36 - Anxiety and Worry Flashcards
Describe the prehistoric brain
- Our brains function as if we were still in a predatory environment.
- Limbic and amygdala
- -> Triggers the fear responses – engage and fight or run for safety
- -> Triggers the release of stress hormones like adrenaline
- Rational and discriminating responses come later
- The alert system that helps to keep us alive turns on quickly, but shuts down more slowly
Describe the brain’s response systems
Emotional system –> sensory thalamus
Two systems
- Fear (emotional) system
- Reasoning (cognitive) system
Describe the fear (emotional) system
- Amygdala –> hypothalamus –> release of stress hormones to blood stream
- Rapid, general ideas about avoid/approach; flee/fight
Describe the reasoning (cognitive) system
- Path through the sensory cortex
- Longer path, takes more time, is more precise and discriminating
What are general screening questions to assess worry in your patients?
Do you frequently worry about things?
Do you have difficulty controlling your worry?
Have you ever experienced sudden fear or anxiety that seems to come from nowhere or is related to a particular situation or setting?
Does your worry significantly interfere with your life, work or relationships?
How do you respond to a patient’s worries about surgeries?
First
- What is the worry? – Always ask the patient
- Don’t assume you know or minimize the worry
What are common concerns about surgery?
Common concerns:
- Loss of control and/or ability to trust (asleep during surgery; assurance about the team and their experience )
- Pain (How will it be managed, and by whom?)
- Access to social support/significant others (Prior to surgery and in recovery)
- Access to sources of comfort (Special music before, during, after surgery)
What is the BATHE model for responding to worried patients?
B = background
- “What is going on in your life besides your illness?”
- “Tell me about the stressors in your life.”
A = affect
- “How do you feel about it?”
T = trouble
- “What troubles you most about it?”
H = handling
- “How are you handling or coping with it?”
E = empathy
- “That must be very difficult.”
What are some areas to consider in terms of assessing the coping capacity of patients with anxiety and worry?
Assess CAPACITY and ACCESS
- Health & energy
- Positive beliefs
- Material resources
- Problem solving skills
- Social skills
- Social Support
In addition to medical intervention, what else should you consider?
- Appropriate response to patient’s worries
- Education
- Life Style Modification
- Insomnia & other sleep difficulties
- Pharmacological treatment
- Psychotherapy
Describe the provider as an “affect regulator”
You need to remember that with emotional issues, it is not just what you do that is healing for patients, but also who you are
- You have a patient and a provider with a safe environment, attention and understanding
- But what really helps with patient care is affect regulation
- If you can help someone who is scared to calm down, that is very healing
Define fear
a response to a known and definite threat
Define anxiety
a response to a threat that is sometimes known, but may also be unknown, internal, vague or conflictual
It is a necessary functional human emotion, not always a disorder
Define existential anxiety
Worry about matters of ultimate concern, e.g. death
Define trait anxiety
Characterological; across settings
This is a personality trait that you have
Define state anxiety
Contextual; situational
This based on the state you are in
Define signal anxiety
A signal to take care of something
Define anxiety DISORDERS
Anxiety that is severe, persistent and disabling & persists beyond developmentally appropriate periods of time.
What is the prevalence of anxiety disorders?
- One in four people meet the criteria for one disorder in their lifetime
- More prevalent in women than men
- Prevalence increases with lower levels of socio-economic status
What are the difficulties seen in anxiety disorders
- Common in general medical settings, but often undiagnosed since multiple somatic concerns are common & focus is on acute care
- High resistance to psychiatric referral due to somatic nature of presenting symptoms
- Often begin in childhood and quite often become chronic
- Screen for the presence of other mental disorders since there are high rates of comorbidity
What are the key features of anxiety disorders?
Physical (somatic) symptoms
- tachycardia, lightheaded
Affective symptoms
- uneasiness, panic
Behavioral symptoms
- avoidance, compulsions
Cognitive symptoms
- apprehension, worry, obsessions
What are the 3 As of anxiety disorders?
