Anxiety disorder, OCD and PTSD Flashcards
“Stress” – Refers to the overpowering pressure of some adverse force or influence exerted on the body
“Stress” – Refers to the overpowering pressure of some adverse force or influence exerted on the body
Anxiety – Body’s response to “stress”
• Psychological and physical (somatic) symptoms
– An adaptive response caused by perception of real or perceived danger
• “fear, fight or flight” response to perceived threat/stimulus.
– A common, natural, usually self-limiting emotion
• Anxiety symptoms generally subsides after the trigger subsides
Anxiety – Body’s response to “stress”
• Psychological and physical (somatic) symptoms
– An adaptive response caused by perception of real or perceived danger
• “fear, fight or flight” response to perceived threat/stimulus.
– A common, natural, usually self-limiting emotion
• Anxiety symptoms generally subsides after the trigger subsides
What is anxiety disorder
Anxiety Disorders
– Severe, excessive, persistent anxiety and irrational fears that impairs functioning with everyday living; pathological.
• When anxiety is out of proportion to the actual danger or threat of the situation
• Persists long after original trigger disappeared (typically, more than 6 months)
– Increase risks for developing cardiovascular, cerebrovascular, gastrointestinal and respiratory disorders.
specific anxiety related disorders that are most amendable to drug treatment
Panic Disorder* Social Anxiety Disorder (SAD)* Generalized Anxiety Disorder (GAD)* Obsessive Compulsive Disorder (OCD)* Post Traumatic Stress Disorder (PTSD)*
Brief Description
Panic Disorder* Social Anxiety Disorder (SAD)* Generalized Anxiety Disorder (GAD)* Obsessive Compulsive Disorder (OCD)* Post Traumatic Stress Disorder (PTSD)*
Generalized Anxiety Disorder (GAD)*
= Excessive anxiety and worries > 6 mths
Panic Disorder*
= Anticipatory Anxiety of Recurrent Panic Attacks
Social Anxiety Disorder (SAD)*
= Fear of being scrutinized or humiliated by others in public
Obsessive Compulsive Disorder (OCD)*
= Obsessional thoughts/impulses that causes anxiety, followed by Compulsive behaviors to relieve that anxiety
Post Traumatic Stress Disorder (PTSD)*
= Re-experiencing of Trauma; Persistent Avoidance; Increased Arousal
Etiology and Pathophysiology
Circuits
– The “fear circuit” and symptoms are regulated by the amygdala
– The “worry circuit” and symptoms are regulated by the cortico-striatal-thalamiccortical (CSTC) loop.
Neurochemical Dysregulation:
– The Defense System
• Originates in amygdala of limbic system,
• Responsible for “fear, fight or flight” responses
• Responds to both learned and unlearned threats
– The Behavioral Inhibition System
• Based in hippocampus and septum of limbic system
• Responsible for avoidance behaviour.
OVERDRIVE OF BOTH SYSTEM
– Neurotransmitters:
• Norepinephrine (NE) (esp. in locus coeruleus, that projects from brain stem to amygdala and CSTC loop)
• Serotonin (5-HT): pathological fear/anxiety is related to over-activation of the amygdala.
However, the amygdala receives input from serotonergic neurons which can inhibit its outputs.
• Inhibitory neurotransmitter: gamma-aminobutyric acid (GABA),
- Medical Conditions
- Drug-induced
Medical Conditions Associated with Anxiety
1) Cardiovascular
Angina, arrhythmias, congestive heart failure, ischemic heart disease, myocardial infarction
2) Endocrine/ Metabolic
Cushing’s disease, hyperparathyroidism, hyperthyroidism, hypoglyceamia, hyponatraemia, hyperkalaemia, pheochromocytoma, vitamin B12 or folic acid deficiencies
3) Neurologic
Dementia, delirium, migraine, Parkinson’s disease, seizures, stroke, neoplasms, inadequate pain control
4) Pulmonary
Asthma, chronic obstructive pulmonary disease, pulmonary embolism, pneumonia
5) Others
Anemias, systemic lupus erythematosus, vestibular dysfunction
Drug induced anxiety
Sympathomimetics
- Pseudoephedrine
Stimulants
- Amphetamines, Methylphenidate, Cocaine
Methylxanthines
- Theophylline, caffeine
Thyroid hormone
- Levothyroxine
Corticosteriods
- Prednisolone
Antidepressants
- SSRIs, TCAs: esp. initiation or rapid dose escalation
Dopamine agonists
- Levodopa
Beta-adrenergic agonists
- Salbutamol (esp. systemic/oral)
Anticonvulsants (carbamazepine),
Antibiotics (quinolones, isoniazid),
NSAIDs (ibuprofen),
Herbals (Ma Huang, ginseng, ephedra)
Other Drug-Related Causes (with examples)
1) Drug Withdrawal
Caffeine, alcohol, sedatives, benzodiazepines, antidepressants, nicotine
2)Drug Intoxication
Anticholinergics, Antihistamines, Digoxin
3) Akathisia
Antipsychotic-induced
Clinical Presentation
“Panic Attack
A discrete period of intense fear/discomfort, in which
≥ 4 of the following Sxs developed abruptly and reached a peak w/in 10mins (usually lasts no more than 20-30 min):
– Palpitations, pounding heart, ↑PR
– Sweating
– Trembling/ shaking ****
– Sensations of shortness of breath **
– Feeling of choking
– Chest pain/ discomfort
– Nausea or abdominal distress
– Feeling dizzy, unsteady, lightheaded, faint
– Derealization (feelings of unreal) or depersonalization (being detached from oneself)
– Fear of losing control or going crazy**
– Fear of dying **
– Paresthesias (numbness or tingling sensations)
– Chills or hot flushes
– Can be expected or unexpected
– Can be listed as a Specifier that is applicable to all DSM-5 disorders
Clinical Presentation: GAD
– Excessive anxiety and worry (apprehensive expectation), occurring more days than not for ≥ 6 months, about a number of events or activities (e.g. work, school performance).
