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Year 2 - Theme 3 > Anxiety disorders - clinical picture > Flashcards

Anxiety disorders - clinical picture Flashcards

1
Q

How long does an acute stress reaction last for

A
  • Acute stress reaction lasts hours to 3 days
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2
Q

Typical symptoms of acute stress

A
  • Feelings of being numb or dazed
  • Insomnia
  • Restlessness
  • Poor concentration
  • Autonomic arousal
  • Anger/anxiety/depression
  • Withdrawal
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3
Q

Adjustment disorder

A

• Wide range of emotional or behavioural symptoms
• Stressor not necessarily life threatening
• Out of proportion to stressor
Lasts up to 6 months

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4
Q

PTSD

A

• Response to exceptionally threatening or catastrophic event
• … experienced ,witnessed … event that involved actual or threatened death or serious injury …. or threat to physical integrity of self or others.
… response involved intense fear, helplessness or hor

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5
Q

PTSD - difference in genders

A
  • Men experience more traumatic events than women

* Women more likely to develop PTSD following trauma (except rape)

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6
Q

PTSD symptoms

A
  • Re-experiencing flashbacks/nightmares
  • Numbness/detachment
  • Avoidance
  • Hypervigilance/startle
  • Insomnia
  • Anxiety/depression
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7
Q

PTSD course

A
  • Usually immediate onset
  • Most recover within 1 year
  • Rape victims
    • 94% at 2 weeks
    • 65% at 1 month
    • 42% at 6 months
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8
Q

Effect of depression and substance abuse on PTSD

A
  • Increases risk
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9
Q

Models of post-traumatic reactions concur that recovery is thought to require:

A
  • ‘Working through’ the trauma memory (going through the experience again in one’s own mind)
  • Understanding the meaning of the event
  • Distinguishing which of the stimuli present at the time of the trauma are dangerous & which are innocuous
  • Readjusting basic beliefs about the self and the world
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10
Q

Effect of stress on neurons

A
  • causes functional changes
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11
Q

Features of generalised anxiety disorders

A
  • Symptoms are persistent
  • Symptoms are not restricted to or strongly predominating in any particular set of circumstances
  • Characteristic features:
    • Worry & apprehension
    • Headache & motor tension (restless / trembling)
    • Autonomic hyperactivity (sweating / palpitations / dry mouth / epigastric discomfort / dizziness)
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12
Q

Psychological symptoms of GAD

A
  • Fearful anticipation
  • Irritability
  • Sensitivity to noise
  • Restlessness
  • Poor concentration
  • Worrying thoughts
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13
Q

GI physical symptoms of GAD

A

• Dry mouth, difficulty swallowing, epigastric discomfort, excessive wind, frequent/loose motions

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14
Q

Respiratory physical symptoms of GAD

A
  • Tight chest, difficulty inhaling, hyperventilation
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15
Q

CVS physical symptoms of GAD

A
  • Palpitations, chest pain, missed beats
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16
Q

Additional symptoms of GAD

A

Sleep disturbances - insomnia, night terrors

  • Sadness
  • Depersonalisation
  • Fixation with details
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17
Q

Co-morbidities associated with GAD

A
  • 70%

- Especially simple phobias, social phobia, panic disorder and depression

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18
Q

Gender - GAD

A
  • Women>men
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19
Q

Lifetime prevalence of GAD

A
  • 8.9%
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20
Q

Where is GAD more prevalent

A
  • Estimated to be 3x higher in patients in primary care clinics (indicated increased use of health care services)
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21
Q

Aetiology of GAD - Genetic predisposition

A
  • Five fold increase in 1st degree relatives1
    • 19.5% in relatives of GAD sufferers
    • 3.5% in relatives of controls
  • Monozygotic = dizygotic
  • Shared heritability for GAD and mood disorders
  • In summary: Genetic factors play a modest role
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22
Q

What is believed to mediate the effects of stress

A
  • Mediated through cortisol - some evidence exists for abnormalities in the HPA axis
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23
Q

What are noradrenergic pathways associated with

A
  • Fear, arousal and stress response; role in persistent anxiety states implicated but unclear
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24
Q

Specific stressors associated with an increase in risk of GAD

A
  • Early parental death
  • Rape
  • Combat
  • Chronically dysfunctional marital and family relationships
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25
Q

What is the attachment theory

A
  • Parents or other consistent caregivers serve important function in a child’s development
  • They provide a protective and secure base from which the child can operate
  • Disruption leads to anxious apprehension and dependency
  • Severe disruption leads to withdrawal and depression
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26
Q

