Anxiety Disorders Flashcards

1
Q

Anxiety Disorder

A

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

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2
Q

Subdivisions of anxiety disorders

A

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)

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3
Q

Normal Anxiety

A

Response to threat; Feeling of Apprehension Plus Physiological response;
Attention and Concentration focussed on threat;
Beneficial response

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4
Q

Abnormal Anxiety

A
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
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5
Q

GAD

A

• 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)

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6
Q

GAD Aetiology

A

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

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7
Q

Diagnosis of GAD

A

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

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8
Q

GAD Symptoms

A

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

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9
Q

GAD Associations

A

• 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

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10
Q

Management of GAD

A

• 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

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11
Q

Panic Disorder

A

• 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

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12
Q

Panic Attacks

A

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

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13
Q

Aetiology of Panic Disorder

A

Genetics (7-8× if Relatives); Biochemical Hypothesis (Imbalance of Neurotransmitter activity), Cognitive Hypothesis (Fearful cognitions regarding physical
symptoms of anxiety)

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14
Q

Diagnosis of Panic Disorder

A

• 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

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15
Q

DDx of Panic Disorder

A

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

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16
Q

Management of Panic Disorder

A

• 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

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17
Q

Management of Panic Attackq

A

• 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

18
Q

Phobic Disorders

A
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)
19
Q

Specific/ Isolated Phobia

A

• 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

20
Q

Specific/ Isolated Phobia Diagnosis

A

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

21
Q

Specific/ Isolated Phobia: Aetiology

A

Most begin in childhood; Often frightening experience; Theories of Conditioning
(Reinforcement of Learned Behaviour after Negative Experience)

22
Q

Specific/ Isolated Phobia: Treatment

A

• 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

23
Q

Social Phobia

A

• 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

24
Q

How does social phobia manifest

A

Usually begins with Acute Anxiety in public place; Subsequently occurring in similar places,
with episodes becoming more severe and increasing avoidance

25
Q

Social Phobia: Associations

A

• Co-Morb with other Anxiety Disorders, Depression, PTSD, and ETOH Misuse

26
Q

Social Phobia: Aetiology

A

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

27
Q

Diagnosis of social phobia

A

• 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

28
Q

Management of Social Phobia

A

• 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
29
Q

Agoraphobia

A

• 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

30
Q

Agoraphobia Associations

A

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

31
Q

Agoraphobia Aetiology

A

Believed to be due to Conditioning, although cause of first panic attack is uncertain

32
Q

Agoraphobia Diagnosis

A

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

33
Q

OCD

A

Characterised by Obsessional Thinking and Compulsive Behaviour; Driven to perform
according to specific rules in order to prevent an Imagined, Dreaded Events

34
Q

Features of OCD: Obsessions

A

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

35
Q

Features of OCD: Compulsions

A

Repeated but Senseless activities (which may be Mental, or

Behaviours); Rituals are followed by temporary release of distress

36
Q

Other Features of OCD

A

Anxiety and Depression, Depersonalisation; Might also have obsessional personality

37
Q

Diagnosis of OCD

A

• 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

38
Q

Body Dysmorphic Disorder

A

• 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

39
Q

Screening Questions for OCD

A
  • 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?
40
Q

Aetiology of OCD

A

• 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

41
Q

Management of OCD

A

• 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

42
Q

Management of OCD: Pharmacotherapy

A

• 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