Anxiety Flashcards
what are the biological (physical) symptoms of anxiety
Sweating, hot flushes or cold chills
Trembling or shaking
Muscle tension or aches and pains
Numbness or tingling sensations
Feeling dizzy, unsteady, faint or lightheaded
Dry mouth (not due to medication or dehydration)
Feeling of choking
A sensation of a lump in the throat, or difficulty in swallowing
Difficulty breathing
Palpitations or pounding heart, or accelerated heart rate
Chest pain or discomfort
Nausea or abdominal distress (e.g. churning in stomach)
(autonomic overstimulation)
what are cognitive symptoms of anxiety
Fear of losing control, “going crazy or dying
Feeling keyed up, on edge or mentally tense.
Difficulty in concentrating, “mind going blank”
Feeling that objects are unreal - derealization
Feeling that the self is distant or “not really here” -depersonalisation
Hypervigilance (internal and external)
Racing thoughts
Meta-worry (worry about everything, worrying about worrying)
Health anxiety
Beliefs about the importance of worry
Preference for order and routine
what are the pathological cognitive symptoms of anxiety
Feeling that objects are unreal - derealization
Feeling that the self is distant or “not really here” -depersonalisation
Meta-worry (worry about everything, worrying about worrying)
what are the behavioural symptoms
Avoidance of certain situations
Exaggerated response to minor surprises or being startled
Difficulty in getting to sleep because of worrying
Excessive use of alcohol/drugs (prescription or “recreational”)
Restlessness and inability to relax
Persistent irritability
Seek reassurance from family/GP
Checking behaviours
what is the stress reponse
exposure to stress:
Amygdala acts as the emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response (milliseconds)
this is modified by later-received cortically processed signal (i.e., act first, think later!)
there are a series of responses to the stressor prior to the point at which stimulation of the adrenal gland causes the release of cortisol
describe cortisols role in the stress response
acute stress leads to dose-dependent increase in catecholamines and cortisol
cortisol acts as to mediate (& shut down) the stress response
through negative feedback it acts on the pituitary, hypothalamus, hippocampus and amygdala
these sites are responsible for the stimulation of cortisol release
acute stress therefore increases cortisol levels
when is anxiety pathological
in extent- more extreme than normal
in context- not normally anxiety provoking situations
if it causes significant distress and impairment of social/ occupational/ other function
name the 6 types of anxiety disorders
Generalised Anxiety Disorder Panic Disorder Agoraphobia Social Phobia Specific Phobia Obsessive Compulsive Disorder
what is generalised anxiety disorder
anxiety that is generalised and persistent, not restricted to/ sronger in particular circumstances
is free floating
what are the dominant symptoms of generalised anxiety disorder
(variable)
persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed
what does generalised anxiety disorder need to be to be diagnosed
severe enough to:
be present on most days for at least 6 months
not controllable
cause significant distress/ impairment in function
what is generalised anxiety disorder typically associated with
restlessness/ feeling keyed up or on edge
easily fatigued
difficulty concentrating/ mind going blank
irritability
muscle tension
sleep disturbance
what is the typical age of onset of GAD
20-40
who gets GAD
2:1 F:M
associated with disability, medically unexplained physical symptoms, and overutilisation of health care services and resources
what is the usual course of GAD
chronic, fluctuating
what is usually co morbid with GAD
90% have other psychiatric disorders, e.g. depression, substance abuse, other anxiety disorders
what is the treatment for GAD
Cognitive Behavioural Therapy – treatment of choice
SSRIs / SNRIs – reasonable (Duloxetine, venlafaxine)
Pregabalin – long term anxiety disorder
Benzodiazepines (short term only)
how does CBT work
identifying an individual’s automatic thoughts, cognitive biases and schemas
Help the individual identify thoughts, assumptions, misinterpretations and behaviours that reinforce and perpetuate the anxiety
what is panic disorder
is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable, happen at any time
what are the dominant features of panic disorder
sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). There is often also a secondary fear of dying, losing control, or going mad
what condition does panic disorder often occur with
agoraphobia
what do you need to exclude in a diagnosis of panic disorder
not due to drug or other conditions (e.g. caffeine, hyperthyroidism)
is not caused by another mental disorder (e.g. panic can occur due to a depressive episode)
who gets panic disorder and what is its course
Lifetime prevalence between 2-3%
Typical onset late adolescence to mid-30’s
50-67% also have Agoraphobia
Usual course is chronic - waxing and waning
10 year follow-up - 1/3 unchanged or worse, 1/3 modest improvement, 1/3 well
what can be co morbid with panic disorder