What is agoraphobia

A
  • a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed
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27
Q

Clinical picture of panic - psychic

A

Psychic - fear of losing control, going mad, fainting, dying, derealisation, depersonalisation

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28
Q

Clinical picture of panic - somatic

A

Somatic: Palpitations, tachycardia, sweating, trembling, dyspnoea, choking, chest pain, nausea, ‘butterflies’, urgency, dizziness, faintness, paraesthesia, chills/flushes

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29
Q

Panic differential diagnosis - endocrine

A
  • Hypoglycaemia
  • Phaeocromocytoma
  • Carcinoid
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30
Q

Panic differential diagnosis - CVS

A
  • Arrythmia
31
Q

Panic differential diagnosis - Respiratory

A
  • Asthma
32
Q

Clinical picture of agoraphobia

A
  • Anxiety in specific context:
    • Away from home
    • In crowds
    • In situations they cannot easily leave
33
Q

Presentation of agoraphobia

A
  • Anxiety symptoms and panic attacks
  • Anxious cognitions about fainting and loss of control are common
  • Avoidance is common
34
Q

Prevalence of panic attacks

A
  • 7-9% of the population
  • 1.5-2.5% lifetime prevalence
  • Onset has two peaks 15-24 and 15-54
35
Q

Risk factors for panic attacks

A
  • Widowed, divorced or separated individuals in cities

* Limited education, early parental loss & physical/sexual abuse

36
Q

Panic attacks - gender

A
  • Females>males
  • Agoraphobia is especially prevalent in females
  • Males - longer duration but less agoraphobia and depression
37
Q

Genetic predisposition - panic attacks

A
  • Increased risk in 1st degree relatives ~ 7 fold
  • Increased concordance in all but one monozygotic twin study
  • Modest inheritability suggested by family & twin studies
  • At least 50% environmental influences
38
Q

Environmental factors - panic attacks

A
  • Precipitating events in 60-96% of cases
    • Separation / loss
    • Relationship difficulties
    • New responsibilities
  • Traumatic early life events
    • Early parental separation
    • Traumatic childhood event – 3 fold increase
    • Early sexual abuse (<5 years of age)
39
Q

Where might panic attacks be triggered in the brain

A
  • Locus coeruleus

- Increased firing associated with increased CO2 etc

40
Q

Noradrenergic agents that can stimulate attacks in sufferers

A
  • Yohimbine and isoproterenol stimulate attacks in sufferers
41
Q

Effect of SSRIs in panic attacks

A
  • Effective but contradictory findings regarding the role of serotonin
42
Q

Role of GABA - panic attacks

A
  • γ-Aminobuyric acid (GABA) has a role:
    • Benzodiazepine agonists are clearly effective
    • Benzodiazepine antagonist (flumazenil) aggravates attacks
43
Q

Role of cholecystokinin - panic attacks

A
  • Causes panic attacks in animals
44
Q

Role of pentagastrin - panic attacks

A
  • Causes attacks in panic disorder patients
45
Q

Clinical picture of specific phobias

A
  • Inappropriate anxiety in the presence of one or more particular objects or situations
  • Characterised by adding the name of the stimulus (e.g. Spider Phobia)
  • Avoid jargon (e.g. Arachnophobia)
46
Q

Specific phobias - subtypes

A
  • Inappropriate anxiety in the presence of one or more particular objects or situations
  • Characterised by adding the name of the stimulus (e.g. Spider Phobia)
  • Avoid jargon (e.g. Arachnophobia)
47
Q

Specific phobias - individuals with blood - injection - injury phobias

A
  • Individuals with blood–injection–injury phobias exhibit a biphasic anxiety reaction:
    • Initial short-lived sympathetic arousal
    • Followed by parasympathetic arousal
    • May result in vasovagal syncope
    • The subjective experience tends to disgust and repulsion rather than pure apprehension
48
Q

Specific phobias - other subtypes

A
  • In other subtypes, exposure to the phobic stimulus evokes intense anxiety that may meet the criteria for a situationally bound panic attack
  • There is extreme apprehension and desire to escape or avoid the phobic stimulus
49
Q

What percentage of the population experience at least one lifetime psychiatric disorder

A

> 80%

50
Q

Lifetime prevalence of specific phobias

A
  • 11.3%
51
Q

Mean age of onset for specific phobias

A
  • 15 years
52
Q

Specific phobias - gender

A
  • Women>men

- Blood-injection-injury phobia did not differ

53
Q

Aetiology of specific phobias - genetics

A
  • All Specific Phobias: evidence for genetic transmission
    • 31% of 1st degree relatives affected
  • Animal phobias:
    • monozygotic 26%
    • Dizygotic 11%
54
Q

