Anxiety Disorders Flashcards
Components of anxiety
Thoughts (subjective) of being apprehensive, nervous or frightened Physical reaction (objective) to anxiety
Normal reaction –> pathological when DISPROPORTIONATE, causes FUNCTIONAL IMPAIRMENT + focus on physiological response rather than threat (if any)
Patterns of pathological anxiety - generalised vs paroxysmal
Generalised
- lasts for hours, DAYS or longer
- mild to moderate severity
- EXCESSIVE worry about many normal life events (not one discrete situation or threat)
Paroxysmal
- ABRUPT onset, discrete episodes –> minimal baseline anxiety in between
- quite SEVERE, RAPIDLY BUILD UP to peak level (mins)
- most severe = panic attacks
- SHORT LIVED, usually <1 hr
- strong autonomic symptoms may lead to believe that they are dying, have heart attacks, going mad
- vicious cycle of anxiety producing physical symptoms which the individual focuses on and becomes concerned about their cause/ consequence leading to more anxiety and symptoms
- can be spontaneous or in response to specific threat e.g. phobias
Signs and symptoms of anxiety
Psychological symptoms (note not pathognomonic of anxiety disorder, also present in MDD/SA etc)
- dread and threat
- irritability
- panic, inner terror
- anxious anticipation
- worrying over trivia
- difficulty in concentrating
- inability to relax
- initial insomnia
- depersonalisation
Physical signs
- CVS: tachycardia, palpitations, HT, chest pain
- Resp: SOB, rapid breathing, choking
- Neuro: tremors, shaking, muscle tension, dizziness, syncope, headaches
- autonomic: dry mouth, sweating, cold skin, pupil dilation, urinary frequency
- amenorrhea, erectile dysfunction
- GI: n/v/d, abdominal discomfort
Differential diagnosis of anxiety/fear/avoidance
Phobic disorders
- agoraphobia
- social phobia
- specific phobia
Non-situational disorders
- GAD
- panic disorder
Reaction to stress
- acute stress reaction
- PTSD
- adjustment disorder
Obsessive-compulsive disorder secondary to psychiatric disorders (MDD, psychosis)/ medical condition/ alcohol use
Assessment and Ix of anxiety
Hx
- fear
- avoidance
- symptoms: cognitive, behavioural, emotional, somatic
- FUNCTIONAL IMPAIRMENT or distress
- current/past? how many episodes?
(if chronic hx, ask about worst ever episode)
Ix
- exclude disease or SA implicated in hx
- TFT for thyrotoxicosis
- urine toxicology for substance
- ECG
- consider withdrawal symptoms
Anxiety disorders - prevalence, common comorbidities
Most common psychiatric disorder - 1 year prevalence of 14%
>50% have comorbidities with 2 anxiety disorders (higher severity, poorer prognosis)
50-66% comorbid with MDD (mixed anxiety and depressive disorder)
Bidirectional relationship between somatic symptoms and anxiety (lifestyle, compliance, dysreg of psychobiology, stress system)
e.g. anxiety increased CVS risk by 1.5x and somatic symptoms increase anxiety
Neuroanatomy of anxiety disorders
Amygdala, stria terminalis, hippocampus, medial prefrontal cortex, insula
Functional MRI showing altered response in temporal and prefrontal brain regions when threat response in evoked
Increase error-related negativity which may signify threat hypersensitivity
Classification of anxiety disorders
Continuous
- GAD
Episodic +
Non situational –> panic disorder
Specific situations –> phobia
mixed pattern –> panic with agoraphobia
Generalised anxiety disorder diagnosis
廣泛性焦慮症/經常焦慮症
- EXCESSIVE/IRRATIONAL anxiety and worry, occurring MORE DAYS THAN NOT (persistence) for AT LEAST 6 MONTHS about A NUMBER OF EVENTS or ACTIVITIES (non-specific, common things)
- DIFFICULT TO CONTROL the worry 放唔低
- associated with THREE OR MORE of the following:
- restlessness 坐立不安
- irritability “meng zeng”
- sleep disturbance (initial insomnia and fragmented sleep; unpleasant dreams, night terrors)
- muscle tension (shoulder/neck pain)
- difficulty concentrating
- easily fatigued - causes significant distress or impairment in one of the 5 domains of functioning e.g. school, occupation, social, self, family
- not attributable to SA or other medical condition
- not better explained by other anxiety disorder, PTSD, delusional beliefs etc
(and also a/w many physical symptoms e.g. HYPERVENTILATION, GI discomfort, sweating, SOB, palpitations, easily scared, tremors, amenorrhea - but not part of DSM)
If symptoms for <6 months, dx is stress or adjustment disorder
GAD epidemiology - lifetime risk, F:M ratio, age of onset, more common in which groups of people
4-5% lifetime risk
3% prevalence in 1 yr
F>M 2-3:1
Variable onset but avg: 21 yrs old
Second peak at 40-59
More common in caucasians and lower socio-economic groups in high income countries
GAD aetiology - predisposing (4), precipitating and perpetuating (3)
Predisposing factors
- genetic (important of all anxiety disorders): 5x more prevalent in 1st degree relatives, higher monozygotic concordance
