Anxiety Disorders Flashcards
Anxiety Disorder
Characterised by Marked and Persistent Mental
and Physical symptoms of Anxiety not secondary
to another disorder and impacts negatively on
individual’s life
o Most common Psychiatric disorder (LTR
13%); Either Primary, or in response to
stress associated to other physical illness
or treatment
Subdivisions of anxiety disorders
Sub-divided into Generalised Anxiety, Phobic and
Panic disorders; Mixed states are common
(=Minor Mood Disorders); Often with Depressive
Disorders and treated as Mood disorders
o GAD (Continuous Symptoms), Panic
(Episodic to any situation) and Phobic
(Particular Situations: Simple, Social or
Agora); Also, can be Mixed (Agoraphobia
with Panic)
Normal Anxiety
Response to threat; Feeling of Apprehension Plus Physiological response;
Attention and Concentration focussed on threat;
Beneficial response
Abnormal Anxiety
Similar; Out of proportion to threat, or more prolonged, or occurs when there is no threat; Difference also that attention is not onto external threat, but onto physiological response itself (Cycle of Anxiety) ▪ Further Autonomic arousal due to perception of physiological response as threatening; Drives further anxiety regarding response o Abnormal Anxiety becomes relevant when distress or impairment to ADL
GAD
• 2F:M; Caucasian, Lower SES; Peaks at 21yrs and
between 40-59yrs (Midlife)
• Excessive, Uncontrolled, Irrational worry about
Everyday events that are out of proportion to actual source of worry; Impairing function as patient typically Catastrophises and becomes overly concerned with normal issues (E.g.
Health, Relationships, Occupation, Finances)
o Related to Stress and Adjustment Disorder (if symptoms occur for a shorter time)
GAD Aetiology
Aetiology believed to be Genetic (5×RR if relatives), Neurobiological (Increased SNS activity
and reduced HPA Axis negative feedback), Childhood (Inconsistent parenting, Poor
attachments, Chaotic lifestyles) and Personality Traits
Diagnosis of GAD
Excessive Anxiety + Worry most days for >weeks about a number of ordinary events or activities which are difficult to control; >3/6 of Restlessness, Fatigability, Irritability, Muscle
Tension, Insomnia/Poor sleep, Poor concentration; Symptoms cause clinically significant
distress/impairment to function, and not due to Substance, General medical conditions, and
does not occur during Mood/Psychotic and Pervasive Developmental Disorder
GAD Symptoms
o Physical symptoms reflect overactivity of SNS and skeletal muscle tension
o Sleep is characteristically described as difficultly settling and intermittent waking; Often unpleasant dreams and nightmares; Early waking and failure to settle after also see in Depressive Disorder
o Can also have Panic Attacks (Sudden episodes of very severe anxiety) but more
common in Panic Disorder
GAD Associations
• Co-morbid with Depressive Disorder, Social Phobia and Panic Disorder; Also, ETOH misuse and
Drug Abuse frequently co-occur
o DDx – Depressive Disorder (ask about Depressive Symptoms), Schizophrenia (Ask about Psychotic Symptoms), Dementia (Formal assessment of Memory), Drugs
(ETOH, Cannabis, Antidepressants/psychotics, Caffeine), Thyroid, Phaeo, Arrhythmia
Management of GAD
• Step 1: Identification and Assessment, Education (E.g. Self Help, Sleep aids), Active Monitoring
• Step 2: CBT-based Self-Help, Psychoeducation
• Step 3: High Intensity Psychological Interventions (CBT, Applied Relaxation) or
Pharmacotherapy (SSRI First-line Setraline, or alternative SSRI or SNRI if ineffective); Offer Pregabalin if unable to tolerate SSRI or SNRI
o Benzodiazepines should only be offered for Short-term for Crisis; Antipsychotics
should not be used
• Step 4: Specialist Assessment
Panic Disorder
• 2F:M, Urban, Lower SES, Physical/Sexual Abuse; Peak 15-24yrs and 45-55yrs, rare after 65yrs
• Etymology of Panic: The Greek god Pan inspiring fear into people and animals when they
