Anxiety disorders: clinical picture Flashcards
Anxiety disorders
Panic disorder without agoraphobia
Panic disorder with agoraphobia
Agoraphobia without history of panic disorder
Specific phobia
Social phobia
Obsessive compulsive disorder
PTSD
Acute stress disorder
Generalised anxiety disorder
Secondary anxiety disorder
Clinical picture of acute stress reaction
Acute stress reaction lasts hours to 3 days
Response to exceptionally stressful events
Initial daze
Mixed and usually changing picture
Individual vulnerability
Typical symptoms of acute stress
Feelings of being numb or dazed
Insomnia
Restlessness
Poor concentration
Autonomic arousal
Anger/ anxiety/ depression
Withdrawal
Adjustment disorder
Wide range of emotional or behavioural symptoms
Stressor not necessarily life threatening
Out of proportion to stressor
Lasts up to 6 months
PTSD
Response to exceptionally threatening or catastrophic event
PTSD symptoms
Re-experiencing flashback/ nightmares
Numbness/ detachment
Avoidance
Hyperviligance/ startle
Insomnia
Anxiety/ depression
PTSD course
Usually immediate onset
Most recover within 1 year
Rape victims
- 94% at 2 weeks
- 65% at 1 month
- 42% at 6 months
Aetiology of stress: psychological models
Working through the trauma memory
Understanding the meaning of the event
Distinguishing which of the stimuli present at the time of the trauma are dangerous and which are innocuous
Readjusting basic beliefs about the self and the world
Aetiology of stress: biological models
Extreme stress affects neurons, resulting in functional changes
Speculation concerning the neurotransmitters involved
- catecholamines
- glucocorticoids
- serotonin
- endogenous opiods
Clinical picture of GAD
Symptoms are persistent
Not restricted to or strongly predominating in any particular set of circumstances
Characteristic features of GAD
Worry and apprehension
Headache and motor tension
Autonomic hypersensitivity
Psychological symptoms of GAD
Fearful anticipation
Irritability
Sensitivity to noise
Restlessness
Poor concentration
Worrying thoughts
Physical symptoms of GAD
Gastrointestinal
Respiratory
Cardiovascular
Genitourinary
Neuromuscular
Gastro symptoms of GAD
Dry mouth
Difficulty swallowing
Epigastric discomfort
Excessive wind
Frequent/ loose motions
Respiratory symptoms of GAD
Tight chest
Difficulty inhaling
Hyperventilation
Cardio symptoms of GAD
Palpitations
Chest pain
Missed beats
Genitourinary symptoms of GAD
Frequent/ urgent micturition
Erectile failure
Dysmenorrhoea
Amenorrhoea
Neuromuscular symptoms of GAD
Tremor
Paraesthesia
Tinnitus
Dizziness
Headaches
Muscular aches and pain
Additional symptoms of GAD
Sleep disturbances (insomnia, night terrors)
Sadness
Depersonalisation
Fixation with details
Epidemiology of GAD
Lifetime prevalence: 8.9%
Women > men
3 x higher in patients in primary care clinics
High level of co-morbidity
Genetic predisposition of GAD
Five fold increase in 1st degree relatives
Monozygotic = dizygotic
Shared heritability for GAD and mood disorders
Aetiology of GAD neurobiological mechanisms
Most evidence comes from animal studies
Effects of stress apparently mediated through cortisol- some evidence exists for abnormalities in HPA axis
Benefit from SSRIs and venlafaxine suggests role for serotonin
Noradrenergic pathways associated with fear, arousal and stress
GABA has a role and benzodiazapine type agonists are effective
GAD: association with life events
Several studies found association with stressful/ traumatic life events
GAD: parenting
Lack of warmth and encouragement leads to general perception of personal inefficacy
Overprotection coupled with lack of warmth and responsiveness can lead to anxiety
Mothers of anxious preschool children more critical and intrusive and less responsive
Psychic picture
Fear of losing control
Going mad
Fainting
Dying
Derealisation
Depersonalisation
Somatic picture
