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Neuro Behavioral Med 3 > 36 - Anxiety and Worry > Flashcards

36 - Anxiety and Worry Flashcards

1
Q

Describe the prehistoric brain

A
  • 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
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2
Q

Describe the brain’s response systems

A

Emotional system –> sensory thalamus

Two systems

  • Fear (emotional) system
  • Reasoning (cognitive) system
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3
Q

Describe the fear (emotional) system

A
  • Amygdala –> hypothalamus –> release of stress hormones to blood stream
  • Rapid, general ideas about avoid/approach; flee/fight
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4
Q

Describe the reasoning (cognitive) system

A
  • Path through the sensory cortex

- Longer path, takes more time, is more precise and discriminating

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5
Q

What are general screening questions to assess worry in your patients?

A

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?

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6
Q

How do you respond to a patient’s worries about surgeries?

A

First

  • What is the worry? – Always ask the patient
  • Don’t assume you know or minimize the worry
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7
Q

What are common concerns about surgery?

A

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)
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8
Q

What is the BATHE model for responding to worried patients?

A

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.”

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9
Q

What are some areas to consider in terms of assessing the coping capacity of patients with anxiety and worry?

A

Assess CAPACITY and ACCESS

  • Health & energy
  • Positive beliefs
  • Material resources
  • Problem solving skills
  • Social skills
  • Social Support
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10
Q

In addition to medical intervention, what else should you consider?

A
  • Appropriate response to patient’s worries
  • Education
  • Life Style Modification
  • Insomnia & other sleep difficulties
  • Pharmacological treatment
  • Psychotherapy
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11
Q

Describe the provider as an “affect regulator”

A

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
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12
Q

Define fear

A

a response to a known and definite threat

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13
Q

Define anxiety

A

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

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14
Q

Define existential anxiety

A

Worry about matters of ultimate concern, e.g. death

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15
Q

Define trait anxiety

A

Characterological; across settings

This is a personality trait that you have

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16
Q

Define state anxiety

A

Contextual; situational

This based on the state you are in

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17
Q

Define signal anxiety

A

A signal to take care of something

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18
Q

Define anxiety DISORDERS

A

Anxiety that is severe, persistent and disabling & persists beyond developmentally appropriate periods of time.

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19
Q

What is the prevalence of anxiety disorders?

A
  • 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
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20
Q

What are the difficulties seen in anxiety disorders

A
  • 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
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21
Q

What are the key features of anxiety disorders?

A

Physical (somatic) symptoms
- tachycardia, lightheaded

Affective symptoms
- uneasiness, panic

Behavioral symptoms
- avoidance, compulsions

Cognitive symptoms
- apprehension, worry, obsessions

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22
Q

What are the 3 As of anxiety disorders?

A
  • Anticipation/apprasial (cognitive, cortical)
  • Arousal (physiological subcortical including limbic system)
  • Avoidance (behavioral)
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23
Q

Describe A –> A and E –> E

A

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

24
Q

Describe separation anxiety (DSM 5)

A
  • Developmentally inappropriate, excessive & recurring fear related to separation from home and/or attachment figures
25
Q

What does separation anxiety include?

A
  • 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
26
Q

Describe the issues of concern in panic attacks

A
  • 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
27
Q

Describe panic attacks

A
  • Can result in withdrawal, isolation, and avoidance of going out in public
  • Severe impairment possible; prelude to anxiety disorder &/or agoraphobia
28
Q

Describe the complications of the vast majority of patients seek help in their primary care setting (often ER)

A
  • Diagnosis is often missed or made too late

- This can also indicate a resistance to mental health treatment

29
Q

Describe the implication of panic attack patients complaining of somatic complaints

A
  • Differential diagnosis is critical

- Somatic nature of the complaints makes mental health referral more difficult

30
Q

What is the implication missed diagnosis of panic attack patients?

A
  • Results in more medical visits and lab tests, and fewer mental health referrals
  • Repeated visits to ER are also common; more frequent attacks
31
Q

Describe interventions that can help with panic attacks

A
  • Normally reaches a peak within 10 minutes, and resolves itself in 20 – 30 min
  • With assistance, patients can learn to “ride out” attacks ***
32
Q

What are the goals of panic attack interventions?

A
  • 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

33
Q

What is a panic disorder (DSM 5)?

A

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

34
Q

What is the treatment for panic disorder?

A
  • Cognitive behavioral therapy

- Family therapy

35
Q

What is agoraphobia (DSM 5)?

A

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
36
Q

What is the etiology of agoraphobia?

A
  • 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
37
Q

What is a specific phobia (DSM 5)?

A
  • 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
38
Q

Describe the therapeutic treatment approaches of a specific phobia

A

Behavioral approaches

  • Exposure to the phobic stimulus
  • Systematic desensitization
  • Teaching mental and physical relaxation
  • Rehearsal of fearful situations

Clinical hypnosis

Supportive and family therapy

39
Q

Describe the treatment of social anxiety disorder

A
  • Cognitive behavioral therapy

- Group therapy

40
Q

What is social anxiety disorder (DSM 5)?

A

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

41
Q

What is generalized anxiety disorder (DSM 5)?

A

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
42
Q

What are common clinical features of generalized anxiety disorder (GAD)?

A
  • 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 **

43
Q

What are the complicating factors of GAD?

A

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
44
Q

Describe anxiety related to medical conditions

A

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

45
Q

What are common conditions related to anxiety symptoms?

A

Common conditions related to anxiety symptoms:

Endocrine disease, cardiovascular disorders, respiratory illness, metabolic disturbances, neurological illness

46
Q

What are the pharmacological treatment options for anxiety and worry?

A

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
47
Q

Describe follow-up in anxiety and worry treatment

A
  • 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
48
Q

Describe the therapy of exposure

A
  • Gradually facing and learning to endure the feared situation; can include rehearsals
  • Good for agoraphobia, specific phobia, social anxiety disorder
49
Q

Describe the therapy of progressive relaxation

A
  • Progressively relaxing parts of the body, often in association with deep breathing
  • Good for panic disorder, GAD
50
Q

Describe the therapy of visualizations

A

Guided imagery focusing on slowing down & relaxing; exposure

51
Q

Describe the therapy of desensitization

A
  • 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
52
Q

Describe the therapy of clinical hypnosis

A

Use of hypnotic approaches to relaxation, desensitization, graduated exposure, suggestions, ego building, unc. exploration

53
Q

Describe behavioral therapy

A
  • Award/punishment systems – token economies; reinforcement and extinguishing approaches
  • Good for specific phobia, social anxiety disorder
54
Q

Describe cognitive-behavioral therapy (CBT)

A
  • 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
55
Q

Describe family therapy

A
  • Focusing on the psychosocial issues associated with the disorder
  • Good for agoraphobia, specific phobia, social anxiety disorder

Neuro Behavioral Med 3 (16 decks)

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