Anxiety Flashcards
types of anxiety disorder
GAD
Phobia
Panic
PTSD
OCD
Neurosis
psychiatric disorder characterised by distress, that are non-organic and have discrete onset. Delusions and hallucinations are absent.
Definition of anxiety
an unpleasant emotional state involving subjective fear and somatic symptoms. If they become excessive or inappropriate = anxiety disorder
Yerkes Dodson Law
anxiety can be beneficial up to a plateau of optimal functioning. Can be helpful for motivation up to a point, then begins to hinder again.
Most common in order with 14% prevalence overall
- Specific phobia
- Social phobia
- GAD
- Agoraphobia
- Panic disorder
- OCD
ICD 10 classifications of anxiety
- Phobia anxiety disorders - agoraphobia (with or without panic disorder), social or specific phobia.
- Other anxiety disorders - GAD, mixed anxiety, depressive disorder, panic disorder
- OCD - obsessional thoughts
- Reaction to severe stress and adjustment disorders - PTSD, acute stress
Generalised symptoms
Psychological - Anticipatory fear, worrying, poor con, poor attention, depersonalisation and derealisation
Cardio - palpitations and chest pain
Resp - hyperventilation, cough and chest tightness
GI - Abdominal pain, loose stools n+v, dysphagia and dry mouth
GU - frequency micturition, failure of erection and menstrual discomfort
Neuro - Tremor, myalgia, headache, paraesthesia and tinnitus.
History points in Anxiety
- Rate of onset
- Duration
- Severity
- Spontaneous or situational?
- Psychiatric or medical conditions in the past / present / family
Two types of anxiety and difference
- Generalised - present most of the time and not associated with specific objects or situations. Normal life events and typically longer duration
- Episodic / Paroxysmal - Abrupt onset and discrete episodes. Severe and short lived with strong autonomic symptoms.
GAD
Ongoing uncontrollable widespread worry about many events or thoughts that the patient recognises as excessive and inappropriate.
Symptoms must be present on most days for at least 6 months in duration.
Aetiology GAD
2-4% in general population. More common in females at ratio of 2:1
Neurophysiological pathophysiology of GAD
Dysfunction of autonomic nervous system, exaggerated responses in the amygdala and hippocampus. Alterations in GABA, serotonin and noradrenaline.
Predisposing factors for GAD
Genetics, Childhood, personality type and demands for high achievement. Being divorced, living alone or as a single parent and low SES
Precipitating factors GAD
Stressful life events such as domestic violence, unemployment and relationship problems
Maintaining factors of GAD
Continuing stress events and marital status. Living alone and ways of thinking which perpetuate anxiety.
Symptoms of GAD
WATCHERS
- Worry
- Autonomic hyperactivity
- Tension in muscles / Tremor
- Conc difficulty / chronic aches
- Headache / Hyperventilation
- Energy Loss
- Restlessness
- Startled easily or sleep disturbance
Chest and Abdo symptoms of GAD
Difficulty breathing, choking, chest pain, nausea, abdominal distress and loose motions
Brain symptoms of GAD
Dizziness, fear of dying, losing control and derealisations
General symptoms of GAD
Hot flushes, numbness or tingling and headache
Tension symptoms of GAD
Muscle tension, aches or pains, restlessness, on edge, difficulty swallowing and sensation of lump in throat
Non-specific symptoms of GAD
Being startled, concentration difficulty, persistent irritability, sleep problems.
MSE GAD
Appearance - worried, restless, sweaty, hyperventilating and lip biting or pallor with tense posture
Speech - trembling and slow
Mood - anxious
Thought - repetitive worrying thoughts
Perception - no hallucinations
Cognition - poor memory and reduced conc
Insight - may or may not have.
Increased HR, BP and RR
Ix GAD
BT - FBC - infection or anaemia, TFT - Hyperthyroidism, Glucose - Hypoglycaemia
ECG - sinus Tachy
Questionnaires - GAD-2, Becks anxiety inventory and hospital anxiety / depression scale
Biological treatment GAD
1st line - SSRI - Sertraline
2nd Line - SNRI - Venlafaxine or duloxetine
3rd - Pregabalin
Benzodiazepines should NOT be offered unless short term during crises - issues with dependence
Psychosocial treatment GAD
Psychological - Psychoeducational groups / CBT / Applied relaxation
Social - Self help methods / Support groups / Exercise
Stepped care model of GAD
- Assessment and psychoeducation
- Low intensity psych interventions - self help and guided self help with. group based support
- Medication or CBT
- Multi agency teams and high specialist input. Combination of both medication and therapy. May need crisis team.
