Anxiety disorders

Question 1

Describe normal anxiety

Answer 1

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

Question 2

Describe anxiety disorder

Answer 2

= 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

Question 3

Name the DSM 5 anxiety disorders

Answer 3

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

Question 4

Describe generalised anxiety disorder

Answer 4

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

Question 5

Prevalence of GAD

Answer 5

Lifetime prevalence is ± 5%
Onset usually in childhood / adolescence
Ration of women: men = 2:1 in clinical setting

Question 6

Risk factors of GAD

Answer 6

History of trauma (physical / emotional)

Family history

Question 7

Co-morbids of GAD

Answer 7

Frequently comorbid with other anxiety disorders, alcohol and drug abuse and depression

Question 8

Biological factors that could lead to GAD

Answer 8

Serotonergic and noradrenergic neurotransmitters
Dysregulation in the GABA and the Cholecystokinin (CCK) systems
Hypothalamus-pituitary-adrenal (HPA) axis overactive

Question 9

Psychosocial factors that could lead to GAD

Answer 9

Trauma

Negative child rearing

Question 10

Family patterns that could attribute to GAD

Answer 10

Genetic contribution

Family members of individuals with GAD have increased risk

Question 11

Course and prognosis of GAD

Answer 11

Untreated: chronic, fluctuating severity
Worsening during periods of stress
Benefit significantly from treatment

Question 12

Clinical presentation of GAD

Answer 12

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

Question 13

Treatment for GAD

Answer 13

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

Question 14

Describe panic disorder

Answer 14

“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)

Question 15

Diagnostic features of a panic disorder

Answer 15

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

Question 16

What is agoraphobia

Answer 16

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

Question 17

Prevalence of panic disorder

Answer 17

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

Question 18

Explain the causes of panic disorder

Answer 18

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

Question 19

Mechanism of action of benzodiazepines

Answer 19

They act byfacilitating the binding of the inhibitory neurotransmitter GABA at various GABA receptors throughout the CNS.

Question 20

Describe familial patterns in panic disorder

Answer 20

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

Question 21

Course and prognosis of panic disorders

Answer 21

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

Question 22

Clinical presentation and management of panic disorders

Answer 22

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)

Question 23

Treatment of panic disorder

Answer 23

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

Question 24

Describe social phobia and specific phobia

Answer 24

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

Question 25

Describe the two types of social phobias

Answer 25

Generalised type: multiple fears of speaking, writing, eating in public (“performance anxiety”)
Non-generalized type: fear is around a particular social situation such as public speaking
Both types will typically avoid their feared situations

Question 26

Prevalence of phobias

Answer 26

Most common mental disorder
Lifetime prevalence > 10%
Epidemiological samples: females > males, clinical samples not always true
Phobias generally have earlier age of onset than other anxiety disorders
Mean age of onset of social phobia mid-teens to early 20s
Different subtypes of specific phobias begin at different ages:
= Natural environment phobias in childhood
= Situational phobias early adulthood

Question 27

Causes of phobias

Answer 27

Biological underpinnings not well understood
Biologically prepared to develop certain phobias (e.g. snakes) more easily than others (e.g. electric plugs)
Learning plays a role; traumatic incident
Blood, injection or injury type – may be increased reactivity of vasovagal reflex
Social phobia: a number of neurotransmitters may be involved incl serotonin, NA, Dopamine
Familial patterns

Question 28

Course and prognosis of phobias

Answer 28

Untreated: lifelong
Social phobia in particular can be associated with substantial impairment
Influenced by patients’ occupation and social position
Commonly use alcohol or other sedative drugs to alleviate anxiety – may lead to dependence problems

With treatment: favorable prognosis
Pts with Specific phobias around blood, injection or injury may refuse to comply with needed medical treatments

Question 29

Clinical presentation and assessment of social phobia

Answer 29

As with many anxiety disorders, patients with social phobia don’t present complaining of the symptoms of the disorder itself
Underdiagnosed in primary settings
Simply see themselves as “shy”
Experience symptoms of anxiety e.g. tremors, sweating, GIT discomfort, blushing in feared situation
Often underachieve in school and work due to avoidance
Have difficulty being assertive, poor social skills, poor eye contact
Depression and substance abuse are frequent consequences
May be difficult to differentiate from avoidant personality disorder – latter can be seen as severe variant of social phobia

Question 30

Phobias management

Answer 30

Pharmacotherapy:

• SSRIs
• Pregabalin, Gabapentin
• Propranolol: performance anxiety only
• Clonazepam as augmentation

Only consider switching to second-line medication after dosage of the first drug has been optimised, an adequate duration of treatment has been allowed (at least 6 weeks), treatment adherence is confirmed and alternative or comorbid diagnoses have been considered.

Referral to a specialist psychiatrist should be considered in patients who do not respond to first line agents.

Question 31

Psychotherapy in phobias

Answer 31

Psychotherapy:
Exposure interventions
Cognitive restructuring:
 - negative automatic thoughts and cognitive bias
Social skills training
Systematic desensitization

Question 32

Medical conditions that may present with anxiety symptoms

Answer 32

Physical cause should be suspected / ruled out:
- Recent onset, signs or symptoms of medical illness
Look out for / ask:
- Medication changes, substances
- Benzo withdrawal, alcohol withdrawal,
- stimulant abuse, corticosteroids
- Endocrine metabolic disorders: hyperthyroidism, hypoglycemia
- Neurological: seizures, head trauma