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ANXIETY AND ASSOCIATED CONDITIONS Flashcards

1
Q

Whats the epidemiology of anxiety?

A

Most common psychiatric disorder - accounts for 25% of cases
15% lifetime prevalence
F:m 2.5:1

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2
Q

Whats the usual age of onset for anxiety?

A

15-20

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3
Q

Whats the most prevalent anxiety disorder?

A

GAD

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4
Q

What does the Yerkes-Dodson curve show?

A

We perform best at moderate levels of arousal
But at high levels of arousal our performance declines

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5
Q

What are the genetic aetiological factors for anxiety?

A

60% of pts with panic disorders have at least 1 relative with the same disorder

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6
Q

What are the changes in neurotransmitters for anxiety?

A

Decreased GABA
Catecholamines are increased
Alterations in serotonin and dopaminergic systems
Hyperactivity of amygdala in social anxiety

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7
Q

What are the social aetiological factors for anxiety?

A

Adverse life experiences
Lack of social support
Work stress
Lack of social skills
Conflicts
Unresolved conflicts from childhood psychosexual development

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8
Q

What are the psychological aetiological factors for anxiety?

A

Cognitive model
Learned helplessness
Psychoanalytical theory

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9
Q

Whats the cognitive model of panic attacks?

A

A susceptible individual misinterprets a normal body sensation and assumes it’s something physically wrong. This fear activates the sympathetic NS leading to a real tachycardia, sweating etc. this vicious cycle ensues in which the perception of increasing cardiac effort convinces the sufferer that they are on the point of an MI. This may lead to a full blown panic attach

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10
Q

Which area of the brain has heightened activity during anxiety?

A

The brain’s limbic system, comprised of the hippocampus, amygdala, hypothalamus and thalamus, is responsible for the majority of emotional processing. Individuals with an anxiety disorder may have heightened activity in these areas.

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11
Q

What are the physical symptoms of anxiety?

A

Sympathetic overactivity causes…
Tachycardia, Palpitations, Hypertension, pale skin, sweating, dry mouth, nausea, diarrhoea, frequent urination, Butterfly feeling in stomach
SOB
Chest pain
Choking sensation
Tremors
Muscle tension
vomiting
Dizziness, light headedness, syncope
Pupil dilation
Tingling fingers/toes
Sleep disturbances - insomnia and night terrors

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12
Q

What are the psychological symptoms of anxiety?

A

CNS: poor concentration, memory, derealisation
Mood: fear, panic, worry, irritability
Thoughts: fearful anticipation, fear of dying, worrying about worrying

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13
Q

What are the panic pairs in anxiety?

A

Dizziness - collapsing
Breathlessness - suffocating
Palpitations - MI/dying
Tingling fingers - stroke
Derealisation - going mad
Headache - stroke

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14
Q

What are some unhelpful behaviours often seen in anxiety?

A

Pacing the room, writing hands, sighing
Attempts at coping e.g. caffeine, smoking, alcohol, drugs
Avoidance of fear-provoking situations
Safety behaviours
Asking for reassurance e.g. visiting GP, checking the body

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15
Q

Outline the different types of anxiety disorders under ICD10?

A

F40 - phobic anxiety disorders
F41 - other anxiety disorders
F42 - Obsessive compulsive disorder
F43 - reaction to severe stress, and adjustment disorders
F44 - dissociative disorders
F45 - somatoform disorders
F48 - other neurotic disorders

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16
Q

According to ICD10, what are the types of phobic anxiety disorders?

A

Agoraphobia
Social phobias
Specific/isolated phobias
Other phobic anxiety disorders

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17
Q

According to ICD10, what are the types of other anxiety disorders?

A

Panic disorder
Generalised anxiety disorder
Mixed anxiety and depressive disorder
Other mixed anxiety disorders
Other specified anxiety disorders

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18
Q

According to ICD10, what are the types of obsessive-compulsive disorders?

A

Predominantly obsessional thoughts or ruminations
Predominantly compulsive acts
Mixed obsessional thoughts and acts
Other obsessive-compulsive disorders

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19
Q

According to ICD10, what are the types of reaction to severe stress, and adjustment disorders?

A

Acute stress reaction
PTSD
Adjustment disorders
Other reactions to severe stress

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20
Q

According to ICD10, what are the types of dissociative disorders?

A

Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and possessions disorders
Dissociative motor disorders
Dissociative convulsions
Dissociative anaesthesia and sensory loss
Mixed dissociative disorders
Other dissociative disorders

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21
Q

According to ICD10, what are the types of somatoform disorders?

A

Somatisation disorder
Undifferentiated somatoform disorder
Hypochondriacal disorder
Somatoform autonomic dysfunction
Persistent somatoform pain disorder
Other somatoform disorders

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22
Q

According to ICD10, what are the types of other neurotic disorders?

