Anxiety Flashcards
What is the Yerkes-Dodson curve?
There is an optimum level of anxiety which enables an efficiency of performance.
What is the most common mental disorder in the UK?
Mixed anxiety and depression
What are key aspects in the clinical assessment of anxiety?
—>Whether the anxiety is pathological and interferes with the patient’s daily life
—> Patient personality is trait vs state
—> Context of the anxiety, if it is continuous or situational
What is trait anxiety?
Anxiety which is prominent and forms part of a person’s cognitive thinking or personality
What is state anxiety?
Anxiety which occurs temporarily at a specific point of time.
What is psychoses?
Severe mental illness where there is a loss of reality.
What is neuroses?
Umbrella term for mental illness charactersied by anxiety and emotional distress. Disorders include phobias, adjustment disorders, OCD and PTSD. These have similar treatment responses e.g
Antidepressants as anxiolytics
Anti-OCD agents and exposure therapy is useful as a behavioural exposure therapy for PTSD
What is Generalised Anxiety Disorder?
Excessive persistent distress which is continuous and generalised free-floating anxiety of a duration over 6 months and is unrelated to a specific event, causing restlessness and tension.
It is one of the most common mental disorders which typically presents with depression.
What are the characteristics of generalised anxiety disorder for diagnosis?
—>Initial insomnia at night due to sleep disturbances with worrying
—> Restlesness
—> Fatigue
—> Difficulty concentrating
—>Muscular tension causing neckache, backache and headache
—> Autonomic symptoms of sympathetic activation with sweating, palpitations, and a dry mouth.
What are potential differential diagnoses for GAD?
—> Depression is a common co-morbidity
—> Substance misuse/withdrawal (caffeine, alcohol or drugs)
—> Physical causes of thyrotoxicosis, phaechromocytoma and hypoglycaemia
—> Schizophrenia and dementia
What are the psychiatric causes of generalised anxiety disorder?
Depression
Avoidant personality disorder
Dementia
Schizophrenia
—> These are all common co-morbidities with generalised anxiety disorder
What is the epidemiology of GAD?
Prevalent in young adults
Affects more women than men
Those in poor mental or physical health
Low income
Presence of multiple stressors
—> Prognosis is generally good after a year
What is the aetiology of GAD?
Genetic predisposition
Physical or mental co-morbidity such as diabetes and depression’
Environmental factors like childhood upbringing, adversity and trauma
Substance use disorder
Personality traits of neuroticism
Which investigations should be performed for a differential diagnosis of generalised anxiety disorder?
—> Thyroid function test to rule out thyrotoxicosis
—> Blood glucose test to rule out hypoglycaemia
—> Echocardiogram to rule out cardiac abnormalities and organic cause
—> Toxicology to rule out drug misuse
What is the treatment for generalised anxiety disorder?
CBT to promote mindfulness, which is the purposeful non-judgmental attentiveness to your experiences, thoughts and feeling
SSRIs to inhibit the action of serotonin transporters, increasing the availability of serotonin to improve mood and sleep by acting on 5-HT receptors in the brain.
How is Generalised Anxiety disorder diagnosed?
GAD-7 questionairre, where patients are asked to rate their responses to 7 questions based on their experiences in the last 2 weeks which include:
Restlessness, on edge, impending doom and inability to control excessive worrying.
**Scores of 5, 10 and 15 are the cutoff for diagnosis of mild, moderate and severe anxiety.
What is panic disorder?
Sudden extreme anxiety with recurrent unexpected panic attacks that peak at 10 minutes and lack a specific trigger.
These occur for 1 month+, with symptoms such as palpitations and impending sense of doom. As a result of the panic attacks, patients will experience fear or worry for over one month about the panic attacks and develop behavioural changes like avoidance to the triggers.
What are the features of panic disorder?
Difficulty breathing
Shortness of breath
Heart palpitations
Depersonalisation
Derealisation
Feeling close to death
What is the CBT model of panic disorder?
Catastrophic misinterpretation of bodily sensation is key to maintenance in response to normal physiological symptoms.
This causes selective attention and avoidance of anxiety provoking situations.
What is the psychodynamic theory of anxiety?
Unresolved past conflicts and distress creates emotional regression and leads to neurosis. These present as defence mechanisms, so it is important to explore childhood events, relationship with parents to find the underlying anxiety.
What is the aetiology of panic disorder?