- neurobiological: prolonged ANS response to stimulation and negative feedback of HPA axis buy cortisol is reduced
- childhood: inconsistent parenting, poor attachment, chaotic lifestyle, teenage OCD/phobia, trauma affecting emotional sensitivity/defensive responses
- personality: anxious and worry-prone
Precipitating factors
- stressful events e.g. relationships, work, finance, ill health, natural disasters
Perpetuating factors
- continuing stress
- depressive disorder
- cycle of anxiety
GAD prognosis and comorbidities
CHRONIC but FLUCTUATING course
- 80% still have disorder 3 yrs after onset without treatment
Higher rates of unemployment and divorce
Worse prognosis in severe cases with agitation, derealisation, conversion symptoms or suicidal ideas
50% with have depressive episode (or have depression with anxiety features)
68% comorbid with another psychiatric disorder e.g. MDD, social phobia, panic disorder, SA
Important Ddx to rule out in GAD
Depression
- mood symptoms more prominent than anxiety
- mood symptoms appear first
- presence of other depressive symptoms
- anxiety more prominent in the morning
Schizophrenia
- screen psychotic features
Dementia
- assess memory in older patients
Drugs
- alcohol, cannabis, antidepressants (1st 2 wks), antipsychotics, BZD, caffeine, sedatives, cocaine
- bronchodilators, anti-HT, anti-arrhythmias, anticonvulsants, thyroxine, chemotherapy, antibiotics
Withdrawal from drugs/alcohol
- BZD, caffeine, cocaine, nicotine, sedatives
- anxiety more severe in the morning suggests alcohol dependence (or depression)
Physical illnesses
- thyrotoxicosis (irritable, restless, tachycardia, tremor) –> look for thyroid eye signs, enlarged thyroid, A-fib, do TFT
- hypoPTH, phaeochromocytoma, hypoBG, Cushing’s disease, arrhythmias, temporal lobe epilepsy, respiratory disease e.g. COPD, asthma, CHF, PE, carcinoid tumours, meniere’s disease
Management of GAD - mild-mod cases, mod-severe cases, comparison of efficacy, continuation therapy
Medication and psychotherapy give similar effects at 1st line treatment
Mild-moderate GAD (as for any anxiety disorder)
- problem solving techniques, time management, scheduling
- self-help books based on CBT principles
- CBT (1hr weekly for 4 months)
- relaxation methods (avoid exposure)
- psychoeducation to explain condition and decrease concern about symptoms
(consider med if non-responsive)
Moderate-severe GAD (non-med + med = synergism)
- non pharmacological – CBT, applied relaxation
- pharmacological
- –> 1st line: SSRI - paroxetine may be most effective
- –> short term relief of symptoms by BZD (2-3 wks before SSRI takes effect) or buspirone
- –> alternative SSRI, SNRI venlafaxine, pregabalin if initial treatment ineffective
Continuation of drug 6 months-1 yr after improving –> need gradual down titration over 1-2 months then continuation to avoid acute discontinuation syndrome of SSRI
Phobic anxiety disorders vs GAD - 3 main differences
Anxiety in reaction to SPECIFIC CIRCUMSTANCES
- intense, irrational fear of an object or situation
- may be severe enough to take the form of a panic attack
AVOIDANCE of the feared situation
ANTICIPATORY ANXIETY when there is prospect of encountering such situations
Simple phobia diagnostic criteria
- Marked, excessive anxiety/fear to clearly specific and discernible objects or situations
- almost always provokes immediate fear and anxiety
- actively avoided or endured with intense fear or anxiety
- out of proportion to the actual danger posed by the specific object/situation
- fear/anxiety/avoidance persists for MORE THAN 6 MONTHS
- causes clinically significant distress or functional impairment
- not better explained by other anxiety disorders, OCD, PTSD
Examples of phobias:
- heights (acrophobia), insects, animals, public transport, darkness, blood, vomiting
Simple phobia epidemiology (lifetime risk, age of onset, F:M) and aetiology
12.5% lifetime risk (but many don’t seek medical care)
Age of onset variable (animal phobia avg is 7)
F>M
Aetiology
- strong GENETIC component with 1/3 1st degree relatives also having simple phobia
- childhood phobias (common) that persist into adulthood for unknown reason
- adult onset phobia usually after frightening experience
- CLASSICAL CONDITIONING model –> reinforcing a learned behaviour after a negative experience e.g. something a/w anxiety and avoiding it reduces anxiety –> reinforce avoidance (PERPETUATING)
Simple phobia prognosis, comorbidities
Little reliable info
Those beginning in childhood persist for many years and those in adulthood may improve
Individuals adjust lifestyle to avoid stimulus which perpetuates disorder
83.4% will have another psychiatric disorder in their lifetime – commonly another anxiety disorder or MDD
