Anxiety Flashcards
What are theories for anxiety?
- Underactive neurotransmitter (serotonin, noradrenaline, GABA)
- Psychological - behaviour, cognitive therapies (classical conditioning, negative reinforcement, cognitive theories)
- Neuroatomical - hyperactivity of amygdala, leading to anxiety
What is generalised anxiety disorder (GAD)?
continuous, generalised anxiety for >6 months NOT triggered by a specific stimulus
Minimum 4 symptoms
Causes worrying about anything
What are differential diagnoses for GAD?
Organic: hyperthyroidism, substance misuse (intoxication,withdrawal), excess caffeine
Depression/mixed anxiety and depression
> anxiety symptoms are common in depression
> diagnose whichever came first
Another anxiety disorder
- panic disorder / social anxiety disorder / PTSD
Anxious/avoidant Personality Disorder
Dementia
Schizophrenia
What are symptoms of GAD?
Psychological:
- fears/worries
- poor concentration
- irritability
- unreality (depersonalisation, derealisation)
- insomnia
- night terrors
Motor symptoms:
- restless, fidgety
- unable to relax
Neuromuscular:
- trembling, tremor
- headache (tension headache)
- muscle ache
- dizziness
- tinnitus
GI
- dry mouth, difficulty swallowing
- nausea
- indigestion, stomach pains
- butterflies in stomach
- flatulence
- frequent, loose stool
CV
-palpitations
Resp
- difficulty inhaling
- tight,constricted chest
GU
- urinary frequency
- erectile dysfunction
- amenorrhoea
What are phobic anxiety disorders?
Intermittent anxiety occurring in SPECIFIC but ordinary circumstances
What does the seriousness of a phobia depend on?
On how easily the person can avoid the thing they fear
So on what kind of disability it causes
What is agoraphobia?
fear of being unable to escape to a safe place
> fear of open spaces /confined places
What are examples of places someone with agoraphobia will struggle with?
trains, planes, lifts, supermarkets, large crowds
What are symptoms of agoraphobia?
Overwhelming urge to return to safety
Prospect of leaving home generates anxiety
Presence of dependable companion helps
What are differentials for agoraphobia?
Depression (social withdrawal)
Social phobia (fear of scrutiny, humiliation)
OCD (rituals can confine people to their homes)
Schizo (confined to home, esp if paranoid)
What is a social phobia?
Social anxiety disorder
The fear of being scrutinised or criticised by others
What situations are hard for those with social phobia?
Small groups, where the focus is on them
Dinner parties, board meetings, public speaking
How do patients with social phobia self medicate?
With alcohol/drugs
What are differentials for social phobia?
Shyness
Agoraphobia (getting to safe space > social scrutiny)
Anxious PD (PPP)
ASD
When do specific phobias develop?
In childhood
What is panic disorder?
Intermittent anxiety with no obvious trigger and recurrent panic attacks for several months
What are patients with panic disorder like in between episodes?
Free of anxiety
How do you investigate anxiety disorder?
history and physical exam
Anxiety Rating scale
Social and occupational assessment for QoL assessment
COllateral hx
What are examples of anxiety rating scales?
GAD7 questionnaire
Beck anxiety inventory
What is the benefit of using anxiety rating scales?
They provide a baseline score for measuring treatment response
How do you manage anxiety disorders without medication?
Mild - advice and reassurance
Basic counselling
Problem-solving (to help deal with stressors)
Relaxation techniques, breathing exercises
CBT - provided by IAPT
What kind of therapy is good for phobias?
Exposure therapy
- gradual exposure to threat > desensitisation
- Habituation
- Extinction
What is pharm management for anxiety disorders?
Antidepressants:
- SSRI - therapeutic dose for anxiety higher than for depression and response takes longer (6-8 weeks)
- SNRI
- TCA
Anxiolytics:
- Buspirone (increases action of SSRI)
- Pregabalin
- Benzodiazepines
Beta-blockers (for adrenergic sx)
What is the MOA of Buspirone?
Serotonin Partial Agonist
What do you need to keep in mind when prescribing Benzos?
Tolerance builds quickly, dependence is an issue
Give for SHORT TERM anxiety treatment only
How long can you prescribe Benzos for?
2-4 weeks MAX
What are Side Effects of Benzos?
amnesia
ataxia
resp depression
What is the prognosis in anxiety disorders?
Rule of 3s
1/3 recover
1/3 improve partially
1/3 do poorly > have considerable disability
How do you diagnose OCD?
Either obsessions or compulsions (or both), present on most days for a period of at least two weeks.
What is an obsession?
Recurrent unwanted obtrusive thought/images/impulses that enter the pt’s mind despite attempts to resist them
How are obsessions different to delusions?
Patient is aware obsession is untrue/irrational and their own (not a thought insertion)
What is a compulsion?
repeated and stereotyped rituals that the patient feels compelled to carry out, even though it is irrational and may not be associated to the obsession
What are ddx for OCD?
