Anxiety Flashcards
Features of pathological anxiety
Autonomy: no or minimal environmental trigger
Intensity: exceeds patient’s capacity to bear the discomfort
Duration: symptoms are persistent
Behaviour: anxiety impairs functioning and/or results in disabling behaviours – avoidance or safety behaviours
Constant vs episodic anxiety disorders
Constant: GAD
Episodic: OCD PTSD Phobias Panic disorder
Psychological symptoms of anxiety
Worrying thoughts Irritability Sensitivity to noise Restlessness Fearful anticipation Poor concentration
Sleep symptoms of anxiety
Difficulty falling asleep Night terrors (PTSD)
Physical symptoms of anxiety
Muscle tension - tremors, aches Autonomic arousal: Dry mouth Diarrhoea Difficulty breathing Palpitations Chest discomfort Frequent and urgent micturition
Consequences of hyperventilation:
Dizziness
Tingling numbness
ICD10 criteria of GAD
Generalised and persistent somatic (physical) and psychological symptoms of anxiety on most days for at LEAST SEVERAL WEEKS at a time and usually several months
Anxiety symptoms usually involve elements of
Apprehension
Motor tension
Autonomic overactivity
ICD 10 criteria for panic disorder (episodic paroxysmal anxiety)
Several attacks within one month
In circumstances with no objective danger
Not confined to known or predictable situations
With comparative freedom from anxiety symptoms between attacks
Agoraphobia (ICD 10?)
Psychological and autonomic symptoms primarily manifestations of anxiety and not secondary to other symptoms, such as depression or delusions.
Anxiety must be restricted to at least two of the following: crowds, public places, travelling alone, travelling away from the home
Avoidance of the phobic situation must be a prominent feature.
ICD10 criteria of social phobia
Psychological, behavioural or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
The anxiety must be restricted to or predominate in particular social situations
The phobic situation is avoided whenever possible
Common anxiety symptoms are:
Blushing or shaking
Fear of vomiting
Urgency or fear of micturition
ICD 10 of specific phobias
Psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
The anxiety must be restricted to the presence of the particular phobic object or situation
The phobic situation is avoided whenever possible
What are obsessions
thoughts, ideas or images, which are:
acknowledged as excessive or unreasonable.
Repetitive
Intrusive and resisted by the patient (although the resistance may diminish in chronic OCD)
Unpleasant – i.e. the thought gives no pleasure
Originate in the mind of the patient and are not imposed by outside persons or influences (i.e. not thought insertion)
Cause distress
Interfere with functioning
What are compulsions?
Physical act:
Acknowledged as excessive or unreasonable
Repetitive
Intrusive and resisted by the patient, causing mounting anxiety
Unpleasant – i.e. the act itself gives no pleasure, but may relieve tension or anxiety.
The desire to carry out the act originates in the mind of the patient and are not imposed by outside persons or influences ie not a made act arising from psychosis.
Causes distress and interferes with functioning, usually due to wasting time.
Magical thinking can occur – eg. “if I touch this door frame five times, no harm will come to my family”
Which physical conditions can present with symptoms of anxiety?
Thyroid dysfunction
Phaeochromocytoma
Acidosis (eg. DKA)
Hyper or Hypothermia
Hypoxia (eg. CHF, angina, anaemia, COPD) Seizures Arrhythmias such as SVT Alcohol/opiate withdrawal Drug intoxication (caffeine, cocaine, amphetamines)
Consider the comorbid psychiatric disorders in anxiety
Presence of depressive symptoms - Are these causing the anxiety or resulting from it?
Drug / alcohol misuse - significantly complicates treatment
Personality disorders
Anxiety symptoms secondary to organic pathology
What is the effect of anxiety on the person’s life?
Avoidance and Safety behaviours to avoid triggers for anxiety.
Unfortunately, these behaviours feed into the anxiety and worsen the illness
Step 1 of anxiety management (all suspected cases)
Psychoeducation and active monitoring
Step 2 of anxiety management (no improvement after education and monitoring)
Guided self-help and low-intensity psychological interventions (primary care psychological services: IAPT)
Step 3 of anxiety management (inadequate response to step 2 or marked functional impairment)
High intensity psych intervention (CBT) Or DRUG treatment (primary care)
Step 4 of anxiety management (complex/refractory, very marked functional impairment)
Referral to secondary care - complex drug or psychological treatment regimes; input from multi-agency team
Educate a patient on his/her anxiety
Definition and nature of illness
Explaining cycle of anxiety for this diagnosis
Precipitating and maintaining factors
Treatment (medications and psychological)
CBT approach
Social interventions
Prognosis
Implementation of psychoeducation and guided self-help
Psychoeducation usually with support of trained professionals (involves patient, family, carers)
Guided self-help: done by patient through access to resources (books, computers etc)
Usually guided by a trained person for efficacy
What is eye movement desensitisation processing?