A

Neurasthenia
Depersonalisation-derealisation syndrome
Other specified neurotic disorders

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23
Q

What are phobic anxiety disorders?

A

A group of disorders in which anxiety is triggered by specific situations that are not dangerous. These situations are characteristically avoided. The pt concern may be on symptoms like palpitations and is often associated with secondary fears of dying/losing control etc. it may be so severe it may take the form of a panic attack.
Contemplating entry to the phobic situation usually generates anticipatory anxiety

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24
Q

What is agoraphobia?

A

A cluster of phobias with extreme or irrational fear of entering open or crowded places, of leaving one’s own home, or of being in places from which escape is difficult. Panic disorder is a frequent feature. Avoidance of the phobic situation is often prominent and some may even become housebound or refuse to leave the house unless accompanied. It’s coded as agoraphobia with or without panic disorder.

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25
Q

What is social phobia?

A

Fear of scrutiny by other people leading to avoidance of social situations.
More pervasive social phobias are usually associated with low self-esteem and fear of criticism.
They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem.
Symptoms may progress to panic attacks.

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26
Q

What is a specific phobia?

A

Phobias restricted to highly specific situations such as proximity to particular animals, heights, thunder, darkness, flying, closed spaces, urinating or defecating in public toilets, eating certain foods, dentistry, or the sight of blood or injury.
Though the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobia.

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27
Q

What is panic disorder?

A

The essential feature is recurrent attacks of severe anxiety, which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.
As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and depersonalization or derealization. There is often also a secondary fear of dying, losing control, or going mad.
They often have anticipatory anxiety
These attacks 5-30 minutes

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28
Q

What is generalized anxiety disorder?

A

Anxiety that is characterised by excessive worry about every day issues that is disproportionate to any inherent risk
At least three of the following symptoms are present most of the time: restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance. Includes the main 3 elements of apprehension, motor tension and autonomic overactivity.
Symptoms are present for more days than not for at least 6 months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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29
Q

What are risk factors for GAD?

A

Female sex x2
Comorbid anxiety disorder
FHx psychiatric disorder
Childhood adversity
History of physical, sexual or emotional trauma
Social demographic factors such as separation, unemployment, low socioeconomic status, low education levels
Substance dependence or exposure to organic solvents
Chronic physical conditions

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30
Q

What are the complications of anxiety?

A

Distress, substantial disability and impaired quality of life
Impaired social and occupational functioning
Comorbidities - psychiatric and physical
Suicidal ideation and attempts
Increased use of healthcare resoirces

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31
Q

What is mixed anxiety and depressive disorder?

A

This category should be used when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately.

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32
Q

What is obsessive compulsive disorder?

A

The essential feature is recurrent obsessional thoughts or compulsive acts. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.

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33
Q

Whats the ICD10 diagnostic criteria for OCD?

A

Obsessions or compulsions must be present for at least 2 consecutive weeks and are a source of distress or interfere with the pts functioning
They are acknowledged as coming from the pts own mind
The obsessions are unpleasantly repetitive
At least 1 thought or act is resisted unsuccessfully
A compulsive act is not in itself pleasurable

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34
Q

What are obsessional thoughts?

A

ideas, images, or impulses that enter the patient’s mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant.

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35
Q

What are compulsive acts?

A

stereotyped behaviours that are repeated again and again.
They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks.
Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur.
Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist.

36
Q

What are examples of the most commonly occurring obsessions and their associated compulsions?

A

Fear of contamination -> excessive washing and cleaning or avoidance of contaminated objects

Pathological doubt e.g. ‘have i turned the cooker off?’ -> exhaustative checking of the possible omission

Need for symmetry -> repeatedly arranging objects to obtain perfect symmetry

37
Q

What is acute stress reaction?

A

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress
Occurs 0-28 days after trauma occurs
Lasts 3 days-4 weeks
Symptoms include depersonalisation and derealisation
E.g. intrusive memories/dreams, feeling that the event is recurring, intense psychological distress when reminded of the event, perstent inabiity for positive emotions, memoru loss, efforts to avoid distressing memories and external reminders, irritability or anger outbursts, hypervigilence, difficulty concentrating, startle response

Symptoms must cause significant distress or significantly impair functioning

38
Q

What is post traumatic stress disorder?

A

A mental health condition following exposure to a major traumatic event. It may present with a range of symptoms that persist for at least 1 month after the traumatic event.

The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change

39
Q

What are some examples of major traumatic events which could cause PTSD/

A

A serious/life-threatening accident.
Physical or sexual assault.
Abuse, including childhood or domestic abuse.
Work-related exposure to trauma, including remote exposure.
Trauma related to serious health problems or childbirth experiences (for example, intensive care admission or neonatal death).
War and conflict.
Torture.