other anxiety disorders (esp agoraphobia), depression, drug & alcohol misuse
what is the biology of panic attacks
can be trigger in those susceptible by infusion of lactate (by product of muscular activity)
or by re breathing air (increased CO2)
increased metabolism in anterior pole of temporal love (parahippocampal gyrus)
what is the treatment for panic disorder
cognitive behavioural therapy
SSRIs/SNRIs/ tricyclics
benzodiazepines (short term only)
what are the three types of phobia
agoraphobia
social phobia
specific phobia
when do phobias usually start
Agoraphobia
50% presented by 20; 75% by early 30’s
Social & Specific phobias
80% by early adolescence; 75% by early 20’s
what typifies phobias
avoidance and anticipatory anxiety
what is agoraphobia
A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes. Avoidance of the phobic situation is often prominent
what can agoraphobia be secondary to
other pathology eg panic disorder or depression
rare to have it on its own, usually alongside another condition
what are common avoidance techniques in agoraphobia
others do shopping (for or with the patient)
drink alcohol to overcome fear
go shopping to 24 hour store at night (when quiet)
Internet shopping!
what is a specific phobia
a marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation
what are the features of a specific feature
exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, akin to a panic attack
the person recognises that the fear is excessive or unreasonable
the phobic situation(s) is avoided or else endured with intense anxiety or distress
normal functioning impaired by the avoidance, anxious anticipation, or distress in the feared situation(s)
what is the treatment of specific phobias
Behavioural Therapy – exposure
Graded exposure / systematic desensitisation
Add in CBT if necessary
SSRIs / SNRIs if required
what is social phobia/ social anxiety disorder
a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others- more than just being shy
what are the features of social anxiety disorder
the individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.
typically this occurs in relatively small social settings
exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound panic attack.
what are common symptoms in social anxiety disorder
blushing or shaking
fear of vomiting
urgency or fear of micturition or defaecation
struggle to eat in public
what can social phobia cause
poor school performance, school refusal, poor employment history
Linked to behavioural inhibition:
tendency to react to novel situations by avoidance and withdrawal to safety
Can be identified in toddlers / pre-school children
what is the biology of social phobia
Increased bilateral activation of the amygdala and increased rCBF to the amygdala (& related limbic areas) that normalizes on successful treatment (pharmacological or psychological)
what is the treatmenr of social phobia
Cognitive Behavioural Therapy
SSRIs / SNRIs
Benzodiazepines (short term only)
what is obsessive compulsive disorder
Recurrent obsessional thoughts and/or compulsive acts
Obsessional thoughts:
Ideas, images or impulses entering the mind in a stereotyped way
Recognised as the patients own thoughts
But unpleasant, resisted and ego-dystonic (causes sense of self discomfort)
Compulsive Acts Repeated rituals or stereotyped behaviours Not enjoyable Not functional Often viewed as “neutralising” Recognised as pointless Resistance may diminish over time
what must be present to be diagnosed with OCD
Obsessional symptoms or compulsive acts must be present most days for at least 2 weeks AND be a source of distress and interference with activities
Obsessions must be individuals own thoughts
Resistance must be present
Rituals are not pleasant
Obsessional thoughts/images/impulses must be repetitive
what are the most common obsession in OCD
contamination from dirt, bugs, fbody fluids, sticky substances, dangerous material
fear of harm
excessive concern with order or symmetry
obsession with the body/ physical symptoms
religious/ blasphemous thoughts
sexual thoughts (being paedophile/ homosexual)
hoarding
violence/ aggression
what are common compulsions in OCD
checking cleaning repeating acts mental compulsions (words repeated in specific order) ordering, symmetry, exactness counting hoarding/ collecting
who gets OCD
no gender/ socioeconomic bias
any age- mean onset 20 (males 13-15, females 24-25)
familial
what can OCD be co morbid with
schizophrenia, tourettes and other tic disorders, body dysmorphic disorder, eating disorders, trichtillomania
60-90% experience at least 1 major depressive episode
what is the treatment for OCD
Cognitive Behavioural Therapy
Including response prevention
SSRIs / Clomipramine
how do benzodiazepines work
The GABA-A receptor is an inhibitory ionotropic receptor
In the presence of GABA the ion channel allows chloride ion influx
Membrane hyperpolarisation
Results in inhibitory postsynaptic potential
Benzodiazepines enhance the effect of GABA (allosteric modulation)
what activates the GABA- A receptor
benzodiazepines
alcohol
barbiturates
what do antagonists/ agonists of the GABA-A receptor do
Agonists produce relaxation and anticonvulsant effects
antagonists cause anxiety and are pro-convulsant.
