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Psychiatry > Anxiety Disorders > Flashcards

Anxiety Disorders Flashcards

1
Q

What is anxiety?

A

It is an emotional response in anticipation of a future threat
Normal anxiety- not as in’s tense and is adaptive
Pathological anxiety-inappropriate anxiety that is inappropriate in its intensity and duration

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2
Q

What is the classification of anxiety disorders?

A
  1. Separation anxiety disorder
  2. Selective mutism
  3. Specific phobia
  4. Social anxiety disorder
  5. Panic disorder
  6. Panic attack
  7. Agoraphobia
  8. Generalised anxiety disorder
  9. Substance or medication induced anxiety disorder
  10. Anxiety disorder due to another medical condition
  11. Other specified anxiety disorder
  12. Unspecified anxiety disorder
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3
Q

What are the most common psychiatric disorders ?

A

Anxiety disorders

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4
Q

When is the age that anxiety usually begins?

A

It usually starts at the childhood, adolescent years And early adulthood but only diagnosed in late adulthood

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5
Q

Which group of people are typically affected by anxiety?

A

Women(2:1)

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6
Q

What is the aetiology in anxiety?

A
  1. Genetics and epigenetics
    - ask about family history
  2. Environmental factors
    - negative life events, childhood trauma
  3. Structural
    - limbic system
  4. Neurotransmitters(Monoamine transmitters)
    - dopamine, noradrenergic and serotonin
  5. Decreased Inhibition by GABA and increased excitation in glutamate
  6. Neuropeptides:
    - corticotrophin releasing factor, neuropeptide Y, Vasopressin, oxytocin
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7
Q

What is the explanation of the limbic system and the possible cause of anxiety?

A

The limbic system that comprises of the amygdala, the hippocampus, the medial prefrontal cortex, the anterior cingulate cortex, insular cortex, subcallosal cortex, and medial frontal gyrus which are involved in modulation of affect
-hippocampalvolume and neurogenesis have been implicated in in the responsivity of the HPA stress response and the resilience of mood disorders

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8
Q

What are the screening tools we can use in primary healthcare to help diagnose anxiety disorders adequately?

A
  1. Hospital anxiety and depression scale (HADS)

2. PRIME-MD-primary care evaluation of mental disorders

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9
Q

How long does it take for pharmacological agents to work on the patient?

A

4-8 weeks

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10
Q

What is the pharmacological treatment of anxiety disorders?

A
  1. SSRI’s like fluoxetine
  2. SNRI’S like venlafaxine which treats the acute phase of the anxiety and prevents future recurrences of pathological anxiety
  3. Benzodiazepines but these should be used with an antidepressant because it will help reduce the chance of addiction and it only works on the acute anxiety
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11
Q

What is the psychotherapy we can offer patients with anxiety?

A
  1. Cognitive behavioral therapy-where the patient identifies maladaptive automatic thoughts and behaviors and restructures those faulty thoughts by using therapeutic exercises like progressive muscle relaxation and breathing techniques
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12
Q

What is the definition of panic disorder?

A

When the patient experiences unexpected, recurrent and spontaneous panic attacks

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13
Q

What is the definition of panic attacks?

A

These are discrete periods of intense anxiety with physical symptoms such as sweating, trembling, increased heart rate , shaking and shortness of breath with possible cognitive symptoms like fear of losing control or going crazy

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14
Q

What is the definition of agoraphobia?

A

It is the fear of being in places or situations where help may not be available or where escape Amy be difficult

  • this leads to avoidance of places like supermarkets, , churches, freeways
  • this anxiety or fear leads to impairment in functioning in daily routine, work or social activities
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15
Q

What is the epidemiology associated with panic disorder?

A

It usually affects women more than men
The onset of age is 25 years
The lifetime prevalence is 2-4%

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16
Q

What is the epidemiology associated with agoraphobia?

A

The age of onset is usually 17 years

The lifetime prevalence is 2%

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17
Q

What is the aetiology of panic disorder?

A
  1. Genetics
    First degree relative has a 4-6 fold chance of developing panic disorder
  2. Functional neuroanatomy
    - amygdala coordinates fear related behavior and fear responses in animals and humans
    - Locus ceruleus receives sensory information relating to the internal and external environment
    - thalamus which acts as a sensory relay system
    - hippocampus
    - HPA axis
  3. Neuroimaging:
    Structural and functional brain abnormalities have been found
  4. Neurochemistrty:
    - noraadrenaline-abnormalities in the presynaptic alpha 2 adrenoreceptors
    - serotonin
    - carbon dioxide and lactic acid/lactate-this provokes panic attacks in sensitive people
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18
Q

How do panic attacks usually occur?

A 
Patients present with physical symptoms like:
Sweating
Shaking
‘Palpitations
Shortness of breath
Dry mouth
Hot or cold flushes
Chest pain
Dizziness
Tremor
Nausea
Feeling of losing control, going crazy
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19
Q

What is the diagnostic criteria of panic disorder?