40
Q

What are typical features of PTSD?

A

Flashbacks
Hallucinations or illusions
Distress caused by cues which resemble the stressor
Avoidance of stimuli associated with stressor
Increased arousal e.g. hypervigilance, anger, irritability
Emotional numbing
Dissociation
Negative mood and thinking and self-perception

41
Q

What are adjustment disorders?

A

An emotional or behavioural reaction to a stressful event or change. The reaction is considered an unhealthy or excessive response.
Occurs within 1 month of the event and does not typically last >6 months.
Interferes with social functioning and performance.

May cause mild symptoms of depression and feelings of being unable to cope. There may be disturbances of conduct in some cases.

42
Q

What are the diagnostic criteria for diagnosing adjustment disorder?

A

The adjustment reaction must occur within 1 month of the stressful life event and the duration of symptoms do not usually exceed 6 months
It’s a diagnosis of exclusion

Bereavement reaction >6 months can be coded as a form of adjustment disorder

43
Q

What is ‘disscoiation’?

A

Mental disorders that involve experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity
The most common examples of a dissociative state is hypnosis.

44
Q

What are examples of dissociative disorders?

A

Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and possession disorders
Dissociative motor disorders
Dissociative convulsions
Dissociative anaesthesia and sensory loss

45
Q

Whats the ICD10 requirements for dissociative disorders?

A

Some evidence of psychological causation in association with the onset of the dissociative symptoms
All types of disorders tend to remit after a few weeks or months.
There can’t be a diagnosis made if there is any evidence of physical or psychiatric disorders which may explain the sympotms

46
Q

Whats dissociative amnesia?

A

The main feature is loss of memory, usually of important recent events, that is not due to organic mental disorder, and is too great to be explained by ordinary forgetfulness or fatigue. The amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements, and is usually partial and selective.

47
Q

What is dissociative fugue?

A

a temporary state where a person has memory loss (amnesia) and ends up in an unexpected place.

48
Q

What is dissociative stupor?

A

a disease characterized by the reduction or absence of voluntary movements and responsiveness to external stimuli, potentially induced by stress

49
Q

What are trance and possession disorders?

A

Disorders in which there is a temporary loss of the sense of personal identity and full awareness of the surroundings. Include here only trance states that are involuntary or unwanted, occurring outside religious or culturally accepted situations.

50
Q

What are dissociative motor disorders?

A

loss of ability to move the whole or a part of a limb or limbs

51
Q

What are dissociative convulsions?

A

Dissociative convulsions may mimic epileptic seizures very closely in terms of movements, but tongue-biting, bruising due to falling, and incontinence of urine are rare, and consciousness is maintained or replaced by a state of stupor or trance.

52
Q

What is dissociative anaesthesia and sensory loss?

A

naesthetic areas of skin often have boundaries that make it clear that they are associated with the patient’s ideas about bodily functions, rather than medical knowledge. There may be differential loss between the sensory modalities which cannot be due to a neurological lesion. Sensory loss may be accompanied by complaints of paraesthesia.

53
Q

How do we screen for generalised anxiety disorder?

A

GAD2 and GAD7

54
Q

What is GAD7?

A

The person should be asked ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’:
Feeling afraid, as if something awful might happen.
Becoming easily annoyed or irritable.
Being so restless that it is hard to sit still.
Trouble relaxing.
Worrying too much about different things.
Not being able to stop or control worrying.
Feeling nervous, anxious, or on edge.

55
Q

Outline how we interpret the results of GAD7?

A

The score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’ adding up to a possible total of 21.
Scores of 5, 10, and 15 are taken as cut-off points for mild, moderate, and severe anxiety respectively

56
Q

What is GAD2?

A

When you ask… Over the last 2 weeks, how often have you been bothered by the following problems?

1) Feeling nervous, anxious or on edge
2) Not being able to stop or control worrying

Score based on 0=not at all 1= severel days 2= more than half the days 3= nearly every day
An anxiety disorder is likely if a person answers 2 or 3 to one or both questions

57
Q

What 5 areas should you questions when taking a history for anxiety?

A

Situations/triggers
Thoughts
Emotions
Physical reactions
Behaviours before/during/after

58
Q

How do we investigate anxiety?

A

Physical - blood tests (hyperthyroidism), MCV/GGT (alcohol misuse), glucose, urine drug screen, urinary normetanephrine (Phaeochromocytoma - rare), ECG, MRI head, EEG (temporal lobe epilepsy)
Psychoglocial - GAD7 and PHQ9
Social - collateral history

59
Q

How do you manage GAD first line?

