Anxiety disorder- clinical picture

Question 1

Normal response to a stressor

Answer 1

1. Amygdala detects sensory information indicating danger—> stimulates the hypothalamus
2. Hypothalamus stimulates the sympathetic NS—> stimulates release of NA from the adrenal medulla
3. NA–> Tachycardia, hypertension, bronchial dilation, sweating, hyperventilation

Question 2

GAD

- Clinical presentation

Answer 2

Persistent features that are not restricted or strongly presenting before certain circumstances

• Worry
• Headache
• Motor tension
• Autonomic hyperactivity [sweating, dry mouth etc]

Question 3

Psychological GAD symptoms

Answer 3

Fearful anticipation of things

Irritability

Sensitivity to noise

Restlessness

Poor concentration

Thoughts of worry

Question 4

GI symptoms of GAD

Answer 4

Dry mouth

Difficultly swallowing

Epigastric discomfort

Frequent wind

Question 5

Respiratory symptoms of GAD

Answer 5

Hyperventilation

Tight chest

Difficulty inhaling

Question 6

Cardiovascular symptoms of GAD

Answer 6

Chest pain

Palpitations

Feeling of ‘missed beats’

Question 7

Genitourinary symptoms of GAD

Answer 7

Urinary urgency/ frequency

Dysmenorrhea

Amenorrhea

Erectile failure

Question 8

Neuromuscular symptoms of GAD

Answer 8

Tremors

Trembling

Paraesthesia

Tinnitus

Dizziness

Headaches

Question 9

GAD presentation in primary care

Answer 9

Presents a lot more than in general population

• Lifetime prevalence [8-9%]
• 3x more in GP

Also contains very high co-morbidity
- 70%

Question 10

Genetics of GAD

Answer 10

5x increase in 1st degree relatives

Genetic factors have a modest role
- Monozygotic twins show no difference with dizygotic twins

Question 11

Neurobiological mechanism of GAD

Answer 11

No clear studies related to humans

Abnormal APA axis

Possible role of serotonin–> Benefits from SSRIs

GABA agonists are effect–> Possible GABA mechanism

NA pathways possibly implicated

Question 12

Psychological etiology of GAD

Answer 12

Stressful and traumatic life events= increases risk of developing GAD

Just one very negative event= 3x risk

Question 13

Parenting effects on GAD

Answer 13

Disruption in early attachment–> anxious apprehension and dependency
- Withdrawal and depression can occur when disruption is severe

Overprotection + lack of warmth and responsiveness
- Can lead to anxiety

Question 14

Endocrine differential diagnosis of panic disorders

Answer 14

Hypoglycaemia

Phaeocromocytoma–> neuroendocrine tumor of adrenal medulla

Carcinoid–> slow growing neuroendocrine tumour

Question 15

Cardiovascular differential diagnosis of panic disorders

Answer 15

Arrhythmias

Question 16

Respiratory differential diagnosis of panic disorders

Answer 16

Asthma

Question 17

Neurological differential diagnosis of panic disorders

Answer 17

Seizures

Question 18

Agoraphobia

- Clinical presentations

Answer 18

Fear and avoidances of places that may induce panic

• Specific context
• Example: in crowds, away from the house

Can present with panic attacks and general anxiety

Question 19

Panic epidemiology

Answer 19

Panic attacks
- 7-9% of population

Panic disorder
- 1.5-2.5% lifetime prevalence

Peak onsets:
15-25, 45-54

Risks

• Living in city
• Broke relationship
• Less educated
• Previous abuse
• Being female

Question 20

Panic genetic predisposition

Answer 20

Increase risk in first degree relatives
- 7x

Moderate inheritability

Question 21

Biological model

- Panic

Answer 21

Panic attack triggered by activation of locus coeruleus–> Release of NA

SSRI are effective [though SRT studies are contradictory]

GABA agonists are effective

Pentagastrin and CCK seen to cause panic attacks

Question 22

Specific phobias

Answer 22

Inappropriate anxiety in the presence of one or more particular objects/ situations

Question 23

Aetiology of phobia

Answer 23

1. Biological preparedness
   - Objects that historically threatened the survival of an organism is feared.
2. Previous unresolved unconscious conflict
3. Classical condition–> Fear is learned in association with negative symptoms

Question 24

Autonomic response to blood/injury phobia

Answer 24

Vasovagal syncope:

1. Sigh of blood/ needles= initial tachycardia and hypertension
2. Then blood pressure and heart rate drops–> Decrease cerebral artery blood flow

Question 25

Social phobias

Answer 25

Inappropriate anxiety when a person is observed or scrutinised

Question 26

Epidemiology of social phobia

• Lifetime risk
• GP presentation
• Co-morbidity
• Onset
• Sex

Answer 26

Lifetime risk
- 2.4-13.3

GP
- Can be as high as 7%

Co-morbidity
- 81% meet another psychiatric disorder at one point

Peaks

• before 5
• 11-15
• Unusual after 30

Sex
- Women more than men

Question 27

Aetiology of social phobia

Answer 27

Genetic and environmental

- Monozygotic> dizygotic twins