A

If the patient has recurrent and unexpected panic attack fro one month in addition to:

  1. Worrying about having additional attacks
  2. Worrying about the implications of the attacks
  3. Significant change in behavior because of the attacks
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20
Q

What is the differential diagnosis of panic disorder?

A
  1. Medical-neurological, cardiac, pulmonary, endocrinological
  2. Psychiatric-major depressive disorder, phobias, social anxiety disorder, PTSD
  3. Substances-cocaine, cannabis, amphetamines
  4. Other conditions-anaphylaxis, electrolyte disturbance
  5. Factitious didsorder
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21
Q

What is the medical differential diagnosis?

A
  1. Neurological
    - transient ischaemic attack
    - migraines
    - cerebrovascular event
    - epilepsy
  2. cardiovascular
    - heart failure, angina, anaemia
  3. Lungs:
    - hyperventilation
    - pulmonary embolism
    - asthma
  4. Endocrinology
    - hyperthyroidism
    - hypoglycaemia
    - Addisons disease
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22
Q

What is the course of panic disorder?

A

The patient often presents in early adulthood but it can start at any age
-can be complicated by MDD in 40-80% of patients and alcohol is used to self medicate

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23
Q

What is the treatment of panic disorder?

A
  1. SSRI’s fluoxetine
  2. SNRI’S venlafaxine
  3. Tricyclics antidepressants- imipramine
  4. Benzodiazepines (clonazepam)
  5. Monoamine oxidase inhibitors (phenelzine) or Reversible inhibitors of Monoamine oxidase (moclobemide)
24
Q

Why do we aim to start the patient on low doses of medication?

A

We start low, go slow and end high because the patient may feel worse before they get better initially and once symptoms have resolved they need to take their medication for a period of 12 months at least

25
Q

What are the possible side effects of using SSRI’s?

A
  1. Headache
  2. Nausea
  3. Loss of appetite
  4. Worsening anxiety upon initiation of treatment
  5. Loss of libido and anorgasmia
26
Q

What is the dose of SSRI(fluoxetine we giv in patients with panic disorder?

A

2,5mg starting

Average is 20-40mg and the highest dose is 60mg

27
Q

What other SSRI’s can we give and what is the dose?

A
  1. Citalopram 10mg per day mean dose is 20-40mg per day

2. Paroxetine 10mg per day mean is 20-40m,g

28
Q

What is the SNRI we can give in panic disorder and what is the does?

A
  1. Venlafaxine-37,5 mg and mean dose is 10mg max dose is 225mg daily
29
Q

What are the two tricyclics antidepressants we can give in panic disorder?

A
  1. Imipramine and Clomipramine
    Starting at 10mg daily and gradually increasing every 2-3 days to 25mg
    The usual effective dose is 150mg
    Maximum dose is 300 mg
30
Q

What is the main side effect of tricyclics antidepressants?

A

They cause anticholinergic symptoms
-these include dry mouth, dilated pupils, hyperthermia, tachycardia, orthostatic hypotension, cycloplegia-dilated ciliary muscles, constipation, blurred vision, cardiovascular problems
If they are taken above the maximum dose of 300mg they can kill a patient

31
Q

Which benzodiazepines do we usually give in panic disorder?

A
  1. Clonazepam and alprazolam
    - clonazepam-start at 0,5mg per day and effective dose is 1-2mg daily
    - alprazolam: starts at 0,75mg per day and effective dose is2-4mg daily
32
Q

What are the monoamine oxidase inhibitors and the reverse inhibitors of monoamine?

A
  1. Phenelzine is a MAOI and needs a tyramine free diet
    Food that contains high amount of tyramine is: aged cheese, soy sauce, aged meats and pickled fish
  2. RIMA is moclobemide acute treatment of panic disorder and we don’t need strict diets
33
Q

What other treatment can we offer the patient for panic disorder?

A
  1. Psycho-education
    This provides the patient with the necessary information about their condition such as the aetiology, course and treatment
    This allows the patient to take control of their situation and support groups could also be helpful to this patient
  2. Cognitive beahavioural therapy
    -this is effective as as first line treatment
    The patient has 10-15 weekly sessions which include self monitoring, countering anxious beliefs, modifying anxiety maintaining behaviours through behavioral technique, exposure to fear cues and relapse prevention studies
34
Q

How do we diagnose agoraphobia?

A

It is diagnosed when a patient experiences fear or anxiety for a duration of six months or more in at least 2 out of the 5 situations:

  1. Being in open spaces
  2. Being in enclosed spaces
  3. Being outside the home alone
  4. Using public transport
  5. Standing in a line or crowd

These fear provoking situations should not be situations in which the patient should be threatened in -like walking outdoors at night

35
Q

What is the aetiology of agoraphobia?