– The person finds it difficult to control.
– Anxiety and worry are associated with ≥ 3 of the following 6 Sxs (with at least some Sxs present for more days than not for the past 6 months.
**
• Restlessness or feeling keyed up or on edge
• Being easily fatigue
• Difficulty concentrating or mind going blank.
• Irritability
• Muscle tension
• Sleep disturbance (insomnia, restless unsatisfying sleep)
****
– The focus of the anxiety and worry is not confined to the features of another mental disorder
– Sxs cause significant functional impairment
– Sxs are not due to another mental condition or direct physiological effects of a substance (e.g. drugs)
Clinical presentation Panic Disorder, with or without Agoraphobia
A. Both (1) and (2)
(1) Recurrent unexpected panic attacks, and
(2) ≥ 1 of the panic attacks has been followed by ≥ 1mth of ≥ 1 of the following:
(a) Persistent anticipatory anxiety of having additional panic attacks
(b) worry about implications of the panic attack
(c) significant change in behaviour related to the panic attacks
B. Indicate absence or presence of agoraphobia
C. Panic attacks are not due to direct physiological effects of a substance (e.g. drugs) or a general medical condition.
D. Panic attacks are not better accounted for by another mental disorder
Clinical Presentation: SAD
– Marked & persistent fear of ≥ 1 social/performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others/peers. He/she fears that he/she will act in a way (or show anxiety sxs) that will be humiliating or embarrassing.
• Exposure to the phobic stimulus almost invariably provokes an anxiety response (may be a situationally bound/ predisposed panic attack)
• Duration > 6 months
– The feared social/performance situations are avoided or endured with intense anxiety/distress
• The avoidance, anxious anticipation or distress in the feared situation(s) significantly impairs functioning
– Sxs are not due to another mental condition or direct physiological effects of a substance (e.g. drugs)
– Differential diagnosis: “Avoidant Personality Disorder”
Clinical Presentation: OCD
Either Obsessions or Compulsions
Obsessions:
(1) Recurrent and persistent thoughts/impulses/images that are experienced, at some time during the disturbance, as intrusive and inappropriate and causing marked anxiety/distress
(2) The thoughts, impulses or images are not simply excessive worries about real life problems.
(3) The person attempts to ignore or suppress such thoughts/impulses/images, or to neutralize them with some other action/thought.
(4) The person recognizes that the obsessional thoughts/images/impulses are a product of his own mind.
Compulsions:
(1) Repetitive behaviours (e.g. hand washing, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rigid rules.
(2) The behaviours or mental acts are aimed at preventing/reducing the distress but NOT connected in a realistic way with what they are designed to neutralize/prevent or are clearly excessive.
- At some point , the person recognized that the obsessions/compulsions are excessive or unreasonable
- The obsessions/compulsions cause marked distress, are time-consuming (take ≥ 1hr a day), or significantly impairs functioning
- If another mental condition is present, the content of the obsession/compulsions is not restricted to it.
- Sxs are not due to another mental condition or direct physiological effects of a substance (e.g. drugs)
Clinical Presentation: Posttraumatic Stress Disorder (PTSD)
Stressor
- The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties.
Intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (one required)
1. Recurrent, involuntary, and intrusive memories.
2. Traumatic nightmares.
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli
Avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)
1. Trauma-related thoughts or feelings.
2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)
1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest in (pre-traumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.
Alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required) 1. Irritable or aggressive behavior 2. Self-destructive or reckless behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems in concentration 6. Sleep disturbance
• Persistence of symptoms (in Criteria B, C, D, and E) for > 1 month.
– Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.
• Significant symptom-related distress or functional impairment – (e.g., social, occupational).
• Disturbance is not due to medication, substance use, or other illness.
Monitoring Outcomes
Clinician rated
Hamilton Anxiety Scale (HAM-A) Significant anxiety = Score 18-20 Response = 40-50% reduction Recovery = score < 7 PROS = GOLD STD in RCT CONS = 10-15min
Self rated Beck Anxiety Inventory (BAI) Scoring: 0-7: Minimal 8-15: Mild 16-25: Moderate 26-63: Severe Anxiety
PROS
- Brief (5-10min)
- Distinguishes anxiety from depression
- Evaluated in adolescent and geriatric populations
CONS
More specific for panic Sxs
Zung Self-rated Anxiety Scale Scoring: 20-44: Normal 45-59:Moderate 60-74:Moderate-severe 75-80: Extreme anxiety
PROS
Good measure of severity
CONS
Not for use in children/ adolescents