Simple phobia management - most common, other options
Most patients need no treatment beyond sensible advice
Mild-mod
- self help
- (others as in GAD e.g. psychoeducation, relaxation etc)
Mod-severe
- CBT - graded exposure therapy +/- modelling, flooding, systematic desensitisation
- pharmacological - BZD for rarely occurring situations requiring immediate relief of symptoms - ONLY SHORT TERM
Social phobia/Social anxiety disorder diagnostic criteria
- Marked fear or anxiety about one or more social situations in which the individual is EXPOSED TO SCRUTINY BY OTHERS e.g. social interactions, being observed during eating/drinking, speaking in public
- fears that they will act in a way to show anxiety symptoms which will be NEGATIVELY EVALUATED (humiliating, embarrassing) and provide evidence of their inadequacies
- social situations almost always provoke fear or anxiety
- avoided or endured with intense fear and distress
- fear is OUT OF PROPORTION to actual threat
- lasting MORE THAN 6 MONTHS
- significant impairment
- not SA or medical condition
- not better explained by other disorder
Social phobia course, epidemiology (lifetime prevalence, M:F, age of onset), comorbidities
Onset usually acute attack of anxiety in public place with subsequent anxiety in similar places with increasing severity and avoidance
Persists for many years
Lifetime prevalence: 12.1%
12 month prevalence: 6.8%
M=F
Mean age of onset 13-20 yrs
80% will have another psychiatric diagnosis e.g. anxiety, MDD, PTSD, ALCOHOL use (more common in social phobia than other phobias)
Ddx of social phobia
GAD/Panic disorder --> non-situational Depressive disorder --> core symptoms Schizophrenia Anxious/avoidant personality disorder --> lifelong shyness and lack of self-esteem similar but starts at younger age and develops more gradually than social phobia Social inadequacy --> lack of social skills leading to anxiety (vs social phobics who have the skills)
Social phobia aetiology
Uncertain
- may be exaggerated normal concerns in adolescents –> increased and prolonged
- parenting styles (overprotective) and early childhood experiences
- low self-esteem and perfectionism
GENETICS component (but extent uncertain) - higher risk in 1st degree relatives
Social phobia management
Non-pharm:
- CBT graded exposure therapy
Pharm:
- 1st line: SSRI - paroxetine, fluoxetine, citalopram, sertraline effective in the short term
- 2nd line: SNRI - venlafaxine (poorer S/E profile)
- MAOi only if other drugs ineffective (need strict dietary restrictions)
- BZD only for immediate short term relief
- beta adrenergic antagonists e.g. propranolol occasionally to control tremor and palpitations but not effective for controlling social anxiety
Agoraphobia diagnostic criteria
- Marked fear or anxiety about TWO or more of the following situations:
- using public transportation
- being in open spaces
- being in enclosed spaces
- standing in line
- being outside of the home alone - fears or avoids situations because of the thoughts that escape might be difficult or help not available in the event of developing panic-like symptoms
- almost always provokes fear or anxiety
- actively avoided or requires presence of communion or endured with intense fear
- out of proportion to the actual danger
- lasting 6 MONTHS OR MORE
- cause clinically significant distress or impairment
- not better explained by another mental disorder e.g. other phobias, OCD, PTSD
Anxiety symptoms in agoraphobia - typical, most severe cases, most common comorbidity
Anticipatory anxiety severe (several hrs before)
Avoidance
Typical symptoms listed before +
Fainting and loss of control
Depression, depersonalisation, panic attacks
In most severe cases - may be almost confined to home
Up to 95% of agoraphobia presentations have a current or past hx of panic disorder
- panic disorder with agoraphobia
- close relationship – patients develop fear of not being able to escape if they were to have a panic attack
Agoraphobia epidemiology - lifetime risk, 1yr prevalence, F:M, age of onset
Lifetime risk 1-2%
1 yr prevalence (without panic disorder) 1.8%
F>M 2:1
2 peaks of onset: 15-30 and 70-80
Agoraphobia course, comorbidities and prognosis
Usually starts with unexplained panic attack in public setting –> individual hurries home or seeks help
Same situation encountered and have anxiety symptoms again –> escape
Recurrence with avoidance pattern
Development late in life is often linked to physical frailty e.g. fear that an accident will occur
–> become increasingly dependent on partner or other relatives
Comorbidities: panic attacks, 50% social phobia, depression, alcohol misuse
Prognosis: likely to persist at least 5 years (if has been present continuous for 1 yr)
Ddx of agoraphobia
GAD
Social phobia
- both fear of going out but for different reason!
