anxiety disorders Flashcards
define anxiety
= a state consisting of psychological and physical symptoms brought about by a sense of apprehension at a perceived threat
Anxiety is a normal response to stressors Known problem e.g. Exam, football match • Definable • Lasts a short period of time • If mild: helpful, If severe: harmful
pathophysiology of anxiety
When danger is perceived or anticipated the brain
activates the autonomic nervous system
Sympathetic - primes the body for action (release of
adrenaline and nor-adrenaline)
Perceived threat can be many external like agoraphobia
(wide spaces), social phobia and specific phobias OR internal
as in panic disorder, generalised anxiety disorder and OCDnaline and nor-adrenaline)
psychological Sx of anxiety
• feelings of fear or impending doom, apprehension • Dizziness and faintness • Restlessness • Exaggerated startle response • Poor concentration • Irritability • Insomnia • Night terrors • Depersonalisation • Derealisation • Globus hystericus (lump in throat&gulp) • Themes of misfortune • Belief of inability to cope with stress
physical Sx of anxiety
•Cardiovascular: palpitations, tachycardia, chest discomfort •GI: dry mouth, lump in throat, nausea, abdominal discomfort, diarrhoea •Resp: hyperventilation, difficulty catching breath, chest tightness •GU: urinary frequency, failure of erection, amenorrhoea •Other: hot flushes/cold chills, tremor, sweating, headache and muscle pains, numbness and tingling sensations around the mouth and in the extremities, dizziness and faintness
types of pathological anxiety
• Secondary to other psychiatric illnesses e.g. Psychotic and
delusional (worried about being stabbed)
• Secondary to physical conditions e.g. Thyrotoxicosis, drug use
(inc caffeine), drug withdrawal (BDZs), phaeochromocytoma,
hypoglycaemia and alcohol
• High trait anxiety (personality), worrier from childhood
RFs for anxiety
– Personality traits
– Childhood factors (loss/separation, abuse)
– Stress: relationships
– Social supports: families, less social support = more anxiety
– Genetic/biological factors
define phobia
intense, irrational fear of an object, situation, place or person that is recognised as excessive (out of proportion to the threat) or unreasonable.
- Marked avoidance of such object or situations
types of phobia
agoraphobia - fear of public spaces
social phobia- social situations which may lead to humiliation, criticism or embarrassment.
Specific phobias: fear of a specific object/location. Commonly enclosed spaces
(claustro-), heights (acro-), darkness (achluo-), blood (haemato-). Begin in early
childhood. Thought to be passed on to help future generations survive! Leads
to avoidance
what is agoraphobia
-> Fear of places that are difficult/embarrassing to escape from e.g. Crowd, alone at home, public transport
• Linked to poor spatial orientation
• Suffer acute anxiety attacks when in, or anticipate being in these situations
• Actively avoid situation
2 symptoms one of autonomic arousal
Mx
CBT
Pychoeducation
lifestyle changes/self-help groups
Antidepressants - SSRIs
BDZs are short term
self help groups
what is social phobia
At its core lies a fear of negative evaluation by others
Extreme persistent fear of being judged and embarrassed/ humiliated in all/specific social situations
• Either
– Marked fear of being the focus of attention or fear of behaving in an embarrassing/humiliating way
– Marked avoidance of being the focus of attention or situations that have the potential to be embarrassing/humiliating
Onset adolescence/childhood. CHRONIC COURSE.
• ?genetic predisposition
two Sx of anxiety and one of those blushing/fear of vomiting/urgency or fear of micturtion/defecation
Alcohol/BDZ abuse more common.
what is panic attack
intense fear, Rapid onset of severe anxiety, peak at 10 mins lasting 20-30mins.
