Anxiety Disorders Flashcards
Define neurosis
Functional illness
- not psychotic - patients are distressed but no delusions or hallucinations
Synonymous with anxiety disorders
Pathology of anxiety disorders
When danger perceive or anticipated brain activates autonomic nervous system
- sympathetic response primes body for action - release of adrenaline and nor-adrenaline
Brain unable to distinguish between physical and psychological threat - responds to false alarm
Define specific phobias
Marked fear of specific object or situation
- > marked avoidance of such object or situation
- dogs, spiders, thunder, balloons, snakes, flying
Define panic disorder
Fear of you own physiological and psychological reactions
Bodily changes viewed as signs of impending collapse, insanity or death
Agoraphobia - Accompanying avoidance of situations that may trigger these reactions
Cognitive model of panic disorder
Internal/external trigger
- > perceived threat
- > anxiety
- > physical/cognitive symptoms
- > misinterpretation
- > further anxiety and avoidance/safety behaviours
Define generalised anxiety disorder
Worry problem
- specific content of (type 1) worries changes/varies
- includes worries about worries (type 2 worries)
Usually accompanied by low level physical symptoms
- insomnia, muscle tension, GI problems, headache
Often maintained by belief that worry is useful - positive worry beliefs
- motivates, shows responsibility etc
Social anxiety disorder
Fear of negative evaluation of others
-> avoidance of feared situations, use of safety behaviours, anticipatory anxiety and unhelpful post-mortems following social encounters
Define OCD
Obsessive Compulsive Disorder
Obsessions = unwanted recurring distressing intrusive thoughts or images
Compulsions = manage distress caused by intrusion the patient conducts neutralising behaviours
Examples of obsessions
Contamination
Doubting
Aggression or horrific impulses
Sexual imagery
Examples of compulsions
Overt - seen - washing - checking - ordering/aligning Covert - within head - praying - counting - repeating words
Cognitive behavioural model of OCD
Trigger
- > intrusive thought
- > interpretation and appraisal
- > emotion
- > neutralisation
- > consequences
Define body dysmorphic disorder
Characterised by a preoccupation with an imagined defect in appearance
- leads to time consuming behaviours - mirror gazing, comparing features to others, excessive camouflaging tactics, skin picking and seeking reassurance
Define PTSD
Post Traumatic Stress Disorder Caused by exposure to event or situation of exceptionally threatening or catastrophic nature which would be likely to cause pervasive distress in almost anyone 3 main features - re-experiencing - avoidance - hyperarousal
Problems associated with anxiety disorders
Increased autonomic arousal Avoidance Time consuming anxiety reducing behaviours Worry Procrastination/inability to make decisions Reduced concentration Impact on functioning Impaired sleep patterned Alcohol and drug dependence
Differential diagnosis of anxiety disorders
Adjustment disorders or bereavement Other functional psychiatric illness Organic disorders - endocrine - hyperthyroidism - neurological - dementia, MS, lupus - drug induced - steroids, antihypert - alcohol and illicit drug misuse and withdrawal - miscellaneous - infection, anaemia
Define neurosis
Collective term for psychiatric disorders characterised by distress
- non-organic
- discrete onset
- delusions and hallucinations absent
Define anxiety
Unpleasant emotional state involving subjective fear
- normal human experience but can become excessive or inappropriate
Types of anxiety disorders
Specific phobia Social phobia Generalised anxiety disorder Agoraphobia Panic disorder OCD
Common symptoms of neurosis
Pscyhological
- anticipatory fear of impending doom, worrying thoughts, restlessness, poor concentration and attention, irritability, depersonalisation and derealisation
CVS
- palpitations, chest pain
Resp
- hyperventilation, cough, chest tightness
GI
- abdo pain, loose stools, N+V, dry mouth
GU
- increased frequency, failure of erection, menstrual discomfort
Neuromuscular
- tremor, myalgia, headache, paraesthesia, tinnitus
Classification of neurosis
Paroxysmal anxiety
- situation dependent
- phobic anxiety disorder
- specific phobia
- agoraphobia
- social phobia
- situation independent
- panic disorder
Continuous anxiety
- generalised anxiety disorderGeneralised vs espisodic anxiety
Generalised - present most of the time - excessive or inappropriate worry about normal life event - longer duration Episodic - abrupt onset - discrete episodes - severe with strong autonomic symptoms - short lived
