Anxiety disorders Flashcards
What are some factors that may increase risk of anxiety disorder
Genetic factors - Biological vulnerability to fear
Behavioural factors - Classical and operant conditioning to fear
Cognitive factors - Attention biases and selective attention
What are the functions of the stress response?
To allow for instantaneous and concurrent biological responses allow assessment of danger and organisation of an appropriate response
Describe the neurobiology of the stress response
The amygdala acts as an emotional filter of the brain, assessing the need for a stress or fear response
This is modified by later-received cortically processed signals
Acute stress leads to dose-dependant increases in catecholamines and cortisol
Cortisol mediates the stress response via the pituitary, hypothalamus, hippocampus and amygdala
What are some physical symptoms of anxiety (Normal or abnormal)?
- Sweating, hot flushes or cold chills
- Trembling or shaking
- Muscle tension or aches and pains
- Numbness or tingling sensations
- Feeling dizzy, unsteady, faint or lightheaded
- Dry mouth (not due to medication or dehydration)
- Feeling of choking
- A sensation of a lump in the throat, or difficulty in swallowing
- Difficulty breathing
- Palpitations or pounding heart, or accelerated heart rate
- Chest pain or discomfort
- Nausea or abdominal distress (e.g. churning in stomach)
What are some cognitive symptoms of anxiety?
- Fear of losing control, ‘going crazy’ or dying
- Feeling keyed up, on edge or mentally tense
- Difficulty in concentrating, ‘mind going blank’
- Feeling that objects are unreal - derealization
- Feeling that the self is distant or ‘not really here’ depersonalisation
- Hypervigilance (internal and external)
- Racing thoughts
- Meta-worry (worry about everything, worrying about worrying)
- Health anxiety
- Beliefs about the importance of worry
- Preference for order and routine
What are some behavioural symptoms of anxiety?
- Avoidance of certain situations
- Exaggerated response to minor surprises or being startled
- Difficulty in getting to sleep because of worrying
- Excessive use of alcohol/drugs (prescription or ‘recreational’)
- Restlessness and inability to relax
- Persistent irritability
- Seek reassurance from family/GP
- Checking behaviours
What are some forms of anxiety disorder?
Generalised anxiety disorder (GAD)
Panic disorder
Phobias
OCD
What is generalised anxiety disorder?
Anxiety that is generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is “free-floating”)
Describe the aetiology of GAD
20-40
Female (2:1)
Co-morbid with other psychiatric disorders
How does GAD usually present?
- Persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort
- Fears that the patient or a relative will shortly become ill or have an accident are often expressed
What are some associated symptoms of GAD?
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, restless unsatisfying sleep)
How severe do symptoms have to be for a diagnosis of GAD to be made?
- Long-lasting (most days for at least 6 months)
- Not controllable
- Causing significant distress/impairment in function
How is GAD managed?
- Psychoeducation
- Self-help/psychoeducation groups
- High intensity psychological intervention (CBT) OR drug treatment (SSRI)
- Consider short term use of benzodiazepines <2 weeks
- SNRI
- Pregabalin
- Combination of CBT and drug treatment
What is a panic disorder
A disorder in which the essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
Describe the aetiology of panic disorder
Adolescence - 30s
Comorbid psychological disorders
What are some of the main symptoms of panic disorder?
- As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization)
- There is often also a secondary fear of dying, losing control, or going mad
How is panic disorder managed?
Acute - Breathing control
1. Self help
2. CBT or SSRIs
3. Tricyclics
What are the 3 main categories of phobia?
Agoraphobia
Social phobia
Specific phobia
When does agoraphobia usually present?
20-30s
When do social and specific phobias usually present?
Early adolescence - early 20s
What is agoraphobia?
A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes
How may people deal with agoraphobia?
Avoidance of the phobic situation is often prominent, and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
- Often involves other people, alcohol or technology to avoid anxiety
- Others do shopping (for or with the patient)
- Drink alcohol to overcome fear
- Go shopping to 24 hour store at night (when quiet)
- Internet shopping
How can agoraphobia be managed?
- Self-help
- CBT or SSRI if long standing or no benefit from CBT
- Consider tricyclics e.g. clomipramine, desipramine if there is no improvement after 12 weeks and further medication is indicated
What is a specific phobia?
A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation
What are some examples of specific phobias?
- Flying - Aerophobia
- Heights - Acrophobia
- Animals or insects - E.g. Arachnophobia (Spiders)
- Receiving an injection - Trypanophobia
How do specific phobias present?
- Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, akin to a panic attack
- The person recognises that the fear is excessive or unreasonable
- The phobic situation(s) is avoided or else endured with intense anxiety or distress
- Normal functioning impaired by the avoidance, anxious anticipation, or distress in the feared situation(s)
How is a specific phobia managed?
- Behavioural therapy - exposure
- Graded therapy/systemic desensitisation
- Add CBT if necessary
- SSRIs/SNRIs if required
What is a social phobia (Social anxiety disorder)
A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
Describe the neurobiology of social phobia
Increased bilateral activation of the amygdala and increased rCBF to the amygdala (and related limbic areas) that normalizes on successful treatment (pharmacological or psychological)
What causes anxiety symptoms in social phobia?
- The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating
- Typically this occurs in relatively small social settings
- Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound panic attack
- Linked to behavioural inhibition - tendency to react to novel situations by avoidance and withdrawal to safety
How is social phobia managed?
- Individual CBT
- SSRI (escitalopram or sertraline) - review at 12 weeks
- SSRI plus CBT
- Alternative SSRI (fluvoxamine or paroxetine) or SNRI (venlafaxine)
- MAOI (moclobemide)
What is OCD
A disorder in which there are recurrent thoughts and/or compulsive acts
What is the peak age of OCD onset in males and females
- Peak incidence for males - 13-15
- Peak incidence for females - 24-25
What are the 2 forms of presentation of OCD?
Obsessional thoughts
Compulsive acts
How do obsessional thoughts present in OCD?
Unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore
E.g. overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind
How do compulsive acts present in OCD
- Repetitive actions the person feels they must do, generating anxiety if they are not done
- Often these compulsions are a way for the person to handle the obsessions
E.g. checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down - This is a normal behaviour, but in OCD the person may check every plug in the house 10 times before being able to go to sleep or leave
What are the diagnostic criteria for OCD
- Obsessional symptoms or compulsive acts must be present most days for at least 2 weeks AND be a source of distress and interference with activities
- Obsessions must be individuals own thoughts
- Resistance must be present
- Rituals are not pleasant
- Obsessional thoughts/images/impulses must be repetitive
How is OCD managed?
- Low intensity psychological intervention - CBT and ERP
- More intensive psychological intervention or SSRI
- If effective continue for 1 year
- Consider increase in dose after 4-6 weeks
- SSRI plus CBT and ERP
- Clomipramine (tricyclic antidepressant)
- Augmentation with antipsychotic or clomipramine plus citalopram