Recurrent, unexpected panic attacks (no specific stimulus)
ass with >1 month subsequent, continued anxiety about attacks
Sx
physical anxity
fear of dying
depersonalisation/derealisation
what is generalised anxiety disorder
Essentially a WORRY problem
feelings of apprehension about everyday events/problems, with symptoms of muscle and psychic tension, causing significant distress/functional impairment.
at least 6 months
Specific content of (type 1) worries changes/varies
Includes “worries about worries” (type ll worries)
Usually accompanied by low level physical symptoms (e.g. insomnia, muscle tension, GI problems, headache)
Often maintained by the belief that worry is useful (positive worry beliefs) – e.g. it motivates, shows responsibility, prepares for problems, or stops bad things happening
what is OCD
obsessions
- Unwanted ideas, images or impulses that repeatedly enter the individual’s mind.
- Distressing for the individual who attempts to resist them
- recognizes them as absurd (egodystonic) and a product of their own mind.
Compulsions:
- Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing.
- not inherently enjoyable, nor do they ersult in completion of inherently useful tasks
- Performed to prevent some objectively unlikely event
- Usually recognized by the person as pointless or ineffectual and repeated
attempts are made to resist them
They are overt (observable by others) or covert (mental acts not observable).
OVERT: - washing- checking- ordering/aligning
COVERT: - praying- counting- repeating words
PERIOD OF TWO WEEKS
classifications of OCD
Predominantly obsessional thoughts - uncertain about their thoughts unlike delusions
– Predominantly compulsive acts
– Mixed obsessional thoughts and acts
• Obsessional thoughts are:
o Ideas, images, or impulses that enter the person’s mind again and again in
stereotyped form.
o Almost invariably distressing, and the person often tries, unsuccessfully, to
resist them.
o Recognized as the person’s own thoughts, even if they are involuntary or
repugnant.
• Compulsive acts or rituals are:
o Stereotyped behaviours that are repeated again and again.
o Not inherently enjoyable, nor do they result in completion of inherently
useful tasks.
o Performed to prevent some objectively unlikely event, often involving harm
to, or caused by, the person, which he or she fears might otherwise occur.
o Usually recognized by the person as pointless or ineffectual and repeated
attempts are made to resist them.
• Anxiety is almost invariably present; if compulsive acts are resisted the anxiety
gets worse
what is PTSD
1 month
- Caused by exposure to event or situation of exceptionally threatening or catastrophic nature within the last 6 months
which would be likely to cause pervasive distress in almost anyone
3 main features:
- re-experiencing
- avoidance
- hyperarousal
negative self view
Common PTSD co-morbidities-Other anxiety disorder/Depression/Substance misuse
DD for PTSD
- Adjustment disorders or bereavement
- Other functional psychiatric illnesses
- ORGANIC DISORDERS:
- endocrine
- neurological (dementia, MS, lupus etc.)
- drug induced (steroids, antihypert etc.)
- alcohol & illicit drug misuse
- misc. (infection, anaemia etc.)
Mx for anxiety
Primarily psychological- CBT (flooding/graded exposure/exposure and response prevention)
Primarily in primary care (severity-secondary and tertiary care)
Antidepressants- SSRIs first choice (usually require higher doses)
Antipsychotics- usually in secondary care
Social adjustments- work/family
pathophysiology/aetiology of OCD
- Decreased serotonin and abnormalities of the frontal cortex and basal ganglia.
- Twin and family studies suggest a genetic contribution to OCD
- Childhood group A beta-haemolytic streptococcal infection may have a role in causing OCD symptoms by setting up an autoimmune reaction which damages the basal ganglia (this is called PANDAS).
Psychoanalytic: Filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness.
Behavioural: Compulsive behaviour is learned and maintained by operant conditioning. The anxiety created by the obsession is reduced by performing the compulsion, and subsequently the need to perform the compulsion is increased.
associations of OCD
DDx of OCD
RFs of OCD
depression schizophrenia sydenham's chorea tourettes anorexia nervosa
DDx
- Hypochondriacal disorder - anankastic personality disorder
- schizophrenia
- depression
- generalized anxiety disorder
- common in early adult hood and is equally common in M/F
- FH o f OCD
- carryong out hte compulsive act
- Developmental factors such as neglect, abuse, bullying and social isolation may have a role.
what is ERP
involves exposing a pt to an anxiety provoking situation
Mx for OCD
Mild OCD/pt prefers low intensity approach
- CBT - ERP
- self-help materials
- telpehone
- group
This fails/moderate FI
- SSRI or more intensive CBT
- Severe -> SSRI and CBT
ERP is a technique in which patients are repeatedly exposed to the situation which causes them anxiety (e.g. exposure to dirt) and are prevented from performing the repetitive actions which lessen that anxiety (e.g. washing their hands). After initial anxiety on exposure, the levels of anxiety gradually decrease.
