Anxiety Flashcards
Anxiety is persistent => general anxiety
OR
Anxiety is episodic, regularly triggered by a cue => phobia
OR
Anxiety is episodic without a regular trigger => panic disorder
*Patient with one anxiety disorder may develop another
INFO CARD
What is generalised anxiety disorder (GAD)?
GAD => persistent, chronic general anxiety
More common in women
Physical symptoms of GAD:
GI: => Dry mouth => Difficulty in swallowing => Epigastric discomfort => Aerophagy (swallowing air) => Diarrhoea
Respiratory: => Feeling of chest contraction/tightness => Difficulty inhaling => Over-breathing => Choking
Cardiology:
=> Palpitations
=> Awareness of missed beats
=> Chest pain
Physical symptoms of GAD:
GU:
=> Increased frequency
=> Failure of erection/loss of libido
CNS: => Fatigue => Blurred vision => Dizziness => Sensitivity to bright light/noise => Headache => Sleep disturbance => Trembling
Mixed anxiety and depressive disorder => most common mood disorder in primary care
=> equal elements of depression and anxiety
INFO CARD
What is a panic disorder?
Repeated sudden attacks of overwhelming anxiety accompanied by severe physical symptoms related to:
=> hyperventilation
AND
=> sympathetic nervous system over-activation i.e. palpitations, tremor, restlessness and sweating
People with panic attack have catastrophic illness belief that they are going to die => fear, terror and impending doom
What are the clinical features of panic disorder?
=> fear, terror and impending doom
=> dyspnoea
=> palpitations
=> chest pain or discomfort
=> suffocating sensation
=> dizziness
=> paraesthesia in hands and feet or perioral
=> Sweating
=> carpopedal spasms
What causes hyperventilation in anxiety?
Over-breathing leads to a decrease in PaCO2 and an increase in arterial pH, causing relative hypocalcaemia
How do you manage panic attacks?
Explanation and reassurance
Patient trained in relaxation techniques and slow, controlled breathing
Patient asked to breathe into a closed paper bag
What are phobic (anxiety) disorders?
Phobia is an abnormal, intense fear triggered by a stimulus
=> stimulus is predictable + usually of no concern
=> leads to avoidance of stimulus
=> can be disabling
=> treatable with behaviour therapy
=> e.g. agoraphobia, claustrophobia, social phobia
What is the aetiology underlying phobias?
=> Caused by classical conditioning i.e. fear and avoidance becomes conditioned to a previous benign stimulus e.g. a lift or after an emotional shock e.g. being stuck in a lift
=> In children, phobias arise via imagined threats i.e. ghost stories
Phobias affects which group of people more?
Women > men [2:1]
Phobias aggregate in family - genetic factors
Phobias:
- Agoraphobia:
=> direct translation ‘fear of marketplace’
=> fear of being away from home, with travelling, walking down the road and going to supermarket
=> most disabling, patients don’t leave their rooms - Social phobia:
=> fear & avoidance of social situations i.e. crowds, strangers, parties and meetings
=> Public speaking = worst nightmare
Phobias:
- Simple phobias:
=> Arachnophobia (phobia of spiders) most common in esp in women
=> Other common phobias = insects, bats, dogs, snakes, heights, thunderstorms and the dark
=> Children phobic about dark, ghosts and burglars the most but most grow out of it
Phobias:
- Agoraphobia:
=> direct translation ‘fear of marketplace’
=> fear of being away from home, with travelling, walking down the road and going to supermarket
=> most disabling, patients don’t leave their rooms
- Social phobia:
=> fear & avoidance of social situations i.e. crowds, strangers, parties and meetings
=> Public speaking = worst nightmare
Phobias:
- Simple phobias:
=> Arachnophobia (phobia of spiders) most common in esp in women
=> Other common phobias = insects, bats, dogs, snakes, heights, thunderstorms and the dark
=> Children phobic about dark, ghosts and burglars the most but most grow out of it
In people with brief episodes, discussion with a doctor about their anxiety and its precipitant is enough.
What is the psychological management of anxiety disorders?
- Relaxation techniques:
=> Effective in mild to moderate anxiety
=> Complementary techniques i.e. meditation, yoga
=> Conventional relaxation training by slowing down rate of breathing, muscle relaxation and mental imagery - Anxiety management training (2 stages):
=> 1st Stage: verbal cues & mental imagery to arouse anxiety and demonstrate the link with symptoms
=> 2nd Stage: training to reduce this anxiety by relaxation, distraction and reassuring self-statements - Behaviour therapies:
=> Change behaviours thus change symptoms assoc. with phobia
=> Graded exposure or ‘systematic den-sensitisation’
=> Identify and rate phobias in a hierarchy of worsening fears
=> Then practice exposure to the least fearful stimulus until no fear is felt
What is the psychological management of panic attacks?
CBT => treatment of choice for GAD and panic attacks
=> Therapist and patient identify mental cues i.e. thoughts and memories that subtly provokes exacerbations of anxiety or panic attacks
What is the drug treatment for anxiety?