Differential diagnosis of anxiety
Medical - hyperthyroid, hypoglycaemia, anaemia, phaeochromocytoma, Cushing’s disease, COPD, congestive cardiac failure (CCF), malignancies Substance related - Intoxication - Withdrawal - Side effects Psychiatric - eating disorders, depression, schizophrenia, OCD, PTSD
Define GAD
Generalised Anxiety Disorder
Syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the patient recognises as excessive and inappropriate
- symptoms present most days for at least 6 months
Pathophysiology of GAD
Biological - genetic - neurophysiological - alterations in GABA, serotonin and noradrenaline Environmental - stressful life events - substance dependence
Risk factors of GAD
Predisposing
- genetics, childhood upbringing, personality type and demands for high achievement, divorced, living alone, low socioeconomic status
Precipitating
- stressful life events, unemployment, relationship problems, personal illness
Maintaining
- continuing stressful events, marital status, living alone, ways of thinking which perpetuate anxiety
Clinical features of GAD
Worry - excessive, uncontrollable Autonomic hyperactivity - sweating, increased pupil size, increased HR Tension in muscles Tremor Concentration difficulty Chronic aches Headache Hyperventilation Energy loss Restlessness Startled easily Sleep disturbance
ICD-10 criteria for GAD
A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems
At least four of the following symptoms with at least one symptom of autonomic arousal
- symptoms of autonomic arousal, palpitations, sweating, shaking/tremor, dry mouth
Differential diagnosis of GAD
Other neurotic disorder - panic, specific phobias, OCD, PTSD
Depression
Schizophrenia
Personality disorder
Excessive caffeine or alcohol consumption
Withdrawal from drugs
Organic - anaemia, hyperthyroidism, phaeochromocytoma, hypoglycaemia
Management of GAD
Biological - SSRIs - sertraline - 1st line - SNRIs and pregabalin - benzodiazepines only for short term due to dependence Psychological - psychoeducational groups - low intensity - CBT - high intensity - applied relaxation Social - self help - writing down thoughts - support groups - exercise
Step care model for management of GAD
Step 1 - identification and assessment - psychoeducation - monitoring Step 2 - low intensity psychological interventions Step 3 - high intensity psychological interventions - drug treatment Step 4 - highly specialised input - combination of drug and psychological therapies - crisis team
Define phobia
Intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonalbe
Define agoraphobia
Fear of public spaces or entering a public space from which immediate escape would be difficult in the event of a panic attack
Define social phobia
Fear of social situations which may lead to humiliation, criticism or embarrassment
Risk factors for phobias
Adverse experiences Stress and negative life events Other anxiety disorders Mood disorders Substance misuse disorders Family history
Clinical features of phobias
Biological
- tachycardia
- vasovagal response (bradycardia) in need and blood phobias -> syncope
Psychological
- anticipatory anxiety
- inability to relax
- urge to avoid situation
- fear of dyingICD-10 criteria for agoraphobia
Marked and consistently manifest fear in or avoidance of at least two of the following
- crowds
- public spaces
- travelling alone
- travelling away from home
Symptoms of anxiety in the feared situation with at least two symptoms present together
- at least one symptom of autonomic arousal
Significant emotional distress due to the avoidance or anxiety
- recognised as excessive or unreasonable
Symptoms restricted to feared situation
ICD-10 criteria for social phobia
Marked fear or marked avoidance of being the focus of attention or fear of acting in a way that will be embarrassing or humiliating
At least two symptoms of anxiety in the feared situation
- blushing
- fear of vomiting
- urgency or fear of micturition/defecation
Significant emotional distress due to the avoidance or anxiety
- recognised as excessive or unreasonable
Symptoms restricted to feared situation
ICD-10 criteria for specific phobia
Marked fear or avoidance of specific object or situation that is not agoraphobia or social phobia
Symptoms of anxiety in the feared situation
Significant emotional distress due to the avoidance or anxiety
- recognised as excessive or unreasonable
Symptoms restricted to feared situation
General management of phobias