Aetiology of specific phobias - psychological approach

A

• Psychoanalytic approach: Symptoms related to unresolved unconscious conflicts

55
Q

Aetiology of specific phobias - classical conditioning

A

phobias are learned through association of negative experience with an object or situation

56
Q

Aetiology of specific phobias - Preparedness theory

A

• Marks’ ‘preparedness’ theory maintains that commonly feared objects are those that historically threatened the survival of the individual or the species

57
Q

Link between observational learning and phobias

A

• Large number of studies suggest that phobias may be acquired via observational learning

58
Q

Clinical picture of social phobia

A
  • 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
59
Q

Symptoms of social phobia

A
  • Anticipatory anxiety
  • Feeling anxious
  • Blushing
  • Trembling (observed writing is a problem)
  • Relieved by alcohol (potential for abuse)
60
Q

Epidemiology of social phobia

A

• Possibly as high as 7% of primary care patients
• Lifetime risk 2.4 – 13.3% depending upon the definition of “caseness”
81% at some time meet the criteria for another psychiatric disorder (very high comorbidity)

61
Q

Onset of social phobia

A

• Onset usually early in life
• 1st peak before age 5
• 2nd peak between 11 – 15
Presentation unusual after age 30

62
Q

Social phobia - gender

A

• Women > men, but men more likely to present

63
Q

Social phobia - genetics

A
  • Both genetics and environmental factors contribute, with genetics contributing < ⅓ of the variance in the transmission
  • 16% of relatives of probands vs 5% of relatives of controls
  • Monozygotic > dizygotic
64
Q

Clinical picture of OCD - 1

A
  • 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 – ‘just right’
65
Q

OCD symptoms

A
  • Contamination - washing

- Doubts - checking

66
Q

Clinical picture of OCD 2

A
  • Obsessional impulses
    • Urges to perform acts
  • Obsessional rituals
    • Magic words or numbers
    • Desire to complete acts (e.g. hand washing)
  • Compulsions – the need to act on the obsessions
67
Q

Epidemiology of OCD - 1

A
  • Several researchers have reported lifetime prevalence of 2-3%1,2
  • This rate has been confirmed across different cultures2
  • Others suggest that the diagnosis of OCD by the Diagnostic Interview Schedule administered by lay people leads to over-diagnosis, and so have proposed lower prevalence rates of 1-2%3,4
68
Q

Epidemiology of OCD - 2

A
  • Men = women
  • Some reports suggest a slight female predominance
  • During adolescence, boys > girls.
  • Mean age of onset is ~ 20 years of age.
  • Prevalence 2-3%
69
Q

OCD co-morbidities

A
  • Major depressive episode: ~67% lifetime prevalence
  • ↑ lifetime risk for:
    • alcohol disorders
    • social phobia
    • specific phobia
    • panic disorder
    • eating disorders
    • Schizophrenia
    • tic disorders (~ 40% in juvenile OCD)
  • ↑ prevalence of Tourette’s syndrome in relatives
  • Unclear relationship between OCD & obsessive–compulsive personality disorder (OCPD), but it appears that OCPD is not a prominent risk factor for OCD
70
Q

Aetiology of OCD neurotransmitters

A
  • Serotonin dysregulation:
    • Evidence from efficacy of various serotonergic drugs
  • Dopamine dysfunction:
    • Evidence from abundance of OCD symptoms in basal ganglia disorders (Tourette’s syndrome, Sydenham’s chorea, & postencephalitic parkinsonism)
    • The therapeutic benefits from co-administration of dopamine blockers and SSRIs in a subset of patients with OCD and tic disorders
71
Q

OCD - genetics

A
  • Monozygotic&raquo_space; dizygotic

* First-degree relatives of patients with childhood-onset OCD have a higher than expected incidence of OCD

72
Q

OCD - Behavioural factors(learning theory)

A
  • Obsessions are conditioned stimuli: when a relatively neutral stimulus is coupled with an anxiety-provoking stimulus, it produces anxiety when presented alone
  • Compulsions reduce anxiety and the patient repeats them and learns them in order to avoid anxiety
  • Avoidance strategies are learned and become fixed
73
Q

OCD - behavioural factors(dynamic theory)

A
  • Obsessional Neurosis first described by Freud

* The disorder was thought to result from a regression from the Oedipal Phase to the Anal Phase

Year 2 - Theme 3 (9 decks)

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