4 - Anxiety Disorders Flashcards
What is neurosis and some examples of neurotic disorders?
Class of functional mental disorder involving distress but not delusions or hallucinations, where behavior is not outside socially acceptable norms
Anxiety, Depressional, Obsessive (not personality disorders)
What are some examples of anxiety disorders?
Exaggerated response to threat or danger that lasts more than 3 weeks and interferes with lives. Threat is often psychological and does not exist
- Panic disorders
- Phobias
- Generalised anxiety
- PTSD
- OCD
- SAD
What is the epidemiology of anxiety disorders and what are some co-morbidities associated with it?
10% of the population affected, predominantly female
Comorbidity: Depression, Substance misuse, Personality disorders
If individual presents after age 35-40 years, it is more likely due to depressive disorder or organic disease
What are some risk factors for anxiety disorders?
- Family history
- Childhood adverse events
- Life events
Associations: Lower social class, unemployment, divorced, renting rather than owning, no educational qualifications, urban living
What are some symptoms of anxiety?
- Psychological: Fears, worries, poor concentration, irritability, depersonalization, derealisation, insomnia, night terrors
- Motor symptoms: Restlessness, fidgeting, feeling on edge, tremor
- Neuromuscular: tremor, tension headache, muscle ache, dizziness, tinnitus
- GI: Dry mouth, nausea, indigestion, butterflies, flatulence, frequent or loose motions
- CVS: Chest discomfort, palpitation
- Respiratory: Difficulty inhaling, Tight/constricted chest
- GI: Urinary frequency, erectile dysfunction
What is the epidemiology of GAD and the risk factors for this?
3-5% of the population with 2x more females than males
Risk factors: Chronic Pain or Condition
What is the ICD-10 diagnostic criteria for GAD?
- Anxiety which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances
- Variable dominant symptoms: persistent nervousness, trembling, muscle tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort
- Apprehension: expression of fears such as that the person or a relative will shortly become ill or have an accident.
What are some differential diagnoses for GAD?
- Hyperthyroidism (look for goitre, tremor, tachycardia, weight loss, arrrythmia, exopthalmos)
- Substance misuse (intoxication – amphetamines; withdrawal – benzo, alcohol)
- Excess caffeine
- Depression
- Anxious (avoidant) personality disorder:
- Dementia (early)
- Schizophrenia (early)
What is a questionnaire you can use to aid diagnosis of GAD and how do you interpret the scores?
GAD-7
7 questions about the last 2 weeks
5, 10, 15, 20 cut off scores for mild, moderate, moderately severe, severe
What is the stepwise management for generalised anxiety disorder?
ASSESS SUICIDE RISK
Step 1: All known and suspected presentations of GAD
- Explain the diagnosis and its meaning to the patient. Provide written information
- Assess severity, duration and impact on normal life
- Assess for depression
- Chronic co-morbidities should be reviewed and management optimised
- Substance abuse issues that may exist must be addressed
- Sleep hygiene, exercise, meditation advice
Step 2: Diagnosed GAD that has not improved after step 1 interventions
Offer low-intensity psychological interventions e.g non-facilitated self-help, individual guided self-help and psychoeducational groups
Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions
Offer one of:
- High-intensity psychological intervention e.g CBT
- Pharmacological treatment
Step 4
Referral to specialist care particularly for those at risk of self harm or suicide, significant co-morbidities or self neglect. Also refer patients in whom the first three steps have not managed their symptoms
Benzodiazepines may be used for acute anxiety, what is the concern with prescribing these?
- Should not be prescribed for more than 10 days due to risk of dependency and sedation
- Use only to overcome symptoms so severe they obstruct initiation of more appropriate psychological treatment
- Diazepam preferred due to longer half life (less risk of withdrawal symptoms with neurotic symptoms)
What medication is used for GAD treatment?
Usually this or psychological intervention, no evidence that increased efficacy using them together
First line: SSRI or SNRI (Venlaxafine or Duloxetine)
Second Line: Pregablin
Monitor every 2-4 weeks for first 3 months then every 3 months thereafter
B-Blockers can be used for somatic symptoms (CI asthma and heart block)
What is the prognosis with GAD?
May fluctuate in severity:
- The more chronic the condition, the worse the prognosis
- Comorbidity with depression is poor prognosis
- Stable premorbid personality good prognostic sign
- 50% recover with SSRI treatment
What is the epidemiology of panic disorder and what are some symptoms of this?
- 1-2% in general population with 2-3x more common in females
- Bimodal: peaks at 20yo and 50yo
- Agorophobia occurs in 30-50%
Symptoms
- Breathing difficulties
- Chest discomfort
- Palpitations
- Tingling or numbness in hands, feet or around the mouth
- Shaking, sweating, dizziness
- Depersonalization/ derealisation
- Can lead to fear of situation where panic attacks occur or agoraphobia
- Conditioned fear of fear pattern develops
Why may someone with panic disorder have tingling/numbness in their hands and feet?
Hyperventilation blows off CO2, raising pH
Calcium binds to albumin leads to hypocalcaemia. If extreme, carpopedal spasm (curling of fingers and toes can occur)
What is the ICD-10 criteria for panic disorder?
- Recurrent attacks of severe anxiety (panic) not restricted to any particular situation or set of circumstances and therefore unpredictable
- Secondary fears of dying, losing control or going mad
- Attacks usually last for minutes often there is a crescendo of fear and autonomic symptoms
- Freedom from anxiety symptoms between attacks (but anticipatory anxiety is common)
What are some differential diagnoses for panic disorder?
- Other anxiety disorders: GAD and agoraphobia
- Depression (if depression prescedes, it takes precedence)
- Alcohol or drug withdrawal
- Organic causes: CVS or respiratory disease
- Others: hypoglycaemia, hyperthyroidism
- Phaeochromocytoma
What is the management of panic disorder?
ALWAYS OFFER CBT BEFORE SSRIS
Step 1 – recognition and diagnosis
- Provide written information
- Support groups
Step 2 – treatment in primary care
- Low intensity intervention (telephone CBT, support groups)
- Exercise and sleep hygiene
Step 3 – review and consideration of alternative treatments
If moderate to severe then offer CBT or Antidepressants (SSRI, SNRI, TCAs, Clomipramine)
Step 4 – review and referral to specialist mental health services
If 2 interventions have not worked
What is the prognosis with panic disorder?
80-100% remission with CBT
50-60% remission with medication
What is mixed anxiety and depressive disorder?
- ICD-10 criteria: symptoms of anxiety and depression are both present but neither clearly predominates
- Treat with counselling, cognitive therapy or psychotherapy, especially interpersonal therapy
- Treating the depression usually relieves anxiety symptoms (SSRIs are best)
What are phobic disorders?
Anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread
Becomes a disorder when they cause marked distress and/or significantly impair a person’s ability to function
Examples: Agoraphobia, Social Phobia, Specific Phobias
What is Agoraphobia?
ICD-10 criteria: Fear not only open spaces but also of related aspects, such as the presence of crowds and difficulty of immediate easy escape back to a safe place, usually home (may occur with or without panic disorder)
- Commonly in 20s or mid-thirties
- May be gradual or precipitated by a sudden panic attack
What is social phobia?
Most common anxiety disorder
- ICD-10 criteria: Fear of negative evaluation by other people in comparatively small groups (around 5-6 people, usually 1-2 or crowds is fine), leading to avoidance of social situations
- Physical symptoms: blushing, fear of vomiting, palpitations, trembling, sweating. Symptoms can progress to panic attacks
- Patients think secondary manifestations are the primary problem