A
  1. EXPLAIN AND EDUCATE! And active monitoring
  2. Low-intensity psychoglocial interventions e.g. Individual non-facilitated self help, Individual guided self help and psycho educational groups

Also offer advice on sleep hygiene, benefits of regular exercise

60
Q

How do you manage GAD if low-intensity psychological interventions dont help or if they have marked functional impairment?

A

Individual high-intensity psychological intervention e.g. CBT
Drug treatment

61
Q

What are some effective psychotherapy treatments in PTSD?

A

Systematic desensitisation
CBT
Psychodynamic therapy
Eye movement desensitisation and reprocessing therapy (EMDR)

62
Q

Outline potential drug treatment options for anxiety?

A
  1. SSRI (sertraline)
  2. SSRI or SNRI
  3. Pregabalin

TCAs can be offered (as effective) but have more adverse effects
MAOIs can be offered but have severe adverse effects and can interact with certain foods and drinks
Benzos can be offered in short term for crises

63
Q

When do we offer beta blockers to manage anxiety?

A

Can help reduce autonomic symptoms

64
Q

Outline the prognosis of GAD?

A

GAD is likely to be chronic, but fluctuating, often worsening during times of stress

65
Q

Whats the treatment for phobic disorders?

A

Graded exposure/systematic desensitisation = the deliberate confrontation of a feared object or situation until the anxiety evoked reduces to 50% of maximum

66
Q

Whats the panic vicious circle?

A

Sensation -> misinterpretation -> emotion (panic)

67
Q

Whats Clarke’s CBT model for panic attacks?

A

The person misinterprets normal body sensations as meaning that a physical or mental disaster is imminent – ‘catastrophic misinterpretation’
The ‘fight or flight’ survival response produces more symptoms - which fuel the ‘vicious cycle’ of panic
Attempts by the person to manage panic bring short term relief but make it worse in the long term (avoidance + safety behaviours)

68
Q

Whats the issue with hyperventilation in anxiety

A

Respiratory alkalosis?

69
Q

Which type of anxiety is pharmacotherapy not the standard treatment?

A

Specific phobias

70
Q

What are some differential diagnoses of anxiety and panic disorders?

A

Drug withdrawal or side effects
Hyperthyroidism
Phaeochromocytoma
Hypoglycaemia
Cushing syndrome
Parathyroid disease
Angina
Arrhythmias
Asthma or COPD
Agitated depression
Mixed anxiety and depressive disorder
Adjustment disorder
Acute stress reaction
Avoidant personality disorder

71
Q

Why is CBT effective for managing anxiety?

A

CBT helps individuals identify the links in the chain that lead to worse anxiety and depression: the thoughts, feelings, behaviors, and physical sensations that are intimately connected to one another
It helps us overcome learned helplessness by changening how we think and act

72
Q

What type of CBT is particularly useful for people with phobias or OCD?

A

Exposure therapy

73
Q

What are the warnings with SSRI and anxiety?

A

If under 30 years old then warn about increased risk of suicidal thinking and self harm
Anxiety may get worse for the first few weeks of treatment
Weekly follow up in the first month

74
Q

What are the nice guidelines for managing OCD?

A

Low intensity psychological treatments - CBT including exposure and response prevention

If insufficient or can’t engage then either offer a course of SSRI or more intensive CBT including ERP

75
Q

What is ERP?

A

Exposure and Response Prevention
a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

76
Q

What are the protective factors for GAD?

A

Aged 16 - 24
Being married or cohabiting

77
Q

What is the psychoanalytic component of anxiety?

A

Freud described that anxiety arises from unresolved conflicts from childhood psychosexual development

78
Q

Whats the prognosis of panic disorders?

A

Dependant on treatment, up to 50% of panic disorder patients may be symptoms free after 3 years but 1/3rd of patients have chronic symptoms that are sufficiently distressing to significantly reduce QOL

79
Q

What’d the prognosis of PTSD?

A

Half patients with PTSD will recover fully within 3 months but 1/3rd of pts are left with moderate-severe symptoms in the long term

80
Q

Whats the prognosis of OCD?

A

Most pts with OCD have a chronic, fluctuating course with worsening symptoms during times of stress

81
Q

What is systemic desensitisation therapy used to treat?

A

Anxiety
Phobic disorders
PTSD

82
Q

How does systematic desensitisation therapy work?

A
  1. Teaching deep muscle relaxation techniques and breathing exercises
  2. Creating a fear hierarchy
  3. Working up through the fear scale through exposure
83
Q

Whats the first line treatment for acute stress reaction?

A

trauma-focused cognitive behavioural therapy

84
Q

What are the flashbacks in PTSD also known as?

A

Pseudohallucinations

85
Q

What are the most common symptoms of PTSD/

A

re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached

PSYCHIATRY (20 decks)

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