Establish good rapport with patient
Avoidance of anxiety-inducing substances - caffeine
Screen for co-morbidities - substance misuse and personality disorders
Refer to specialist if there is a risk of self-harm, suicide, self-neglect or significant co-morbidity
Management of agoraphobia
CBT - graduated exposure
SSRIs
Management of social phobia
CBT Graduated exposure Pharmacological - SSRIs - sertraline - SNRIs - venlafaxine - MAOI - moclobemide Psychodynamic psychotherapy for those who decline CBT or medication
Management of specific phobia
Exposure using self-help or formally CBT
Benzodiazepines - short term
Define panic disorder
Recurrent, episodic, severe panic attacks which are unpredictable and not restricted to any particular situation of circumstance
Aetiology of panic disorders
Biological - genetic - neurochemical - post-synaptic hypersensitivity to serotonin and adrenaline - sympathetic NS - fear or worry stimulates SNS increases CO increases anxiety Cognitive - misinterpretation of somatic symptoms Environmental - presence of life stressors
Risk factors for panic disorders
Family history Major life events Age 20-30 Recent trauma Females Other mental disorders White ethnicity Asthma Cigarette smoking Medication - benzodiazepine withdrawal
Clinical features for panic disorders
Peak within 10 minutes and rarely persist beyond an hour
Panic attacks
- intense fear/discomfort
- autonomic arousal
ICD-10 criteria for panic disorder
Recurrent panic attacks that are not consistently associated with specific situation or object - often occur spontaneously
Characterised by
- discrete episode of intense fear of discomfort
- starts abruptly
- reaches crescendo within a few minutes and lasts a few minutes
- at least one symptom of autonomic arousal - palpitations, sweating, shaking, dry mouth
- other symptoms of anxiety
GAD vs panic disorder vs phobic anxiety
GAD - persistent - a/w agitation - constant worry - a/w depression Panic disorder - episodic - a/w escape - fear of symptoms - a/w depression, agoraphobia, substance misuse Phobic anxiety - situational - a/w avoidance - fear of situation - a/w substance misuse
Management of panic disorder
SSRIs - 1st line
- if not improvement after 12 weeks then TCA - imipramine or clomipramine
CBT
Self help methods - bibliotherapy, support groups, encouraging exercise
Step care approach to management of panic disorders
Recognition and diagnosis Treatment in primary care Review and consider alternative treatments Specialist referral Care in mental health services
Define post-traumatic stress disorder
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
Define abnormal bereavement
Delayed onset, more intense and prolonged (>6 months)
Impact of loss overwhelms individuals coping capacity
Define acute stress reaction
Abnormal reaction to sudden stressful events
Define adjustment disorder
Significant distress accompanied by an impairment in social functioning
Aetiology of PTSD
Exceptionally stressful event
- severe assault
- major natural disaster
- serious RTC
- observer/survivor of civilian disaster
- involvement in wars
- freak occurrences
- physical torture
- pow or hostage
- unexpected injury or violent death of family member/friend
Risk factors for PTSD
Exposure to traumatic event
- armed forces, police, fire service, journalists, doctors
- refugees, asylum seekers
Pre-trauma
- previous trauma, history of mental illness, females, low socioeconomic backgrounds, childhood abuse
Peri-trauma
- severity of trauma, perceived threat to life, adverse emotional reaction
Post-trauma
- concurrent life stressors, absence of social support
Clinical features of PTSD
Occur within 6 months of event
Relieving situation
- flashbacks, vivid memories, nightmares, distress when exposed to similar situations
Avoidance
- locations or associated people, excessive rumination, inability to recall aspects
Hyperarousal
- irritability, difficultly with concentration and sleep, hypervigilance, exaggerated startle response
Emotional numbing
- negative thoughts, difficulty experiencing emotions, feelings of detachment from others, giving up previously enjoyed activities
ICD-10 criteria for PTSD
Exposure to a stressful event or situation - likely to cause distress in anyone
Persistent remembering/reliving
Actual or preferred avoidance of similar situations
Inability to recall some important information about period of exposure or persistent symptoms of increased psychological sensitivity and arousal
All occur within 6 months of stressful event
Stages of grief
Denial Anger Bargaining Depression Acceptance