- Pharm therapy
SSRIs - fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
clomipramine
pregablin in treatment resitant OCD
mild
low intesnity psyh interventions - exposure response prevention
moderate
high intensity CBT + ERP
1st line SSRI/clomipramine
severe
referral -> secondary care mental health team
combined drug
Mx of PTSD
PTSD present within 3 months of trauma
- watchful waiting if mild <4 weeks
- Trauma-focused CBT should be given at least once a week for 8–12 sessions.
Short-term drug treatment may be considered in the acute phase for management of sleep disturbance (e.g. zopiclone).
Risk assessment is important to assess risk for neglect or suicide.
PTSD where Sx >3 months
- trauma focused psychological therapy
- – CBT
- – EMDR -> eye movement desensitisation + reprocessing
pharm considered when (1) little benefit from psych therapy
(2) pt prefer not to
venlafaxine/SSRI
Paroxetine, mirtazapine, amitriptyline and phenelzine are licensed for treatment of PTSD
Risperidone - severe cases
armed forces - more rapid secodnary referral
define neurotic disorders
class of functional mental disorder involving distress but not delusions or hallucinations, where behavior is not outside socially acceptable norms.
Sx/Signs of social phobia
blushing trembling dry mouth sweating avoidance
self-medication with an axxiolytic
Sx of GAD accroding to ICD-10
Sx for at least 6 months
- tension, worry, feelings of apprehension adn one symptom of autonomic arousal
Worry (excessive, uncontrollable) Autonomic hyperactivity (sweating, pupil size, HR) Tension in muscles/Tremor Concentration difficulty/Chronic aches Headache/Hyperventilation Energy loss Restlessness Startled easily/Sleep disturbance
Ix
-> Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia).
-> ECG: may show sinus tachycardia.
-> Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and
Depression Scal
Sx of panic dis
PANICS Disorder Palpitations Abdominal distress, Numbness/Nausea Intense fear of death Choking feeling/ Chest pain, Sweating/Shaking/Shortness of breath, Depersonalization/Derealization.
• Palpitations, pounding heart, or accelerated heart rate.
• Sweating.
• Trembling or shaking.
• Sense of shortness of breath or smothering.
• Feeling of choking or difficulties swallowing (globus hystericus).
• Chest pain or discomfort.
• Nausea or abdominal distress.
• Feeling dizzy, unsteady, light-headed, or faint.
• Derealization or depersonalization (feeling detached from
oneself or one’s surroundings).
• Fear of losing control or going crazy.
• Fear of dying (angor animus).
• Numbness or tingling sensations (paraesthesiae).
• Chills or hot flashes.
PANIC disorder Mx
SSRIs are first line - no improvement aftre 12 weeks then a TCA e.g. imipramine or clomipramine may be considered.
CBT intervention of choice
Self-help methods include bibliotherapy (giving written information on panic disorder and
how to overcome it), support groups and encouraging exercise to promote good health.
Mx
step1 recognition + diagnosis
step 2 Tx in primary self-help mild-moderate -> individuaised non-faciliated self-help -> individualised self-help
step 3 - CBT
SSRI/SNRI/TCA
referral to specialist help
body dysmorphic disorder
Characterised by a preoccupation with an imagined
defect in appearance.
Leads to time consuming behaviours e.g. mirror gazing,
comparing particular features to those of others,
excessive camouflaging tactics, skin picking and
reassurance seeking.
