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
