Anxiety Flashcards
Causes, Pathophysiology and Diagnosis
Caused by interaction with bio-psychosocial factors.
- Examples: genetic vulnerability, situations, stress, trauma.
Treatment: combo of psychotherapy or psychotherapy + pharmacotherapy
In the CNS major mediators of anxiety symptoms unknown but look to be noradrenaline, serotonin, dopamine, GABA, peptides
Peripherally ANS and sympathetic NS mediate the symptoms.
Categories of anxiety:
Medical condition anxiety, substance induced anxiety, acute stress disorder, PTSD, OCD, adjustment disorder with anxiousness, social phobia, specific phobia,
Anxiety - high rates of comorbidities with major depression and alcohol and drug abuse
Chronic anxiety - Increased risk of CV morbidity and mortality.
Mood disorder + anxiety = more chance of suicide
Generalised anxiety disorder (GAD)
NO clear reason/focus for this anxiety.
Vulnerable to stress.
Chronic condition can fluctuate in severity.
Defined by DSM 5 or ICD 11.
Common in 35 to 55 yrs old
Symptoms present for at least 6 months - cause impairment in social, occupational and other areas of functioning.
Signs and Symptoms:
- Difficulty to control excessive anxiety and worry with at least 3 of:
- restlessness or on edge,
- easily fatigued,
- difficulty concentrating or mind going blank,
- irritability and muscle tension,
- sleep disturbance or suicidal ideation and suicide
Risk factors:
- Females
- Comorbid anxiety disorders
- Family Hx of anxiety disorders.
- Childhood adversity.
- Hx of sexual or emotional trauma.
- Sociodemographic factors.
Pathophysiology unknown. Theories:
- psychodynamic models (conflict with id and the ego)
- conditioning (learned) model
- cognitive-behavioural models (tendency to overestimate the potential for danger)
These patients avoid scenarios out of fear of the worst happening. stay away from heights, crowds, social interaction.
Panic disorder
Unknown cause. Theories:
- genetically inherited neurochemical dysfunction due to autonomic imbalance.
- Panic disorder represent a state of chronic hyperventilation and CO2 receptor hypersensitivity
- Cognitive theory - patients with panic disorder have a higher sensitivity to internal autonomic cues (e.g., tachycardia)
Triggers:
- Injury (accidents, surgery),
- Illness,
- Interpersonal conflict/loss,
- Cannabis use,
- Stimulants use (caffeine, decongestants, cocaine or sympathomimetics [amphetamine, “ecstasy”]),
- Certain settings, eg stores and public transportation.
During EP patient want to run away from situation/place due to fear. Patients start to shy away from stuff and can feel like they are losing their mind. They become more passive, dependent, withdrawn.
Onset is sudden. Peaks at 10 mins.
Signs and symptoms:
Systemic symptoms (4 or+) with 1 month of fear:
* Palpitations, pounding heart, chest pain/ discomfort.
* Sweating, trembling or shaking, chills or hot flashes.
* SOB or feeling of smothering or choking sensation.
* Nausea or abdominal distress, dizzy, unsteady, lightheaded, or faint.
* De-realisation (feeling of unreality) or de-personalisation (being detached from oneself).
* Fear of losing control or going crazy, fear of dying.
* Paraesthesia’s (numbness/tingling sensations).
* Headache, cold hands, diarrhoea, insomnia, fatigue, intrusive thoughts, and ruminations.
Obsessive Compulsive Disorder (OCD)
From bad exp leading to certain behaviour try prevent that exp.
Diagnosis:
- Screen symptoms
- Exclude other conditions
- Assessing severity of functional impairment (mild, moderate, severe)
- Assessing self harm risk
MAIN Diagnosis - presentation and history:
- OBSESSIONS: (contamination, safety, doubting one’s memory or perception, need for order or symmetry, unwanted and intrusive sexual/aggressive thought)
- COMPULSION: (repeating actions a certain number of times or until it “feels right” of cleaning, washing, checking, counting; arranging objects; touching/tapping objects or hoarding, confessing/seeking reassurance, list making).