- Anticipation/apprasial (cognitive, cortical)
- Arousal (physiological subcortical including limbic system)
- Avoidance (behavioral)
Describe A –> A and E –> E
A –> A
This means that avoidance leads to anxiety (elevator example - if you avoid something that makes you anxious, it makes you more anxious)
E –> E
Exposure leads to extinction - if you ride the elevator again and again, you extinct the anxiety
Encourage your patients to continue doing the things that make you anxious
Do this with pain –> moving things or walking, even if it is painful, tell them they need to do it - don’t avoid doing it because you’re fearful of it hurting, then you’ll just be anxious that it will hurt
Describe separation anxiety (DSM 5)
- Developmentally inappropriate, excessive & recurring fear related to separation from home and/or attachment figures
What does separation anxiety include?
- Fear of losing them in some way
- Fear of experiencing an event that takes one away from significant others
- Fear of being alone or sleeping without another or being away from home
- Physical symptoms in response to separation or anticipation of it
- Repeated nightmares of separation
Describe the issues of concern in panic attacks
- Primary complication = fear of future attacks
- Vast majority of patients seek help in their primary care setting (often ER)
- Main presentations are somatic complaints
- Missed diagnosis
Describe panic attacks
- Can result in withdrawal, isolation, and avoidance of going out in public
- Severe impairment possible; prelude to anxiety disorder &/or agoraphobia
Describe the complications of the vast majority of patients seek help in their primary care setting (often ER)
- Diagnosis is often missed or made too late
- This can also indicate a resistance to mental health treatment
Describe the implication of panic attack patients complaining of somatic complaints
- Differential diagnosis is critical
- Somatic nature of the complaints makes mental health referral more difficult
What is the implication missed diagnosis of panic attack patients?
- Results in more medical visits and lab tests, and fewer mental health referrals
- Repeated visits to ER are also common; more frequent attacks
Describe interventions that can help with panic attacks
- Normally reaches a peak within 10 minutes, and resolves itself in 20 – 30 min
- With assistance, patients can learn to “ride out” attacks ***
What are the goals of panic attack interventions?
- Resolve or reduce panic attacks
- Reduce general and anticipatory anxiety; and sensitivity to physical symptoms
- Patient education is important
- Minimize avoidance behaviors
- Treat any comorbidities
Can use medication (SSRIs) or psychotherapy
What is a panic disorder (DSM 5)?
Recurrent, unexpected panic attacks evidenced by at least 4 of the following
- Heart disturbances – racing, palpitations*
- Shortness of breath*
- Chest pain*
- Dizzy, lightheaded*
- Fear of dying*
At least 1 panic attack followed by 1 mo of persistent worry of another attack, or maladaptive behavioral changes to avoid an attack
Infrequent panic attacks is NOT a disorder
What is the treatment for panic disorder?
- Cognitive behavioral therapy
- Family therapy
What is agoraphobia (DSM 5)?
Sources of fear/anxiety (need 2 or more):
- Public transportation (bus, train, plane)
- Open spaces
- Enclosed spaces (elevator, theatre)
- Being caught in a crowd or line
- Being outside the home alone
What is the etiology of agoraphobia?
- Heredity and environment play a role
- 80% of diagnosed patients are female
Developmental scenario could look like this:
- Panic attack strikes spontaneously
- Fear of another attack
- Hypersensitivity to bodily cues can another attack
- Avoid environment in which attack occurred
- Relief reinforces the avoidance
- The number of “safe” places narrows
- Person becomes homebound
What is a specific phobia (DSM 5)?
- Marked fear or anxiety about a specific object or situation
- Specify type based on focus of the fear (snake, storm, planes)
- Feared object or situation is most often a real potential threat, or has been in evolutionary history
Predisposing factors include
- A traumatic event involving the feared object or situation
- Observing others in a fearful situation – modeling
- A panic attack in a particular situation
- Information and education leading to fearfulness
Describe the therapeutic treatment approaches of a specific phobia
Behavioral approaches
- Exposure to the phobic stimulus
- Systematic desensitization
- Teaching mental and physical relaxation
- Rehearsal of fearful situations
Clinical hypnosis
Supportive and family therapy
Describe the treatment of social anxiety disorder
- Cognitive behavioral therapy
- Group therapy
What is social anxiety disorder (DSM 5)?