Ddx GAD
- Panic disorder
- Specific phobias
- Schizophrenia
- Personality disorder
- Excessive caffeine or alcohol consumption
- Withdrawal from drugs
What is a phobia
intense, irrational fear of a stimulus that is recognised as excessive or unreasonable
Agoraphobia
fear of public spaces - immediate escape would be difficult
Social phobia
Fear of social situations - humiliation, embarrassment or criticism
Isolated phobia
Fear of specific object or situation.
Arachnophobia
Haematophobia
Phobia of flying
Phobia of heights
RF of phobias
- Aversive experiences
- Stress and negative life events
- other anxiety disorders
- Mood disorders
- Substance misuse disorders
- Family History
Symptoms of phobias
Biological - Similar to GAD - Autonomic response with tachycardia. Some may lead to vasovagal response —> Syncope e.g. blood phobia.
Psychological - Anticipatory anxiety, inability to relax, urge to avoid situation and a fear of dying.
MSE of phobia
Appearance - restless wanting to escape, pale, sweaty and hyperventilating with or without syncope
Speech - trembling or speechless
Mood - anxious
Thought - unpleasant feelings towards threat, fear of situation or desire to escape
Insight - Poor when feared stimulus present. Good otherwise
Will be normal unless phobia is present / brought up
ICD-10 Agoraphobia
a. Marked and consistent fear in at least 2 of crowds / public spaces / travelling alone / travelling away from home
b. Symptoms of anxiety (2+)
c. Significant emotional distress
D. Symptoms restricted to situation
ICD - 10 Social Phobia
A. Marked fear of being focus of attention or embarrassment in social situations
B. At least 2 symptoms of anxiety plus blushing, vomiting, urgency or micturition / defecation
C. Significant emotional distress
D. Excessive or unreasonable
E. Symptoms restricted to the situation
ICD-10 Specific phobia
Marked fear / avoidance of specific subject
Symptoms of anxiety infrared situation
Significant emotional distress only when linked to situation.
IX for phobias
Minimal - maybe questionnaires but mainly on history
Treatment of Generic phobia
Good rapport
Avoidance of anxiety inducing substances - caffeine, alcohol
Co-morbidities - check for substance missuse or personality disorders
Specialist referral if concern for SH and Suicide.
Treatment of agoraphobia
CBT
Graduated exposure
SSRI
Treatment social phobia
CBT
Graduated exposure
SSRI or SNRI or MAOI - moclobemide (1/2/3)
Psychodynamic psychotherapy
Specific phobia Treatment
Exposure - self help or CBT
Benzodiazepines short term
Difference between GAD and Phobia
Symptoms of GAD occur most of the time whereas features of phobic anxiety disorders occur in response to particular situations
Commonly, agitation is an associated behaviour of GAD whereas avoidance of the particular situation typically occurs in phobic anxiety disorders
Concerning cognition, there is constant worry about everyday life events in patients with GAD whereas patients with phobic anxiety disorders only worry about or fear a particular situation
THINK
SS - specific situations
AA - anticipatory anxiety
AA - attempted avoidance
Panic disorder
Recurrent, episodic and severe panic attacks which are unpredictable and not restricted to any particular situation or circumstance
Aetiology panic disorder
3 x more common in females
Late adolescent onset
1% general prevalence
Pathophysiology of Panic disorder
Genetics - Heritability
Neurochemical - Post synaptic hypersensitivity to serotonin and adrenaline
SNS - Fear or worry stimulates the SNS —> Inc cardiac output which can lead to further anxiety
Cognitive - Misinterpretation of somatic symptoms - e.g. fear of palpitations leading to a heart attack
Environmental - Life stressors
RF panic disorder
- FHx
- Major life events
- 20-30
- Recent trauma
- Females
- Other mental disorders
- White
- Asthma
- Cigarette smoking
- Medication - benzodiazepine withdrawal
Symptom of panic disorder
PANICS Disorder
Palpitations
Abdominal distress
Numbness / Nausea
Intense fear of death
Choking feeling / Chest pain
Sweating, Shaking, SOB
Depresonalisation or derealisation.
Panic symptoms peak within 10 minutes and rarely last longer than an hour.