Simple phobias
Depressive disorder
Schizophrenia (rare paranoid delusions avoid meeting people)
Agoraphobia aetiology - perpetuating factor
Cause of first panic attack uncertain
- panic disorder
- stressful events
Perpetuating factor:
- conditioning –> AVOIDANCE prevents deconditioning
- apprehensive thoughts e.g. fear of fainting or social embarrassment
Agoraphobia management
General measures as for GAD and SAD
- self help, psychoeducation, relaxation techniques
Non-pharm:
- CBT: Graded exposure therapy
+
Pharm:
- 1st line: SSRI - fluoxetine, citalopram, sertraline
- BZD avoided except for short term relief or when waiting for SSRI to take effect
Panic attacks (defining characteristics) and Panic disorder
Panic attacks
- UNPROVOKED, SPONTANEOUS
- 9% population will experience at least on min their lifetime
- period of intense fear with a cluster of typical symptoms that develop rapidly
- may occur in all anxiety disorders, PTSD, OCD, MDD
Panic disorder
- recurrent panic attacks that occur unexpectedly
- not associated with SA/medical conditions or other psychiatric disorders
Panic disorder diagnostic criteria
- RECURRENT UNEXPECTED panic attacks: abrupt surge of intense fear or discomfort which peaks within minutes and during which FOUR of the following occur:
- palpitations, tachycardia
- sweating/flushing
- trembling
- *shortness of breath
- choking
- chest discomfort
- nausea
- dizziness or fainting
- fears of impending death/medical emergency
- depersonalisation (detached from oneself) or derealisation (feeling of unreality)
- chills or heat
- paraesthesias
- fear of losing control or “going crazy” - At least ONE of the attacked FOLLOWED BY 1 MONTH of:
- persistent concern about additional panic attacks or their consequences (ANTICIPATORY ANXIETY; increase sensitivity to symptoms which increases risk of further attacks)
- MALADAPTIVE CHANGE in behaviour e.g. avoidance of specific situations where attack occurred before (potential for agoraphobia) - not attributable to substance or medical condition
- not better explained by another mental disorder e.g. other phobias, OCD, PTSD, separation anxiety
Panic disorder epidemiology - prevalence, F:M, age of onset
Prevalence 7-9% population
F>M 2-3:1
Age of onset: 15-24 and 45-55 (rare after 65)
Panic disorder aetiology and risk factors
Genetics (40% heritable)
- 7-8x higher risk in 1st degree relatives
Biochemical hypothesis
- imbalance in neurotransmitter activity –> panic attacks induced more readily by certain agents
- 5HT and GABA involvement
Cognitive hypothesis
- misinterpretation of body stimulus/ fears concerning physical symptoms of anxiety –> activate sympathetic –> vicious cycle –> crescendo of symptoms –> panic attack
Other risk factors:
- urban living, divorce, limited education, physical or sexual abuse
Panic disorder prognosis and comorbidities
Usually prolonged fluctuating course
- up to 1/2 may be symptom free after 3 yrs (but may recur in another form)
- 1/3 chronic symptoms
Poor prognostic factors: severe, marked agoraphobia, less education, low socio-economic status, long duration
Comorbidities: 75% agoraphobia, 50-60% depression
“Organic” causes of panic attacks
Drug intoxication or withdrawal e.g. caffeine, cocaine, cannabis, ICE, steroids
Endocrine e.g. hyperthyroid, hypoBG, Cushing’s, phaeochromocytoma
CVS e.g. chest pain, arrhythmia, MR
Resp e.g. COPD, asthma
(all applicable for general anxiety)
Panic disorder management - general measures, mild-mod, mod-severe, continuation therapy
General measures as for other anxiety disorders
- psychoeducation (prevent progression of panic attack to panic disorder, prevent recurrence and agoraphobia, explain disadvantage of avoidance), relaxation, self help, problem solving techniques
- hyperventilation control
Mild-mod
- self help on CBT
Mod-severe (frequent episodes, comorbid depression)
- CBT (10-20 wks) - relaxation, breathing techniques, graded exposure for agoraphobia, hyperventilation control
- Pharm
- –> 1st line: SSRI - paroxetine, citalopram, sertraline (all similarly effective)
- –> 2nd line (if SSRI ineffective after 12 wks or C/I): imipramine, clomipramine (effective but poor S/E)
- –> short term BZD pro
- –> beta blockers can reduce autonomic arousal
Continuation of medication for at least 6 months after symptoms resolve
Other psychiatric conditions associated with anxiety
Depression Eating disorder Somatisation disorder Hypochondriacal disorder Delusional beliefs OCD Personality disorder (separation/abandonment, inadequacy)