Yale brown scale 5 obsession 5 compulsion each scored 0-4. Total 40.
Symptoms can worsen with stress.
Management depends of level of functional impairment:
- CBT including exposure and response prevention
- SSRi or clomipramine (TCA). For <18 SSRi only if assessed by specialist
- Refer to specialist. Urgent if self harm risk high.
Monitor:
During each review -
- Alert for suicide ideation
- Monitor progress
- Check adherence
- If effective continue drugs for 1 year minimum,
- Re-evaluate amount of follow ups needed
- Review need for drugs if taken for 1 year and in remission.
Post-Traumatic Stress Disorder (PTSD)
Can develop after a traumatic event and affect all ages.
Signs and symptoms:
Onset is 1st month after traumatic event. some people symptoms delayed months or years
Needs to be >1month.
DSM criteria:
- Re-experiencing (flashbacks, nightmares etc) AND 2 or + of:
- difficulty sleeping
- Decreased concentration
- Hypervigilance/arousal
- Anger outburst or irritated mood WITH 3 or + of:
- Avoidance and emotional numbing
- Negative self perception
- Disassociation
- Cant recall aspect of the event
For adults most people resolved naturally some more severe and enduring.
Diagnosis:
- Had traumatic event
- Via symptoms assessment
- Confirmation via specialist and DSM 5 or ICD 11
Management:
Ask about PTSD effects on life to asses severity =
Mild - distress by symptoms manageable and no significant impairment on functioning.
Moderate - Mild to severe affect on functioning NO risk of suicide.
Severe - Unmanageable symptoms from distress and significant affect on functioning and risk of suicide.
- High suicide risk = same day referral
- Active monitoring done for ppl not in need or urgent referral.
- >1 month symptoms refer to specialist.
- Venlafaxine or SSRi if decline psychological therapy, prefer drugs or referral delayed. Review effectiveness evert 2 to 4 weeks for first 3 months, THEN every 3 month
- Sleeping problems try advise or hypnotic short term
- Trauma focused psychological therapies - 1st line
Follow up:
- To monitor symptoms and progress.
Phobias
Social:
- Can come from traumatic social experience or social skill deficit.
Specific: Acquired form experience
Signs and symptoms:
- Worry/avoid social activities
- Worrying stuff is embarrassing - blushing, sweating
- Fear of criticism
- Feeling sick, sweating, trembling, palpitations
- Panic attacks
Treatment for ALL types
1st line for ALL - SSRi - Sertraline, escitalopram, paroxetine
ALT Pregabalin
Panic 2nd line - Venlafaxine SNRi
OCD 2nd line - Clomipramine TCA
Social 2nd line - moclobemide MAOi
ACUTE short term (2-4 weeks) relief for severe, disabling, or unacceptable distress and for severe insomnia AND as combo until antidepressants work = BENZODIAZPINE
Diazepam, temazepam, nitrazepam
Benzo withdrawal: needs to be gradual. withdrawal symptoms can be: insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances. For short term user usually takes 2-4 weeks but long term may take several months or more.
NICE STEPPED CARE MODEL:
STEP 4 Complex treatment refractory GAD and high functional impairment like self neglect or risk of self harm: - Highly specialist treatment eg complex drug and/or psychological treatment. multiagency teams crisis service, day hospitals/inpatient care.
STEP 3 GAD with inadequate response to step 2 or marked functional impairment: - High intensity psychological intervention (CBT/applied relaxation) OR drug treatment (SSRi - Sertraline if FAIL then ALT SSRi or SNRi)
- Pregnant - 1st line psychological treatment. SSRi/SNRi after 20 weeks of pregnancy can cause new born with persistent pulmonary HTN
STEP 2 diagnosed GAD not improved after education and active monitoring: - Low intensity psychological interventions ( individual non facilitated self help, individual self guided help AND psychoeducational groups)
STEP 1 All known and suspected presentation of GAD: - Identification and assessment = education on GAD and treatment options and active monitoring