Classification ICD-10 Panic disorder
ICD-10
- Recurrent panic attacks that are not consistently associated with a specific situation or object and occur spontaneously
- All of the following
- Discrete episode of intense fear or discomfort
- Starts abruptly
- Crescendo within a few minutes
- Autonomic arousal
- Other symptoms of GAD
Ix Panic disorder
Hx - Same as GAD, but appearance and behaviour may be more intense - hyperventilating - in case of panic attack
BT - FBC - infection or anaemia, TFT - Hyperthyroidism, Glucose - Hypoglycaemia
ECG - sinus Tachy
Questionnaires - GAD-2, Becks anxiety inventory and hospital anxiety / depression scale
Treatment panic disorder
- SSRI
- If not suitable after 12 weeks then switch to TCA - imipramine or clomipramine
- NO BENZO
- CBT
- Self help methods
Stepwise approach to panic disorder
- Recognition and diagnosis
- Treatment in primary care
- Review and consider alternative treatments
- Specialist mental health
- Care with specialist mental health services - hospitalisation
Ddx panic disorder
- Other anxiety disorders
- Organic - phaechormocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndrome, arrythmias, substance withdrawal
Age of onset for GAD, panic and phobia
Variable / Late adolescence / Childhood to late ado
Occurrence of GAD, panic and Phobic
Persistent
Episodic
Situational
Associated behaviour of GAD, panic and Phobic
Agitation
Escape
Avoidance
Cognition of GAD, panic and Phobic
Constant
Fear of symptoms
Fear of situation
Associations of GAD, panic and Phobic
Depression
Depression, agoraphobia and substance misuse
Substance misuse
PTSD
Intense, prolonged and delayed reaction following exposure to an exceptionally traumatic event
Abnormal Bereavement
Delayed onset, is more intense and prolonged >6 months
Acute stress reaction
Abnormal reaction to sudden stressful events
Adjustment disorder
Significant distress accompanied by an impairment in social functioning.
Cognitive pathophysiology of PTSD
failure to process emotionally charged events causes memories to persist in an unprocessed form and can intrude on conscious awareness.
Examples of traumatic events
- Severe assault
- Major natural disaster
- Serious RTA
- Civilian disaster
- War
- Freak occurrences - near drowning when on holiday etc
- Physical torture
- Prisoner of war or hostage
- Violent or unexpected death
RF of PTSD
- Exposure to a major traumatic event
- Pre trauma - previous, history of mental illness, low SES, childhood abuse
- Peri-trauma - severity, perceived threat to life, adverse emotional reaction
- Post-trauma - Concurrent life stressors, absence of social support
Symptoms PTSD
- Reliving the situation - Flashbacks, vivid memories, nightmares, distress when thinking of similar situations
- Avoidance - Avoiding reminders of trauma and excessive. Inability to recall some events
- Hyperarousal - Irritability or outbursts, insomnia or hypersommnia and exaggerated startle response
- Emotional numbing - negative thoughts of oneself, difficulty controlling and expressing emotions, detachment
MSE PTSD
Appearance - hyper vigilance
Speech - slow and trembling
Mood - anxious
Thought - pessimistic
Perception - No hallucinations and may have illusions
Cognition - poor attention and concentration
Insight - Good
ICD-10 PTSD
- Exposure to traumatic event
- Persistent remembering
- Avoidance of similar situations
- Inability to recall some important aspects OR increased psychological sensitivity or arousal
- Within 6 months of stressful event or at end of period of stress.
Ix PTSD
- Trauma screening questionnaire TSQ
- Post traumatic diagnostic scale
- CT head - if head injury is suspected
Treatment PTSD >3 Months
- CBT or Eye movement desensitisation and reprocessing (EMDR)
- Drug - if little benefit from therapy, pt choice to not undergo therapy or co-morbid depression or severe hyperarousal
- Paroxetine, mirtazapine, amitriptyline and phenelzine
PTSD treatment <3 months
Within 3 months
- Watchful waiting
- Trauma-focused CBT - 8-12 sessions
- Short term drug treatment - sleep disturbance - zopiclone
- RA
Ddx PTSD
- Adjustment disorder, acute stress or bereavement disorder.
- Dissociative disorder
- Head injury or alcohol / substance misuse.
Stages of grief
DABDA
Denial
Anger
Bargaining
Depression
Acceptance
Consideration for diagnosis of PTSD
Pt may present with loss of loved one. Bereavement is a unique traumatic stress which is a normal human experience and not unnatural. It should not extend over 6 months and if it does think bereavement disorder or adjustment disorder - NOT PTSD
OCD
recurrent obsessional thoughts or compulsive acts
Compulsions
Repetitive stereotyped behaviours or mental acts that a person feels driven to performing. Either overt or convert.
