1- Mental health conditions (Anxiety disorders 1/2) Flashcards
define neuroses
Is a collective term for psychiatric disorders characterized by distress, that are non-organic, have a discrete onset and where delusions and hallucinations are absent.
- Functional and not an organic illness
- Not psychotic
o Patients are distressed, but no delusions
- Synonymous with anxiety disorders
classification of neuroses
- Paroxysmal or episodic anxiety
- Continuous or generalised anxiety
Common symptoms of neuroses
clinical features of neuroses
Clinical features
- Common symptoms (see above)
- Associated cognitions inc worries or fears that are inappropriate or excessive
- Associated behaviour inc avoidance or escape from the situation that causes anxiety
- Depressive symptoms
Conditions associated with anxiety
anxiety
- Anxiety is an unpleasant emotional state involving subjective fear and somatic symptoms.
- Every human experiences anxiety, but if these anxieties become excessive or inappropriate they are described as an illness.
The Yerkes–Dodson law
states that anxiety
can actually be beneficial up to a plateau of
optimal functioning. Beyond this level of
anxiety however, performance deteriorates
The most common anxiety disorders, in order of prevalence are:
o Specific phobia
o Social phobia
o Generalized anxiety disorder
o Agoraphobia
o Panic disorder
o OCD
Anxiety disorders can be split into
- Specific phobias
- GAD and panic disorders
aetiology of anxiety
- Positive / re-entry feedback loops
- Trait anxiety: a stable characteristic arising from a multitude of genetic and environmental factors, particularly adaptive responses to experiences of potential threat during development
- State anxiety simply the state of feeling anxious. This is not rocket science (we’re all familiar with the experience of anxiety), but like any illness, the disorder is identified when these symptoms become severe and persistent enough to cause significant distress and functional impairment.
langs three system model
basis of many CBD models
Padeskys anxiety equation
Neurotic and stress-related disorders (ICD-10 classification) are split into:
Split into:
Phobic anxiety disorders
o Specific phobia
o Agoraphobia
o Social phobia
Other anxiety disorders:
o Panic disorder,
o Generalised anxiety disorders
o Mixed anxiety
o Depressive disorder
Obsessive-compulsive disorder: predominantly obsessional thoughts, predominantly compulsive thoughts, mixed
Reaction to severe stress and adjustment disorders
o Acute stress reaction
o Post-traumatic stress disorder
o Adjustment disorder
define GAD
Generalized anxiety disorder (GAD) is a syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the patient recognizes as excessive and inappropriate. Symptoms must be present on most days for at least 6 months duration
Type 1 vs Type 2 GAD
- Type 1- specific content of worries change/ varies
- Type 2- worries about worries
Often maintained by the belief that worry is useful e.g. it motivates
prevalence of GAD
o GAD has a prevalence of 2–4% in the general population.
o It is more common in F at a ratio of 2:1.
risk factors for GAD
Causes of GAD
biospychosocial
Difference between GAD and stress
Stress is typically caused by an external trigger
- Trigger can be short term, such as a work deadline or a fight with love one
- Can experience mental and physical symptoms
Irritability
Anger
Fatigue
Muscle pain
Difficulty sleeping
Anxiety is defined as persistent, excessive worries that don’t go away even in the absence of a stressor
- Can lead to identical set of symptoms as stress
Differential diagnosis for GAD
- Other neurotic disorders: panic disorders, specific phobias, OCD, PTSD
- Depression
- Schizophrenia
- personality disorder
- Excess caffeine or alcohol
- Withdrawal from drugs
Organic
o Anaemia
o Hyperthyroid
o Phaeochromocytoma
o Hypoglycaemia
presentation of GAD
Symptoms concerning chest and abdomen
Difficulty breathing
Feeling of choking
Chest pain or discomfort
Nausea
Abdominal distress or pain
Loose motions.
Symptoms concerning the brain and mind
Feeling dizzy or light headed
Fear of dying
Fear of losing control
Derealization and depersonalization.
General symptoms
Hot flushes or cold chills
Numbness or tingling
Headache.
Symptoms of tension
Muscle tension, aches or pains
Restlessness
Feeling on edge
Difficulty swallowing
Sensation of lump in throat.
Non-specific symptoms
Being startled
Concentration difficulty and mind blanks
Persistent irritability
Sleep problems.
Diagnosis/investigations for GAD
1) Screening tool e.g. GAD 2/7
2) Full history / ICD-10
3) MSE
4) Physical exam
5) Investigations
GAD-2/7
MSE for GAD
ICD-10 for GAD
general management of GAD
Psychological therapies address the problem (for instance by helping the patient to break some of the positive feedback loops described above), and medications reduce the intensity of state anxiety to better enable the person to engage with psychology.
Psychological treatment most important
- Often both approaches are essential.
- Treatment is effective but takes time and significant effort because the patient is required to go against their innate self-protective impulses (such as avoidance).
General management
- Self help methods
- Exercise
- Support groups
stepwise approach to anxiety
The stepwise treatment algorithm, depending on severity, is as follows:18
1. Psychoeducation, sleep hygiene, and self-guided cognitive-based therapy (CBT) relaxation techniques: it may be helpful to acknowledge that these can appear basic/low intensity, but emphasise their evidenced effectiveness for mild/moderate anxiety if done regularly.
2. CBT: identifying then gradually unlearning the maladaptive patterns of thought/behaviour which are perpetuating symptoms. A CBT practitioner may employ techniques such as exposure therapy (allows extinction of erroneously learned fears) and applied relaxation.