Palpitations
Tachycardia
Sweating
Trembling
Dyspnoea
Choking
Chest pain
Nausea
Butterflies
Urgency
Dizziness
Faintness
Paraesthesia
Endocrine diagnosis of panic
Hypoglycaemia
Phaeocromocytoma
Carcinoid
Cardiovascular diagnosis of panc
Arrhythmia
Respiratory diagnosis of panic
Asthma
Neurological diagnosis of panic
Seizures
Vestibular
Clinical picture of agoraphobia
Anxiety in specific context
- away from home
- in crowds
- in situations they cannot easily leave
Presents with anxiety symptoms and panic attacks
Anxious cognition about fainting and loss of control are common
Avoidance is common
Epidemiology of panic
Panic attacks: 7-9% of the population
Panic disorder: 1.5-2.5% lifetime prevalence
Onset has two peaks: 15-24, 45-54
Panic risk factors
Widowed, divorced or separated individuals in cities
Limited education, early parental loss and physical/ sexual abuse
Females > males
Genetic predisposition of panic
Increased risk in 1st degree relative 7 fold
Increased concordance in all but one monozygotic twin study
Modest inheritability suggested by family and twin studies
At least 50% environmental influences
Environmental factors of panic
Separation/ loss
Relationship difficulties
New responsibilities
Early parental separation
Traumatic childhood event
Early sexual abuse
Biological models of panic
Panic attacks may be triggered in locus coeruleus
Noradrenergic agents stimulate attacks in sufferers
SSRIs are effective but contradictory findings regarding the role of serotonin
GABA has a role
Cholecystokinin causes panic attacks in animals and pentagastrin causes attacks in panic disorder patients
Clinical picture of specific phobias
Inappropriate anxiety in the presence of one of more particular objects or situations
Characterised by adding name of stimulus
Specific phobias- subtypes
Blood, injections, injury
Animals and insects
Aspects of high nature
Situational
Blood/ injection/ injury phobia response
Initial short lived parasympathetic arousal
Followed by parasympathetic arousal
May result in vasovagal syncope
Subjective experience tends to disgust and repulsion rather than pure apprehension
Psychological theories of specific phobias
Symptoms related to unresolved unconscious conflict
Phobias learned through association of negative experience with object or situation
Large number of studies suggest phobias may be acquired via observational learning
Clinical picture of social phobia
Inappropriate anxiety in
- situations where the person is observed
- situations where there is potential for criticism
Leads to avoidance of trigger situations
- eating in public
- dinner parties
- committees, seminars, public speaking
Symptoms of social phobia
Anticipatory anxiety
Feeling anxious
Blushing
Trembling (observed writing is a problem)
Relieved by alcohol (potential for abuse)
Clinical picture of OCD
Obsessional thoughts/ images
- words, ideas, beliefs and/ or images
- recognised as own
- intrude forcibly into the mind
- they are resisted
Compulsions reduce anxiety
Cleaning/ checking
Precision
OCD symptoms
Contamination- washing
Doubts- checking
Clinical picture of OCD 2
Obsessional impulses
- urges to perform acts
Obsessional rituals
- magic words or numbers
- desire to complete acts
Compulsions- the need to act on the obsessions
Epidemiology of OCD
Lifetime prevalence of 2-3%
Men = women
During adolescence, boys > girls
Mean age onset ~ 20 years
OCD co-morbidity
Mejor depressive episode
Increased risk for
- alcohol disorders
- social phobia
- specific phobia
- panic disorder
- eating disorder
- schizophrenia
- tic disorder
Increased prevalence of tourette’s in relatives
Aetiology of OCD: neurotransmitters
Serotonin dysregulation
Dopamine dysfunction
Aetiology of OCD: genetics
Monozygotic»_space; dizygotic
First degree relatives of patients with childhood onset OCD have higher than expected incidence of OCD