A
  1. Environmental factors:
    Death of a parent, early separation
  2. Temperamental factors
    - neuroticism
  3. Genetic factors
  4. Parenting style:
    Over protective parents
  5. Anxiety sensitivity
36
Q

Which disorders usually precede agoraphobia(occur first)?

A

Anxiety disorders

37
Q

Which disorders usually proceed agoraphobia?

A

Substance use and mood disorders

38
Q

What is generalised anxiety disorder?

A

It is a anxiety disorder characterised by pervasive and excessive worry about a variety of things such as school, work, family, health, money occurring more days than not for a period of 6 months
-it is sometimes associated with somatic symptoms which causes reduction in social and work functioning

39
Q

How do patients with GAD usually present?

A

With somatic symptoms like muscle tension, difficulty sleeping, restlessness and fatigue

40
Q

What is the prevalence and which group of people suffer from GAD the most?

A

The prevalence is 3-8% and the people that suffer the most are women

41
Q

What is the aetiology of GAD?

A
  1. Biological :
    Involves the limbic system, the frontal lobes, and basal ganglia
    Involves neurotransmitters such as serotonin, noradrenaline and GABA
  2. Psychological factors:
    Patients respond to unresolved unconscious conflicts
42
Q

To who do GAD patients usually present to first?

A

The physician or the psychiatrist and they usually present with somatic symptoms like palpitations and constipation

43
Q

What is the diagnostic criteria for GAD?

A
  1. Patients presenting with excessive, pervasive worry more days than not for a period of 6 months or more concerning a number of events
  2. The patient finds it difficult to control the worry
  3. The anxiety is associated with at least 3 of these six symptoms
    - difficulty concentrating
    - fatigue
    - sleep disturbance
    - muscle tension
    - irritability
  4. The anxiety causes impairment in important areas of life
  5. The distrubance is not due to the physiological effects of substance or medical conditions
  6. The disturbance is not better explained by another mental disorder
44
Q

What other psychiatric conditions present similarly to GAD?

A
  1. Major depresseive disorder
  2. Adjustment disorder
  3. Obsessive compulsive disorder
  4. Persistent depressive disorder
  5. Other anxieties: social anxiety, panic disorder
45
Q

What is the treatment for GAD in patients?

A

First line: SSRI’S and SNRI’S
Specifically paroxetine and sertraline and SNRI: venlafaxine

  1. Benzodiazepines:
    We need to be cautious about the use of benzos in a chronic condition. It is better to use a long half life like diazepam over a short half life like lorazepam
  2. Buspirone
  3. Other agents like -agomelatine which is a melatonergic agonist
  4. CBT
46
Q

What is social anxiety disorder?

A

It is disproportionate fear and anxiety to the negative evaluation of others (humiliation/embarrassment) by other other people in social and performance based situations

47
Q

What is the epidemiology of SAD?

A

It occurs mainly in adolescence and 95% of them would have already experienced the significant symptoms of SAD by 20

48
Q

What is the aetiology of SAD?

A
  1. Environmental factors
    Overprotective parents, parents who are less caring and rejecting, major life triggers
  2. Genetic factors
    -first degree relatives have a 3 times risk
  3. Neuroanatomy
    - problems with the noradrenergic, dopamine system
    - the anatomical areas include the amygdala and medial frontal areas
49
Q

How do we diagnose SAD?

A
  1. Anxious anticipation
  2. Avoidance of the sistuation
    It can also be characterised as those situations that involve social situation or performance based like public speaking
    -it is diagnosed if symptoms persist for more than 6 months
50
Q

What is the differential diagnosis of SAD?

A
  1. Panic disorder
  2. Specific phobias
  3. Agoraphobia
  4. Schizophrenia
  5. Substances like hallucinogens
  6. Personality disorder like avoidant or schizoid personality disorder
  7. OCD
  8. Illness anxiety disorder
51
Q

What are the common mimics of social anxiety disorder?

A
  1. Hyperthyroidism
  2. Caffeine
  3. Central nervous system tumours
  4. Cerebrovascular conditions
52
Q

What is the treatment of SAD?

A
  1. Pharmacotherapy
  2. Psychotherapy
  3. Psychoeducation
53
Q

What is the pharmacological treatment of SAD?

A
  1. SSRI’S- fluoxetine 20mg per day
  2. SNRI’S can be up to 75mg per day
  3. RIMA (moclobemide) and Tricyclic antidepressants like clomipramine are not usually used
  4. Anticonvulsants (garbapentin)
  5. Benzodiazepines like clonazepam
54
Q

What can we give the patient fro performance based anxiety?

A

Beta blockers like propranolol (10-40mg) 20-30 minutes before the performance

55
Q

What is the predicted treatment journey that the patient will take?

A
  1. Start the patient on the treatment and only evaluate after 8-12 weeks
  2. Ask patient about side effects like sexual side effects
  3. Measure targeted symptoms using LSAS
  4. Motivate the patient to continue using medication for 1 year, thereafter we can start weaning off 25% every 2 months

Psychiatry (17 decks)

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