Anxiety disorders Flashcards
Describe normal anxiety
is a self-limiting/transient response to external stressors
Stimulus that is perceived to be potentially challenging / harmful
Evolutionary function, can enhance performance & attention
Fight / Flight / Freeze
Similar physiological and psychological features
Describe anxiety disorder
= when these features are:
An excessive response to stressor
Persist for a longer period than expected and/or
become disabling / result in impairment of the individual’s functioning and quality of life.
False alarms / brake failure
Name the DSM 5 anxiety disorders
Generalized Anxiety Disorder Panic Disorder Social Anxiety Disorder / Social Phobia Specific Phobia Agoraphobia Separation Anxiety Disorders Selective Mutism Anxiety Disorder Due to Another Medical Condition
Describe generalised anxiety disorder
Highly prevalent
“Worriers”
Numerous variable symptoms
Excessive and continual worry and tension
Psychological symptoms: e.g. poor concentration, restlessness, irritability
Somatic symptoms: muscle tension, headaches, fatigue
Symptoms of hyperarousal are more common in other disorders e.g. panic disorder / PTSD than in GAD
Prevalence of GAD
Lifetime prevalence is ± 5%
Onset usually in childhood / adolescence
Ration of women: men = 2:1 in clinical setting
Risk factors of GAD
History of trauma (physical / emotional)
Family history
Co-morbids of GAD
Frequently comorbid with other anxiety disorders, alcohol and drug abuse and depression
Biological factors that could lead to GAD
Serotonergic and noradrenergic neurotransmitters
Dysregulation in the GABA and the Cholecystokinin (CCK) systems
Hypothalamus-pituitary-adrenal (HPA) axis overactive
Psychosocial factors that could lead to GAD
Trauma
Negative child rearing
Family patterns that could attribute to GAD
Genetic contribution
Family members of individuals with GAD have increased risk
Course and prognosis of GAD
Untreated: chronic, fluctuating severity
Worsening during periods of stress
Benefit significantly from treatment
Clinical presentation of GAD
Varied symptoms, may mimic a variety of medical conditions
Seek help for breathing problems, GIT discomfort etc
Pts with GAD typically have comorbid mood or substance-use disorders
Treatment for GAD
Pharmacotherapy and psychotherapy
Pharmacotherapy:
1st line = SSRIs and SNRIs e.g. escitalopram, fluoxetine, sertraline, venlafaxine
Start at low dose, increase over few weeks
Continue 9 months – 1 year
Antidepressants vs Anxiolytics: slow and steady vs quick and dirty
- Benzodiazepines: BEWARE!
- SHORT TERM ONLY (max 2-4 weeks)
- Dependency, rebound anxiety with withdrawal, cognitive impairment, respiratory depression, falls in the elderly
Others: Buspirone, beta blockers quetiapine, pregabalin as adjuvants
Psychotherapy:
Reassurance, CBT, relaxation exercises, exposure therapy
Describe panic disorder
“Panic” is derived from Pan, Greek Mythology, god of nature.
Spontaneous quality of panic attacks = distinguishing characteristic
Unprovoked by external circumstances
Initial panic attack is usually spontaneous, but subsequently apprehension develops about future attacks (anticipatory anxiety)
Diagnostic features of a panic disorder
Hallmark feature: spontaneous, unexpected and repeated occurrence of panic attacks
Panic attacks:
- short-lived episodes, usually less than an hour
- Intense anxiety /fear
range of autonomic symptoms, often incl cardiovascular, respiratory and GIT symptoms
- Sudden onset, peak intensity within minutes
Not better accounted for by another medical / psych illness or a substance (e.g caffeine)
Unexpectedness of the attacks in contrast with social phobia, specific phobia, PTSD
What is agoraphobia
Often a complication of panic disorder
Fear of experiencing a panic attack, typically in a public place from which escape may seem impossible or embarrassing, or help may be unavailable
Mostly leads to avoidance of places or situations in which panic attacks have previously occurred (eg shops, cinemas, restaurants, lifts, airplanes)
In severe instances pts become housebound
Can be diagnosed in absence of Panic Disorder
Many with Panic Disorder develop agoraphobia
Prevalence of panic disorder
Life time prevalence 1.5 – 3.5% or more
Women 2-3 x more likely
- ?true difference
- Men less likely to seek treatment, self medicate with alcohol
Age of onset = variable but mostly late adolescence – mid30s
Explain the causes of panic disorder
Limbic system, brainstem and prefrontal cortex all play role
Panic attacks appear to involve a discharge of the NA system
Limbic system has a high density of GABA receptors – consistent with efficacy of benzodiazepines in reducing anxiety
Prefrontal cortex: phobic avoidance involves a learned association of panic attacks with triggers and judgment to avoid these
Role of separation and loss: history of childhood separation anxiety
Link to early parental separation or loss
Mechanism of action of benzodiazepines
They act byfacilitating the binding of the inhibitory neurotransmitter GABA at various GABA receptors throughout the CNS.
Describe familial patterns in panic disorder
As with other anxiety disorder, genetic factors play a role
Family and twin studies suggest that panic d/o = hereditary
1st degree relatives have 4-8 x greater chance of developing, more if onset was in adolescence
Course and prognosis of panic disorders
Without treatment = chronic, complicated by persistent anxiety, avoidant behavior, social dysfunction, alcohol and drug abuse, increased utilization of medical services
Increased mortality rate – from cardiovascular complications and suicide
With treatment = 1/3 experience remission or significant improvement
Waxing and waning course
Lifetime suicide risk higher
Clinical presentation and management of panic disorders
During panic attack, multiple somatic symptoms
Often believe they are dying or going crazy, concerned that they have had a heart attack
May receive unnecessary referrals for specialist evaluations
Appropriate physical exam (pulm / cardiac), lab tests e.g. thyroid
Often comorbid with other anxiety disorders
Exclude GMC & substances (meds or illegal) which may mimic panic attacks (caffeine, stimulants, cannabis)
Treatment of panic disorder
Combination: Pharmacotherapy and Psychotherapy
Psychoeducation, avoid caffeine
Pharmacotherapy:
- 1st line: SSRIs, (more tolerable than TCA / MAOIs)
- Start low, go slow
- Patients can experience initial exacerbation of symptoms - reassure
- 8 – 12 months
- Other: MAOIs, venlafaxine, imipramine
- Benzodiazepines:
- Have rapid effect
- But panic symptoms return quickly
- NICE guidelines does not recommend
Psychotherapy:
CBT, breathing exercises, anxiety management skills
Describe social phobia and specific phobia
Phobias are excessive, irrational fears of specific objects, places or situations
Specific phobias involve the excessive fear of
- Animals (e.g. snakes)
- Natural environments (e.g. heights)
- Situations (lifts, closed spaces, flying)
Social phobia: excessive fear of embarrassment or humiliation in public places, fear public scrutiny
Patients with specific and social phobia may experience a panic attack on exposure to the feared stimulus or autonomic arousal / avoidance
Panic attacks in social phobia are often characterized by blushing and trembling whereas panic attacks in panic disorder often involve sense of choking / suffocation
