Anxiety disorders and management Flashcards
Biological (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 Feeling of choking Sensation of a lump in throat Difficulty breathing Palpitations or pounding heart Chest pain or discomfort Nausea or abdo distress
What are the pathological cognitive symptoms of anxiety?
Derealization
Depersonalisation
Meta-worry
Behavioural symptoms of anxiety?
Aviodance of certain situations Exaggerated response to minor suprises or being startled Difficulty in getting to sleep due to worry Excessive use of alcohol/ drugs Restlessness and inability to relax Persistent irritability Seek reassurance from family/ gp Checking behaviours
What is the stress response?
Exposure to stress results in instantaneous and concurrent biological responses (to assess danger and organise an appropriate response)
What is the emotional filter of the brain?
Amygdala; emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response
Modified by later-received cortically processed signals
Which hormone is particularly active in stress?
Cortisol and catecholamines via adrenal gland
Different types of anxiety disorders?
GAD Panic disorder Agoraphobia Social phobia Specific phobia OCD
What is generalised anxiety disorder?
Anxiety that is generalised and persistent but not restricted to, or even strongly predominating in any particular environmental circumstances (free floating)
What is a buzzword for GAD?
Free-floating
What are the dominant symptoms of GAD?
Persistent nervousness Trembling Muscle tensions Sweating Lightheadedness Palpitations Dizziness Epigastric discomfort
Criteria for diagnosis of GAD?
Long lasting; most days for at least 6 months
Not controllable
Causing significant distress/ impairment in function
What is the lifetime prevalence of GAD?
9%
Typical age of onset of GAD?
20-40
Treatment of GAD?
1st line: CBT
2nd line: SSRI/SNRI
Long term anxiety disorder: pregabalin
Benzodiazepines (short term only)
What is CBT?
An evidence based psychological treatment based on identifying an individual’s automatic thoughts, cognitive biases and schemas
Helps the individual identify thoughts, assumptions, misinterpretations and behaviours that reinforce and perpetuate the anxiety
What is panic disorder?
Recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
Dominant symptoms in panic disorder?
Sudden onset of palpitations
Chest pain
Choking sensations
Dizziness
Feelings of unreality (depersonalization, derealization)
Secondary fear of dying, losing control or going mad
What will panic order tend to occur with?
Agoraphobia
Direct physiological effects of a substance or general medical condition; hyperthyroidism, caffeine intoxication
Can get panic in depression
What % of those with panic disorder will have concurrent agoraphobia?
50-67%
What can trigger a panic attack in susceptible individuals?
Infusion of lactate
Re-breathing air (inc CO2)
What can be seen on the PET scan of someone who has panic disorder?
Increased metabolism in the anterior pole of the temporal lobe; parahippocampal gyrus
What is the treatment for a panic disorder?
1st line: CBT
2nd line: SSRI/SNRI/tricyclics
Benzodiazepines (short term only)
What are the 3 types of phobia?
Agoraphobia
Social phobia
Specific phobia
What is agoraphobia?
Well-defined cluster of phobia embracing fears of leaving home, entering ships, crowds and public places, or travelling along in trains, buses or planes
Will people with phobias recognise that their phobia is irrational?
Yes
What is a specific phobia?
Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation
What is the treatment for a specific phobia?
Behavioural therapy; exposure
Graded exposure/ systematic desensitisation
Add in CBT if necessary
SSRI/ SNRI if required
What is a social phobia?
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
What are common anxiety symptoms of social phobia?
Blushing or shaking
Fear of vomiting
Urgency or fear of micturition or defecation
When does social anxiety tend to start?
In school; results in poor school performance, school refusal, poor employment history
What is the biological basis of social phobia?
Increased bilateral activation of the amygdala and increased rCBF to the amygdala (and related limbic areas) that normalizes on successful treatment (pharma or psychological)
Treatment of social phobia?
CBT
SSRI/ SNRIs
Benzo (short term only)
What are examples of obsessional thoughts?
Ideas, images or impulses entering the mind in a stereotyped way
Recognised as the patients own thoughts
Unpleasant, resisted and ego-dystonic
Buzzword for obsessional thoughts?
Ego-dystonic
What are examples of compulsive acts?
Repeated rituals or stereotyped behaviours Not enjoyable Not functional Often view as neurtralising Recognised as pointless Resistance may diminish over time
Criteria for diagnosis of OCD?
Obsessional thought 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 own thoughts
Resistance must be present
Rituals are not pleasant
Obsessional thoughts/ images/ impulses must be repetitive
What does OCD commonly co-exist with?
Schizophrenia Tourettes and other tic disorders Body dysmorphic disorder Eating disorders Trichtillomania
Treatment for OCD?
CBT; including response prevention
SSRI/ clomipramine
Mode of action of benzodiazepines?
Act on GABA-A receptor (inhibitory ionotropic receptor) to cause chloride influx and membrane hyperpolarisation and therefore inhibitory post-synaptic potential
Problems with benzodiazepines?
Sedation and psychomotor impairment
Dependency and abuse
Alcohol interaction
Can worsen co-morbid depression
