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
