ANXIETY Flashcards
performance anxiety relationship
yerkes-dodson law
The interalated components of anxiety
- thoughts of having apprehensive, nervouse or frightened
2. the awareness of a physical reactio to anxiery (autonomic or peripheral anxiety)
anxiety patterns of pathology
1 Generalised (free floating) anxiery - mild/moderate lasting hours days around normal life events 2 Paroxysmal anxiety- abrupt onset and stron autonomic sx - can be on background of GAD but phobias most common
Physical sx of anxiety
- tachycardia
- palpitations
- htn
- sob
- chest pain/discomfort
- choking sensation
- tremors/shaking
- muscle tension
- dry mouth
- sweating
- cold/skin
- N&V
- Diarrhoea
- abdominal discomfort
- dizziness/syncope
- mydrias
Anxiety hx
- onset
- severity
- duration (general or paroxysmal)
- to specific threat or spontaneously?
- only in context of pre-existing medical or mental health condition
DDX
Anxiety diorders
-phobic disorders (agoraphobia, social phobia, specific phobia)
Non situational anxiery disorder
- GAD
- Panic Disorder
Reaction to stess or OCD
Other psychiatric conditions
-65% of patients with anxiett gave deppressive sx
anxiety secondary to general medical conditon or psychiatricx substance
Phobic disorders
agoraphobia
-crowded spaces - particularly if cannot escape in context of panic disorder
Social phobia
-fear of scrutiny in general but can be specific (e.g public speaking)
Specific phobia
- situational (flying, elevators)
- natural environmental (heights, storms, water)
- blood injection/injury: seeing blood or injury (bradycardia!)
- animal
GAD ICD-10
excessive worry on minor matters and apprehensive most days for 6/12
1) apprehension
2) motor tension (restless, fidgetting, tension headaches, inability to relax)
3) autonomic overactivity
Panic disorder
NOT restricted to situation or object
- anticipatory anxiety is anxiety about having panic attacks and can lead to agoraphobia
other psychiatric conditions
cause second anxiety with focus in (brackets)
- eating disorder (gaining weight)
- somatisization disorder (having many physical complaints)
- hypochondriacal disorder (having serious illness)
- delusional beliefs in paranoid schizophrenia (fear of being poisened or killed)
- deppression (gait or worthlessness)
- OCD (when having obsessional thought and resisting compulsion)
- personality disorder (seperation or abandoment, or being rejected or inadequated
- ADHD (restless and unable to concentrate
- autism spectrum disorder (unable to understand others)
- delirium/dementia (not understanding what is going on)
- anxiery and depression closly related
anxiety medical conditions
causing dyspnoea
- CCF
- PE
- COPD
- pulmonary disease
- asthma
causing increased sympatheitc outflow
- hypoglycaemia
- phaeochromocytoima
causing pain
-malignancies
Other
- cerebral trauma
- cushings disease
- hyperthyroidism
- temporal lobe epilepsyt
- vitamin deficiencies
substances
intoxications
- alcohol
- amphetamines
- caffeine
- cannabis
- cocaine
- hallucinogens
- inhalants
- ketamine
- NPS
- phencyclidine
withdrawal
- alcohol
- benzodiazepams
- caffeine
- cocaine
- Gamma-hydroxybutyrate/ gamma-butyrolactone
- nicotine
- other sedatives and hypnotics
- opiates
SE of prescribed
- ADDs (SSRIs in first 2 weeks and rapid discontinuation particularly of paroxetine or venlafaxine)
- corticosteroids
- sympathomimetics
- Thyroid hormones
- compound analgesics
- containing caffeine
- anticholinergics
- antipsychotics (akathisia)
anxiety hx questions
- do you sometimes wake up feeling anxiousand dreading the day (any form of anxiety)
- do you worry excessivly about minor matters on most days of the week? (generalised)
- have you ever been so frightened that your heart was pounding and you thought you might die? (panic attack)
- do you avoid leaving the house alone becuase you are afraid of having a panic attack or being in situations (like crowded shop/train) from which escape would be difficult/embarrassing? (agoraphobia)
- do you get anxious in social situations like speaking in front of people (social phobia)
- do some things or situations make you scared? . . . . do you avoid them? (specific phobia)
epidemiology
overall anxiety 12-17% 1 year prevelence prevelence % and f:m GAD = 3% AND 2-3:1 pANIC DISORDER = 4% AND 2-3:1 social phobia = 4% and 1:1 specific phobia = 4% and 2:1 PTSD =4% and2:1 OCD = 2% and 1:1
onset most is childhood/adolescence with panic disorder and bit later and ptsd anytime
generally more wommen except social and OCD whcih is equal
aetiology
30-50% heritability with considerable genetic overlap with anxiety
panic disorder and ocd most heritable
-GABA, serotonin and NA most associated
-OCD with caudate nucleus damage
-amygdala hyperactivation in PTSD and other anxiety
- significant traumatic life event needed for PTSD but only 10-30% will develop
- CBT suggests thuought patterns (innapropriate) lead to overestimation of dangers
- pavlovian relationship with some phobias eg car crash
Thought process when approaching anxiety
anxiety or low mood?