Pathophysiology of OCD
Biological - Dec serotonin and abnormalities in the frontal cortex and basal ganglia.
PANDAS - Childhood group A beta-haemolytic streptococcal infection can have a role as damages basal ganglia.
Psychoanalytic - filing the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness
Behavioural - Compulsive behaviour by operant conditioning.
Obsession
Unwanted intrusive thoughts that repeatedly enter individuals mind. Distressing
RF OCD
- Other psychiatric disorders - depression, anorexia nervosa, Tourettes and sydenhams chorea
- Early adulthood and equal among genders
- Developmental factors - neglect, abuse or bullying / social isolation
- Carrying out compulsive act is a maintaining factor.
Symptoms of obsessions
contamination, fear of harm, excessive concern with order and symmetry, sex violence or blasphemy
Symptoms of compulsions
Checking gas taps, cleaning, repeating acts or arranging objects, mental compulsions, hoarding
Symptoms and Cycle of OCD
FORD Car
Failure to resist
Originate - from pt mind
Repetitive
Distressing
Carrying out obsessive thought is not pleasurable.
OCD Cycle:
Obsession —> Anxiety —> Compulsion —> Relief
MSE OCD
Pt may be easily startled or visibly worried
Anxiety
Thoughts are unwanted and intrusive
Obsessions leading to poor concentration
Insight is usually very good.
Sub categories of OCD
- Predominantly obsessional thoughts
- Predominantly compulsive acts
- Mixed obsessional thoughts and acts
ICD-10 OCD
ICD-10
- Obsessions or compulsions present on most days for at least 2 weeks
- Obsessions or compulsions share a number of features all of which must be present
- The obsession or compulsions cause distress or interfere with the subjects social or individual functioning.
Treatment OCD
- CBT - including ERP (exposure and response prevention)
- Pharmacology - SSRI - fluoxetine or sertraline or citalopram
- Clomipramine or antipsychotic in case of needing adjustment
- Psychoeducation, distratcing techniques and self-help books
- RA for suicide risk
- Treatment of co-morbidities - depression
Ddx OCD
- AN and BN ED
- Anankastic personality disorder
- Body dysmorphic disorder
- Primary obsessions or compulsions - anxiety / depression / tourettes
- Kleptomania
- Organic - dementia, epilepsy or head injury
What are somatoform disorder
group of disorders whose symptoms are suggestive of a physical disorder but in the absence of physiological illness - presumed to be caused psychologically.
Causation Types of somatoform disorder
- Multifactorial - for primary or secondary gain.
- Biological - neuroendocrine genes
- Psychological - a high proportion of those with PTSD / association to physical or sexual abuse
- Social - adopting the sick role in order to gain relief from stress
RF of somatoform disorders
CRAMPS
Childhood abuse
Reinforcement of illness behaviours
Anxiety disorders
Mood disorders
Personality disorders
Social stressors
Dissociation
Separating if certain memories from normal consciousness as a psychological defence mechanisms used to cope with emotional conflict distressing for the patient
Conversion
distressing events are transformed into physical symptoms.
Dissociative amnesia
Amnesia for partial or complete for recent events that were traumatic. Too extensive to be ordinary forgetfulness.
Dissociative fatigue
Unexpected physical journey away from usual surroundings followed by amnesia for the journey.
Dissociative stupor
Profound reduction in or absence of voluntary movements speech and normal responses to stimuli.
Trance and possession disorder
Trance = temporary alteration in state of consciousness. Possession = absolute conviction by the patient that they have been taken over by spirit or power or person.
Dissociative motor disorders
Loss of ability to perform movements that are under voluntary control or ataxia.
Dissociative convulsions
Sudden, unexpected spasmodic movements that resemble epilepsy without loss of consciousness
Dissociative anaesthesia and sensory loss
Partial or complete loss of cutaneous sensation, vision, hearing or smell.
Types of dissociative disorder
Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and Possession disorders
Dissociative motor disorders
Dissociative convulsions
Dissociative anaesthesia and sensory loss.
MSE Somatoform disorders
- Appearance and behaviour reflects underlying mood or anxiety disorders
- Thoughts will show preoccupation to a physical disorder and symptoms
- Insight into having psychiatric illness will probably be clouded.
