Anxiety Flashcards
Is anxiety normal
It can be!
Not in itself pathological - can be a normal response to a stressful situation
List some biological 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 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
What is the cause of biological symptoms of society
Due to autonomic activation
Seen in the normal flight or flight response but also pathologically in anxiety disorders
List some of the 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
Health anxiety
Beliefs about the importance of worry
Preference for order and routine
What is meta-worry
Worrying about everything
Worrying about worrying
List behavioural symptoms of anxiety
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 Restlessness and inability to relax Persistent irritability Seek reassurance from family/GP Checking behaviours
What is the role of the amygdala in the stress response
It acts as the emotional filter of the brain
Assesses whether sensory material via the thalamus requires a stress response
This is later modified by the cortex - act first think later
which hormone is most involved in the stress response
Catecholamines and cortisol
They both increase in acute stress responses
When does anxiety become abnormal
When it is pathological - more extreme than normal
When it occurs in situations that are not normally anxiety inducing
When it causes significant distress and impairment of social / occupational / other function
List the most common anxiety disorders
Generalised Anxiety Disorder Panic Disorder Agoraphobia Social Phobia Specific Phobia Obsessive Compulsive Disorder
Describe generalised anxiety disorder
Anxiety that is generalised and persistent but is not restricted to a specific circumstance - worry about a lot of different things all of the time
Physical symptoms are also persistent - trembling, nausea, palpitations
Fears of illness or accidents are common
What are the criteria for diagnosis of generalised anxiety disorder
Needs to be present most days for at least 6 months
Not controllable
Causes significant distress or impairment in function
Which symptoms are common in generalised anxiety disorder
Being restless or feeling on edge Being easily fatigued Difficulty concentrating or mind blanks Irritability Muscle tension Sleep disturbance
Who typically presents with GAD
2:1 female to male
Typical age of onset between 20-40
Commonly seen in primary care - may present with unexplained
How do you treat GAD
Cognitive Behavioural Therapy
SSRIs / SNRIs
Pregabalin
Benzodiazepines - short term use only
Why can benzodiazepines not used long term
Because they are very addictive Sedation and psychomotor impairment Discontinuation/withdrawal problems Alcohol interaction Can worsen co-morbid depression
What is a panic disorder
Recurrent attacks of severe anxiety/panic which are not restricted to a particular situation
Unpredictable attacks
Lots of severe physical symptoms are often have fears or dying, losing control etc
What are the common physical symptoms
Sudden onset palpitations Chest pain Choking sensations Dizziness Feelings of unreality Overwhelming and severe
Panic disorder commonly occurs alongside which other conditions
Other anxiety disorders
Agoraphobia
Depression
Drug and alcohol misuse
What age does panic disorder commonly present
Typical onset is in late adolescence to mid-30s
How do you treat a panic disorder
Cognitive Behavioural Therapy
SSRIs / SNRIs / Tricyclics
Benzodiazepines (short term only)
What can be used to trigger a panic attack
Infusions of lactate - if a susceptible individual
Re-breathing - increased CO2
What is a phobia
A fear which is recognised as irrational
Typified by avoidance and anticipatory anxiety
What is agoraphobia
A well-defined cluster of phobias around leaving home, being in crowded public areas or confined areas
Avoidance of the phobic situation is often prominent
What is a specific phobia
A marked and persistent fear which is unreasonable or excessive
Caused by the presence or anticipation of a specific object or situation - spiders, heights etc
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response
Normal functioning is impaired by the avoidance or distress caused
How can you treat a phobia
Behavioural Therapy – exposure
Graded exposure / systematic desensitisation
Add in CBT if necessary
SSRIs or SNRIs can be added if needed
What is a social phobia/social anxiety
A persistent fear of one or more social or performance
More than just shyness
They fear that they will humiliate themselves and be judged by others
Exposure to the feared situation almost always promote an anxiety response or panic attack
What anxiety symptoms are commonly seen in social phobia
blushing or shaking
fear of vomiting
urgency or fear of micturition or defaecation.
