Anxiety Disorders Flashcards
Definition: developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached
separation anxiety disorder
Definition: consistent failure to speak in specific social situation in which there is an expectation for speaking (school, social settings) despite speaking on other situations
Symptoms: poor educational or occupational achievement
selective mutism
Definition: marked fear or anxiety about specific object or situation that almost always provokes immediate fear or anxiety
Subtypes: animal (spider, snakes, insects, dogs), natural environment (height, storms, water), situations (blood-injection-injury, airplanes, elevators, enclosed spaces)
Symptoms: active avoidance of object or object endured with intense fear or anxiety which is out of proportion to the actual danger posed, causes significant impairment
specific phobia anxiety
Social Anxiety Disorder
Definition: marked fear or anxiety about one or more
__ situations in which the individual is exposed to possible __ by __. Individual fear that they will __ in a way or show anxiety symptoms that will be __ evaluated by others (humiliated or embarrassed) and will lead to __
Symptoms: avoid or endured with intense anxiety social situations, __, __, __
Complications: under-employment, poor relationships
Social Anxiety Disorder
Definition: marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Individual fear that they will act in a way or show anxiety symptoms that will be negatively evaluated by others (humiliated or embarrassed) and will lead to rejection
Symptoms: avoid or endured with intense anxiety social situations, blushing, sweating, tremor
Complications: under-employment, poor relationships
Panic Disorder
Definition: recurrent ____ panic attacks (at least 4 of __, __, __, __, feeling of __, __ pain, __, __/lightheadedness, __, __, fear of losing __, fear of __, __, __, __ flashes)
AND
followed by ___month of either persistent concern or worry about additional panic attacks/consequences OR significant maladaptive change in behaviour related to the attacks
Symptoms: palpitations, accelerated HR, sweating, trembling, shaking, SOB, feeling of choking, chest pain, N/V, dizziness, chills, paresthesia, derealization, fear of during, fear of losing control.
Symptoms peak at 10min
Management: make sure they’re not having a heart attack or stroke.
Can precipitate agoraphobia
Panic Disorder
Definition: recurrent unexpected panic attacks (at least 4 of palpitations, sweating, trembling, SOB, feeling of choking, chest pain, nausea, dizziness/lightheadedness, derealization, depersonalization, fear of losing control, fear of dying, chills, numbness, hot flashes)
AND
followed by 1month of either persistent concern or worry about additional panic attacks/consequences OR significant maladaptive change in behaviour related to the attacks
Symptoms: palpitations, accelerated HR, sweating, trembling, shaking, SOB, feeling of choking, chest pain, N/V, dizziness, chills, paresthesia, derealization, fear of during, fear of losing control.
Symptoms peak at 10min
Agoraphobia
Definition: intense fear about at least ____ different types of situations for ____+.
Situations include: using public transportation, being in open space, being in enclosed places, standing in line/being in a crowd and being outside of the home alone
Symptoms: provoking situations avoided or endured with intense fear or anxiety, fear or anxiety is out of proportion to actual danger, substantial functional impairment
Agoraphobia
Definition: intense fear about at least two different types of situations for 6mo+.
Situations include: using public transportation, being in open space, being in enclosed places, standing in line/being in a crowd and being outside of the home alone
Symptoms: provoking situations avoided or endured with intense fear or anxiety, fear or anxiety is out of proportion to actual danger, substantial functional impairment
GENERALIZED ANXIETZY DISORDER
Definition: excessive anxiety and worry about a number of events or activities/existing in a number of different ____, occurring more days than not for ____mo+. The anxiety is hard to control and impacts social/occupation
Symptoms: at least 3 of the following- restlessness/on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
Definition: excessive anxiety and worry about a number of events or activities/existing in a number of different domains, occurring more days than not for 6mo+. The anxiety is hard to control and impacts social/occupation
Symptoms: at least 3 of the following- restlessness/on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
Investigations/questionnaire of GAD
GAD-7
key substances that are linked to substance-induced anxiety disorder
Definition: panic attacks or anxiety development during or soon after substance intoxication or withdrawal or after exposure to the medication
Etiology: alcohol, caffeine, cannabis, hallucinogens, inhalant, opioids
Cannabis use is associated with development of schizophrenia and psychosis, starting cannabis earlier in life increases the likelihood and can cause more impairment.