ICD-10 criteria for acute stress reaction
Exposure to an exceptional physical or mental stressor followed by an immediate onset of symptoms (within 1 hour)
Divided into mild, moderate and severe
Clinical features of acute stress reaction
Anxiety symptoms Narrowing of attention Apparent disorientation Anger or verbal aggression Despair or hopelessness Uncontrollable or excessive grief
ICD-10 criteria for adjustment disorder
Identifiable psychosocial stressor within one month of onset
Symptoms not severe enough to be classed as a specific psychiatric disorder
Present for less than 6 months
Management of PTSD
< 3 months
- watchful waiting for mild symptoms < 4 weeks
- military personal access to treatment provided by armed forces
- trauma-focused CBT
- short-term drug treatment for actue sleep disturbance - zopiclone
- risk assessment for neglect of suicide
> 3 months
- trauma-focused psychological intervention
- CBT
- eye movement desensitisation and reprocessing (EMDR)
- drug treatment
- paroxetine
- mirtazapine
- amitriptyline
- phenelzine
Define OCD
Obsessive-compulsive disorder
Recurrent obsessional thoughts or compulsive acts
Define obsessions
Unwanted intrusive thoughts, images or urges that repeatedly enter the individuals mind
- distressing for individual who attempts to resist them and recognises them as absurd
- product of their own mind
Define compulsions
Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing
- overt - observable by others
- covert - mental acts not observable
Aetiology of OCD
Biological
- reduced serotonin
- abnormalities of the frontal cortex and basal ganglia
Psychoanalytical
- filling mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness
Behavioural
- compulsive behaviour learned and maintained by operant conditioning
Risk factors for OCD
Relative with OCD
Carrying out compulsive act exacerbates obsessions - maintaining factor
Developmental factors
- neglect, abuse, bullying and social isolation
ICD-10 criteria for OCD
Either obsessions or compulsions present on most days for a period of 2 weeks of less
Obsessions share a number of features all which must be present
Obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning usually by wasting time
ICD-10 specifications of OCD
Predominately obsessional thoughts or ruminations
Predominately compulsive acts
Mixed obsessional thoughts and acts
Examples of obsessions
Contamination - dirt, viruses, germs, bodily fluids Fear of harm - door locks not safe Excessive concern with order or symmetry Sex Violence Blasphemy Doubt
Examples of compulsions
Checking - gas or water taps, doors Cleaning or washing Repeating acts - counting, arranging objects Mental compulsions - special words repeated in a set manner Hoarding
Features of obsessions or compulsions
Failure to resist Originate from patient's mind Repetitive Distressing Carrying out the obsessive thought is not itself pleasurable
OCD cycle
Obsession
Anxiety
Compulsion
Relief
Differential diagnosis for OCD
Obsessions and compulsions - eating disorders - anankastic personality disorder - body dysmorphic disorder Primarily obsessions - anxiety disorders - depressive disorders - hypochondriacal disorder - schizophrenia Primarily compulsions - Tourette's syndrome - kleptomania Organic - dementia - epilepsy - head injury
Management of OCD
CBT
- ERP - exposure and response prevention involved repeated exposure to situation and prevention of performing repetitive actions
Pharmacological
- SSRIs
- fluoxetine
- fluvoxamine
- paroxetine
- sertraline
- citalopram
Psychoeducation, distracting techniques and self-help books can be usedManagement stages of OCD
Mild
- low intensity psychological intervention - < 10 hours per patient
Moderate
- SSRI or high intensity psychological intervention
Severe
- combined SSRI and CBT (with ERP)
Define somatoform disorders
Group of disorders whose symptoms are suggestive of or take the form of a physical disorder
- in the absence of a physiological illness leading to the presumption that they are causes by psychological factors
- sufferers repeatedly seek medical attention despite it consistently failed to benefit them
Define dissociative (conversion) disorders
Characterised by symptoms which cannot be explained by a medical disorder
- convincing associations in time between symptoms and stressful events, problems or needs
Pathophysiology of somatoform disorders
Biological
- possible implication of neuroendocrine genes
- genetic component
Psychological
- high proportion of those with PTSD suffer from somatoform disorders