Genetics
Biological mechanisms involving the 5-HT1a receptor pathway
Adverse childhood experiences
Environmental factors
What is the epidemiology of panic disorder?
Primarily affects women over men
Prevalence in those aged 25-34 years old
Co-morbidity with depression, GAD, phobia disorder, smoking and alcohol use
What are phobic anxiety disorders?
Related to a specific situation, where there is intermittent anxiety that can lead to habitual avoidance and anticipatory anxiety in relation to the circumstances. The three types of phobic disorders:
Agoraphobia
Simple phobia
Social phobia
What is simple phobia?
Typical onset is childhood with anxiety around a specific object or circumstance that lasts for longer than 6 months. Treatment is typically habituation/systemic desensitisation.
Fear of animals is typical in children aged 2-4
Fear of creatures is typical in children aged 4-6
Fear of death and war is common in teenagers
How do phobias develop?
Classical conditioning, where there is an association of a conditioned stimulus with an unconditioned responses.
Operant conditioning, where the response is maintained.
What is the epidemiology of specific phobia?
More common in children, affects more women than men. There is an absence of correlation to other disorders, and a low score for neuroticism.
It worsens if untreated.
What is social anxiety?
Anxiety related to social situations such as public speaking or performing. This can be treated with SSRIs in the longterm and beta blockers to dampen the sympathetic response in the short term.
What is the epidemiology of social anxiety?
Onset is typically in the teens, affecting more women than men.
It has a common co-morbidity with low self esteem and social anxiety has a typical development into depression, persisting for decades.
What is agoraphobia?
It is a type of anxiety disorder which is a co-morbidity typically with panic disorder where a patient experiences an irrational fear of pubic areas and crowds, where symptoms are provoked by being away from the home and in crowded or confined spaces. Onset usually occurs before 35 years old and patients are vulnerable to anxiety symptoms and prone to misinterpreting
What is the aetiology of agoraphobia?
Genetics, with family history of agoraphobia
Personality traits like neuroticism
Cognitive model
Conditioning and avoidance, reinforced by family and friends
Family influences
What is the epidemiology of agoraphobia?
Affects women over men
Onset is early adult life
History of school refusal and attachment disorders
Triggered by life events
What is obsessive compulsive disorder?
Anxiety disorder lasting at least 2 weeks where there is an internal source of intrusive thoughts which creates distress that patient tries to resist but is relieved through repetitive compulsions and actions. The patient recognises it comes from within and that it is nonsensical and irrational.
Common actions include hand washing, counting, insistence of symmetry and aggressive thoughts.
What are the spectrum of conditions included in OCD?
->Hypchondriasis
->Tourette’s disorder
->Pathological gambling
->Nail biting
->Body dysmorphia
What is the pathological process of OCD?
Neuronal loop hypothesis where the connections between the:
Corpus striatum
Thalamus
Frontal cortex
Cingulate gurus
Become altered due to a dysfunction of serotonin transmission, that causes increased thalamus activity from the corpus striatum which acts on the cingulate gyrus to drive compulsions. OCD patients show greater metabolic activity in these regions.
What are the obsessional phenomena in OCD?
Thoughts that are repetitive and unpleasant
Impulses to perform violent or embarrassing acts
Ruminations about trivial problems
Rituals such as counting and repetitive checking
What are the important differential diagnoses for OCD?
Normal intrusive thoughts
Schizophrenia
Depressions if obsessions outweigh the compulsions
Anankastic personality disorder: preoccupation with rules and lists and perfectionism which interferes with list completion
Organic head injury or CNS infection, however it is impossible to resist thoughts
What is the epidemiology of OCD?
Mean age of onset is 20 years old with equal incidence between men and women. Incidence decreases past 25 years old.
What is the aetiology of OCD?
Genetic pre-disposition
Environmental stress from increased responsibility
Personality types that are predisposed include avoidant and anakastic (perfectionist.)
Dysfunction in the cortical-striata-thalamus pathway involving the direct pathway to initiate behaviour and the indirect pathway for modulating and inhibiting behaviour. There is hyperactivity of the direct pathway due to dysfunction of serotonin signalling which creates repetitive thoughts and actions.
Gille de la Tourette syndrome
Encephalitis lethargica
High levels of glutamate, serotonin or dopamine.
Maladaptive beliefs create a predisposition, such as perfectionism and a need for control
What is the behavioural theory of OCD?
