Anxiety Disorders Flashcards
Theories of anxiety
Genetics - some heritable element linked to trait neuroticism
Life events - linked to childhood adversity and difficult life events
Neurochemical - 5HT,NA and GABA are all dysregulated
Behavioural - classical conditioning & negative reinforcement
Cognitive - automatic thoughts & attachment theory
Epidemiology of anxiety disorders
Very common
Total incidence:18.1%
Total prevalence:28.8%
2:1 (women:men), except social phobia (1:1) and OCD (more men)
Classical conditioning
The simplest stimulus-response association
Repeated pairing of a neutral stimulus with a frightening one causes a fear response to the neutral stimulus
Little Albert
Negative reinforcement
The reinforcement of a behaviour by the removal of an unpleasant stimulus
Most commonly this reinforces avoidance or running away from a frightening stimulus
Cognitive theories of anxiety
Anxious thoughts are repeated in an automatic, ruminative way which induces and then maintains anxiety
Attachment theory
The quality of the attachment between children and their parents effects their confidence as adults
Insecurely attached children become anxious adults
Genetics of anxiety
Strong heritability but no specifically linked genes
Associated with trait neuroticism (Fullerton et al 2003)
Significant genetic overlap between anxiety and depression (Kendler 1996)
Generalised anxiety disorder GAD
Continuous, free-floating anxiety not triggered by anything
Symptoms may occur at any time with panic attacks if severe
For diagnosis symptoms must be present for 6months although symptoms may fluctuate
Incidence: 3.1% Prevalence: 5.7%
Differential diagnosis for GAD
Hyperthyroidism
Substance abuse (intoxication or withdrawal) -> excess caffeine
Depression, if severe diagnose both, if not ‘mixed anxiety & depressive disorder’
Anxiety may be an early symptom of dementia or schizophrenia
Consider anxious/avoidant PD if no recent increase in anxiety
Phobias (phobic anxiety disorders)
Intense anxiety in response to specific but ordinary stimuli
Patients will usually be avoidant and hypervigilent
Seriousness is defined by the level of disability the patient experiences
Incidence: 8.7% Prevalence : 12.5%
Agoraphobia
The fear of being unable to easily escape to a safe place (home)
This includes a fear of open, crowded and enclosed spaces
Onset in mid-20/30s, gradual or after sudden panic attack
Anxiety increases with distance, decreased by companion or car.
Incidence: 0.8% Prevalence: 1.4%
Differential diagnosis for phobic disorders
Depression -> can cause social/agoraphobia but may also be comorbidity or develop secondarily
Social phobia–> specifically a fear or scrutiny or humiliation
OCD -> rituals or germ fear may confine the patient at home
Schizophrenia -> either due to negative symptoms or paranoia
Social phobias
Centred around fear of criticism or humiliation by others
Can cope with an anonymous crowd (unlike agoraphobics) but small groups are very difficult - may have specific worry (eating)
Often self medicate with drugs/drink -> psychological avoidance
Incidence: 6.8% Prevalence: 12.1%
Differential for social phobia
A shy person -> for social phobia there must be ‘overt fear’
Agoraphobia -> specific fear of being away from home
Anxious/avoidant PD -> lifelong disabling shyness/anxiety
Poor social skills/ASD -> social skills poor even when relaxed
Benign essential tremor -> familial and worse in social situations
Blood, injury or needle phobias
Unusually for phobia these produces strong vasovagal reaction causing bradycardia and hypotension
May have evolutionary advantage of falling into recovery position when injured
Panic attacks
Episodic and ‘comes out of the blue’ with total anxiety with physical symptoms (difficulty breathing, palpitations, tightness)
Attacks are self-limiting (30mins) but may feel longer
The pt fears they will die, provoking further anxiety and engages in ‘safety’ behaviours (calling an ambulance, etc)
Panic disorder (episodic paroxysmal anxiety)
A disorder of intermittent panic attacks with little anxiety in between
For diagnosis the patient must have recurrent attacks, usually several in one month
Incidence: 2.7% Prevalence: 4.7%
Differential diagnosis for panic disorders
Another anxiety disorder -> GAD or agoraphobia
Depression -> if criteria for diagnosis are met it takes precedence
Alcohol/drug withdrawal -> anxiety mistaken for panic attacks
Organic causes -> cardio/resp conditions or pharochromocytoma
Calcium parasthesia
Hyperventilation blows off CO2 causing raised pH and hypocalcaemia which affects nerve conduction
This can cause parasthesia in the fingers, toes and around the mouth
In extreme cases this leads to carpopedal spasm of the fingers and toes
Treatments for anxiety disorders
CBT
Exposure therapy
Pharmacological
Cognitive behavioural therapy
Challenging the pt’s expectations of danger and the central beliefs involved in that using behavioural experiments & role play
Education about the physical and psychological aspects of anxiety, and coping strategies to counter them
Combating -ve automatic thoughts and vicious cycles of worry
CBT is particularly useful for
GAD - testing predictions of worry and errors in thinking as well as terminating avoidance/reassurance behaviours
Panic disorder - education about their symptoms to remove the need for safety behaviours
Exposure therapy
This a part of CBT which is useful where avoidance and escape behaviours are central parts of a disorder (phobias)
In the absence of physical symptoms the body can only maintain anxiety for about 45mins before it habituates, reducing anxiety to extinction-> this involve increasing exposure to a phobic stimulus forcing them to habituate to it
SSRIs for anxiety
Useful and can be combined with CBT
therapeutic dose for anxiety is higher than depression and there is a longer delay before effect (6-8 weeks)
Suddenly stopping SSRIs can cause reflex anxiety symptoms
