Anxiety Disorders Flashcards
Physical symptoms of anxiety?
Sweating, hot flushes or cold chills
Trembling or shaking
Muscle tension or aches and pains
Numbness or tingling sensations
Feeling dizzy, unsteady, faint or lightheaded
Dry mouth (not due to medication or dehydration)
Feeling of choking
A sensation of a lump in the throat, or difficulty in swallowing
Difficulty breathing
Palpitations or pounding heart, or accelerated heart rate
Chest pain or discomfort
Nausea or abdominal distress (e.g. churning in stomach)
Cognitive symptoms of anxiety?
Fear of losing control, “going crazy or dying
Feeling keyed up, on edge or mentally tense.
Difficulty in concentrating, “mind going blank”
Feeling that objects are unreal – derealization (feels like cardboard cut outs, dream like trance)
Feeling that the self is distant or “not really here” -depersonalisation
Hypervigilance (internal and external)
Racing thoughts
Meta-worry (worry about everything, worrying about worrying)
Health anxiety
Beliefs about the importance of worry
Preference for order and routine
Behavioural symptoms of anxiety?
Avoidance of certain situations
Exaggerated response to minor surprises or being startled
Difficulty in getting to sleep because of worrying
Excessive use of alcohol/drugs (prescription or “recreational”)
Restlessness and inability to relax
Persistent irritability
Seek reassurance from family/GP
Checking behaviours
What are phobic disorders typified by?
avoidance and anticipatory anxiety (because the person knows what will make them anxious)
What makes anxiety pathological?
anxiety disorders are pathological in EXTENT - ie the anxiety is more extreme than normal and/ or pathological in CONTEXT - ie anxiety in situations that are not “normally” anxiety provoking
anxiety disorders cause significant distress and impairment of social/ occupational/ other function
3 categories of symptoms of anxiety?
physical, cognitive, behavioural
Describe the stress response and what happens in pathological anxiety?
Exposure to stress results in instantaneous and concurrent biological responses. The amygdala acts as the emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response (occurs in ms). This is modified by later-received cortically processed signal (ie act first, think later). With pathological anxiety there is an initial physical response and then cognition kicks in to perpetuate the response.
Define generalised anxiety disorder?
anxiety that is generalised and persistent but not restricted to, or even strongly predominating in any particular environmental circumstances
it is persistent and chronic with a fluctuating course (ie go through really bad phases when real stressors and better phases where low level anxiety)
anxiety is not about a particular thing but many things
needs to be long lasting (most days for at least 6 months)
Dominant symptoms of GAD?
Dominant symptoms are variable but generally include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness and epigastric discomfort
GAD cannot be explained by _____
cant be explained by any other disorder if for example hyperthyroid is making someone generally anxious they dont have GAD because it will go away when hyperthyroid is treated
What is GAD typically associated with?
restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind goes blank, irritability, muscle tension, sleep disturbance
Typical age of onset of GAD?
young
20s to 40s
so if someone presents older you want to rule out an organic cause of anxiety or rule out depression
People with GAD may often present to their GP with ______ as opposed to complaining of anxiety
physical symptoms
Management of GAD?
CBT is treatment of choice
can use SSRIs or SNRIS, or pregabalin as add ons
in general benzodiazepines should be avoided due to it being a chronic condition
Define panic disorder?
Essential feature is recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
Major difference between panic disorder and GAD?
in panic disorder anxiety is more severe but shorter lasting, feeling fine after the episode vs in GAD it’s a chronic low level of anxiety
Dominant symptoms of panic disorder?
sudden onset chest pain, palpitations, choking sensations, dizziness and feelings of unreality, also secondary feelings of fear of dying, losing control or going mad
Is panic disorder more or less common than GAD?
less common than GAD
Typical age of onset of panic disorder?
late adolescence to mid 30s
Management of panic disorder?
CBT is treatment of choice
SSRIs, SNRIs if long standing or no benefit from CBT
tricyclics may also be used
benzodiazepines short term only
Define agoraphobia?
a fairly well defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places or travelling alone in trains, buses or planes
Why do some people with agoraphobia experience little anxiety?
avoidance of the social situation is often prominent and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
Agoraphobia may be a _______ or ________ disorder
primary disorder or secondary disorder e.g. secondary to panic disorder or depression
Management of agoraphobia?
