Anxiety Flashcards
Definition of anxiety?
A normal and adaptive response to stress and danger (fight or flight), which is pathological if prolonged, severe of out of keeping with the real threat of the external situation
When is anxiety clinically significant?
Anxiety disorders must cause problems severe enough to cause marked distress and/or cause substantial interference with day-to-day life.
(We don’t want to get rid of all anxiety but to manage it successfully.)
What are the two components of anxiety?
Psychic anxiety: an affect characterised by increased arousal, apprehension, sense of vulnerability and dysphoria.
Somatic anxiety: bodily sensations of palpitations, sweating, dyspnoea, pallor and abdominal discomfort.
Epidemiology of anxiety?
The one week prevalence of anxiety is 6.6%.
In 2013: 8.2 million cases of anxiety in the UK.
Women are twice as likely to be diagnosed with anxiety disorders than men.
Different classifications of anxiety?
Generalised anxiety disorder (GAD)
Panic disorder
Phobias (agoraphobia, specific phobias, social phobias)
Obsessive compulsive disorder
Adjustment disorders
GAD ICD Definition?
- Persistent anxiety present most days for several weeks to months
- Symptoms involve combination of apprehension and work, motor tension and autonomic overactivity (causing significant distress/ functional impairment.)
- Free-floating (anxiety unrelated to particular environmental events)
GAD Prevalence?
10-15% have a lesser degree of anxiety
15% of GP attenders are seeking treatment for anxiety
3.1% lifetime prevalence
Lowest in 18-29 years and 60+ years
Highest in 45-59 years
Early onset associated with childhood fears and marital/ sexual disturbance;
Later onset associated with stressful life events, single marital status’ and unemployment.
GAD Symptoms?
At least 4 out of:
Symptoms of autonomic arousal
‘Physical’ symptoms = Breathing difficulties, choking sensation, chest pain/discomfort, nausea/abdominal distress
Mental state symptoms = Feeling dizzy, unsteady, faint or light-headed, derealisation, fear of losing control, passing out
General symptoms = Hot flushes/cold chills, numbness
Symptoms of tension
Concentration difficulties
Risk factors of GAD?
- FHx of anxiety
- Physical or emotional distress
- Hx of physical or emotional trauma
- Female gender
- Other anxiety disorder
- Diabetes
DD for GAD?
'Normal worries' Depression Mixed anxiety and depression Other anxiety disorders Drug or alcohol problems Medical conditions Side effects of medications
Medical conditions associated with anxiety like symptoms?
- CVS: arrythmias, IHD, mitral valve disease, cardiac failure.
- Respiratory: asthma, COPD, HVS, PE, hypoxia.
- Neurological: TLE, vestibular nerve disease.
- Endocrine: Hyperthyroidism, hypoparathyroidism, hypoglycaemia, phaeochromocytoma.
- Miscellaneous: Anaemia, porphyria, SLE, carcinoid tumour, pellagra.
Meds causing anxiety like symptoms?
- CVS: antihypertensives, anti-arrhythmics.
- Respiratory: bronchodilators, alpha-1 and beta-adrenergic agonists.
- CNS: anaesthetics, anticholinergics, anticonvulsants, anti-Parkinsonian agents, antidepressants, antipsychotics, disulfiram reactions, withdrawal from BDZs and other sedatives.
- Miscellaneous: Levothyroxine, NSAIDs, antibiotics, chemotherapy.
GAD aetiology
•Generalised biological vulnerability:
Genetics have a modest role
Neurobiological system implications- Diminished autonomic nervous system responsiveness, Loss of regulatory control of cortisol in HPA axis (1/3 GAD patients show reduced cortisol suppression using dexamethasone suppression test)
•Generalised psychological vulnerability:
Diminished sense of control- Trauma or insecure attachment to primary care givers, leading to intolerance of uncertainty.
Parenting- Overprotective or lacking warmth, leading to low perceived control over events.
•Specific psychological vulnerability:
Stressful life events- Trauma (early parental death, rape, war), Dysfunctional marital/ family relationships.
The above aetiologies are classed as the triple vulnerability model.
Psychological management of GAD?
- Generally less effective than in other anxiety disorders
- Some evidence for CBT (treat avoidance by exposure, use of relaxation and control of hyperventilation
- Teaching about bodily responses to anxiety/education about panic attacks
Pharmacological management of GAD?
- This is directed towards predominant anxiety symptom patients.
- Psychic symptoms: Buspirone (beneficial effects may take 2-4 weeks)
- Somatic symptoms: BDZs (Lorazepam/ diazepam)
- Depressive symptoms: TCAs (unlicensed use) such as Imipramine/ Clomipramine, Trazodone, SNRIs (duloxetine/ venlafaxine), SSRIs (escitalopram/ paroxetine)
- Cardiovascular/ autonomic symptoms: Beta blockers (atenolol)/ Pregabalin.
- Physical: Psychosurgery for severe/ intractable anxiety.
