Anxiety Disorders Flashcards
Classify 5 common anxiety disorders according to DSM-5
- The anxiety disorders
Generalized anxiety disorder
Panic disorder
Phobia - The Obsessive-compulsive disorders
Obsessive Compulsive Dxso - The Traumatic and Stressor related dxso
PTSD
General anxiety disorder
Persistent, prominent and exaggerated worry/ tension apprehension about everyday events and problems
Feeling on edge most of the time
Muscle tension/aches
Restlessness/irritability
Difficulty concentrating/mind going blank
CF Panic dxso
Acute onset of severe anxiety with no obvious trigger(out of the blue)
Reach a peak over the next few seconds/mins the subsides over few minutes.
Prominent autonomic symptoms
Fear of dying
Anticipatory anxiety
Clinical features/Stages of phobias
Acute episodes of anxiety that are precipitated by exposure to specific triggered
Escape: pt escape from triggers to reduce the duration of anxiety
Avoidance: pt avoids exposing oneself to trigger
Symptoms similar to panic
Types of phobias
Simple phobias
Agoraphobia
Social phobia
Simple/specific/isolated phobias
Spiders/dogs
It
Enclosed spaces/lifts
Flying
Needles
Blood
Hospitals
Choking
Agoraphobia
Crowds
Public places
Leaving home
Traveling alone
Social anxiety disorder (Social Phobias)
Fear of being the focus of attention
Fear of behaving in an embarrassing way
Avoidance of social situations
Pt unhappy, acknowledges that fear is excessive and unnecessary
CF of OCD
It’s xteris by obsession and compulsion
What is obsession
Obsession
Recurrent intrusive unignorable distressing thought impulse or image arising from the subject mind and recognized as such.
Contamination, safety, illness, sex, violence, religion, doubt
What is compulsion
Compulsion
A receptive, irresistibly, time-consuming behavioral ritual that is performed as an attempt to neutralize the anxiety induced by the obsession despite the pt being aware that the ritual is unnecessary
Social signs of OCD
Inability to break routine
Need to check the same thing over and over again
The constant need for reassurance
Intense anxiety when things are not orderly or symmetrical
Fear of shaking hands or touching things in public
Raw hands from too much hand washing
Having trouble getting to work on time of keeping to a schedule due to rituals
At least an hour daily on unwanted thoughts or rituals
Counting for no reason, repeating same words phrase or action
Avoidance of certain situations that trigger the obsessive thoughts
CF of PTSD
After an exceptionally threatening catastrophic event
Pt relieves that trauma in the form of flashbacks while awake and nightmares while asleep
Avoids places conversations people asso with the trauma
Hypervigilant
Easily startled
Others: Emotional numbing, insomnia, irritability, poor concentration, misuse of alcohol/drug, despensation/derealization
Diagnostic criteria and duration
GAD: ICD10 - At least 6 months
DSM-5 At least 6 month
Panic dxs: ICD-10 At least 4 attacks within a 4 week period
DSM-5 at least 1 month of impairment
Phobias: DSM 5: at least 6 months
OCD: At least 2 weeks
PTSD: Not specified but within 6 months of trauma
Atielogy of anxiety dxso
Neurotransmitters: COMT, 5-HTT, CRF
Amygdala - the insula, anterior cingulate cortex
Hormonal factors
Assessment of Anxiety Dxso
- Hxs, rule out hyperthyroidism
- Psychiatric assessment; Rule out schizophrenia, BPSD, Delirium tremens of alcohol withdrawal, unipolar, bipolar
- Routine blood test (CBC, LFT, U&E, IFT, Glucose) ECG
- Neuroimaging, EEG, Psychometric testing
Differential
- Substance Abuse cocaine amphetamine
- Cardiac causes: atypical MI, supra ventricular tachycardia,
- Hypoglycemia
- Phaecochromocytoma
- Neurological: Atypical seizures,
Rating scales for anxiety disorders
GAD- HAM-A
Panic Disorder - PDSS, PAS
Phobias - Liebowitz social anxiety scale, SPIN
OCD- Y-Bocs, MOCI
PTSD - IES-R, CAPS
CBT for GAD
Cognitive behavior therapy is the tx of choice
Education
Self Monitoring
Relaxation, training: progressive muscular relaxation, relaxation, breathing exercises, meditation.
Cognitive restructuring: help pt make more realistic estimations of likelihood of danger and ones ability to cope
CBT for Panic Disorders and Phobias
Help pt.
1. Make more realistic appraisal of the anxiety
2. Educating the pt that anxiety will not last forever and will not kill
3. Avoiding the anxiety -short term, long term avoidance perpetuates the problem.
4. Facing the anxiety may worsedn short term but in die course will help overcome
Behavioral strategies for panic disorder
Familiarize pt with symptoms to help pt realize it’s not ominous sign
CBT for phobias
Graded exposure
Response prevention
Systematic desensitization
Extinction
CBT for OCD
Exposure and response prevention: I.e Facing the anxiety without performing their habitual compulsive rituals.
Done gradually
CBT FOR PTSD
Education about nature and impact of trauma
Relaxation training
Identifying and correcting cognitive distortion
Discussion of the trauma
Exposure to trauma reminders where necessary and appropriate
Other options for anxiety disorders
Self-help books : bibliography gives simple practical steps
Online CBT
Support Group
Exercise therapy
Yoga
Meditation
Pharmacological tx of anxiety dxso
SSRI for long-term and maintenance
Benzodiazepines for immediate, short-term symptomatic Rx.
For all except simple phobias an SSRI Fluoxetine escitalopram is the first line
For GAD consider venlafaxine, duloxetine, mirtazapine, buspirone, and pregabalin
For OCD consider: Clomipramine(sereotgenic TCA)
Not >2 weeks
B-blockers d sympathetic symptoms of anxiety - tachycardia and tremors
Tx resistant OCD: SSRI + low dose antipsychotic(haloperidol, risperidone)
General Prognosis of anxiety disorders
Unlikely to remit spontaneously without Tx
Best prognosis - simple phobias
Remission of 50% within 3 years
1:3 likely to relapse
Factors associated with poor prognosis
Earlier onset
Long delay before seeking treatment/chronicity
Severity
Co-morbidity (alcohol/substance misuse, depression, personality disorder)
Previous unsuccessful treatment
Noncompliance with medication/lack of motivation in CBT
Ongoing social issues (isolation/unemployment), relationship
Overall, there is an increase in suicidal ideation and attempts in patients with Anxiety Disorders