Rituals, avoidance and reassurance provide short term relief but in the long term, worsen the issue through negative reinforcement and operant conditioning.
What is the cognitive theory of OCD?
Exaggerated appraisal of threat by the patient whom assumes excessive responsibility for the consequences and attempts to suppress these thoughts.
How is OCD managed?
Combined therapy of CBT with SSRIs, tricyclic antidepressants or beta blockers.
Firstline treatment is exposure and prevention therapy for the compulsions, where a patient is exposed to their trigger and prevented from engaging in their obsessive compulsive behaviour.
What is important in the management of OCD?
Patients should be made to understand the nature of the disorder, and their comorbidities of depression and anxiety must be detected and treated.
CBT should focus on the obsessions avoiding resistance to obsessional thoughts, and making realistic estimates of the likelihood of its occurrence.
What are the NICE guidelines for mild OCD?
CBT with a structured help or support group
What are the NICE guidelines for moderate OCD?
SSSRI or CBT
What are the NICE guidelines for severe OCD?
Combination of CBT and SSRI.
-> If no response with current SSRI, increase to clomipramine
Referral to multidisciplinary team with expertise in OCD
ALTERNATIVES:
Inpatient admission
Social care
Antipsychotic additional therapy
How is the management of children with OCD different?
CBT is the first line for all stages of OCD, even severe for a minimum of 12 weeks
SSRIs will only be offered if aged over 12
Emphasis on age appropriate family and group interventions
What is adjustment disorder?
Anxiety/abnormal grief reaction related to a specific event that lasts for less than six months as a response to a stressful experience which is proprotionate
What is Gille-De la Tourette syndrome?
Also known as Tourette’s, it is a neuropsychiatric disorder with an onset in childhood where there is involuntary movement or sounds. It is aetiologically linked to OCD, with the majority of patients with OCD or Tourette’s having the other as a co-morbidity.
What is encephalitis lethargica?
Acute central nervous system infection that is characterised by headaches, double vision and a delayed mental and physical response.
What is post-traumatic stress disorder?
Triggered by a life’s event, with symptoms lasting longer than 1 months.
It is characterised by hyperarousal, hyperavoidance of triggers, intrusive symptoms, disassociations and cognitive changes.
Symptoms are worst in the 1st week following trauma, and can be predicted by a high resting heart rate for one week.
What are the NICE guidelines for management of PTSD?
Use of screening instruments if suspected for re-experiencing, avoidance, hyperarousal, dissociation, negative alterations in mood and thinking, and functional impairment.
Offer 8-12 sessions of CBT to adults with PTSD presenting more than 1 month after a traumatic event.
EMDR therapy
What is EMDR therapy?
Eye movement desensitisation reprocessing
What is Type 1 PTSD?
Occurs after a single traumatic event that are unexpected and typically life threatening, such as motor accidents
What is Type 2 PTSD?
Exposure to multiple or prolonged traumas, with common misdiagnosis as a personality disorder. Behavioural presentation as impulsivity, aggression and substance misuse.
What is the aetiology of PTSD?
Predisposition with a history of abuse and trauma, drug and alcohol abuse.
Interpretation of stressful event
Environment following even
Which biological mechanisms are involved in PTSD?
Catecholeamines systems where:
Locus coreleus system increases activity of amygdala
Dopamine system increases prefrontal cortex activity
Sensory nervous system increases physiological arousal and noradrenaline and adrenaline secretion
What does cognitive therapy for PTSD involve?
Exposure therapy targets fear and anxiety, however cognitive therapy targets the patient’s automatic negative thoughts and underlying assumptions.
Which beliefs are altered following a traumatic experience?
The world is a benevolent and safe place
The world is meaningful and people have control
The self is worthy and moral
What is acute stress disorder?
Begins immediately after a traumatic event and lasts less than one month, with hyperarousal and physiological symptoms such as tachycardia and sympathetic system over activation.
What are the physical symptoms of anxiety?
Muscle tension, headaches and fatigue
Hyperventilation -> respiratory alkalosis
Paraesthesia
Tachycardia
Dizziness
Sympathetic over activity, resulting in loose stools, sweating, increased heart rate, dry mouth and high blood pressure.
Why does paraesthesia occur in anxiety?
Low CO2 due to respiratory alkalosis causes an imbalance in Ca2+ levels and results in numbness and tingling.
What are the effects of anxiety on the GI tract?