were alone; Without warning and all of a sudden
o Unprovoked, Spontaneous nature
o Essential for Recognition and Diagnosis
• 9% of population experiences Panic attack without lifetime; Associated with significant social
and occupational disability
Panic Attacks
Cluster of Symptoms that develop rapidly, lasting a few minutes, and during
which person fears some catastrophe will occur
o Palpitations, Tachycardia, Sweating and Flushing, Trembling, Dyspnoea, Chest
Discomfort, Nausea, Dizziness, Fainting, Depersonalisation
o Spontaneously without Provocation; One to two per week is usual
o Can lead to Agoraphobia due to avoidance of areas of panic attacks
Aetiology of Panic Disorder
Genetics (7-8× if Relatives); Biochemical Hypothesis (Imbalance of Neurotransmitter activity), Cognitive Hypothesis (Fearful cognitions regarding physical
symptoms of anxiety)
Diagnosis of Panic Disorder
• Recurrent Unexpected Panic Attacks plus at least one attack being followed by ≥1/12 of ≥1 of
the following: Persistent concern of further attacks, worrying about implications and
Significant change in behaviour related to attacks
• Not due to direct physiological effects of substance or other condition
• Panic attacks not accounted for by another disorder e.g. Social Phobia, Specific Phobia, OCD,
PTSD or Separation Anxiety Disorder
DDx of Panic Disorder
Other Anxiety Disorders, Depressive Disorders, PTSD, OCD, Drugs (Intoxication or
Withdrawal); Endocrine, Cardiac or Respiratory Disorders
• Co-morbid with Agoraphobia (3/4rds), Half fit diagnostic criteria of Depressive Disorder
Management of Panic Disorder
• Benzodiazepines only in short term; Sedating Antihistamines and Antipsychotics should not
be prescribed for Panic Disorder
• Step 1: Recognition and Diagnosis; Need to exclude acute physical problems if presenting
with Panic attack (E.g. ECG, Trop)
• Step 2 and 3: Psychological Intervention (E.g. CBT), Pharmacotherapy (SSRIs e.g. Citalopram
and TCAs e.g. Clomipramine, Imipramine) trial for 12/52 and change if no improvement,
Bibliotherapy (Self-help based on CBT principles)
• Step 4-5: Referral to Specialist service; Reassessment, Treatment of Co-morbid, CBT with
experienced staff, Pharmacotherapy
Management of Panic Attackq
• Focus on breathing, Stamp on the stop, Focus on other senses, Ground techniques
o Grounding: Breathing, Listening, Walking Barefoot, Wrapping in Blanket and feeling it
around you, touching something or Sniffing something with a strong smell
o Post-attack: Think about Self-care, tell someone you trust
• More information and self-management on Mind UK
• Hyperventilation leads to Hypocapnia causing Respiratory Alkalosis; Paradoxical
breathlessness occurs, causing further hyperventilation
• Rebreathing from a paper bag increases Alveolar concentration of carbon dioxide, correcting
the Alkalosis and decreasing breathlessness
• Prevent further episodes through practising slow, controlled breathing
Phobic Disorders
Similar Symptoms to GAD but: Occurs only in Particular Circumstances (E.g. Situations, Living things, Natural Phenomena), Avoidance of these Circumstances, and Anticipatory Anxiety of such circumstances (C/f GAD: Unprovoked, Unexpected, Co-morb Agoraphobia)
Specific/ Isolated Phobia
• Inappropriately Anxious in the presence of Particular Object or Situation or when anticipating
encounter; Mean onset animal phobias 7yrs; Situational phobias in young adulthood
o Blood, Excretion, Vomit, Needles, Injections, Animals (E.g. Snakes, Spiders), Dentists,
Darkness, Elevators, Illness, Heights, Storms, Airplanes
• Strong Avoidance Urge; Most actual avoidance; Anticipatory Anxiety is often severe
Specific/ Isolated Phobia Diagnosis
Marked and Persistent, Excessive or Unreasonable Fear cued by
Presence/Anticipation of Specific Objection/Situation; Exposure almost invariably leads to
Anxiety Response; Insight to excessiveness/unreasonableness, Avoidance interferes with life
