Anxiety Disorders Flashcards
What normal physiological responses are normal in anxiety?
Increased HR Increased BP Sweating Shaking GI symptoms Muscle tingling Nausea
Anxiety is normal, what makes it pathological? (3)
- -when its inappropriate for your situation
- -when its all the time
- -when it stops you functioning normally
What are some examples of anxiety disorders?
Phobic anxiety (agoraphobia, social) Panic disorder Generalised anxiety disorder OCD Stress reactions and PTSD Somatoform disorders
If anxiety is continuous what diagnosis would you be considering?
Generalised Anxiety Disorder (GAD)
Continuous persistent feelings of anxiety is its defining feature
If feelings of anxiety were intermittent and can happen in any situations what diagnosis should you be thinking?
Panic disorder
What is a panic attack?
Discrete episode of overwhelming anxiety usually accompanies by physical symptoms of:
- Racing heart, tachypnoea, sweating, sense of impending death,
They are usually sudden onset and only last a few minutes (they can last longer)
If anxiety symptoms are intermittent and as a response to a specific situation what diagnosis should you be considering?
Phobic disorder
How long does continuous anxiety have to last before before GAD is considered (in theory) and what are some common themes for anxiety?
GENERALISED ANXIETY DISORDER
- present for6 months
- Money, health, family and housing
- Pattern of thought usually based around lots of ‘what ifs’ - trains of thought get carried away and people catastrophise
What are the ICD-10 criteria for anxiety?
- Persistent, free-floating anxiety not related to external stimulus
- Accompanying symptoms such as
Psychological (worry, apprehension, fear)
Arousal (hyper vigilance, restlessness, increased startle response)
Motor (muscle tension, trembling, headaches)
Autonomic (CVS, palpitations, difficulty breathing, loose stools, dizziness)
How do we manage anxiety disorders?
CBT - originally designed for anxiety and so is a really important part of treatment
What medications can be used in anxiety?
First line recommendation is SSRI in low dose (SERTALINE)
Anxiolytics can be useful but should be avoided in the long term
BENZODIAZEPINES - should only be considered when anxiety is severe and disabling and use in the short term only (2-4 weeks before review)
HYPNOTICS (help with sleep)
Consider Zopiclone, Clomethiazole, Melatonin or low dose BZDs
What are obsessions?
Recurrent and intrusive thoughts that are unpleasant and distressing
These thoughts enter the mind against conscious resistant and people recognise an obsession as being a thought from their own mind
What is a compulsion?
An act that is done to ease an unpleasant, obsessive thought
They are usually recurrent mental or physical actions that ease obsessions
Patients often recognise them as pointless or symbolic
How long must symptoms have been present for to make a diagnosis of OCD?
2 weeks
What other psychiatric co-morbidity should you consider in OCD?
Depression
Over 2/3 of people with OCD will have depression and around 20% of patients with depression will exhibit obsessive compulsive traits at some point
What are the ICD-10 guidelines for making a diagnosis of OCD?
Obsessions and Compulsions present for at least 2 weeks
Acknowledged as coming from the patients own mind
Unpleasantly repetitive
Resisted unsuccessfully
The compulsive act is not in itself pleasurable but anxiety is relieved from having performed it
How is OCD managed?
CBT mostly
ERP exposure and response prevention
PHARMA: sometimes sertraline, fluoxetine and the TCA Clomipramine are used with success
What is PTSD?
A stress disorder caused after a ‘traumatic life event’ that would cause ‘pervasive feelings of stress in anyone’e.g. war, rape, witnessing death, NDEs
What is the cerebro-anatomical processing of PTSD?
Memories appear to get stuck in the midbrain and don’t become transferred to cortex
What are some characteristic traits and behaviours of PTSD?
Flashbacks, intrusive thoughts and nightmares
Avoidance of activities known to stimulate
Hyper-arousal and vigilance
Numbness/emotional blunting
Depression and suicidal ideation
Explore affect on HORDES (hobbies, job, relationships, eating and drinking)
According to ICD-10 when should PTSD symptoms be there for until diagnosis can be made?
how is the prognosis?
