Anxiety Disorders

Question 1

Anxiety Disorder

Answer 1

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.

Question 2

Generalized anxiety disorder (GAD)

Answer 2

Highly prevalent.
“Worriers”
Excessive and continual worry and tension.
Psychological Sx: poor concentration, restlessness, irritability.

Somatic Sx: muscle tension, headache, fatigue.

Question 3

GAD: Epidemiology

Answer 3

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

Question 4

GAD: Aetiology

Answer 4

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

Question 5

GAD: Course and prognosis

Answer 5

Untreated: chronic, fluctuating severity

Worsening during periods of stress

Benefit significantly from treatment

Question 6

GAD: Clinical presentation and Mx

Answer 6

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

Question 7

GAD: Pharmacotherapy

Answer 7

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

Question 8

GAD: psycotherapy

Answer 8

Reassurance, CBT, relaxation exercises, exposure therapy

Question 9

Panic disorder

Answer 9

“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)

Question 10

PD: Diagnostic features

Answer 10

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

Question 11

Agoraphobia

Answer 11

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

Question 12

PD: Epidemiology

Answer 12

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

Question 13

PD: Aetiology

Answer 13

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

Question 14

PD: Familial patterns

Answer 14

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

Question 15

PD: Course and prognosis

Answer 15

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

Question 16

PD: Clinical presentation and Mx

Answer 16

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).

Question 17

PD: Pharmacotherapy

Answer 17

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

Question 18

PD: Psychotherapy

Answer 18

CBT, breathing exercises, anxiety management skills

Question 19

Social Phobia and Specific Phobia

Answer 19

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

Question 20

Types of social phobia

Answer 20

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

Question 21

Social phobia: Epidemiology

Answer 21

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

Question 22

Social phobia: Aetiology

Answer 22

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

Question 23

Social phobia: Course and prognosis

Answer 23

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

Question 24

Social phobia: clinical presentation and assessment

Answer 24

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

Question 25

Social phobia: Pharmacotherapy

Answer 25

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.

Question 26

Social phobia: Psychotherapy

Answer 26

Exposure interventions

Cognitive restructuring:
negative automatic thoughts and cognitive bias

Social skills training

Systematic desensitization

Question 27

Medical conditions that may present with anxiety symptoms

Answer 27

Medication changes, substances
Benzo withdrawal, alcohol withdrawal, stimulant abuse, corticosteroids

Endocrine metabolic disorders: hyperthyroidism, hypoglycemia

Neurological: seizures, head trauma