ICD-10 criteria for PTSD
two or more persistent Sx of increased psychological sensitivity and arousal
- difficulty falling or staying asleep
- irritability/outbursts/anger
- difficulty in concetrating
- hypervigiliance
- exaggerated startle response
- reexperiencing
RFs for PTSD
Vulnerability factors: low education, lower social class, Afro- Caribbean/Hispanic, ♀ gender, low self-esteem/neurotic traits,
previous (or family) history of psychiatric problems (esp. mood/anxiety disorders), previous traumatic events (including adverse childhood experiences and abuse).
- Peri-traumatic factors: trauma severity, perceived life threat, peri- traumatic emotions, peri-traumatic dissociation.
- Protective factors: high IQ, higher social class, Caucasian, ♂ gender, psychopathic traits, chance to view the body of a dead person.
DDx for anxiety
Adjustment disorders or bereavement Other functional psychiatric illnesses ORGANIC DISORDERS: - endocrine - neurological (dementia, MS, lupus etc.) - drug induced (steroids, antihypert etc.) - alcohol & illicit drug misuse - misc. (infection, anaemia etc.)
aetiology of GAD
biological
- genetic
- neurophysiological -
Dysfunction of autonomic nervous system, exaggerated responses in the amygdala and hippocampus. Alterations in GABA, serotonin and noradrenaline.
environmental
- Stressful life events: history of child abuse, problems with relationships, personal illness, employment or finances
- substance dependence
RFs of GAD
Predisposing
Genetics, childhood upbringing, personality type and demands for high achievement. Being divorced.
Living alone or as a single parent.
Low socioeconomic status.
Precipitating
Stressful life events such as domestic violence, unemployment, relationship problems and personal illness (e.g. chronic pain, arthritis, COPD).
Maintaining
Continuing stressful events, marital status, living alone and ways of thinking which perpetuate anxiety (e.g. ‘What will happen if others notice that I am anxious?’).
DD for GAD
Excessive caffeine or alcohol consumption.
Withdrawal from drugs.
Organic: anaemia, hyperthyroidism,
phaeochromocytoma, hypoglycaemia
Other neurotic disorders: panic disorder, specific phobias, OCD, PTSD.
Depression.
Schizophrenia.
Personality disorder (e.g. anxious PD, dependent PD).
Mx of GAD
mx -
step 1 - written info/active monitoring, Psychoeducation
step 2 low intensity psych interventions - individual non-facilitated self-help - individual guided self-help - psychoeducational group based therpay
step 3
high-intensity psychological intervention - CBT
pharm
1st SSRI - sertraline after 8 weeks maximum no effect go to another SSRI
2ND SNRI - venlafaxine, duloxetine
3rd line - pregablin
social
- self help methods
- support groups
- exercise
RFs for phobias
Aversive experiences (prior experiences with specific objects or situations) - Stress and negative life events - Other anxiety disorders - Mood disorders - Substance misuse disorders - Family history
DDx for phobia
Panic disorder, PTSD, anxious personality disorder, somatoform disorders, adjustment disorder, depression, schizophrenia (may avoid socializing because of paranoid delusions).
Mx of agoraphobia
CBT - graduated exposure and desensitisation
SSRIs are first line pharm agent
Mx for social phobia
CBT - graduated exposure
Pharm
SSRIs (escitalopram/sertralin) -> SNRIs (venlafaxine) -> MAOI (moclobemide)
Pyshcodynamic psychotherapy for those who decline CBT/medication
Mx for specific phobia
exposure either using self-help methods or more formally through CBT.
Benzodiazepines may be used as anxiolytics in the short term
RFs of panic disorder
Family history Major life events Age (20–30) Recent trauma Females Other mental disorders White ethnicity Asthma Cigarette smoking Medication (e.g. benzodiazepine withdrawal)
DDx for panic disorder
Psychiatric: Other anxiety disorders (e.g. generalized anxiety disorder, phobic anxiety disorder), dissociative disorder, bipolar affective disorder, depression, schizophrenia, adjustment disorder.
