Anxiety Disorders Flashcards
Pathophysiology of the stress responses
- stress activates pre ganglionic afferent neurones in spinal cord
- project onto other neurones > release NA/Adr
- corticotropin releasing hormone released from hypothalamus > ACTH release from anterior pituitary
- cortisol released from renal cortex
Where is cortisol released from?
Zona fasciculata of adrenal cortex
When does anxiety become a problem?
- difficult to manage
- when response is to perceived threat (not actual threat)
- distinguish from normal anxiety
- symptoms + psychological response remains
- synonymous with neurosis
What occurs in chronic stress?
- causes sensitisation of the normal stress response
- reduces negative feedback of cortisol inhibiting CRH release
- enhances positive drive through amygdala > increasing activity in paraventricular nucleus of hypothalamus
- increased activity in ANS
What does stress habituation mean?
Repeated mild stress exposure leads to reduced response in HPA axis
What is neurosis?
Mental condition that is not caused by organic disease involving symptoms of stress
Types of anxiety disorders
- phobias
- social phobia
- panic disorder
- obsessive compulsive disorder
- PTSD
- generalised anxiety disorder
Epidemiology of anxiety disorders
What type of anxiety disorder is the most common?
- younger women
- generalised anxiety disorder most common
What is anxiety?
Pathological stress response
Symptoms of anxiety
- palpitations
- sweating
- shaking
- dry mouth
- difficulty breathing
- chest pain
- nausea
- abnormal distress (butterflies in stomach)
- lightheadedness
What are the symptoms of anxiety due to?
Sympathetic activation due to cortical stimulation in frontal lobe
What is social phobia?
Inappropriate anxiety about being in social situations
When does social phobia often start?
Adolescence
What is agoraphobia?
Fear of crowds, open spaces, difficulty getting home (travel)
When does agoraphobia often start?
Mid 20s or 30s
Common triggers of agoraphobia
- crowding
- open space
- distance from home
- social situations
Define phobia
Irrational involuntary belief leading to avoidance
Pathophysiology of phobias
Classical conditioning
Treatment of phobias
Guided self help
Relaxation
Desensitisation
What is panic disorder
Recurrent unexpected panic attacks
What is panic
Excessive arousal with fear that the symptoms are evidence of a catastrophe for a short period of time
Treatment of panic
- SSRI
- talk therapy
- cognitive behavioural therapy
- antidepressants
Epidemiology of OCD
- equal gender prevalence
- most start by 30
- 1/3 between 10-15 years old
What is OCD characterised by?
- obsessions: thoughts that persist + dominate an individual’s thinking despite awareness that the thoughts don’t have purpose
- compulsions: a motor act resulting from an obsessions
Features of OCD obsessions + compulsions
- originate in mind of patient
- present on most days for at least 2 weeks
- repetitive + unpleasant
- acknowledged as excessive or unreasonable
- patient tries to resist but at least one is unsuccessfully resisted
What is cognitive behavioural therapy?
A talking therapy that can help manage problems by changing the way you think + behave
Treatment of OCD
- SSRI
- clomipramine
- cognitive behavioural therapy
- family support
- support groups
Pathophysiology of OCD
Re-entrant loop in basal ganglia
- input of thought
- processed in striatum
- sent to globus pallidus + thalamus
- movement occurs
- re entry back to thought
Outline PTSD
- can occur within 6 months after severely traumatic event
- causes repetitive, intrusive recollection or re-enactment of event in memories, daytime imagery or dreams
Pathophysiology of PTSD
Evidence of amygdala hyperactivity causing exaggerated behavioural responses
Treatment of PTSD
- SSRIs
- short term benzodiazepines
- cognitive behavioural therapy
- eye movement desensitisations reprocessing therapy
Psychological symptoms of generalised anxiety
- fearful anticipation
- irritability
- restlessness
- sensitivity
- anxious thoughts
- poor connections
Physical symptoms of general anxiety disorder
- dry mouth
- epigastric discomfort
- tight chest
- dyspnoea
- Tachypnoea
- palpitations
- loose stool
- tremor
- insomnia
- ED
- amenorrhoea
Treatment of generalised anxiety disorder
- reduce stressors
- advise self help
- SSRI
- avoid benzodiazepines
- continue after remission to avoid relapse
Infection associated with emergence of OCD like symptoms + explain
PANDAS
Paediatric
Autoimmune
Neuropsychiatric
Disorders
Associated with
Streptococcal infection
.
After infection, autoantibodies against self basal ganglia > sudden onset of ODC like symptoms + ticks
Diagnosis of generalised anxiety disorder
DSM-5-TR and ICD-11 diagnostic criteria
Symptoms most days for at least 6 months:
Core symptoms:
- excessive anxiety or worry
- difficulty controlling worry or feeling of anxiety
.
3/6 additional symptoms:
- feeling of tension or restlessness
- significant muscle tension
- difficulty sleeping
- irritability
- tendency to become easily fatigued
- difficulty concentration/mind blanks
Outline the stress response
- originates in frontal lobes
- communicates with amygdala
- output via fornix
- projects to mammillary bodies
- project to hypothalamus
- stress response occurs
- CRH released from hypothalamus > ACTH released from anterior pituitary > cortisol released
- AND
- hypothalamus projects to spinal cord + activates sympathetic neurones > adrenaline release
What questionnaire can be used in anxiety?
GAD 7
What is the GAD 7 questionnaire?
What is it used for?
How do you interpret the results?
- It is used as a screening and severity assessment tool in generalised anxiety disorder
- questions answered based on frequency of feeling 7 symptoms (0-3) - out of 21
- 0-4: no anxiety
- 5-9: mild anxiety
- 10-14: moderate anxiety
- 15-21: severe anxiety
How do you interpret GAD 7 results?
- 0-4: no anxiety
- 5-9: mild anxiety
- 10-14: moderate anxiety
- 15-21: severe anxiety
Management of generalised anxiety disorder NICE
NICE recommends a stepwise approach:
- lifestyle advice: regular sleeping schedule, avoid caffeine after 3 pm, regular exercise
- 1: communicate diagnosis + educate on self help options
- 2: guided self help based on CBT
- 3: individual high intensity CBT (12-15 weekly sessions for 1 hour) | SSRI or SNRI first line drug treatment (pregabalin if contraindicated)
First line drug treatment of anxiety
SSRIs or SNRIs
(Pregabalin if contraindicated)
Benzodiazepine reversed for crisis
What information needs to be given to patients when starting SSRIs or SNRIs for anxiety?
Treatment may cause increased anxiety, agitation or sleep problems at the start
Should be a gradual improvement over 1+ weeks
Follow up for anxiety
- follow up within first 2 weeks of prescribing medications to address adverse effects, suicidality
- check monthly for 12 weeks