3. Pharmacological(equal 1st line with CBT). SSRI (e.g. escitalopram or sertraline), SNRI (e.g. duloxetine or venlafaxine) or atypical antidepressant (e.g. Mirtazapine) with the choice depending on side-effect profile.
o Pre-gabalin (addictive)
o Buspirone (seratonergic)
o Benzodiazepines (tranquilisers)
o B blockers for symptoms
DO NOT GIVE BENZODIAZEPINES FOR MORE THAN
4 WEEKS
Anxiety (GAD) history taking
define phobia
is an intense, irrational fear of an object, situation, place or person that is recognized as excessive (out of proportion to the threat) or unreasonable.
types of phobia
1) Agoraphobia
2) Social phobia
3) Specific phobia
prevalence of phobias
specific phobias most common
phobia pathophysiology and risk factors
- Biological: Tachycardia is the usual autonomic response, however in phobias of blood, injection and injury, a vasovagal response (bradycardia) is produced, commonly leading to fainting (syncope). For a complete list of biological symptoms see GAD, Section 5.2.
- Psychological: Include unpleasant anticipatory anxiety, inability to relax, urge to avoid the feared situation and, at extremes, a fear of dying.
- Agoraphobia is strongly linked to panic disorder. Indeed the ICD-10 divides agoraphobia into: agoraphobia with panic disorder and agoraphobia without panic disorder.
define agoraphobia
Agoraphobia literally means a ‘fear of the marketplace’. It is a fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack.
Pathophysiology of agoraphobia
Maintained by avoidance which prevents deconditioning and sets up a vicious cycle of anxiety.
management of agoraphobia
- CBT with graduated exposure
- SSRIs
graduated exposure therapy
Graduated exposure is the process of exposing the patient slowly and methodically to more and more raw aspects of those experiences.
social phobia def
A fear of social situations which may lead to humiliation, criticism or embarrassment- lies a fear of negative evaluation by others
pathophysiology of social phobia (social anxiety disorder)
Uncertain aetiology. Usually begins in late adolescence, an age at which people are concerned about the impression they make on others.
presentation of social phobia
- Can lead to avoidance of feared situation (counter-productive, use of safety behaviours, anticipatory anxiety, and unhelpful ‘post mortems’ following social encounters
management of social phobia
- CBT with graduated exposure to feared situations e.g. to feared situations
- Pharmacological intervention e.g. SSRIs (escitalopram or sertraline), SNRIs (venlafaxine) or if no response to these, a MAOI (moclobemide)
specific phobia def
A fear restricted to a specific object or situation (excluding agoraphobia and social phobia).
speciifc phobias pathophysiology
Conditioning event in early life, i.e. a frightening experience. Possibly a role for learned behaviour, e.g. from parents
management of specific phobias
- Exposure therapy either using self-help methods or through CBT
- Benzodiazepines for short erm e.g. if a patient needs a CT scan and they are claustrophobic
diagnosis/investigations of phobias
1) history
2) ICD-10 criteria
3) MSE
4) Risk assessment
5) Investigations
history taking for phobia
- ‘What situations cause you anxiety or embarrassment?’ (specific phobia)
- ‘Do you get symptoms in situations from which escape would be difficult?’, ‘Do you get symptoms in places or situations where help may not be available?’, ‘Do you get symptoms while being in a crowd or travelling on public transport?’ (agoraphobia)
- ‘Do you ever worry about what people think of you? Does this worry ever lead to you avoiding certain situations?’ (social phobia)
- ‘Do you avoid any situation because you know you will feel panicky?’ (anticipatory anxiety)
ICD criteria for phobias
MSE for phobias
risk assessment for phobias
suicie and self harm
investigations for phobias
- Questionnaires e.g. social phobia inventory and Liebowitz social anxiety scale
Panic disorders characterised by
recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.
panic disorders prevalence
- 1%
- More common in women
- Onset most common in late adolescence
pathophysiology and risk factors of panic disorders
Biological
o Genetics – very heritable
o Neurochemical- post synaptic hypersensitivity to serotonin and adrenaline
o Sympathetic nervous system- fear or worry stimulates the NS -> increased cardiac output which can lead to further anxiety
Cognitive
o Misinterpretation of somatic symptoms (e.g.. feat that palpitations will lead to a heart attack)
Environmental
o Presence of life stressors can lead to panic disorder
panic disorder presentation
Presentation
Panic symptoms usually peak within 10 minutes and rarely persist beyond an hour.
* Shortness of breath
* Chest pain
* Excessive sweating
* Palpitations or tachycardia
* Dizziness or feeling faint
* Trembling or shaking
* Intense feeling of terror
* Nausea
* Tingling or numbness in fingers or toes
* Derealisation/depersonalisation
* Dry mouth
* Chills or hot flashes
* Visual disturbances
* Fear of dying
* Fear of losing control or impending doom
diagnosis/investigations for panic disroders
1) History
2) ICD-10
3) MSE
4) investigations
history for panic disorders
o ‘Are you generally anxious or are there periods where you are anxiety-free?’ (episodic)
o ‘Can you predict when these attacks will come on?’ (unpredictable)
o ‘Have you ever been so frightened that you felt your heart was pounding and that you might die?’ (intense fear and anxiety)
o ‘Are you worried about your health or any other specific things?’ (major life stressors)
ICD-10 panic disoders
MSE for panic disorders
- MSE- same as GAD, may be more intense e.g. hyperventilation and restlessness
- MSE- same as GAD, may be more intense e.g. hyperventilation and restle
investigations for panic disorders
o Bloods: FBC (infection, anaemia), FTFs (hyperthyroidism), glucose (hypoglycaemia)
o ECG: may show sinus tachycardia
o Questionnaires: GAD-2, GAD-7, Becks anxiety inventory, hospital anxiety and depression scale