Marked fear/anxiety of social situations involving exposure to the possible scrutiny of others; concern for acting in a way that is humiliating or embarrassing
Onset
- Often in mid-teens or late childhood
- Can be in response to a humiliating or stressful event, or can be gradual
Common situations feared include
- Social events, meeting new people, public speaking, performing in some way, eating in public, using a public restroom
- Most common fear is public speaking
Duration is often life-long
What is generalized anxiety disorder (DSM 5)?
Excessive anxiety/worry (more days than not) about a number of events or activities
Difficulty controlling the worry/anxiety
Including 3 or more of the following:
- Restlessness, on edge
- Easily fatigued
- Difficulty concentrating or mind goes blank
- Irritability
- Muscle tension
- Sleep disturbance
What are common clinical features of generalized anxiety disorder (GAD)?
- Motor tension – headaches, shakiness, restless
- Autonomic hyperactivity – shortness of breath, sweating, palpitations, gastrointestinal symptoms
- Cognitive vigilance – increased irritability and startle reactivity
- Often seek medical attention for some somatic complaint
** High incidence of comorbid substance abuse resulting from self-medicating behavior **
What are the complicating factors of GAD?
Poor outcomes are associated with each due to:
- Multiple somatic concerns
- Patient resistance to psychiatric diagnosis
- Provider lack of familiarity with current treatment options
- Lack of patient compliance with recommendations
- Focus in primary care on acute episodic care
Describe anxiety related to medical conditions
Suspicious indicators
- Onset of symptoms after age 35
- Lack of a psychosocial history of anxiety
- No childhood issues related to anxiety
- Lack of exacerbating life events*
- Lack of avoidance behaviors*
- Poor response to antianxiety medications*
These indicate that it is actually a MEDICAL condition that is causing the anxiety, not just anxiety
What are common conditions related to anxiety symptoms?
Common conditions related to anxiety symptoms:
Endocrine disease, cardiovascular disorders, respiratory illness, metabolic disturbances, neurological illness
What are the pharmacological treatment options for anxiety and worry?
Always give primary consideration to psychiatric referral
Acute
- Benzodiazepines – possible dependency & withdrawal reactions with long-term use
- Alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium)
Chronic
- SSRI’s (serotonin reuptake inhibitors)
- Paroxetine (Paxil), Sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), venlafaxine (Effexor)
- Panic disorder, social anxiety, OCD, PTSD
Describe follow-up in anxiety and worry treatment
- Long-term follow-up is most effective
- -> Symptoms are often chronic
- -> Relapse to old behavior is common
- Continue 6 – 12 months after good control of symptoms is achieved
- -> Long-term supportive work may be needed
- Focus on preparation for recurrence
- -> Indicators of potential recurrence
- -> Offensive strategies for stressful times
Describe the therapy of exposure
- Gradually facing and learning to endure the feared situation; can include rehearsals
- Good for agoraphobia, specific phobia, social anxiety disorder
Describe the therapy of progressive relaxation
- Progressively relaxing parts of the body, often in association with deep breathing
- Good for panic disorder, GAD
Describe the therapy of visualizations
Guided imagery focusing on slowing down & relaxing; exposure
Describe the therapy of desensitization
- Guided imagery focusing on gradual exposure to the feared situation and becoming less sensitive to it; thought stopping
- Good for specific phobia, social anxiety disorder
Describe the therapy of clinical hypnosis
Use of hypnotic approaches to relaxation, desensitization, graduated exposure, suggestions, ego building, unc. exploration
Describe behavioral therapy
- Award/punishment systems – token economies; reinforcement and extinguishing approaches
- Good for specific phobia, social anxiety disorder
Describe cognitive-behavioral therapy (CBT)
- Misinterpretations and false beliefs about body sensations; knowledge about panic attacks (how they come and go, not life threatening); overcome avoidance behaviors; self-regulate
- Good for agoraphobia, Panic attack & disorder, GAD
Describe family therapy
- Focusing on the psychosocial issues associated with the disorder
- Good for agoraphobia, specific phobia, social anxiety disorder
