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
Tricyclic antidepressants
Clomipramine, imipramine
Used if patients don’t tolerate/respond to SSRIs
Buspirone
A serotonin partial agonist
Not addictive but unpopular because of:
Delayed action
Dysphoric side effects
Benzodiazepines
Bind to GABAa receptor to increase transmission - Eg diazepam
Useful in the short term and are very effective but rapidly develop tolerance/dependence (2-4 weeks)
Side effects –> amnesia, ataxia, respiratory depression, especially in elderly/co-morbid patients
Beta-blockers
Used to treat the adrenergic symptoms that are particularly difficult in social phobia (tremor & palpitations)
Eg atenolol
BUT … Have many contraindications to use
OCD (obsessive compulsive disorder)
Unpleasant, intrusive thoughts relating to particular obsessions which cannot be ignored.
The anxiety produced is relieved by performing compulsive rituals
Linked to basal ganglia and frontal lobe damage.
Usually a chronic disorder but can be treated with SSRIs/CBT
Obsessional thoughts in OCD
Unpleasant, intrusive thoughts relating to particular themes (contamination, harming self/others, infection, religion/morality)
which cannot be ignored.
Patient recognises them as irrational and their own, and may be ashamed/embarrassed.
Compulsions in OCD
Repeated, stereotyped rituals, which while purposeful often lack a link to the obsession
Normally cleaning, counting, checking or ordering
These can become a significant restriction on life and reduce quality of life.
Aetiology of OCD
Heredity –> 3x higher risk in relatives
1/4 pt with OCD previously had anankastic traits (rigidity, orderliness) and stress may precipitate OCD
Basal ganglia and frontal lobe deficits are associated
Brain changes in OCD
Basal ganglia -> diseases which effect the BG show an increased risk (sydenham’s chorea, encephalitis lethargica, Tourette’s)
Anti-BG antibodies have been found in pts with OCD secondary to strep throat infections
Imaging indicates reduced frontal lobe inhibition in OCD pts
Management of OCD
Education and self help is important for improving functionality
CBT -> compulsions can be addressed in the same ways a escapes in phobias, and thus pts can be helped to habituate
This is effective in well-motivated patients
SSRIs –> effective in OCD, as well as clomipramine
Extreme Stress reactions
Adjustment disorders
Acute stress reaction
Post traumatic stress disorder (PTSD)
Acute stress reaction
A ‘state of shock’ following a traumatic event resolving in hours to days (3days max)
Pt will be anxious, dazed, amnesic, may depersonalise/derealise –>can be agitated, irritable or aggressive
Benzos may help in the short term but formal psych debriefing may increase the risk of later PTSD
PTSD - post traumatic stress disorder
Following a ‘life-threatening’ traumatic event
Symptoms usually begin after six months and include re-experiencing, avoidance of reminders of the event and hyperarousal.
May also show emotional detachment or depression
Re-experiencing symptoms in PTSD
Flashbacks - vividly reliving the trauma, feeling as though it is happening all over again
Nightmares
Intrusive memories relating to the event
Avoidance
Avoiding reminders of the event as they will trigger flashbacks
Avoiding places or situations which are similar
Hyper-arousal
Persistent inability to relax Hypervigilence - the patient feels that they always on red alert Enhanced startle reflex Insomnia Poor concentration/irritability
Other changes after traumatic events
Emotional detachment (numbness) Decreased interest in activities Powerful emotions including anger, loss of control, shame and crying
Differential diagnosis of PTSD
Depression or anxiety disorders - both common responses to severe stress
Adjustment disorders
Psychological Management for PTSD
Psychological treatments - CBT - testing and challenging thoughts of vulnerability after the event
EMDR - Eye movement desensitisation and reprocessing - focusing on a moving finger while reliving the event helps reduce stress
Pharmacological management of PTSD
SSRIs - first line combined with psychological therapies
Adjustment disorders
Life changes require adaptations to cope with
Often people can appear to cope with these changes easily will still show transient symptoms of anxiety or depression
In adjustment disorders a persons response is considered greater than expected but not enough to classify as a full disorder
Symptoms start within a month and resolve within 6 months