what are the potential problems with benzodiazepines
(particularly if used over 2 weeks) Sedation and psychomotor impairment Discontinuation/withdrawal problems Dependency and abuse Alcohol interaction Can worsen co-morbid depression
what are the behavioural manifestations of anxiety
avoidance of stressor/ trigger exaggerated response to minor surprises difficulty sleeping, insomnia substance misuse restlessness and inability to relax persistent irritability checking behaviour despite living in order everything is chaotic due to sympathetic overdrive
what are the cognitive manifestations of anxiety
racing thoughts fear of losing control tense difficulty concentrating derealisation and depersonilisation (dissociative symptoms) hypervigilance (internal and external) fear of death (esp in panic disorder) fear of impending doom (PD, anaphylaxis, adenosine) meta worry- worrying about worry (characteristic of GAD) health anxiety dysfunctional assumptions belief about the importance of worry preference of order and routine
who would you not give ketamine to
someone with underlying psychological trauma as is a dissociative anaesthetic
what are the physical manifestations of anxiety
- Tremor
- Tachycardia/ palpitations
- Nausea/ abdominal distress
- Numbness
- Headaches
- Dizzy/ unsteady
- Muscle tension
- Lump in throat/ feeling of choking
- Pounding heart
- Dry mouth
- Chest pain
- Difficulty breathing
how many panic attacks do you need to have had to be diagnosed with panic disorder
2
what are the features of GAD
o Can happen at any point; free floating
o Should be there most of the time for at least 6 months
o All encompassing worry
o Physical symptoms; SOB, tachy etc
o Often comorbid with depression; panic and OCD
what are the features of panic disorder
o More paroxysmal
o Worried going to die
o Happens in 1 in 100 people
what are the features of OCD
o Repetitive behaviours that are negatively impacting on functioning
o Intrusive thoughts; obsessions
o Often ego dystonic; conflict with own view of yourself
o Compulsions; ritual behaviours. Can be related to obsessions
o Compulsions tend to not make obsessions better
o Important with OCD treatment wise is ERP (exposure and response prevention) Need to confront the compulsion and then learn to sit with the anxiety which that provokes
what is the risk in social phobia
alcohol dependence- need it to go out
what is the treatment for specific phobias
o Only phobia that responds to pharmacological therapy is needle phobia
o Treatment is purely psychological; structured CBT response
what are the symptoms of PTSD
o Flashbacks often intense with physiological responses o Nightmares o Emotional outbursts; inappropriate o Hypervigilance o Avoidance
what is the treatment for PTSD
SSRI
EMDR
what SSRIs for GAD
setraline anf fluoxetine
what SSRIs for PTSD
fluoxetine, setraline or paroxetine
what can prazodsin (alpha blocker) be used for
nightmares in PTSD
what drug is first line for anxiety disorders
SSRI
what conditions can mimic anxiety
- MI; in older women you can get nausea and abdominal pain as presenting complaints
- Hyperthyroidism
- COPD; hypercapnia makes you anxious. Don’t give benzodiazepines in COPD
- Arrhythmias; check an ECG if 1st presentation. WPW, supraventricular tachycardia
- Phaeochromocytoma