- association with physical or sexual abuse
Social
- adopting sick role to gain relief from stress
Pathophysiology of dissociative disorders
Must be causally linked to stressful like events
- dissociation - process of separating off certain memories from normal consciousness - psychological defence mechanism used to cope with emotional conflict
- conversion - distressing life events transformed into physical symptoms
Sequence of events in dissociative disorders
Distressing event - tragic death of loved one Emotional distress - anxiety and distress Dissociation - separating distressing event from normal consciousness Conversion - emotional distress to physical symptoms Gain - primary = stress relief - secondary = financial rewards
Risk factors for somatoform and dissociative disorders
Childhood abuse Reinforcement of illness behaviours Anxiety disorders Mood disorders Personality disorders Social stressors
ICD-10 criteria for dissociative amnesia
Amnesia, partial or complete for recent events of problems that were traumatic or stressful
Too extensive and persistent to be explained by ordinary forgetfullness
ICD-10 criteria for dissociative fugue
An unexpected physical journey away from usual surroundings followed by amnesia for the journey
- self care is maintained
ICD-10 criteria for dissociative stupor
Profound reduction in or absence of voluntary movements, speech and normal responses to stimuli
- normal muscle tone
ICD-10 criteria for trance and possession disorders
Trance - temporary alternation in state of consciousness
Possession - absolute conviction by the patient that they have been taken over by a spirit, power or person
ICD-10 criteria for dissociative motor disorders
Loss of the ability to perform movements that are under voluntary control or ataxia
ICD-10 criteria for dissociative convulsions
Sudden, unexpected spasmodic movements that resemble epilepsy but without loss of consciousness
ICD-10 criteria for dissociative anaesthesia and sensory loss
Partial or complete loss of cutaneous sensation, vision, hearing or smell
ICD-10 categories of somatoform disorders
Persistent somatoform pain disorder Undifferentiated somatoform disorder Somatisation disorder Hypochondriacal disorder Somatoform autonomic dysfunction
ICD-10 criteria for somatisation disorder
At least 2 years duration of physical symptoms that cannot be explained by any detectable physical disorder
Preoccupation with symptoms causes physical distress which leads to them seeking repeated medical consultations and requesting investigations
Continuous refusal by patients to accept reassurance from doctors that there is no physical cause for their symptoms
Total of 6 or more symptoms
Common symptoms in somatisation disorder
GI - abdo pain, N+V, bloating, regurgitation, loos bowel movements, swallowing difficulty CVS - chest pain, breathlessness at rest, palpitations GUM - dysuria, frequency, incontinence, vaginal discharge, menstrual problems Others - discolouration or itching of skin - arthralgia - paraesthesia in limbs - headaches - visual disturbance
Features of hypochondriacal disorder
Patient misinterprets normal bodily sensations which leads to non-delusional pre-occupation that they have a serious physical disease
Refuse to accept reassurances from doctors
Features of dysmorphophobia
Excessive preoccupation with barely noticeable or imagined defects in physical appearance
- causes significant distress
Features of somatoform autonomic dysfunction
Symptoms related to autonomic nervous system
- palpitations, tremor, sweating, dry mouth, flushing, hyperventilation
Attributed by patients to a physical disorder
Features of persistent somatoform pain disorder
Persistent (6 months +) and severe pain that cannot be fully explained by a physical disorder
- result of psychosocial stressors and emotional difficulties
- differs from somatisation disorder in that pain is primary feature and multiple symptoms from different systems not present
Malingering and factitious disorders
Physical of psychological symptoms intentionally produced
Malingering - patient seeks advantageous consequences of being diagnosed with a medical condition
Factitious (Munchausen’s) - individual wishes to adopt the sick role in order to receive the care of a patient for internal emotional gain
Management of somatoform and dissociative disorders
Biological - antidepressants - SSRIs for underlying mood disorder - physical exercise enhances self-esteem Psychological - CBT - coping strategies Social - encourage pleasurable private time - involve family where appropriate