Organic causes (Tourette’s, Sydenam’s, Huntington’s)
Anxiety disorders
Depression (50% of OCD patients have depressive sx - depression takes priority)
Anakastic personality disorder
Autism - repetitive behaviour, need for routine
Schizophrenia
How do you manage OCD?
Education and self help, mindfulness (notice thoughts, r rather than avoid them)
CBT - Exposure and response prevention
Medication - SSRI, clomipramine (TCA). second gen antipsychotic if resistant
So:
1. CBT with ERP
2nd line: add SSRI
3rd line (after 12 weeks): clopiramine or alternative SSRI
What are symptoms of an acute stress reaction?
Transience (starts in mins, resolves in hours)
Dazed/detached
Amnesia
Depersonalisation, derealisation
Disorientation, agitation, irritability, panic, aggression
How do you manage Acute Stress Reaction?
Exclude injury
Support and Reassurance
Benzos (short term)
What does PTSD occur following?
Follows exposure to a stressful situation of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
What is the latency period of PTSD?
Usually within 6months of trauma
What is clinical presentation of PTSD?
RE-EXPERIENCING
- Flashback s
- Nightmares
- Intrusive memory
AVOIDANCE
- avoids reminders (e.g. specific setting) of event
- avoids thinking about it
HYPERAROUSAL
- persistent inability to relax
- hypervigilance
- enhanced startle reflex
- insomnia
- poor concentration
- rritability
EMOTIONAL CHANGES
- Emotional detachment
- Powerful emotions e.g. anger, loss of control, shame, crying
- Decreased interest in activities
Ddx for PTSD
Anxiety disorders
Depression
Adjustment
Mx for PTSD
Trauma-Focused CBT
Eye movement desensitisation and processing (EMDR)
Group therapy
SSRI(paroxetine)/Venlaxafine
What is adjustment disorder?
Person’s reaction to life changes that require adaptations to cope is greater than usually expected
Symptoms start within 1 month of stressor, resolve within 6m
What are risk factors for generalised anxiety disorder?
Physical or emotional trauma
Low socioeconomic status
Substance abuse
Chronic painful illness
What is the management for GAD?
- Social:
- relaxation training,
- meditation training,
- sleep hygien
- exercise - Psych: CBT for 4-12 weeks
- Medication: Sertraline (2nd line: other SSRI or SNRI, 3rd line: Pregabalin)
- Specialist assessment
What are drugs given for GAD management=
SSRI
SNRI
Pregabalin
When is Benzo given in anxiety
As a LAST RESORT for <4 weeks
or AS A ONE OFF
What are criteria for agoraphobia diagnosis?
Minimum 2 of fear in the following:
- crowds
- public places
- travelling away from home
- travelling alone
What are signs/symptoms of agoraphobia?
House bound
Panic attacks when outdoors / confined places
Dependency on other
What are signs/symptoms of social phobia?
Social withdrawal Blushing Tremor Panic attack Alcohol abuse
What is a specific phobia?
Out of proportion fear to the demands of a situation, due to specific trigger
Cannot be reasoned away as it is involuntary (stems from the deep brain aka amygdala)
How do specific phobias present?
Avoidance
Fear
Disability
How does a panic attack present?
Breathing difficulty, choking feeling Fear of suffocating/dying Hyperventilation > dizziness, parasthesia Palpitations Depersonalisation / derealisation Lasts <30 mins, self resolving
What differentials do you rule out for panic disorder?
Other anxiety disorders (GAD; agoraphobia)
Depression
Alcohol or drug withdrawal
Organic causes (CV, respiratory, phaeo)
What is the difference in panic attack presentations in panic disorder vs other anxiety disorders?
in panic disorders, they have no obvious trigger
In other disorder (e.g. GAD), they occur with trigger and mark severity of the condition
Give examples of obsession categories that could occur in OCD
Contamination e.g. something getting dirty
Infection e.g. getting HIV
Aggression e.g. thought of harming others
Morality (sex/religion) e.g. sacrilege - shout blasphemous things in a church
e.g. thinking they might be a pedophile
What are examples of compulsion categories in OCD?
Cleaning
Counting
Checking
Ordering objects
What is the triad of symptoms that occurs in PTSD?
Re-experiencing
Avoidance
Hyperaro\usal
What time frame do symptoms have to occur in to be qualified as PTSD
> 4 weeks from event
Usually present within first 6 months
Explain how CBT works for anziety disorders
Aims to reduce patients expectations to threat and the behaviours that maintain threat-related beliefs
Structure:
- explore likelihood and impact of anticipated catastrophe
- Test feared situation using behavioutal experiment
- This increases the patient’s confidence in their capacity to cope with the feared situatio
Explain how exposure therapy works for anxiety
Expose person to perceived threat
Exposure is achieved gradually, via desensitisation
In the absence of actual harm, body can only remain anxious for 45minds before habituation occurs and aniety drops
Anxiety decreases until extinction
How does EMDR work
Eye movement desensitisation and reprocessing
Experience orignal trauma in as much detail as possible (ask patient to narrate)
while they do this, they fix eye on therapists finger as it quickly passess from side to side
eye movements. can be replaced by alternating left right stimulus
this aids memory processing