- Benzodiazepines:
=> centrally acting anxiolytic drugs
=> agonists of GABA (inhibitory neurotransmitter)
=> e.g diazepam and chlordiazepoxide used as anti-anxiety drugs in short term
=> side effects: sedation, memory problems, dependence, tolerance, withdrawal symptoms
- SSRI (1st line):
=> e.g. fluoxetine, paroxetine, sertraline, citalopram
=> symptomatic treatment for GAD, panic disorders and some phobias
=> duloxetine, mirtazapine, venlafaxine and pregabalin alternate treatment for GAD + may prevent depression
=> delayed treatment response
- SSRI = 1st line; if after 2 trials of SSRI GAD still persistent, try SNRI
3. Antipyschotics:
=> quetiapine, olanzapine affective for more severe or refractory cases
What is the treatment for peripheral symptoms of anxiety?
- Beta-blockers:
=> effective in reducing peripheral symptoms of anxiety due to sustained release of adrenaline and noradrenaline from the adrenal medulla and sympathetic nerves
=> e.g. propranolol reduces tremors, palpitations, tachycardia but has no effect on central symptoms i.e. anxiety
What is normal grief?
What are the 3 stages?
Normal grief immediately follows bereavement and is expressed openly through social ceremonies.
3 stages:
=> 1st Stage : shock and disbelief
=> 2nd Stage : emotional phase i.e. anger, guilt and sadness
=> 3rd Stage : acceptance and resolution
This process can take up to a year => people move between all stages throughout
What is pathological (abnormal grief)?
=> Excessive / prolonged grief
=> Absent grieving with abnormal denial of bereavement
=> Usually person is stuck in grief with insomnia and repeated dreams of the dead person, anger at the doctor or at the patient for dying, consequent guilt and inability to say goodbye.
=> Guided mourning uses cognitive and behavioural techniques to help stop grieving and moving on.
What is post-traumatic stress disorder (PTSD)?
=> Prolonged response to a stressful event or situation of an extremely threatening nature causing extreme distress
=> e.g. natural or human disasters, wars, rape, torture, terrorism
=> Predisposing factors i.e. personality type, unresolved traumas, history of psychiatric illness prolongs PTSD further
What are the clinical features of PTSD?
=> Flashbacks : vivid reliving of the trauma triggered by a reminder
=> Insomnia with nightmares
=> Emotional blunting : feeling empty / numb
=> Intense anxiety
=> Avoidance of anything related to the trauma
=> Emotional detachment from people
=> Hypervigilance : autonomic hyperarousal and enhanced startle reaction
2/3 of cases recover by the end of first year.
The rest are prolonged and can be complicated.
What are the complications of PTSD?
=> Depressive illness
=> Alcohol misuse
=> Chronic course of PTSD over years = personality change
Adult consequence of childhood abuse
=> 20% women, 10% men suffer significant, coersive and inappropriate sexual activity in childhood
=> Abuser usually a family member or known to child
=> Adverse childhood experience lead to lifetime health, social and behavioural problem
=> Consequent psychiatric disorders = depression, substance misuse, eating disorders, borderline personality disorder and self-harm
=> Hippocampal atrophy and downregulation of neuroendocrine axis is seen
Management:
- Psychodynamic psychotherapy based on Freud’s idea of pyschosexual development
=> Aim: symptom relief and personality change
- Cognitive analytical therapy
=> Intergration of CBT and psychodynamic therapy
What is obsessive compulsive disorder (OCD)?
Obsessions = certain repeated thoughts
Compulsions = certain repeated routines
Assoc. with depression and Tourette’s syndrome
What are the clinical features of OCD?
=> Time-consuming and intrusive obsessions and compulsions
=> Affect functioning + cause distress
=> Obsessions are unpleasant repetitive thought, out of character i.e. being dirty or violent
=> Leads to compulsive needs to ensure everything and everyone is okay; things have to be done correctly and reassurance cannot resolve the compulsions
=> Some rituals derived from superstitions i.e. turning the switch off a number of times ; start again if interrupted
=> OCD can last many years and can be resistant to treatment
=> Minor obsessions common in healthy population i.e. tidiness, punctuality, ‘perfectionists’
What is the underlying aetiology in OCD?
- Genetic basis
- Neuroimaging studies:
=> dysfunction in the orbito-striatal area (inc caudate nucleus)
=> dysfunction in dorsolateral prefrontal cortex
=> Underactive seroternigic neurotransmission
=> Overactive glutamatergic neurotransmission
What is the psychological management of OCD?
CBT => confronts anxiety provoking stimulus in a controlled environment and not performing the assoc. ritual.
Aim is to habituate the patient to the stimulus and reduce anxiety
*High drop out because provokes anxiety
What is the medical management of OCD?
- Tricyclic antidepressants and SSRI
=> Clomipramine (TCA) and SSRIs - 1st line treatment
=> Higher doses required than in depression
=> High relapse rate on discontinuation
=> 3 months maximum dose treatment for a +ve response
=> Failed response - add an anti-psychotic
- Deep brain stimulation
- Psychosurgery
=> Rare, in cases of chronic and severe OCD refractory to other treatments
What is the prognosis for OCD?
2/3 cases improve within a year
1/3 cases fluctuate or persistent
