Anxiety disorders Flashcards
Main differentials for OCD
- Depressive disorder: Obsessions common
- Psychosis: Delusions are ‘believed’ and seen as reality
- Anankastic (aka obsessive) personality disorder
- Hypochondriasis, body dysmorphia
- Other anxiety disorder
M:F ratio of OCD
1:1
Aetiological factors for OCD
Bio: Genetic vulnerability (3-7% of first degree relatives affected), dysregulation of 5-HT system, ?autoimmune cause (e.g. in Sydenham’s chorea, encephalitis)
Psycho: Anankastic personality
Social: Stressful events precipitate OCD
Maintaining factors for OCD
Avoidance of situations triggering obsessions + performance of compulsions –> prevent habituation of anxiety
Core symptoms of OCD
Must cause distress/functional impairment (behaviours must take >1h per day)
Emotion: Anxiety around topic of obsessional thought
Cognition: Ego-dystonic (i.e. resisted) repetitive obsessional thoughts/images/ruminations/impulses
Behaviour: Compulsions/rituals (may be mental or physical, and may not be present).
Somatic symptoms: Tension, esp if stopped doing compulsions
Age demographics of OCD
Mean age: 20yrs
70% onset <25
15% >35
Prevalence of OCD in general population
0.5-3%
Frequent co-morbidities for OCD
Depression (obsessions follow depression in MDD, and vv for OCD)
Eating disorder
Other anxiety disorder
Tics, Tourette’s
Outcome for OCD
20-30% significant improvement within 1y
40-50% moderate improvement
20-40% chronic/worsening symptoms
Poor prognostic factors for OCD
Personal: Male, comorbid depression or PD
Illness: early onset, long duration, tics, acting on compulsions
Psychological treatment options for OCD
CBT + exposure-response prevention
Pharmacological treatment options for OCD
- First line: SSRI (fluoxetine, paroxetine, sertraline)
- Second line: Clomipramine
Continue for 12mo as maintenance
Important anxiety differentials to rule out in <18
ADHD
ASD
Substance misuse
Eating disorder
Important anxiety differentials to rule out in 18-35
Schizophrenia
Bipolar
Major depressive disorder
Substance misuse
Somatoform disorder
4 components of anxiety to assess
Cognition: What are you worried about? What is the nature? Any triggers?
Body sensations: Head to toe manifestation of symptoms
Behaviour: Anxious-avoidant behaviour that perpetuates anxiety disorder
Impairment: How has it affected your life? Can you put it out of your mind? –> become disorder
Typical duration of a panic attack
Peak at 10-15 min
Last 20-30 min
Definition of generalised anxiety disorder
Free-floating, excessive worry w/ psychic + physical tension causing functional impairment
ICD-10 symptoms criteria for generalised anxiety disorder
At least 4 of:
Autonomic arousal: E.g. palpitations, tachycardia, dry mouth
Physical symptoms: Difficulty breathing, chest pain, abdominal distress
Mental state: Dizziness, light-headedness, fear of dying/losing control/going mad, poor concentration, feeling on edge
Musculoskeletal: Tension, tingling/numbness, globus
Hypervigilance
Sleep disturbance: Nightmares, frequent waking, not EMW usually, that should alert to depression
Time criterion for generalised anxiety disorder
Most of the time for >=6mo, shorter –> likely adjustment
Prevalence of generalised anxiety disorder
lifetime: 5.4%
Demographic risk factors for anxiety disorder
Female
Unemployed
45-59yrs peak incidence
Marital/sexual disturbance or trauma
Biological aetiological factors for generalised anxiety disorder
Genetics: Shared heritability w/ depression, 5x more prevalent in first-degree relatives
HPA axis: Reduced cortisol responsiveness to DMST
NA/5-HT/BDZ axis: Dysregulation
Psychological aetiological factors for generalised anxiety disorder
Diminished sense of control: Trauma or insecure attachment to primary caregivers –> intolerance of uncertainty
Parenting: Overprotective or lacking warmth
Personality: Esp anxious-avoidant
Social aetiological factors for GAD (aka specific psychological vulnerability)
Trauma: war/parental loss/abuse
Dysfunctional family/marital relationships
Medical conditions associated w/ anxiety-like symptoms
Cardio: Arrhythmia, ischaemic heart disease, mitral valve disease, heart failure
Resp: COPD/asthma, PE
CNS: vestibular nerve disease, temporal lobe epilepsy
Endocrine: Hyperthyroidism, hypoparathyroidism, hypercalcaemia, phaeochromocytoma, carcinoid, hypoglycaemia
Prognosis for generalised anxiety disorder
Generally poor
30% remission at 3 years
68% residual symptoms at 6 years
Management for generalised anxiety disorder
Step 1: Psychoeducation - breaking cycle of anxiety + treat any co-morbidity
Step 2: Facilitated/independent self-help - computerised CBT, problem-solving techniques, relaxation techniques
Step 3a: CBT
Step 3b: Pharmacology: sertraline, other SSRI (e.g. paroxetine, escitalopram for social), pregabalin (take longer to be more effective)
Demographic risk factors for panic disorder
Female
Widowed, divorced, separated
Physical/sexual abuse
Early parental loss
15-24yo or 45-54yo
Symptoms of panic attacks
Palpitations, tachycardia, chest pain
Sweating
Trembling/shaking
Hyperventilation, shortness of breath, fealing of choking
Psych: Fear of dying, dissociative symptoms
Paroxysmal: No trigger, or triggered in site of earlier attacks
Common comorbidity for panic disorder
Agoraphobia (esp if untreated)
Substance misuse
Major depressive disorder (should not Dx panic if depressive disorder present at start of panic attacks)
