Anxiety Disorders

Question 1

Physical symptoms of anxiety?

Answer 1

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)

Question 2

Cognitive symptoms of anxiety?

Answer 2

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

Question 3

Behavioural symptoms of anxiety?

Answer 3

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

Question 4

What are phobic disorders typified by?

Answer 4

avoidance and anticipatory anxiety (because the person knows what will make them anxious)

Question 5

What makes anxiety pathological?

Answer 5

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

Question 6

3 categories of symptoms of anxiety?

Answer 6

physical, cognitive, behavioural

Question 7

Describe the stress response and what happens in pathological anxiety?

Answer 7

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.

Question 8

Define generalised anxiety disorder?

Answer 8

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)

Question 9

Dominant symptoms of GAD?

Answer 9

Dominant symptoms are variable but generally include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness and epigastric discomfort

Question 10

GAD cannot be explained by _____

Answer 10

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

Question 11

What is GAD typically associated with?

Answer 11

restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind goes blank, irritability, muscle tension, sleep disturbance

Question 12

Typical age of onset of GAD?

Answer 12

young
20s to 40s
so if someone presents older you want to rule out an organic cause of anxiety or rule out depression

Question 13

People with GAD may often present to their GP with ______ as opposed to complaining of anxiety

Answer 13

physical symptoms

Question 14

Management of GAD?

Answer 14

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

Question 15

Define panic disorder?

Answer 15

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

Question 16

Major difference between panic disorder and GAD?

Answer 16

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

Question 17

Dominant symptoms of panic disorder?

Answer 17

sudden onset chest pain, palpitations, choking sensations, dizziness and feelings of unreality, also secondary feelings of fear of dying, losing control or going mad

Question 18

Is panic disorder more or less common than GAD?

Answer 18

less common than GAD

Question 19

Typical age of onset of panic disorder?

Answer 19

late adolescence to mid 30s

Question 20

Management of panic disorder?

Answer 20

CBT is treatment of choice
SSRIs, SNRIs if long standing or no benefit from CBT
tricyclics may also be used
benzodiazepines short term only

Question 21

Define agoraphobia?

Answer 21

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

Question 22

Why do some people with agoraphobia experience little anxiety?

Answer 22

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

Question 23

Agoraphobia may be a _______ or ________ disorder

Answer 23

primary disorder or secondary disorder e.g. secondary to panic disorder or depression

Question 24

Management of agoraphobia?

Answer 24

CBT and exposure therapy is first line
SSRIs/ SNRIs if needed
Benzodiazepines short term only

Question 25

Define specific phobias?

Answer 25

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

Question 26

Describe insight in specific phobias?

Answer 26

the person generally has good insight and recognises that their fear is excessive or unreasonable

Question 27

Difference between specific phobia and agoraphobia?

Answer 27

agoraphobia is less specific- there are lots of feared situations
specific phobias are very precise in the fear

Question 28

Treatment of specific phobias?

Answer 28

behavioural therapy and graded exposure, add in CBT if necessary, SSRIs/ SNRIs if required can be helpful to augment behavioural therapy

Question 29

Define social phobia/ social anxiety disorder?

Answer 29

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

Question 30

Difference between social phobia and agoraphobia?

Answer 30

social phobia typically occurs in small, intimate social settings whereas in agoraphobia the fear is worse in large crowds

Question 31

Common symptoms of social phobia/ social anxiety disorder?

Answer 31

blushing or shaking, fear of vomiting, urgency or fear of micturition or defaecation

Question 32

Age on onset of social anxiety? What does this result in?

Answer 32

tends to come on early in life resulting in poor school performance, school refusal, poor employment history

Question 33

Treatment of social anxiety?

Answer 33

CBT is treatment of choice, may add SSRI/ SNRI

benzodiazepines short term only

Question 34

Obsessive compulsive disorder diagnostic criteria?

Answer 34

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

Question 35

OCD vs Anankastic PD?

Answer 35

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

Question 36

Mean age of onset of OCD?

Answer 36

age 20

Question 37

What do 60-90% of those with OCD experience?

Answer 37

at least 1 major depressive episode

Question 38

Treatment of OCD?

Answer 38

CBT is main treatment and then may add SSRIs

Question 39

The ___1_____ is involved in the fear response of panic and phobias

The ____2______ is involved in worry which produces anxiety, apprehension and obsessions

Answer 39

1) amygdala centred circuit

2) cortico-striatal-thalamic-cortical circuit

Question 40

What is the main inhibitory neuron in the brain and how does it reduce anxiety?

Answer 40

GABA

reduces activity of neurons in the amygdala and CSTC

Question 41

What do benzodiazepines do to GABA?

Answer 41

enhance GABA action and hence decreases anxiety

Question 42

What GABA receptors do benzodiazepines target?

Answer 42

GABA A

Question 43

MOA of benzodiazepines?

Answer 43

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

Question 44

What are the main benzodiazepines used?

Answer 44

Lorazepam (ativan), diazepam (valium), chlordiazepoxide (in alcohol withdrawal)
NOTE: they all act the same, choice is to do with duration of action

Question 45

Main pharmacological effects of benzodiazepines?

Answer 45

reduce anxiety and depression, hypnosis/ sedation, muscle relaxation, anticonvulsant effect, cause anterograde amnesia

Question 46

Describe BZD and overdose?

Answer 46

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.

Question 47

What can BZD overdose be treated with?

Answer 47

antagonist flumazenil

Question 48

Describe what is meant by tolerance and BZD?

Answer 48

someone can develop tolerance to the drug so it will take higher and higher doses to achieve the same effect

Question 49

Symptoms of BZD withdrawal?

Answer 49

abdo pain, increased anxiety, muscle tension, chest pain, palpitations, sweating, shaking, blurred vision, depression, paraesthesia, nausea, insomnia etc

Question 50

When would withdrawal of BZD occur?

Answer 50

if they were stopped suddenly

Question 51

How to safely withdraw BZD?

Answer 51

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