Cannabis can increase the symptoms of mania and hypomania in bipolar individuals → increased risk of developing depression, and depression is a risk factor for developing problem cannabis use.
mechanism of anxiety
Mechanism: ___ stress + __ factors + __ factors→__ overdrive→increased ___→brain is “hijacked” by the __→neuronal ___ (decrease dendritic arborization, spinal density and loss of discrete populations of cells) + neuronal and __ loss (particularly in __ cortex) + decreased neuronal birth in the ___ (brain-derived neurotrophic factor) → chronic anxiety
*therefore imperative to diagnose and treat as soon as possible.
mechanism of anxiety
Mechanism: chronic stress + genetic factors + physical factors→cortisol overdrive→increased inflammation→brain is “hijacked” by the amygdala→neuronal atrophy (decrease dendritic arborization, spinal density and loss of discrete populations of cells) + neuronal and glial loss (particularly in prefrontal cortex) + decreased neuronal birth in the hippocampus (brain-derived neurotrophic factor) → chronic anxiety
*therefore imperative to diagnose and treat as soon as possible.
which gender is more affected by anxiety disorders
F>M
what countries have a higher prevalence of anxiety
high income countries
Differentiating anxiety disorders:
o __: recurrent, unexpected panic attacks in the absence of triggers
o __: marked, unreasonable fear or anxiety about a situation
o __ __: marked, unreasonable fear or anxiety about a specific object/situation
o __ __ disorder: marked, excessive or unrealistic fear or anxiety about social situations in which there is possible exposure to scrutiny by others
o __ __ disorder: excessive anxiety and worry (apprehensive expectation) about multiple events or activities
o Panic: recurrent, unexpected panic attacks in the absence of triggers
o Agoraphobia: marked, unreasonable fear or anxiety about a situation
o Specific phobia: marked, unreasonable fear or anxiety about a specific object/situation
o Social anxiety disorder: marked, excessive or unrealistic fear or anxiety about social situations in which there is possible exposure to scrutiny by others
o Generalized anxiety disorder: excessive anxiety and worry (apprehensive expectation) about multiple events or activities
how can ADHD mimic anxiety?
ADHD can mimic anxiety (worrying about performance deficits because of their ADHD, excessive mind-wandering, feeling overwhelmed, feeling restless, sleep problems, avoiding situations due to ADHD symptoms, sleep problems)
ASRS: The adult ADHD self-report scale symptom checklist. 18 questions. If 4 or more marks appear in the shaded boxes within part A, then the patient has symptoms highly consistent with ADHD adult and further investigation is warranted. The ASRS is validated as a screening tool.
checklist/screening tool used to diagnose adult ADHD
The adult ADHD self-report scale symptom checklist. 18 questions. If 4 or more marks appear in the shaded boxes within part A, then the patient has symptoms highly consistent with ADHD adult and further investigation is warranted. The ASRS is validated as a screening tool.
T/F the prognosis is worse if anxiety is co-morbid with major depression
Major depression is often accompanied by anxiety disorders or anxious symptoms. Comorbid anxiety disorders amplify the risk of ssuicide attempts in individuals with mood disorders, and make it harder to treat.