Bipolar disorder
Emergency management of panic attack
Reassurance
Exclude medical cause if first presentation
BDZs if severe
Psychiatric referral if recurrent (i.e. panic disorder)
Prognosis of panic disorder
Functional recovery in 25-75% at 1 yr
10-30% at 3 years (chronic course)
If attacks present for >6mo –> will run a prolonged, fluctuating course
Management of panic disorder
1st line: Self-help
2nd line: CBT and/or SSRI (e.g. sertraline, paroxetine, citalopram)
3rd line: TCA (e.g. imipramine, clomipramine)
Aetiological models for panic disorder
NAergic/5-HTergic: Hypersensitivity
Lactate/CO2: brainstem hypersensitivity
GABA: Reduced activity
Cognitive: Hypersensitivity to autonomic cues
Clinical features of agoraphobia
Emotional: Situational anxiety, in open spaces where escape may be difficult or embarrassing
Cognitive: Thoughts of collapsing/having panic attack in public, inability to escape (c.f. fear of scrutiny in SA)
Behaviour: leading to avoidance –> risk of self-neglect
Somatic: +/- panic attacks (i.e. agoraphobia with(out) panic disorder)
Aetiological factors for agoraphobia
Bio: Genetic (first degree relatives have higher incidence of alcohol dependence, MDD, other anxiety disorder)
Psycho: Fear/loss of confidence due to previous panic attack/trauma/physical frailty –> learned response
Differential for agoraphobia
Presence of panic disorder, other anxiety disorder (esp GAD, social)
Presence of delusions in psychotic disorder
Major depressive disorder
Management of agoraphobia
Psychological: CBT, esp exposure therapies
Pharma: SSRIs for panic disorder (e.g. paroxetine, citalopram)
Prognosis: Present for >1year, likely to persist for at least 5y
Definition of simple phobia
Recurring, excessive, unreasonable fear in presnce (or anticipation of) specific stimulus/situation
Cannot be reasoned away, beyond voluntary control
Causes impairment
Mean age of onset for simple phobias
15yo, 7-8 for animal/needle and 20 for situational
Comorbidities in simple phobias
Mood or other anxiety
>80% lifetime comorbidity
Management of simple phobias
Exposure therapy (rarely use BDZs to allow engagement in exposure therapy)
Aetiology of simple phobias
Genetic vulnerability (esp in non-situational)
Learned response (perpetuated by avoidance)
Clinical features of social anxiety
Cognition: Fear of being judged (not harmed) by others, anticipatory anxiety
Bodily sensations: Embarrassment, blushing, hand tremor, nausea, sweating
Behaviour: Avoidance
Associations: Substance misuse, suicidality, low self-esteem, perfectionism, 80% co-morbidity w/ other condition
Aetiology of social phobia
Bio: Minor genetic component (MZ:DZ 24:15)
Psycho: Learned responses e.g. from previous social trauma, learned from parents, overprotective parenting
Management of social phobia
Assessment: Mini Social Phobia Inventory (Mini-SPIN)
First line: CBT or CBT-based self-help book with telephone guidance. >90% response + reduces relapse. Includes behavioural/exposure therapy. May be combined with medication (see below)
Second line: SSRI (sertraline, citalopram are licensed)
Third line: Alternative SSRI, venlafaxine
Neuroses not more prevalent in women (i.e. equal prevalence)
Social phobia
OCD
Panic disorder (equivocal)
Comparison of panic disorder, phobic anxiety, and generalised anxiety, onset
Panic: Paroxysmal
Phobic: Situational
Generalised: Persistent
Comparison of panic disorder, phobic anxiety, and generalised anxiety, behaviour
Panic: Escape (e.g. agoraphobia)
Phobic: Avoidance
Generalised: Agitation
Comparison of panic disorder, phobic anxiety, and generalised anxiety, cognition
Panic: Fear of symptoms/dying
Phobic: Fear of situation/stimulus
Generalised: Worry
Mechanism of action of buspirone
5-HT agonist –> overall decrease in synaptic 5-HT levels + increase in DA/NA
Short-term management of acute anxiety
Benzodiazepines
Buspirone
Review after 2-4w max!
Mechanism of action of benzodiazepines
Allosteric modulators of GABA receptors
Timecourse for withdrawal symptoms from benzodiazepines
Up to 3 weeks after stopping if long-acting, within a day if short-acting
More likely with short-acting
Symptoms of benzodiazepine withdrawal
Tremor, perspiration, seozures
Tinnitus, perceptual disturbances
Low appetite +/- weight loss
Insomnia, anxiety
Common classes of hypnotics
Benzodiazepines
Z-drugs (zopiclone, zolpidem)
Antihistamines (esp promethazine)
Common side effects of benzodiazepines
Mental state: Depression, confusion, drowsiness, ‘hangover effect’, suicidal ideation
Neuro: Ataxia, dizziness, headache, tremor, muscle weakness, vision disorders
Other: Dysarthria, fatigue, GI disturbance, respiratory depression
Timecourse to tolerance of hypnotics
3-14d, should not be used long-term!
Indications for buspirone
Non-sedating anxiolytic, for use in generalised anxiety
Age distribution for GAD
15-30 and 40-60 (bimodal)
Age distribution for agoraphobia
15-30 and 70-80 (bimodal)
Age distribution for social phobia
Childhood - 30years
Age distribution for panic disorder
15-25 and 40-60
Age distribution for OCD
Generally onset in teenage years
Differentials for GAD
Withdrawal from drugs/alcohol
Drugs: e.g. bronchodilators, antiarrhytmics, thyroxine, psychotropics
Dementia
Depression
SCZ
Physical illness
Poor prognostic factors for GAD
Severe symptoms, agitation
Derealisation
Conversion symptoms
Suicidal ideation
Concurrent depressive illness
