Anxiety Disorders Flashcards
Anxiety Disorder
Excessive response to stressors.
Persist for a longer period than expected.
Become disabling/result in impairment of the individual’s functioning and quality of life.
False alarms/ brake failure.
Generalized anxiety disorder (GAD)
Highly prevalent.
“Worriers”
Excessive and continual worry and tension.
Psychological Sx: poor concentration, restlessness, irritability.
Somatic Sx: muscle tension, headache, fatigue.
GAD: Epidemiology
Lifetime prevalence is ± 5%
Onset usually in childhood / adolescence
Ration of women: men = 2:1 in clinical settings
Risk factors:
History of trauma (physical / emotional)
Family history
Frequently comorbid with other anxiety disorders, alcohol and drug abuse and depression
GAD: Aetiology
Biological factors:
Serotonergic and noradrenergic neurotransmitters
Dysregulation in the GABA and the Cholecystokinin (CCK) systems
Hypothalamus-pituitary-adrenal (HPA) axis overactive
Psychosocial factors:
Trauma
Negative child rearing
Familial patterns:
Genetic contribution
Family members of individuals with GAD have increased risk
GAD: Course and prognosis
Untreated: chronic, fluctuating severity
Worsening during periods of stress
Benefit significantly from treatment
GAD: Clinical presentation and Mx
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
GAD: 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
GAD: psycotherapy
Reassurance, CBT, relaxation exercises, exposure therapy
Panic disorder
“Panic” is derived from Pan, Greek Mythology, god of nature.
Mischievous but lonely forest sprite, pastime to torment unsuspecting travelers
Pan would leap from behind trees and frighten them, hence they “panicked”
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)
PD: Diagnostic features
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
Agoraphobia
Greek: “fear of the market place”
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
PD: Epidemiology
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
PD: Aetiology
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
PD: Familial patterns
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
PD: Course and prognosis
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
PD: Clinical presentation and Mx
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).
PD: 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
PD: Psychotherapy
CBT, breathing exercises, anxiety management skills
Social Phobia and Specific Phobia
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
Types of social phobia
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
Social phobia: Epidemiology
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
Social phobia: Aetiology
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
Social phobia: Course and prognosis
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
Social phobia: clinical presentation and assessment
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
Social phobia: 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.
Social phobia: Psychotherapy
Exposure interventions
Cognitive restructuring:
negative automatic thoughts and cognitive bias
Social skills training
Systematic desensitization
Medical conditions that may present with anxiety symptoms
Medication changes, substances
Benzo withdrawal, alcohol withdrawal, stimulant abuse, corticosteroids
Endocrine metabolic disorders: hyperthyroidism, hypoglycemia
Neurological: seizures, head trauma