__ __ __ (___-_): the “HbA1c” of depression. Good for diagnosis and monitoring treatment
o Can diagnosis major depressive disorder + anxious distress
Patient Health Questionnaire (PHQ-9): the “HbA1c” of depression. Good for diagnosis and monitoring treatment
o Can diagnosis major depressive disorder + anxious distress
complications of having anxiety
comorbid major depressive disorder, higher risk of suicide, increased risk of unexplained symptoms (MSK pain, headaches), increased risk of chronic illness, increased risk of CV disease
Obsessive-Compulsive Disorder and Related Disorders
Includes:
Obsessive Compulsive Disorder (OCD),
Body Dysmorphic Disorder,
Hoarding,
Trichotillomania,
Excoriation and Substance/Medication-Induced OCD,
OCD related to another medical condition (PANDAS (peds))
Obsessive Compulsive Disorder (OCD)
obsession vs compulsion
- Obsession: recurrent and persistent thoughts, urges or images that are experience as intrusive and unwanted and that cause marked anxiety or distress
- Compulsion: repetitive behaviours (hand washing, ordering, checking) or mental acts (praying, counting, repeating words) that the individuals feels driven to perform in response to an obsession or according to rigid rules
mechanism of OCD (which part of brain is affected)?
Mechanism: excessive error signals generated by the anterior cingulate→ alerted cognitive motor and affective systems promoting the need to “correct the problem” → compulsive behaviours
The patients degree of insight can vary: can be good (OCD beliefs are not logical and not true), poor insight (probably true), absent insight (completely convinced that their beliefs are true)
two key parts to managing OCD
Management:
- CBT: exposure with response prevention
- Pharmacologic: SSRI (higher doses than depression/anxiety)
Complications: cognitive/social/occupation impairment, high rates of suicide attempt, higher rates of comorbid disorder, increased healthcare utilization, caregiver burn out.
first line pharm therapy for anxiety
Pharmacotherapy: SSRI or SNRI; avoid benzodiazepines
o Augment with gabapentin, pregabalin, lamotrigine, atypical antipsychotics
o Start low and go slow– target doses are often higher than those used in depression. Wait longer before augmenting that with depression (can take 8-12 weeks at sufficient dose for initial response)
*SSRIs can take 4-6 weeks to take effect, and can increase overall energy before increasing the DA.
May need to treat immediate symptoms/worse panic attacks with benzodiazepines
You can augment the SSRIs with other medications like MAOIs, clomipramine, buspirone, gabapentin, lamotrigine, atypical antipsychotics etc depending on specific anxiety disorders and needs. (see image below)
teaches patients to identify worrisome beliefs, challenge beliefs, limit worry to defined 20- 30min period, avoid avoidance
cognitive behaviour therapy
Behavioural Activation as a therapy for anxiety
monitor and structure the day, focus on routine, increase motor activity
Indirect effect on cognitive functions, reduces acute symptoms and prevents onset and relapse.
A dynamic process encompassing positive adaptation within the context of significant adversity.
Resilience: impacted by both genetics and environment
Factors that contribute to resilience;
genetic factors (neuropeptide Y, genes that influence the HPA axis, trauma, neuronal change etc), loving and supportive environment, positive relationships with adults and peers, prosocial romantic attachments, avoid repeated exposure to uncontrollable stress and trauma.
antidote to benzodiazepines
flumazenil– competitively inhibits benzo site
Benzodiazepines
• Mechanism: stimulates benzodiazepine receptors → increases inhibitory function of GABA→ reduced anxiety
Common in clinical practice due to being extremely effective and having rapid onset. However, tolerance will develop (increased doses required) and withdrawal can occur (seizures).
- Side effects: impaired cognition, sedation, impaired coordination, DO NOT TAKE WITH ALCOHOL!!!
- Overdose: lethal by respiratory depression. Antidote is Flumazenil (competitively inhibits Benzo site)
- Examples: midazolam (shortest), lorazepam, diazepam, chlordiazepoxide, clonazepam (longest)
Note: Ways to manage anxiety
Self-help manual
Progressive muscle relaxation: we hang onto our stress in our bodies in the form of muscle tension. PMR involves systematically tensing and releasing different muscle groups.
Positive psychology exercises: doing kind things, noticing positive interactions, thinking about good times.
Creating a worry time
Challenge anxious thoughts
Distinguish between solvable and unsolvable worries.