is it substances?
secondary to depression?
other? . . identify subtype and severity:
-mild-moderate (minimal functional impairment)
-moderate - severe = mild marked functional impairment
Mild moderate Tx
GAD - self help
Panic Disorder - self help
Social phobia - self help
OCD - self help or CBT (Individual or group)
PTSD - <4 watchfull waiting and then trauma focussed CBT
Specific Phobia - self help
Moderate-severe tx
GAD
- CBT/ Applied relaxation
- SSRI (2nd line SSRI /venlafaxine/ pregabalin)
Panic disorder
- CBT
- SSRI (2nd line imipramine)
Social Phobia
- CBT
- SSRI/prn Propanalol (2nd line MAOI and short benzo)
OCD
- Individual CBT with ERP (exposure and response prevention therapy - exposure to fear and resist compulsion . .. . gold standard)
- SSRI (2nd line alt SSRI/ clomipramine)
PTSD
- trama focused CBT/ emdr
- PAROXETINE/MIRTAZOPINE (2ND LINE TCA) + z drub/bezo 4 sleep
Specific Phobia
- CBT
- prn benzo insituations
psychosocial tx
CBT great for most anxiety
- secific phobias = desensitisation, flooding and remodelling CBT
- Panic disorder = slow cycle and how it works and then challenge it
- PTSD = trauma focussed CBT or eye movement desensitising and reprocessing (think about trauma with other stimulus)
- applied relaxtion in GAD (muscle thing)
- counselling for stressful life events
phaemacological tx
- SSRIs, venlafaxine and TCAs take longer to work and may have initial anxiety
- benzos more PTSD or frequent PRN
- pregabalin 2nd line GAD
- clomiparamine more for OCD as SEROTONIN HEAVY
- BETA BLOCKER FOR AUTONOMIC AROUSAL
Prognosis
GAD - likely to be chronic and fluctuating
- Panic D - 1/2 free after 3 years but 1/3 will have chronic life affecting . . .. common to have agoraphobia after 1 year
- social phobia - chronic course fluctiating with life stress
- specific phobias - chronic esp if developed in childhood
- PTSD - 1/2 recover in 3 months, 1/3 will have mod-sever long term dependent on severity, proximity and duration of trauma
- OCD - chronic fluctuatinng with stress and 15% chronic deteriation
Obsessions definition
involuntary thoughts, images or impulses that are:
1) recurrent and intrusive and are experience as unpleasant or distressing
2) enter mind against conscious resistance
3) recognise as produce of own mind (pt often has good insight)
compulsions definition
repetitive mental (eg matra/counting) or physical (checking, handwashing, reassuring) acts that
1) pts feel compelled to do
2) performed to reduce anxiety (even though actions unrelated or exagerated excessivly)
Examples of reslated O and Cs
- fear of contamination leading to excessive washing
- pathological doubt leading to exhaustive checking
- violent/reprimandable thoughts leading to redemption act/ reassurance
- need for symetry/precison leading to repeatedly rearranging objects
OCD ICD-10
- must be present > 2 weeks and are a source of distress or interfering with pt functioning
- aknowledged as coming from own mind
- Os unpleasantly repetitive
- at least one thought/act resisted unsuccessfully
- Compulsion not in itself pleasurable (excluding relief of anxiety)
OCD DDx
- eating disorders (don’t think actions excessive)
- Anakastic PD - not true OCs
- Autism - pleasurable repetition and not resisted
- Hypochondrial disorder
- Schizophrenia - not own thoughts
- Deppression - whcih came firstOC sx often resolve with tx
OCD thinking process
OC sx for more than 2 weeks?
Pt meet criteria for other diagnosis?- no? . . . then diagnose OCD
OCs only about other dx? -yes? Then diagnose that condition only
No? - then diagnose OCD and other conditon