Ix somatoform disorder
- Normally a disorder of exclusion
- A thorough physical examination and investigations rule out an organic cause
- BT - FBC, U+E, TFT and CRP all normal
- Symptoms are investigated depending on system affected.
Classifications of somatoform disorder
ICD-10
PUSHy SOMATOFORM
- Persistent somatoform pain disorder
- Undifferentiated somatoform disorder
- Somatization disorder
- Hypochondriacal disorder
- Somatoform Autonomic Dysfunction
Somatisation disorder
- Briquets syndrome
- Requires all 4 of
- At least 2 years duration of physical symptoms that cannot be explained by any physical detectable disorder
- Preoccupation with symptoms causes physical distress
- Continuous refusal by patients to accept reassurance
- Six or more symptoms :
- Abdo pain / N+ V / Bloating / Regurgitation / Loose bowel motions
- Chest pain / breathlessness / palpitations
- Dysuria / Frequency / Incontinence / Vaginal discharge
- Discolouration or itching / Arthralgia / Headaches / Visual disturbances
Hypochondrical disorder
- Misinterprets normal bodily sensations which leads them to non-delusional preoccupation that they have a serious physical disease.
- Refuse reassurances from doctors
- Dysmorphophobia - excessive preoccupation with barely noticeable or imagined defects in their physical appearance.
Somatoform autonomic disorder
- Symptoms related to autonomic nervous system in multiple systems
- E.g. cardiovascular - palpitations / chest pain / sweating
- Some symptoms may be objective - sweating, tremor or Subjective - pain and paraesthesia
Persistent somatoform pain disorder
- Persistent >6 monts and severe pain that cannot be fully explained by a physical disorder.
- Psychosocial stressors or emotional difficulties attribute to symptoms
- Differs from somatisation disorder in that pain is the primary feature and multiple symptoms from different symptoms are not present.
Ddx somatoform disorder
- Somatoform disorders
- Dissociative conversion disorder
- Factitious Disorder
- Malingering
- Other psych - mood, psychotic or PD
- Multisystemic disease - CT disorder or IBD.
Malingering
patient seeks advantageous consequences of being diagnosed with a medical condition
Factitious disorder
Adopt the sick role in order to receive care and for internal emotional gain.
Management somatoform disorder
Biological -
- SSRI
- Physical exercise - dysmorphophobia
Psychological -
- CBT
Social -
- Stress relieving activities - medication and long walks.
- Interview family members who serve to reinforce the sick role
Explaining a somatoform disorder
Explanation - Many people like yourself have symptoms that we cannot find a reason for. Medically unexplained symptoms
Placing a positive spin - There are still ways we can help. We can train body to feel normal again but not able to pin point an exact cause
Relate to a disorder - We know physical illness can get worse dependent on patients mood - e.g. stress making asthma worse - so we can try to work with mood stabilisation that may help some symptoms.
Munchausens syndrome
In both malingering and factitious disorder - Munchausens syndrome - physical and psychological symptoms are intentionally produced - Faked.
Repression
involuntarily withholding an idea or feeling from conscious awareness
Displacement
Redirection of emotions or impulses to a neutral person or object
Suppression
Intentionally and temporarily withholding an idea or feeling from conscious awareness (vs repression which is involuntary)
Psychotic defences
Denial
Distortion
Splitting
Immature defences
Projection
Acting out
Projective identification
Neurotic defences
Displacement
Reaction formation
Repression
Intellectualisation
Dissociation
Isolation
Regression
Rationalisation
Undoing
Mature defences
Altruism
Sublimation
Suppression
Humour
Identification
Projection
Attributing uncomfortable thoughts or feelings to others
Projective identification
the object of projection invokes in that person precisely the thoughts, feelings or behaviours projected
Reaction formation
Acting in the opposite way to the thought or feeling
Intellectualisation
Focusing on details in an effort to avoid painful thoughts or emotions
Dissociation
Temporary drastic modification of one’s personal identity or character to avoid emotional distress
Regression
Reverting back to an earlier stage of development when faced with an unpleasant thought or emotion
involuntarily turning back the maturational clock and going back to earlier modes of dealing with the world
Rationalisation
The creation of false but credible justifications
Undoing
An attempt to take back an unpleasant thought or emotion
Altruism
Lessening negative feelings by providing constructive service/generosity to others
Sublimation
Redirecting negative thoughts or feelings into a more positive form
Suppression
Process of consciously avoiding thinking about something for example by distracting oneself
Identification
The unconscious modelling of one’s self upon another person’s character and behaviour
BDD IV criteria
Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)