How can you treat a social phobia
Cognitive Behavioural Therapy
SSRIs / SNRIs
Benzodiazepines (short term only)
What is obsessive compulsive disorder
Recurrent obsessional thoughts and/or compulsive acts
Obsessive part is where you have repeated but unpleasant thought
The compulsion is a repeated action/ritual that is done in an attempt to keep the anxiety at bay
Describe the obsessive thoughts seen in OCD
Repetitive thoughts
Ideas, images or impulses entering the mind in a stereotyped way
Recognised as the patients own thoughts
But unpleasant, resisted and ego-dystonic (makes them uncomfortable)
Describe compulsive actions seen in OCD
They are repeated rituals or stereotyped behaviours
It is not enjoyable or functional
Often viewed as keeping the worry at bay or even that it will stop it from happening
They recognise it as irrational
What are the diagnostic criteria of OCD
Must be present for most days for at least 2 weeks
Needs to be a source of distress and interfere with activities
Obsessions must be individuals own thoughts
Resistance must be present
Rituals are not pleasant
Obsessional thoughts/images/impulses must be repetitive
When does OCD usually present
Average age of onset
Peak incidence for males is 13-15
Peak incidence for women is 24-25
What other conditions does OCD often exist alongside
Schizophrenia Tourette's and other tic disorders Body dysmorphic disorder Eating disorder Trichtillomania - hair pulling
How can you treat OCD
Cognitive Behavioural Therapy
Including response prevention
SSRIs / Clomipramine
What is intentional vs unintentional trauma
Intentional = when the event was intended such as robbery, assault or rape
Unintentional - a traumatic accident such as car crash
What type of trauma can affect a whole community
Disasters
Can be human made such as a plane crash or bomb
Or natural like an earthquake or hurricane
What is a centrifugal disaster
When the people affected are only together for the moment of disaster - plane/train crash
What is a centripetal disaster
When the disaster affects an existing community
Seen in natural disasters
What is type 1 trauma
Where there is a single traumatic incident
Sudden and unexpected
What is type 2 trauma
Repetitive trauma that becomes almost expected/routine
Often affects development
E.g. abuse, being taken hostage
May involve betrayal of trust from a primary-care giver - if they are the abuser
Which type of trauma has the highest risk of PTSD
Type 2
Which societal groups are more at risk of trauma
Poor & marginalised are much more likely to be victims
In a traumatic event, do people usually panic
Surprisingly panic is rare
Most people behave rationally
Activism following the event is also common with people starting reconstruction quickly
What other mental health conditions can childhood trauma lead on to
Common in chronic depression and indicates that it will need psychotherapy
High % of those with bipolar report child abuse or deprivation
High rates of trauma in psych inpatients
Does PTSD have an impact on physical health
Raises mortality from all causes
High incidence of chronic disease
How does the body respond to anxiety
It will wither freeze - if the threat is distant or inescapable
Or flee - if threat is near and escapable
Can be a combination of responses dependant on situation - flight, fight, hide etc
What is tonic immobility
involuntary state of profound (but reversible) motor inhibition
Seen in the fear response if threat is inescapable - an attempt to increase chance of survival
Common in sexual assault
How is cortisol affected in PTSD
Levels are low
this is a paradox as cortisol is usually increased in the stress response
Does everyone who experiences trauma get PTSD
NOPE
Up to 50% will recover without intervention
However, some will just get worse or develop chronic symptoms
What are the trauma related risk factors for PTSD
Sudden or unexpected event Man-made event Prolonged exposure to the trauma Perceived threat to life More grotesque events - multiple deaths/injuries and often the involvement of kids makes it worse Personal involvement - losing a child
What are the patient related risk factors for PTSD
Severe acute stress reactions Low serum cortisol Family/personal history of mental disorder Past experience of trauma Loss of daily function Serious physical injury Personality traits and coping skills Lifestyle Female gender
What are the environmental related risk factors for PTSD
Lack of support network Ongoing life stress Reaction of others Economic resources Displacement - MASSIVE risk
How can vulnerability affect the response to trauma
If a person is extremely vulnerable then more minor trauma will cause a big response
More likely to have PTSD
Severe trauma can still affect everyone
List some of the normal reactions to trauma
Numbness or shock Depression and hopelessness Anger Fear Guilt Impaired sleep Flashbacks
When does a normal trauma reaction become PTSD
All dependant on frequency, severity and duration – increased levels in any of the normal symptoms would be considered abnormal
Symptoms must last at least a month but not necessarily the month after the event
What are some of the psychological symptoms of PTSD
Depression Grief Reactions Panic Attacks +/- agoraphobia Alcohol/Drug Dependence Brief Hypomania Specific Phobias - related to initial trauma
Which traumatic events have the highest rates of PTSD
Rape and sexual assault
Which anxiety disorder has the highest association with suicide
PTSD
Which psychiatric conditions are commonly co-morbid with PTSD
Depression, drug and alcohol abuse, and other anxiety disorders
What intrusive phenomena are sometimes seen in PTSD
Recurrent distressing recollections
Nightmares - may make them sleep avoidant Flashbacks
Physiological reactions - heart racing, nausea etc
What avoidance symptoms are sometimes seen in PTSD
Avoid talking or thinking about event Avoiding reminders such as places or people Amnesia of the trauma Isolation Loss of interest in activities Emotional numbing
What hyperarousal symptoms are sometimes seen in PTSD
sleep disturbance irritability / anger concentration difficulties hypervigilance exaggerated startle response
What dissociative symptoms are sometimes seen in PTSD
Depersonalisation
Out of body experience
Derealisation
Loss of awareness of surrounding
Which areas of the brain are affected in PTSD
Hippocampus - involved in memory and stress response
- gets smaller in PTSD
Amygdala - role of fear during both trauma & its recollection - activity increases - important in emotional event memory Deactivation of Broca's area Right hemisphere lateralisation
Describe brain activity during a visual flashback
Visual cortex will become active when a visual flashback occurs – feels like you’re there again
Sensory memories can be triggered by the flashback
How do you manage PTSD
Ensure safety before starting - manage ongoing trauma
Can treat acute symptoms with medication – e.g. sleeping tablets
Long term, many different psychological therapies can be used (trauma focussed)
Patient’s preference
