anxiety Flashcards
physiological anxiety
anticipation of a stressful event
acts as a stimulus to prepare for that event
increased alertness
focus on ‘threat’
pathological anxiety
anxiety is out of proportion to threat
in some cases anxiety can exist without threat
it interferes with day to day activities, and can be very disabling
can be diverse
disorders related to pathological anxiety
generalised anxiety disorder
panic attacks
post traumatic stress disorder
phobias
OCD
Social anxiety
psychological symptoms of anxiety
fearful anticipation
cognitive disturbance
minor depressive symptoms
irritability
physical symptoms of anxiety
sympathetic arousal
-sped up heart rate
-faster breathing and hyperventilation
-sweating
hyperventilation
increase muscle tension
sleep disturbance
epidemiology of anxiety
10-20% of adults have an anxiety disorder in a year
lifetime prevalence of 20-30%
treatments for anxiety
anxiolytic drugs and psychological therapy
types of anxiolytic drugs
beta blockers
anti depressants
pregabalin
buspirone
benzodiazepines
how many people does generalised anxiety disorder affect
5% of the UK,
huge problem from health and economic perspective
2-4% of population in a year
2x as common in women
higher in middle ages, median onset of 30
criterion for diagnosing anxiety
ICD11 and DSM5
DSM 5 criteria
excessive worry and anxiety most of the time for > 6 months
worry is about a number of different things
cannot control worry
at least three of: restlessness, fatigue, poor concentration, irritable, sleep problems
symptoms result in poor functioning, cannot be managed by patient and are not due to drugs or other psychiatric conditions
aetiology of GAD
Twin studies show heritability of about 30%
-No “GAD gene” but links to serotonin and monoamine transmission genes
Risk factors
-childhood trauma
other health conditions e.g. heart attack or stroke
neurobiology of GAD
possibly due to dysfunction of the amygdala, medial prefrontal cortex and insular
involved in memory, decision making, emotional reaction, fear and threat perception
4 step approach to treatment of generalised anxiety disorder from NICE
education: may in itself improve symptoms
individual or group self CBT
drug therapy or high intensity CBT
combinations of drugs or drugs + psychological interventions
-SSRIs, SNRIs, pregabalin (BDZ only for short term use)
Buspirone mechanism
partial agonist at 5H21A receptors
5HT1A receptors found pre and post synaptically
-presynaptic: acts as inhibitory autoreceptors un serotonergic synapses, and as heteroreceptors in other synapse types
Buspirone will modulate the release of 5HT and other neurotransmitters
advantage of buspirone
doesn’t produce pronounced sedation and has relatively mild side effects
Some sources suggest there are no withdrawal effects, others suggest discontinuation syndrome
what is buspirone used for
licenced for GAD and occasionally used in other anxiety disorders
Compulsions
driven by obsessions
Repetitive, involuntary activities that are undertaken to provide temporary relief from these obsessions
types of intrusive/ disturbing thoughts
sexual thoughts
violent thoughts
thoughts of hurting themselves or other people
hygiene or contamination obsessions
obsessions around symmetry or order
types of compulsion
checking
counting
touching
arranging
pure obsession OCD
this is where most problems arise from the intrusive and disturbing thoughts
may still have some compulsions, but they are a minor part of the condition or hidden somehow
causes of OCD
Neurobiology largely unknown
Genetic (50% ish) and epigenetic (childhood trauma)
Can be triggered by atypical antipsychotics
-produce OCD in people who didn’t have it prior to taking the antipsychotic
trichotillomania
Compulsive pulling out of hair
Is sometimes combined with the eating of hair
dermatillomania
compulsive picking of the skin
body focused repetitive behaviours
have a distinct diagnostic category in the DSM
trichotillomania
dermatillomania
very commonly linked with OCD , people with OCD often display these as part of their compulsions
-seems to be common in people who have contamination obsessions
-possible to have these conditions without actually having obsessions
treatment of OCD for mild impairment
Low intensity psychological interventions (<10 h)
CBT inc. ERP (Exposure Response Prevention)
moderate impairment OCD treatment
SSRIs or more intense CBT inc. ERP
severe impairment OCD treatment
SSRIs and more intense CBT inc. ERP
ERP
exposure response prevention
exposure response prevention
You expose the person to what they are fearful of in a controlled way, and you gradually help them to overcome their fear
Can form a part of therapy for PTSD, phobias
neurobiology of OCD
Neuroimaging has mostly implicated the OFC and basal ganglia.