For PTSD (NICE) During the therapy, the original trauma is deliberately re-experienced in as much detail as possible, e.g. by the patient narrating or imagining every step that happened. While doing this, they fix their eyes on the therapist's finger as it quickly passes from side to side in front of them.
What are the pharmacological treatments of anxiety
All antidepressants (SSRIs, SNRIs, TCAs) Warn about possible initial increase in anxiety
Sometimes beta blocker is used for heart rate and autonomic arousal
in severe cases - short term (<4 weeks) benzodiazepines (ADDICTIVE):
lorazepam (short half-life)
diazepam (longer half-life) - not used anymore
In very severe cases, antipsychotics
Acute Stress Reaction
Brief (3 days - 1 month) after severely stressful event (eg. vehicle crash or violent crime)
Symptoms
Anxiety and depression
Numbness, detachment, poor concentration, derealisation, insomnia, restlessness, anger, autonomic symptoms
Avoidance of talking or thinking about the event
Acohol excess is common
Prognosis of acute stress reaction
Majority get better without formal diagnosis.
Those who get formally diagnosed, 78% develops PTSD.
The reasons are - no support network, thus more mental health problems. Also more serious trauma
Management of acute stress reaction
Reduce emotional response - talk to family/therapist Encourage recall (debriefing) Learn effective coping skills Anxiolytics if very severe Hypnotics for sleep disturbance
who is affected by adjustment disorder
Psychological reaction to adapting to a new set of circumstances, e.g. new job/home, divorce, etc.
Starts within 3 months and must be proportionate to the stressful event
in response to bereavement, the onset of terminal illness or sexual assault
Symptoms of adjustment disorder
Anxiety, depression, irritability
Palpitations and tremor
Occasional outbursts of dramatic or aggressive behaviour
Sometimes abuse of alcohol or drugs
Social functioning impaired
Onset more gradual than acute stress reaction, and it takes a more prolonged course
Management of adjustment disorder
If possible, help resolve the change of circumstances e.g. support to make changes at work
Prevent avoidance and denial
Encourage problem-solving to seek solutions
Relieve anxiety by encouraging to talk and express associated feelings
Can refer to talking therapy in primary care - CBT
Prognosis of adjustment disorder
Most last a few months
A few last a few years
Adults generally do well
Adolescents with an adjustment disorder have an increased risk of developing psychiatric illness in adult life
When is bereavement a medical issue?
If it lasts >6 months
Affects the person’s relationships or ability to function.
Certain symptoms can indicate abnormal bereavement:
Guilt about unrelated things
Thoughts of death (except thinking that one would be better off dead etc)
Preoccupation with worthlessness
Significant psychomotor retardation
Prolonged and serious functional impairment
Hallucinatory experiences (other than the deceased person)
What are the normal symptoms in someone going through bereavement
poor energy
low mood
Anhedonia
disturbed sleep and appetite
Even symptoms of anxiety
Should gradually resolve within 3 months
What is classified as PTSD?
Onset of symptoms following trauma, with a latency period of few weeks to months.
Lasts longer than 6 months after trauma (otherwise it would be normal reaction)
Which trauma has a very high prevalence for PTSD?
45% in domestic violence
Otherwise usually 5-10% in different traumas
Symptoms of PTSD
Core triad:
Hyperarousal (anxiety, insomnia, irritable, poor concentration)
Re-experiencing (flashbacks, dreams)
Avoidance (or reminders, detachment, numbness, anhedonia)
Depressive & guilt symptoms common
Substance use as a coping strategy common
Symptoms may begin quickly after, rarely >6 months after
Management of PTSD
Psychological treatment:
psychoeducation
Trauma-focused CBT
Eye Movement Desensitization and Reprocessing (EMDR)
Social:
educate family
avoid alcohol
support reintegration into environment
Biological:
antidepressants (eg. SSRIs)
Prognosis of PTSD
50% recover in 1st year
Poorer Prognosis if co-morbid mental illness, long duration, history of psychiatric illness, family history of mental illness, poor social support or pre-morbid functioning or outstanding compensation claims
