Anxiety disorders Flashcards
what are the different subtypes of anxiety disorders
- specific phobia
- social anxiety disorder
- generalised anxiety disorder
- panic disorder
- agorapobia
- seperation anxiety disorder
- selective mutism
what is a specific phobia
marked fear or anxiety about a specific object or situation (duration 6 months +)
- recognised as excessive but can’t be reasoned away
what is social anxiety disorder
persistent fear or anxiety about 1 or more social or performance situations that is disproportionate (6/12+)
what is GAD
excess worry about a number of events or activities for at least 6 months and difficulty controlling this
- chronic condition with acute episodes
- often begins in early adulthood and twice as common in women than men
what is separation anxiety disorder
excessive fear or anxiety focussed on seperation from home or attachment figures (1/12 in children, 6/12 in adults)
what is selective mutism
consistent failure to speak in social situations when there is an expectation to do so (1/12+)
what is panic disorder
recurrent unforeseen panic attacks, an abrupt surge of intense fear (an initial panic attack, followed by 1/12 of persistent worry about additional attacks )
- can peak within 10 minutes with many somatic/physical symptoms
- can be combined with GAD or phobic disorders
what is agoraphobia
marked fear or anxiety about situations where escape might be difficult (6/12+)
- typically leads to pervasive avoidance, eg. being alone outside home or being in a crowd of people
describe the prevalence of anxiety
- 20% of adult population will be affected at some point
- most likely subtype diagnosis is specific phobia with a prevalence of 13%
- next most prevalent is social anxiety disorder, then GAD
- twice as many women than men affected
how common is comorbidity in anxiety disorders
- presentation is usually complex and differentiation between disorders is difficult
- co morbidity is very common
what is step 1 of the stepped care model
- all known and suspected presentations of GAD identification and assessment
what is the nature of the intervention for step 1 of the stepped care model
education about GAD and treatment options
- active monitoring
what is step 2 of the stepped care model
diagnosed GAD that has not improved after education and active monitoring in primary care
what is the nature of the intervention for step 2 of the stepped care model
- low intensity psychological interventions
- individual non facilitated self help
- individual guided self help
- psychoeducational groups
what is step 3 of the stepped care model
GAD with an inadequate response to step 2 interventions or marked functional impairment
what is the nature of the intervention for step 3 of the stepped care model
- choice of high intensity psychological intervention
- cognitive behavioural therapy/applied relaxation
- or a drug treatment
what is step 4 of the stepped care model
complex treatment refractory generalised anxiety disorder and very marked functional impairment, such as self neglect or a high risk of self harm
what is the nature of the intervention for step 4 of the stepped care model
- highly specialised treatment, such as complex drug/psychological treatment regimens
- input from multi agency teams, crisis services, day hospitals or inpatient care
what are the common characteristics of adults affected by GAD
- Aged between 35 and 54
- divorced or seperated
- living alone or as a lone parent
- less likely to be aged between 16-24 or between 65-74
- less likely to be married or cohabiting
what are the risk factors for anxiety
- family history
- childhood adversity
- stressful life events
- specific personality traits- excessive worrying
- certain parenting styles- overprotective, lacking emotional warmth or parents modelling fear and avoidance
- younger age
- being female, unmarried or unemployed
- poor physical or mental health
what are the presenting symptoms of anxiety
- apprehension
- cued or spontaneous panic attacks
- irritability
- poor sleep
- poor concentration
- avoidance
- increased heart rate/palpitations
- dry mouth
- GI discomfort
- sweating
what are the 10 most common phobias
- arachnophobia
- ophidiophobia
- acrophobia
- agoraphobia
- cynophobia
- astraphobia
- trypanophobia
- social phobias
- pteromerhanophobia
- mysophobia
what is obsessive compulsive disorder
- a time consuming obsession and compulsion which interferes with a person day to day functioning, work or relationship
- if compulsion is resisted, anxiety levels are increased
- lifetime prevalence of 2%
- males and females equally affected
what is post traumatic stress disorder
- intense and prolonged response to a particular trauma
- characterised by emotional numbness, detachment, flashbacks, recurring memories and vivid dreams
- don’t have to be personally involved, can be a bystander or rescue worker
what are mixed disorders
- both anxiety and depression present
