Anxiety Disorders Flashcards
ICD-11 criteria of GAD:
Generalized and persistent ‘free floating’ anxiety symptoms involving elements of:
- Apprehension (worries about future misfortunes, feeling on edge, difficulty in concentrating)
- Motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
- Autonomic overactivity (light-headedness, sweating, tachycardia, epigastric discomfort, dizziness etc)
clinical features of GAD:
- Depersonalization (altered or lost sense of personal reality or identity)
- derealisation (surroundings feel unreal).
Note this is also seen in depression, schizo, alcohol, drugs, epilepsy
Differentials of GAD:
-Hyperthyroidism (look for goitre, tremor, tachycardia, weight loss, arrhythmia, exophthalmos)
-Substance misuse (intoxication – amphetamines; withdrawal – benzo, alcohol)
-Excess caffeine
-Depression: anxiety common feature of depression and likewise. Which came first and which is currently more prominent are useful clues. If both, diagnose mixed anxiety and depressive disorder
-Anxious (avoidant) personality disorder: patient describes themselves as an anxious person with no recent major increase in anxiety levels. (note this disorder can predispose)
-Dementia (early)
-Schizophrenia (early)
Management of GAD:
- Most can be treated in primary care setting
- Advice and reassurance can help early or mild problems from worsening (psycho-education)
- Counselling alone may be very effective – addresses patients worries (reassure about somatic symptoms)
- Self help materials
- CBT has good evidence
- Other therapies: anxiety management training, relaxation techniques, autogenic training (self-monitoring anxiety and applying relaxation techniques), brief focal psychotherapy, marital or familial therapy
Sedatives:
1. Benzodiazapines should not be prescribed for more than 10 days due to risk of dependency and sedation. Use only to overcome symptoms so severe they obstruct initiation of more appropriate psychological treatment
- Diazepam preferred due to longer half life (less risk of withdrawal symptoms with neurotic symptoms, neurological symptoms like ataxia, paraesthesia, hyperacusis and other major symptoms such as hallucinations, psychosis and epilepsy)
Pharmacological therapy:
- First line drug is an SSRI or SNRI
- SSRI combined with CBT may be superior to either alone
- Also, Busipirone (5HT1A¬ agonist) is suitable for short term management
a) Delayed onset of action
b) Diminished efficacy in previous benzo users
Side effects: dizziness, headache and nausea
Minimal sedation - B-blockers effective in patients with somatic anxiety symptoms (CI in asthma and heart block)
- Low-dose antipsychotics can also be used
- Pregabalin may also be of use (If the person cannot tolerate SSRIs or SNRI)
Panic disorder management:
Treatment in primary care
1. NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are 2nd line to CBT
-CBT is first line
-Initial education about nature of panic attacks and fear of fear cycles
-Cognitive restructuring; detecting flaws in logic
-Interoceptive exposure techniques such as controlled exposure to somatic symptoms(breathing in CO2 and physical exercise)
-Secondary agoraphobic avoidance: treat by situational exposure and anxiety management techniques
- If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
ICD-11 criteria for panic disorder:
- Recurrent attacks of severe anxiety not restricted to any particular situation or set of circumstances and therefore unpredictable
- Secondary fears of dying, losing control or going mad
- Attacks usually last for minutes; often there is a crescendo of fear and autonomic symptoms
- Comparative freedom from anxiety symptoms between attacks (but anticipatory anxiety is common)
Epidemiology of panic disorder:
1-2% in general population
2-3x more common in females
Bimodal: peaks at 20yo and 50yo
Agoraphobia occurs in 30-50%
Risk of attempted suicide is raised when comorbid depression, alcohol misuse or substance misuse
Epidemiology of GAD:
1.6% suffering from GAD at any one point
Very rarely begins after 35
clinical features of panic disorder:
Breathing difficulties
Chest discomfort
Palpitations
Tingling or numbness in hands, feet or around the mouth: Hyperventilation blows off CO2, raising pH, Calcium binds to albumin leads to hypocalcaemia. If extreme, carpopedal spasm (curling of fingers and toes can occur)
Shaking, sweating, dizziness
Depersonalization/ derealisation
Can lead to fear of situation where panic attacks occur or agoraphobia
Conditioned fear of fear pattern develops
symptoms of anxiety:
Psychological: Fears, worries, poor concentration, irritability, depersonalization, derealisation, insomnia (can’t fall asleep), night terrors
Motor symptoms: Restlessness, fidgeting, feeling on edge
Neuromuscular: tremor, tension headache, muscle ache, dizziness, tinnitus
GI: Dry mouth, can’t swallow, nausea, indigestion, butterflies, flatulence, frequent or loose motions
CVS: Chest discomfort, palpitation
Respiratory: Difficulty inhaling, Tight/constricted chest
GI: Urinary frequency, erectile dysfunction, Amenorrhoea
features of agoraphobia:
ICD-11 criteria: Fear not only open spaces but also of related aspects, such as the presence of crowds and difficulty of immediate easy escape back to a safe place, usually home (may occur with or without panic disorder)
Differentials for phobias:
Shyness (in social phobia, there is fear)
Agoraphobia
Anxious personality disorder
Poor social skills/autistic spectrum disorders (will not show good skills when relaxed)
Benign essential tremor (familial, worse in social situations, responds to benzo and alcohol)
most common anxiety disorder: expalanation:
social phobia
- ICD-11 criteria: Fear of scrutiny by other people in comparatively small groups (as opposed to crowds), leading to avoidance of social situations
- Comparatively small = around 5-6 people (Usually 1-2 is fine)
- May be specific (public speaking) or generalized (any social setting)
- Physical symptoms: blushing, fear of vomiting
- Symptoms include blushing (characteristic), palpitations, trembling, sweating
- Can be precipitated by stressful or humiliating experiences, death of a parent, separation, chronic stress
- Genetic vulnerability
- May abuse alcohol or drugs (perpetuating problem)
- Mental state examination: may appear relaxed as phobic object or situation not present
investigations of phobias:
- History and Examination
- Rating scales of anxiety: Beck Anxiety Inventory and the HADs score (Hospital anxiety and Depression scale)
- Social and occupational assessments for effect on quality of life
- Collateral History
management of phobias:
Behavioural therapy is treatment of choice,
Exposure techniques most widely used aiming to reach systematic desensitization (using a graded hierarchy approach for e.g.)
- Flooding (taking someone with fear of heights to a tower),
- Modelling (individual observes therapist engaging with phobic stimulus)
- Agoraphobia and panic disorders: CBT treatment of choice
- Social phobia: CBT is the treatment of choice
Drug management
1. SSRIs and MAOIs (phenelzine) most useful in agoraphobia and social phobia
2. Tricyclic antidepressants best for those with depressive component
3. Agoraphobia + panic disorder: CBT first line and SSRI 2nd line
4. Benzodiazepines can be used before a phobic situation
5. B-blockers are effective if somatic symptoms predominate Prognosis
6. Animal phobias have the best outcome
7. Agoraphobias do worse
8. Early diagnosis and treatment are essential (shorter –>better prognosis)