The cingulate cortex (red) has also been suggested a role, with the ACC of showing hyperactivity
bilateral cingulotomy
Psychosurgical technique as a practice of last resort for OCD
-and a few other conditions- intractable pain, depression
Involves severing connections to the cingulate cortex
Is done with the aid of fMRI scans therefore is precise
Is done using electrodes of gamma knife
Recover is generally very quick (a few days), with relatively few people experiencing serious side effects
~40% of those who undergo this procedure to treat OCD are benefitted
side effect of panic attacks
physical symptoms
high level of sympathetic activation, parasthesias
psychological symptoms
depersonalisation, derealisation, fear of loosing control or dying
what are panic attacks
Intense anxiety with a sudden onset
Usually symptoms come on over a period of a few minutes
physical symptoms of panic attacks
heart pounding, accelerated heart rate, palpitations
trembling
sweating
chest pain?
what is parasthesias?
pins and needles feeling
what disorders can panic attacks occur as a part of?
other anxiety disorders, e.g., phobias
as part of a physical condition., hyperthyroidism or pheochromocytoma can sometimes provoke panic attacks
what is needed to be diagnosed as having a panic attack
to be diagnosed as having a panic attack you need to experience 4/13 symptoms listed on the DSM
what is needed to be diagnosed as having a panic attack
to be diagnosed as having a panic attack you need to experience 4/13 symptoms listed on the DSM
what is panic disorder
Recurrent panic attacks and
A period of at least a month in which there is persistent anxiety about having a panic attack and/or
Changed behaviour aimed at avoiding panic attacks e.g. avoiding social situations
treating mild to moderate panic disorder
low intensity psychological interventions
e.g. self help, support groups
moderate to severe panic disorder treatments
CBT o
if CBT not effective
SSRI or SNRI
If SSRI or SNRI not effective
a tricyclic antidepressant
not mentioned in NICDE guidelines: beta-blockers are sometimes used for treating anxiety and panic disorders
main example of a beta blocker
propranolol
what is the mechanism of beta blockers
B1 adrenoreceptor antagonists
what is the effect of beta blockers
Mask symptoms of sympathetic activation
Reduce physical effects of panic attacks
Will not directly treat the psychological symptoms, however may break cycle of physical symptoms making psychological symptoms worse.
More useful in the short term
what is social anxiety disorder?
a fear of social situations
what is the most common anxiety disorder? What is its prevalence?
social anxiety disorder, 12%
criteria for social anxiety disorder
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others
The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated
The social situations almost always provoke fear or anxiety.
The social situations are avoided or endured with intense fear or anxiety
The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
must have lasted 6+ months, cannot be explained by another condition
what is first recommended treatment for social anxiety?
specialised CBT
recommendation for individual therapy, not group therapy
what treatment for social anxiety if CBT is ineffective
further CBT, SSRIs
SNRIs or MAO inhibitors as a potential further treatment
what is PTSD
condition someone can develop following any kind of trauma
people who get PTSD
those who have been in combat experiences (military service)
sexual assault
being in a terrorist attack or involved in an incident
symptoms of PTSD
hypervigilance, aggression, flashbacks to the trauma, cognitive problems, intrusive thoughts and memories, and nightmares
Many people find that episodes of PTSD are provoked by specific triggers that are connected (perhaps only loosely) with original trauma.
suicide and PTSD
These can be extremely distressing and debilitating, which is reflected in a much higher suicide rate (9.8x general population) in people with PTSD
neurobiology of PTSD
Seems to involve reductions in the volume of the hippocampus and prefrontal cortex
The amygdala also shows abnormalities in PTSD
-key structure for emotional processing and the acquisition of fear behaviours
-becomes hyper-responsive and seems to result in an excessive threat responses to non-threatening stimuli
changes in HPA axis
-often have lower plasma cortisol levels and have a greater response to the dexamethasone suppression test than control subjects (surprise as you would expect stress to increase cortisol levels)
-has been hypothesised that a low level of cortisol following a traumatic event may result in increased noradrenergic signalling both in the CNS and in the periphery
-Increased release of noradrenaline by neurons originating in the locus coeruleus may result in “over-consolidation” of fearful memories about the trauma.
prevention of PTSD
Most people who experience a trauma will have an ‘acute stress reaction’ in the immediate aftermath
However, there is often a delay before PTSD ‘properly’ establishes itself
If people who experience acute stress reaction are given specialised CBT for a month following the trauma, it can:
-reduce the rate at which people go on to develop PTSD
-lessen symptoms of those who develop PTSD
treatment of PTSD
NICE does not recommend treating established PTSD with drugs
Recommends treating established PTSD using specialised CBT and for non-combat trauma EMDR can be offered
If patients prefer they can be offered SSRIs or SNRIs instead of CBT
If PTSD has psychotic symptoms, then atypical antipsychotic drug such as risperidone might be considered
EDMR
Eye Movement Desensitisation and Reprocessing
controversial therapy that seems to work, but no-one knows why