Diarrhoea
Dry mouth
Nausea
Difficulty swallowing
Excessive wind
Epigastric discomfort, causing butterflies.
What are the effects of anxiety on the genitourinary tract?
Frequent urination
Reduced libido
Erection failure
Loss of menstruation
High levels of prolactin due to stress
What are the effects of anxiety on the CNS?
Tinnitus
Sensitivity to noise
Blurred vision
Sleep disturbances
What are the psychological symptoms of anxiety?
Common theme is excessive future dread in the future to their physical or mental health
Derealisation/depersonalisation
COGNITION: Hyperarousal causing poor concentration, memory and sleep disturbances. There is excessive focus on bodily sensations
MOOD: Irritability, depression and low mood
What are the typical behaviours of those with anxiety?
Pacing around
Caffeine overconsumption
Avoidance of trigger situations
Implementing safety behaviours
Seeking reassurance through GP appointments
What are the important physical investigations for anxiety?
Thyroid function blood tests
Glucose tests for hypoglycaemia
Urine tests for illicit drug use
ECG to check cardiac abnormality
EEG to check for neurological abnormalities
What is CBT?
Cognitive behavioural therapy is a form of talking therapy primarily used for anxiety and depression, based on a framework that irrational thoughts or cognitive distortions in those with the condition are the source of distress that create a negative cycle, therefore reframing these into rational thoughts by breaking down overwhelming problems in practical ways.
Which conditions is CBT commonly used for?
Anxiety
Depression
Phobia
OCD
Eating disorder
BPD
What is the process of CBT?
1) Challenging negative thoughts/behaviour
2) Generating hypotheses for negative thoughts
3) Gathering data from patient
4) Reinforcement of positive thoughts from reward
5) Cognitive restructuring over time
What is mixed anxiety-depressive disorder?
Both anxiety and depression are equally present of limited but equal intensity, however neither symptoms are severe enough to classify as anxiety or depressive disorder and has some autonomic nervous system features.
What maintains anxiety?
External triggers like phobias
Internal triggers: thoughts of catastrophic misinterpretation, worrrying about worrying
Which neurotransmitters are unregulated in anxiety?
Increased activity of:
—> GABA
—> Serotonin
—> NMDA transmission of the glutamergic receptor
—> Sensitivity to CCK and neuropeptide Y involved in feeding behaviours
—> Corticotropin releasing hormone, involved in stress response
—> Noradrenaline, involved in sympathetic activation
—> Hypersensitivity to the amygdala
How is the brain altered in anxiety?
There is increased connectivity between the amygdala and the hippocampus and structural changes occur for connectivity between the cortex and the amygdala which results in hyperactivity to the fear response.
What is downregulated in anxiety?
Reduced inhibiton of GABA
Downregulation of brain-derived neurotrophic factor
What is the role of BDNF?
Involved in development of the CNS and neuronal plasticity.
What are the differential diagnoses for anxiety?
->Pheochromocytoma
->Asthma
->Atrial fibrillation
->Hyperthyroidism
->Alcoholism
->Delirium
->Diabetic ketoacidosis
-> Substance abuse
Which medical conditions are associated with anxiety?
These conditions have a common CORRELATION with anxiety
Endocrine disorders such as Cushing’s, phaeochromocytoma, Addison’s disease and hypoglycaemia
Cardiovascular disorders such as arrythmias, atypical chest pain and mitral valve chest prolapse
Respiratory conditions such as COPD and asthma
Drug use with caffeine, Cochin and alcohol
What is disassociative disorder?
Psychiatric disorder affecting sensory and motor function, which is involuntary and in the absence of physical pathology. Conversion disorder presents as physical symptoms while disassociative presents as mental symptoms.
A common co-morbidity is anxiety, depression or personality disorder.
What is conversion disorder?
Presents as physical symptoms and signs affecting the voluntary body, causing blindness, paralysis, weakness and bizarre gait
What is the epidemiology of disassociative disorder?
Affects more women than men, with a short disease duration with a decline in incidence
What is the aetiology of disassociative disorder?
Childhood trauma
Parental dysfunction, especially alcohol abuse
How are disassociative disorders managed?
Avoiding excessive medical investigations and trying to determine if patient is consciously manifesting the symptoms. Instead, take a behavioural approach where they are rewarded for healthy behaviours and focus discussions on underlying stressors and encourage self-help