Organic: Phaeochromocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndrome, arrhythmias, alcohol/substance withdrawal (see Table 5.1.1 in Overview of anxiety disorders).
features of PTSD
within 6 months
- reexperiencing - Flashbacks, vivid memories, nightmares, distress when exposed to similar circumstances as the stressor.
- avoidance - Avoiding reminders of trauma (e.g. associated people or locations), excessive rumination about the trauma, inability to recall aspects of the trauma.
- hyperarousal - Irritability or outbursts, difficulty with concentration, difficulty with sleep, hypervigilance, exaggerated startle response
- emotional numbing - Negative thoughts about oneself, difficulty experiencing emotions, feeling of detachment from others, giving up previously enjoyed activities.
Ix of PTSD
- Questionnaires: Trauma Screening Questionnaire (TSQ), Post-traumatic diagnostic scale.
- CT head: if head injury suspected.
Features of OCD
- failure to resist
- originate from pts mind - not imposed by outosde persons or influences
- repetitive and Distressing - excessive or reasonable
- Carrying out the obsessive thought is not in itself pleasurable
CHECKING IS THE MOST COMMON FOLLOWED BY CLEANING
Ix fro OCD
Yale–Brown obsessive–compulsive scale (Y-BOCS) 10-item questionnaire with each item graded from 0–4
DDx for OCD
Organic
Dementia
Epilepsy
Head injury
Obsessions and compulsions
Eating disorders (AN and BN)
Anankastic
personality disorder
Body dysmorphic disorder: Preoccupation with
an imagined defect in physical appearance, resulting in time- consuming behaviours, e.g. mirror gazing
Primarily obsessions Anxiety disorders (e.g. phobic anxiety) Depressive disorder Hypochondriacal disorder schizophrenia
Primarily compulsions
- Tourette’s syndrome
- Kleptomania
(inability to refrain from stealing items)
somatic Sx of GAD
dry mouth
chest pain
difficulty breathing
feeling of choking
nausea, abdominal distress, loose motions
hot flushes or cold chills, numbness or tingling, headache
muscle tension
aches or pains
restlessness, sensation of lump in throat (globus hystericus), difficulty swallowing (dysphagia).
PTSD v adjustment disorder
PTSD - catastrophic event whereas adjustment doesn’t
PTSD - Sx within 6 months v adjustment 1 month
What other (secondary) psychological disorders could a PTSD pt have
developed, or be at increased risk of developing, due to his primary
problem?
Depression; alcohol misuse; other substance misuse; panic disorder;
somatisation; other anxiety disorder
Cognitive theory suggests the following as the most significant underlying factor in
anxiety disorders?
catastrophisation
e key component in panic
disorder (and is vital to explain the mechanism of panic). In other anxiety problems patients
tend to have a higher perception of threat and of an adverse outcome (i.e. they forsee the
worst happening in the future)
when to consider EMDR criteria
r adults with a diagnosis of PTSD or clinically important symptoms of
PTSD who have presented between 1 and 3 months after a non-combat-related trauma if
the person has a preference for EMDR.
Offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD
who have presented more than 3 months after a non-combat-related trauma.”
Patients with PTSD may develop depression; such depression may require treatment in its
own right.
what is diphasic response
¨ Vaso-vagal syncope caused by an
overcompensating rebound parasympathetic
activation following sympathetic arousal
how to prevent syncope with
applied tension
ICD-10 Criteria for the diagnosis of panic disorder
ICD-10 Criteria for the diagnosis of panic disorder
A.Recurrent panic attacks that are not consistently associated with a specific situation or object, and often occur spontaneously. The panic attacks are not associated with marked exertion or with exposure to dangerous or life-threatening situations.
B.Characterized by ALL of the following: (1) Discrete episode of intense fear or discomfort; (2) Starts abruptly; (3) Reaches a crescendo within a few minutes and lasts at least some minutes; (4) At least one symptom of autonomic arousal: palpitations, sweating, shaking/ tremor, dry mouth; (5) Other symptoms: See GAD, Section 5.2.
define acute stress disorder
Mx
acute stress reaction that occurs in the 4 weeks after a traumatic event
Mx
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