o Co-Morbid with other Anxiety Disorders or Depressive Disorder
Specific/ Isolated Phobia: Aetiology
Most begin in childhood; Often frightening experience; Theories of Conditioning
(Reinforcement of Learned Behaviour after Negative Experience)
Specific/ Isolated Phobia: Treatment
• Psychoeducation and CBT with Graded Exposure Therapy (Reintroduce patient to phobic
situation in supportive manner); Short-term Benzos (although itself a form of avoidance)
• Antidepressants not usually appropriate – Highly Intermittent nature of Specific Phobia
Social Phobia
• M=F; Incapacitating, Inappropriate Anxiety in Social Situations that leads to desire for Escape
or Avoidance; Specific concerns about being observed critically and negatively evaluated by
others, and Insight into Irrationality
o Anticipatory Anxiety can occur; Avoidance may be partial or total
o Symptoms include Blushing, Trembling; Concerned about being noticed by others
o Use of ETOH to relieve anxiety; More common vs other Phobic Disorders
o Common traits include Low Self-esteem and Perfectionism
How does social phobia manifest
Usually begins with Acute Anxiety in public place; Subsequently occurring in similar places,
with episodes becoming more severe and increasing avoidance
Social Phobia: Associations
• Co-Morb with other Anxiety Disorders, Depression, PTSD, and ETOH Misuse
Social Phobia: Aetiology
Often in late adolescents (concerned about impression onto others); Parenting and Childhood might have impact; Overprotectiveness might feature
o Persistent for many years but most improve by mid-life
Diagnosis of social phobia
• Marked, Persistent fear of ≥1 Social Performance Situations (Exposure to unfamiliar people,
Possible Scrutiny), Exposure almost invariably provokes immediate response, Exposure almost
invariably leads to Anxiety Response; Insight to Irrationality, Avoidance interferes with life
• The individual fears that he/she acts in a way that is humiliating or embarrassing
o If other medical condition present, must not be related to fear, or avoidance
Management of Social Phobia
• Treatment similar to GAD; SSRI (E.g. Setraline), SNRI (E.g. Venlafaxine); Previously MAOI was
used by SE profile poor (Avoid Tyramine: Strong/aged cheese, cured meats, fermented foods,
soy, sauces, beer/wine/liqueurs etc)
o While on antidepressants, patients advised to practise exposure to situations which
they might have previously avoided
- Anxiolytics for immediate, short-term relief before lasting treatment taken effect
- Propanolol and other non-specific Beta Blockers for tremors and palpitations
Agoraphobia
• 2F:M; Mean 20yrs; Peaks 15-30yrs and 70-80yrs
• Experiences of Anxiety in situations that are unfamiliar, from which they cannot escape or
have little control over leading to Avoidant Behaviour
o Anxious when they are away from home, in crowds, in situations they cannot leave
easily, social situations, and open spaces (Agora = Marketplace)
▪ In older age, Agoraphobia linked to physical frailty, and fear that accident or
major illness will occur
o Patterns of Unexplained Panic Attacks requiring hurried escape, with Recurrence
when same/similar situation encountered again
o Anticipatory Anxiety and Avoidance; Anxious thoughts, Fainting, Loss of Control
o Increased dependence on others to help with activities that provoke Anxiety
Agoraphobia Associations
Comorbid with Panic Disorder, other Anxiety Disorders, Depressive Disorders, ETOH misuse;
50% of Agoraphobia need criteria for Social Phobia
• Coded as Agoraphobia with Panic Disorder, or Agoraphobia without History of Panic Disorder
Agoraphobia Aetiology
Believed to be due to Conditioning, although cause of first panic attack is uncertain
Agoraphobia Diagnosis
Anxiety about being in places/situations where escape is difficult/embarrassing, or
help is not available if panic attack occurs; Situations Avoided or Endured with Marked