- Symptoms should have lasted for 1 month
- Recovery can be expected
What are some predisposing factors to PTSD?
Personality traits (compulsive) Familial - over-sensitive amygdala Prev hx of neurotic illness Scale of trauma (large = more likely) Patients support system
How should PTSD be managed? (5)
what’s the prognosis?
- First line: trauma focussed CBT
- 2nd line: EMDR - eye movement desensitisation and reprocessing
ANTIDEPRESSENTS
-paroxetine or mirtazapine
STRESS RELIEF
TREAT depression, anxiety, substance misuse
Prognosis is goof with 65% recovering with 18/12
what are the characteristics of phobias
AVOIDANCE-People will go out of their way and make their life seemingly more complicated or difficult to avoid certain situations
PANIC ATTACKS
ANTICIPATORY ANXIETY - becoming anxious before being exposed in anticipation.
FEAR CANNOT BE REASONED OR EXPLAINED AWAY
What are the treatments of phobias? (2)
- CBT-mapping out physical symptoms/thoughts/emotions/behaviours
- EXPOSURE therapy- therapists can accompany people out of their houses little by little (start with opening the front door, then taking a step outside, to the bottom of the drive, down the street etc.)
What medication is used in phobias?
No pharmacological treatment for phobias
Who most commonly gets agoraphobia and when does it present?
Agrophobia is more common in women between the ages of 20-35
What is social phobia?
Who most commonly gets social phobia?
When does social phobia present?
Social phobia is often caused by a fear of scrutiny from others which might lead to HUMILIATION or EMBARRASSMENT
These fears can be quite specific isolated fears (being seen eating by others, speaking to others or fear of interacting with the opposite sex)
OR may be extreme and involve all social activities outside the home.
Again these are more common in women and the common age of their onset is adolescence
How many panic attacks must someone have had in order to get a diagnosis of panic disorder?
- Panic disorder is diagnosed when someone has more than 4 panic episodes in 4 weeks
- Lasting min-10mins with sudden onset
Name some diagnostic ICD-10 features of panic disorder
THE PANIC DISORDER ICD-10
- Recurrent attacks in severe anxiety (panic attacks)
- Not restricted to any particular situation or set of circumstances (if they are then think phobias)
- Unpredictable
- Dominant symptoms include: (4+ of these)
○ Sudden onset of palpitations
○ Chest pain
○ Choking sensations
○ Dizziness
○ Feelings of unreality
○ De-personalisation or De-realisation
-Can occur with or without agoraphobia
Whats the treatment for panic disorder?
1st line is SSRI (sertraline) + education + low/high intensity psychological interventions
Try clomipramine if not worked after 12 weeks EDUCATION -your not going to die -ways for parents to help during attack -lifestyle-avoid caffeine
What are some differentials for panic disorder
- Hyperthyroidism
- Phaeochromocytoma (check for weight loss, flank pain)
- Hypoglycaemic episodes
- Cardiac (arrythmias, MI)
- Epileptiform disorders, particularly temporal lobe epilepsy.
- Withdrawal from alcohol/sedatives/opiates.
What is NICE stepwise approach to managing GAD?
NICE advice regarding generalised anxiety disorder:
Step 1: education about GAD + active monitoring
Step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
Step 3: high intensity psychological interventions (cognitive behavioral therapy or applied relaxation) or drug treatment
step 4: highly specialist input e.g. Multi agency teams
First line for GAD is sertraline, what should you try if it doesn’t work after 12 weeks?
If sertraline doesn’t work after 12 weeks for GAD then try
Paroxetine (Seroxat)
Escitalopram (not for long QT)
What can you give for patients with anxiety who are experiencing symptoms like palpitations/sweating/tremor?
Propanolol can be used to treat anxiety with symptoms such as palpitation, sweating and tremor
