Anxiety disorders Flashcards
Types of anxiety disorders
- Non situational a. Panic disorder b. Generalised anxiety 2. Reaction to stress a. ASR b. PTSD c. Adjustment disorder 3. Phobic a. Agoraphobia b. Social phobia c. Specific phobia 4. OCD
Explaining anxiety
- Danger->is it bigger or smaller than me, can I escape?
a) Smaller->fight
b) Bigger and I can escape->Run away
c) Bigger and I cant escape->Freeze
Perception of danger causes behavoural activation, avoidance behaviour or behavioural inhibition
Amygdala->fear response to stimuli, rapid autonomic responses. Hippocampus= cognitive evaluation, learned contextual responses. Limbic outputs to locus ceruleus= sympathetic.
Feed back loop, learned.
Anxiety–>TachyC, dysp, chest pain, dizziness, sweating etc->Im going to die, losing my mind, having a panic attack, everyones looking a me.
Differential diagnosis
- Anxiety disorder 2. Secondary to another psychiatric 3. Psychoactive substance: intoxication, withdrawal and side effects 4. General medical condition
Substances intoxication
Amphetamine Cannabis Hallucinogens PCP Inhalants
Substances withdrawal
Alcohol Benzo Caffeine Nicotine Cocaine Sedatives Hypnotics
Medication side effects
Analgesic Anticholinergic Antidepressants Antipsychotics Steroids Sympathomimetics Thyroid
General medical conditions
CCF PE Temporal lobe Malignancies Phaeochromocytoma Cerebral tumor Cushings Thyroid COPD Hypoglycemia
Etiology
- Biology: +Sympathetic tone, ++response to repeated stimuli, adapts slowly ++Cortisol->rewiring to become hypervigilant +NE in locus ceruleus -ve GABA 2. Psychosocial: a. Analytical->unacceptable wishes of id hindered by ego->comes to surface b. Behavioural->conditioning, learned in response to fearful situation= classical conditioning c. Social learning
Patterns of pathological anxiety
- Generalised free floating: not in response to specific external stimuli 2. Paroxysmal abrupt onset, gradually builds, severe, =+autonomic reactions
History
Wake up feeling anxious Excess worry about minor matters Heart pounding, sweating Avoidance for fear/panic Anxious in social, specific situations Gaining weight, contamination, embarrassment in public, being away from home, past trauma
Examination
- Neurological 2. Endocrinological 3. Vitals, general
When is anxiety a problem
- Out of proportion 2. Continues despite no threat 3. Impairment
Criteria for GAD
- >6 months of excess worry, many situations 2. Difficult to control the worry 3. > 3 of: BE SKIM Blank mind Easily fatigued Sleep disturbance Keyed up Irritability Muscle tension 4. Impairment in functioning 5. Not due to something else
Investigations
Only if suspect underlying medical/substance
Management of GAD
- SSRI: escitalopram, SNRI, buspirone 2. Benzodiazepine: short term, ensure no substance abuse history 3. CBT 4. Relaxation 5. Meditation 6. Sleep hygeine 7. Exercise 8. Self help
Prognosis for GAD
Allow 6-8 weeks for pharmacotherapy to work. Continue for 6-12 months, following that taper and monitor for recurrence of symptoms. Depression co-exists in 30-60%
Criteria for panic disorder
- Recurrent unexpected panic attacks STUDENTS FEAR the 3 Cs Sweating Trembling Unsteadiness, dizziness Depersonilisation, derelaisation Excessive heart rate, palpitations Nausea Tingling SOB Fear of dying, losing control, going crazy Chest pain, chills, choking 2. At least one episode followed by 1 mo + of >1 Persistent concern about additional attack/consequences Significant change in behaviour related to attacks 3. Absence of agorophobia 4. Attacks are not due to physiological effects of substance/GMC 5. Not better accounted for by another mental disorder/social phobia/specific/OCD/PTSD/Stress disorder
Management of panic disorder
- Psychological->CBT, relaxation, breathing techniques, cognitive restructuring 2. Pharmacological->SSRI: citalopram, paroxetine, sertraline, SNRI: velafaxine 3. Explain the +in anxiety that can occur when starting on antidepressants 4. Benzodiazepines may be used in short terms
What is agorophobia
Anxiety about being in places/situation in which escape may be difficult or embarrassing or when help may not be available in the event of a panic attack Fears may involve: Being left alone, in a crowd, standing in a line, travelling on a bus
What is social phobia
Fear of social/performance situationsin which exposed to unfamiliar people/possible scrutiny by others, feels they will act in a humiliating way
Criteria for a phobic disorder
- Exposure almost always provokes immediate anxiety response 2. Recognises as excessive or unreasobale 3. Situations avoided/endured with anxiety/distress 4. Significant interference with functioning 5. If
Management of phobic disorder
- Psychological CBT, graded exposure therapy Behavioural therapy 2. Biological Propranolol or benzoD in acute situations
Criteria for OCD
- Obsessions->recurrent thoughts/impulses/images= intrusive, attempt to suppress, are production of own mind 2. Compulsions: repetitive acts driven in response to obsession, or rules. Aimed at preventing /reducing distress. 3. Recognise as excessive, ego-dystonic 4. Cause marked distress, time consuming 5. Not due to something else
Lifetime prevalence of OCD
Is 2-3% Refractory and chronic
Management of OCD
- CBT: exposure with response prevention 2. Pharmacotherapy: SSRI/SNRI, clomipramine
Explain why benzo’s are not a good idea for anxiety long term
- Patients grow to like the immediate sedation that they feel after taking a benzodiazepine. 2. When they are then prescribed an SSRI or buspirone and do not get that immediate sedation, they complain that the medication is not working and may not stay on it long enough for it to have an effect. 3. Patients quickly develop a tolerance to benzodiazepines and may experience withdrawal anxiety when benzodiazepines are stopped. 4. This only increases the patient’s resistance to stopping a benzodiazepine. 5. As a result, many patients become addicted to prescribed benzodiazepines
Action of buspirone
Non-sedating Non-benzodiazepine Anxiolytic