Distress or Anxiety about having a Panic Attack or symptoms, or requiring Companion
• Management of Agoraphobia similar to Social Phobia
OCD
Characterised by Obsessional Thinking and Compulsive Behaviour; Driven to perform
according to specific rules in order to prevent an Imagined, Dreaded Events
Features of OCD: Obsessions
Features Obsessions – Persistent thoughts, impulses or images that enter mind despite efforts to exclude them;
o Thoughts – Intrude forcibly into mind and patient attempts to exclude them; Usually unpleasant or shocking
o Images – Vividly imaged scenes e.g. Violence, Abnormal Sexual
o Ruminations – Internal debates with endless review of continuous arguments
o Doubts – Thoughts about actions that may have been completely inadequately, or
actions that may have harmed other people
o Impulses – Urge to perform acts met with internal struggle
Features of OCD: Compulsions
Repeated but Senseless activities (which may be Mental, or
Behaviours); Rituals are followed by temporary release of distress
Other Features of OCD
Anxiety and Depression, Depersonalisation; Might also have obsessional personality
Diagnosis of OCD
• Recurrent, Intrusive, Persistent Thoughts, Impulses, Images that cause Marked
Anxiety/Distress; Not simply excessive worries about real-life problems
• Attempts to ignore or suppress, or to distract; Has insight into Obsessions
• Repetitive Behaviours/Mental acts that person feels driven to perform, or rules to follow in
response to Obsession; Behaviour or Acts aimed to prevent/reduce distress, or prevent
dreaded event/situation; However, are not related to issue, or are excessive
• Impairment – Time-consuming (e.g. >1hr per day), Distressing, Functions; Depressive
Body Dysmorphic Disorder
• Persistent, Inappropriate concern about appearance of body (E.g. Shape and Size of Nose or
Breasts), despite reassurance; Many demand cosmetic plastic surgery
o Considered to be part of Obsessive-Compulsive Spectrum of disease; Distinct from
Anorexia; Includes symptoms of Depressive Symptoms and Social Avoidance
• Might also be associated with Delusions regarding others covertly pointing out their flaws
Screening Questions for OCD
- Are there thoughts that keep bothering you that you would like to get rid of, but can’t?
- Washing, Cleaning, checking things, taking a long time to do things
- Are you concerned about putting things in special order, or very upset by mess?
Aetiology of OCD
• Risk 10× if Relatives; Uncertain if Genetic or Family environment
• Organic Abnormalities – PET and fMRI identified increased Frontal Lobe, Caudate Nucleus and
Cingulum activity in OCD patients
• Disordered Neurotransmission; Serotoninergic and Dopaminergic pathways implicated
• Autoimmune Factors – Sydenham’s Chorea
(Autoimmune disease involving Basal Ganglia)
associated with OCD in 2/3rds of cases; Also
link with Group A Strep infection
• Early Experience (Obsessional Mothers and
Social Learning) and Conditioning
Management of OCD
• Treatment based on severity of Functional
Impairment caused by OCD
• CBT, including Exposure and Response
Prevention (ERP); Low intensity approaches
through Self-help/Telephone/Group
o More Intense of CBT plus ERP if Mod
Functional Impairment
o Add-on Pharmacotherapy If Severe
Referral to Specialist services if Risk to life, Severe Self-Neglect, Extreme Distress/Functional
Impairment, Treatment resistant
Management of OCD: Pharmacotherapy
• Pharmacotherapy with SSRIs; Fluoxetine has more evidence of effectiveness in BDD
o Change to different SSRI if side effects are not tolerated
o Increased dose or switch SSRI, if inadequate response after 4-6 weeks; If effective,
continue for at least 12 months to avoid risk of relapse
• If SSRIs ineffective, consider Clomipramine (but not other TCAs)
• Add-on Antipsychotic to SSRI or Clomipramine if still treatment-resistant; Alternatively,
Clomipramine with Citalopram