CBT and exposure therapy is first line
SSRIs/ SNRIs if needed
Benzodiazepines short term only
Define specific phobias?
A marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation e.g. flying, heights, animals, insects, blood
Even talking about the phobia can cause distress
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response akin to a panic attack
Describe insight in specific phobias?
the person generally has good insight and recognises that their fear is excessive or unreasonable
Difference between specific phobia and agoraphobia?
agoraphobia is less specific- there are lots of feared situations
specific phobias are very precise in the fear
Treatment of specific phobias?
behavioural therapy and graded exposure, add in CBT if necessary, SSRIs/ SNRIs if required can be helpful to augment behavioural therapy
Define social phobia/ social anxiety disorder?
a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
Difference between social phobia and agoraphobia?
social phobia typically occurs in small, intimate social settings whereas in agoraphobia the fear is worse in large crowds
Common symptoms of social phobia/ social anxiety disorder?
blushing or shaking, fear of vomiting, urgency or fear of micturition or defaecation
Age on onset of social anxiety? What does this result in?
tends to come on early in life resulting in poor school performance, school refusal, poor employment history
Treatment of social anxiety?
CBT is treatment of choice, may add SSRI/ SNRI
benzodiazepines short term only
Obsessive compulsive disorder diagnostic criteria?
obsessional symptoms or compulsive acts must be present most days for at least 2 weeks AND be a source of distress and interference with activities:
> obsessions must be individuals own thoughts
> resistance must be present
> rituals are not pleasant
> obsessional thoughts/ images/ impulses must be repetitive
OCD vs Anankastic PD?
in OCD the patient doesn’t want to be obsessive, they recognise it is obsessive and it causes them distress, the symptoms are ego-dystonic
In anankastic PD the person views what they are doing as normal and wants to do it, they take pride in it
Mean age of onset of OCD?
age 20
What do 60-90% of those with OCD experience?
at least 1 major depressive episode
Treatment of OCD?
CBT is main treatment and then may add SSRIs
The ___1_____ is involved in the fear response of panic and phobias
The ____2______ is involved in worry which produces anxiety, apprehension and obsessions
1) amygdala centred circuit
2) cortico-striatal-thalamic-cortical circuit
What is the main inhibitory neuron in the brain and how does it reduce anxiety?
GABA
reduces activity of neurons in the amygdala and CSTC
What do benzodiazepines do to GABA?
enhance GABA action and hence decreases anxiety
What GABA receptors do benzodiazepines target?
GABA A
MOA of benzodiazepines?
Binding of GABA to GABA A receptors opens a chloride channel which hyper polarises the membrane, therefore having an inhibitory effect
On GABA A receptor there is a separate benzodiazepine binding site (there is also a site for barbiturates, GA, and ethanol binding sites)
Benzodiazepine binding has a positive allosteric effect making GABA binding more likely and the effect greater
What are the main benzodiazepines used?
Lorazepam (ativan), diazepam (valium), chlordiazepoxide (in alcohol withdrawal)
NOTE: they all act the same, choice is to do with duration of action
Main pharmacological effects of benzodiazepines?
reduce anxiety and depression, hypnosis/ sedation, muscle relaxation, anticonvulsant effect, cause anterograde amnesia
Describe BZD and overdose?
BZD are fairly safe in overdose unless they are combined with other medication or alcohol where there is a risk of respiratory depression. Overdose can be treated with flumazenil.
What can BZD overdose be treated with?
antagonist flumazenil
Describe what is meant by tolerance and BZD?
someone can develop tolerance to the drug so it will take higher and higher doses to achieve the same effect
Symptoms of BZD withdrawal?
abdo pain, increased anxiety, muscle tension, chest pain, palpitations, sweating, shaking, blurred vision, depression, paraesthesia, nausea, insomnia etc
When would withdrawal of BZD occur?
if they were stopped suddenly
How to safely withdraw BZD?
1) transfer patient to equivalent daily dose of diazepam/ chlordiazepoxide preferably taken at night
2) reduce dose 2-3 weeks in steps of 2-2.5mg if withdrawal symptoms occur
3) dont reduce further until symptoms improve
4) may need to reduce in smaller steps
5) may take 4 weeks to a year to stop completely
