way to being psychiatrists some of you may have already gone on amazon and ordered some sick sweater vests because that's what psychiatrists wear apparently next disease post-traumatic stress disorder so post-traumatic stress disorder is seems a little complex to a lot of medical students like people understand the core symptoms of it but putting them together and really thinking about this and conceptualizing this seems to be difficult based on the emails that i've gotten so let's simplify this one and just keep it stupid and keep it simple so what happens in ptsd post-traumatic stress disorder well there's some potential life threat which leads to trauma symptoms and when you hear psychiatrists refer to trauma symptoms they're talking about things like hyper arousal so you know the person is constantly in a heightened sympathetic state or you tap them on the shoulder from behind and they turn around ready to fight because they're they're scared that something was gonna happen to them you also get avoidance symptoms so not only are the patients hyper aware of everything that's going on but they're going to take actions to actively avoid whatever the potential life threat was that gave them post-traumatic stress disorder they also have the intrusive symptoms so intrusive symptoms are the nightmares and the flashbacks surrounding the trauma or the details or events surrounding the trauma so the classic example is a war veteran who had um you know another soldier that that he or she was close with die in combat and therefore when ptsd sets in the war veteran is having nightmares about fighting or serving with their lost friend and flashbacks about the actual death of their friend so those are the intrusive symptoms and then lastly you get a cognitive change and that can look a lot like major depressive disorder or generalized anxiety disorder because cognition and mood changes so some potential life threat occurs trauma symptoms eventually set in and now the question like everything in psychiatry is how long do the symptoms last for and the answer to that question will determine our diagnosis so if the trauma symptoms that you see on this slide last less than one month so not up to 1.0 months but let's say one week or two weeks or three weeks we call that acute stress disorder but if the symptoms last for 1.0 or more months then we indeed have post-traumatic stress disorder so the timeline is very important this is kind of like brief psychotic disorder versus schizophreniform where you've got up to one month and then one plus months but for ptsd it's less than one acute stress one or more post-traumatic stress all right now the treatment here regardless of if we're talking about acute stress disorder or post-traumatic stress disorder is going to be ssris plus therapy and then you can actually do symptomatic treatment for nightmares specifically if the if the core component or the core symptom are nightmares you treat that with prezzosin okay so that's post-traumatic stress disorder let's wrap up our discussion of anxiety disorders by talking about obsessive-compulsive disorder better known as ocd so ocd let's talk about the concept of ocd so the patient gets these intrusive ideas these are referred to as obsessions and those intrusive ideas lead to distress so the person has these ideas racing through their brain they can't stop obsessing over these obsessions and therefore they have distress and the only way to get rid of that distress is to engage in repetitive rituals so the person has obsessions the obsessions might be partially relieved by the acting out of compulsions and these obsessions leading to compulsions is why this disorder is termed obsessive-compulsive disorder let's do a quick example to make sure that everybody is on the same page so a patient might have an obsession that they left the front door to their house unlocked so they're constantly worrying did i leave the door unlocked oh my god did i leave the door unlocked what if the door's unlocked so that obsession is running through their brain non-stop and they might be upstairs laying in bed trying to netflix and chill but they can only think about what if that front door is unlocked you know someone could break in and murder me that obsession is running through their head and because of that they experience subjective distress so they are anxious worried it's nonstop and as a result of this obsession the only way to relieve that distress and it will be only partial relief is to go back and check if the front door is locked so the compulsion component here is going to the front door and seeing that it's locked putting their hands on the lock turning the lock whichever way locks the door even though it's already locked and they do that over and over and over again so you've got the obsession the obsession is the thought they can't get out of their head it causes distress the distress is partially relieved by the compulsion but since it's only partially relieved by the compulsion the patient goes back and back and keeps doing the compulsion because they never get the full relief because even though the door is locked the obsession is that it's not locked and the compulsion checks the obsession and checks if the door is locked and that cycle just continues over and over again let's do one more example this is another one that you might see on us emily or comlex the person thinks that their hand is somehow contaminated with germs so they have this obsession running through their head over and over and over again my hand is dirty my hand is dirty ugh what if i have a disease on my hands and that causes them to stress and the only way to partially relieve that distress is to wash their hands over and over and over again these people literally might wash their hands up to 30 times the skin is gonna be raw and red and just sloughing off their hand like a positive nikolski almost because they're washing it so much and irritating their skin so you've got the obsession or the thought ruminating causing distress leading them to engage in the compulsive behavior okay so this is the overall concept of ocd obsession leads to distress distress is partially relieved by compulsions obsession comes back and the cycle continues now what's really really high yield for usmle and comlex is to know the difference between ocd obsessive-compulsive disorder and ocpd which is obsessive-compulsive personality disorder right so ocd is a disorder ocpd is a personality disorder and we don't really need to get into the nuances of this but the big takeaway for you because it's incredibly high yield is that ocd is ego-dystonic ocpd is ego syntonic now remember from earlier i told you that ego dystonic means the person is aware of it and struggles with it and doesn't like it so ocd patients with ocd really struggle they hate their ocd generally speaking ocpd because it's a personality disorder the person's largely unaware because remember that personality disorders are pervasive traits that are inherent to a person's being or personality so the pd the personality disorder is ego syntonic meaning the person is not really aware of it and doesn't necessarily mind the traits now how do you remember the difference in this terminology well if it's ego dystonic the person dislikes it and they dislike it because they're aware of it it causes them to struggle in life so dystonic means they dislike it they're aware of it they struggle with it syntonic the person is unaware of it doesn't necessarily mind it so that's it we did it we went through all of the anxiety disorders you guys are now ready to be psychiatrists everybody go on amazon order those sweater vests get the comfy chair and get ready to dominate usmle or complex