- essential to consider the differing signs and symptoms presenting - global assessment scales should be used to provide objective measures to confirm diagnosis, assess severity and monitor response to treatment interventions
- variety of pharmacological and psychological interventions may need to be initiated, optimised and monitored on ongoing basis
how are anxiety and stress linked
- anxiety exists naturally as a means of overcoming or responding to a crisis
- an optimal level of anxiety allows us to perform at a maximum level
- in anxiety disorders, the anxiety remains after the stress has ceased
what are the 2 brain systems involved in fear and anxiety
- defence system
- behavioural inhibition system
what is the role of the defence system in the mechanism of anxiety
- responds to both learned and unlearned threats
- can initiate fear, flight, fright or freeze behaviour
what is the role of the behavioural inhibition system in the mechanism of anxiety
- responsible for avoidance behaviour
- neurobehavioral system thought to regulate negative affect and avoidance behaviour in response to threats or punishment
- individuals vary in sensitivity of the system
outline the neurological aspects of anxiety
- techniques such as PET scanning demonstrate altered neuronal pathways
- especially in limbic regions (eg. increased activity in amygdala and hippocampus) - there is a dense concentration of serotonergic and noradrenergic synapses and systems within limbic region
describe the general management of anxiety disorders
- shared decision making between healthcare profession and patient promotes concordance and optimises outcomes
- appropriate and usable info given to patients, carers, including medical information
- patients family should be informed of all appropriate self help or support groups
what are the treatment options for anxiety disorders
- self help
- psychological therapy
- pharmacological therapy
outline the pharmacological treatment
- if person with GAD chooses drug treatment, offer selective serotonin reuptake inhibitor
- consider offering sertraline first- most cost effective
- informed consent obtained
- monitor for adverse reactions - don’t offer benzodiazepines for treatment of GAD in primary or secondary care except as a short term measure during crises
- don’t offer antipsychotic for treatment of GAD in primary care
what is sertraline indicated for the treatment of
- major depressive episodes and prevention of recurrence of major depressive episodes
- panic disorder, with or without agoraphobia
- OCD in adults and paediatric patients aged 6-17
- social anxiety disorder
- PTSD
what are the pharmacological treatment options
- benzodiazepines
- antidepressents
- anxiolytics- buspirone
- pregabalin
- antipsychotics
- BB
- antihistamines
how are benzodiazepines used for treatment
- act on post synaptic GABA-A receptors
- responsible prescribing with appropriate monitoring ensures maximal benefit
- efficacious in certain situations for selected patients
- eg. immediately acting agent for severe symptom control with awaiting other treatment to work (CBT)
what are the indications of benzodiazepines
- short term relief (2-4 weeks) of anxiety that is severe, disabling or causing patient unacceptable distress
- should be used to treat insomnia only when its severe or causing patient distress
how are SSRIs used in treatment of anxiety
- inhibits reuptake of serotonin at post synaptic receptor site
- increase central serotonergic activity
- onset of action may not appear for 6 weeks and full response may take 12 weeks
- discuss with patient - 40% of patients with panic disorders may experience an activation syndrome
how do antidepressants work in anxiety
- 5HT (serotonin) facilitates defensive responses to potential threat related to presentation of anxiety
- this action is exerted at forebrain
- chronic administration of ADs suppress panic attacks by increasing release of 5HT and enhances response of 5HT receptors in midbrain
- efficacy against GAD thought to be due to desensitisation of 5HT 2c and increased stimulation of 5HT1A in forebrain
- results in less activation of amygdala and medial prefrontal cortex by warning signs
how can BBs be used in treatment of anxiety
only used to treat somatic or physical symptoms
how is buspirone used in treatment
- complex MOA- partial 5HT agonist and acts on both noradrenergic and dopaminergic pathways
- takes time to work
- worse than BDZ in terms of efficacy and tolerability
how is pregabalin used in treatment
- binds to auxiliary subunit of voltage gated Ca channels in cNS
- causing conformational changes and reducing excitatory neurotransmission - relatively rapid onset of action and excreted unchanged
- reduce dose in patients with renal impairment
- use when SSRI/SNRIs not tolerated
- monitor for misuse (CD3)
- avoid use in pregnancy
how are antipsychotics used for treatment
- used in PTSD and occasionally OCD
- eg. olanzapine, risperidone and quetiapine - not for routine use in GAD
