Anxiety, Obsessions and Reactions to Stress Flashcards
What are anxiety disorders?
In anxiety disorders, the normal anxiety response is exaggerated, and triggered by a trivial or non-existent threat.
Describe the epidemiology of anxiety disorders.
- Very common (29% lifetime prevalence of having an anxiety disorder)
- Most affect women roughly twice as commonly as men
- Exceptions: social anxiety disorder, OCD, and BDD where men and women are affected equally
What is the aetiology of anxiety disorders based on?
Genetics
Childhood and life events
What are the genetics behind anxiety disorders?
- Risk is 4-6 times higher in relatives of affected people
- Heritability is estimated at 30-50%
- Vulnerability may be conferred by certain personality traits such as: introversion, harm avoidance, and neuroticism.
- ¼ of patients with ICD have a premorbid anankastic personality trait.
- Strong overlap between anxiety disorders and depression
What are the childhood and life events behind anxiety disorders?
- Childhood adversity predisposes to anxiety disorders
- Life events can trigger them - especially of experienced as threatening
- By definition, PTSD is caused by extreme trauma
- The risk is associated with the degree of exposure proximity, and human contribution to the traumatic event
- However only 10% of people who experience extreme trauma develop PTSD
- By definition, PTSD is caused by extreme trauma
- Risk factors:
- Neuroticism
- Personal or FH of psychiatric problems
- Childhood abuse
- Poor early attachment
What are the main theories behind anxiety disorders?
- Neurotransmitter theory
- Neuroanatomical theory
- Psychological theory
What are the neurotransmitter theories behind anxiety disorders?
- Central neurotransmitters: serotonin, noradrenaline and GABA are dysregulated (underactive) in anxiety disorder
- Supported by the drugs we use in anxiety : SSRIs, TCAs, bencodiazepines
- Other substances: excitatory neurotransmitter glutamate, and a range of neuropeptides
What are the neuroanatomical theories behind anxiety disorders?
- Functional hyperactivity of the amygdala (key factor in fear processing) is found in anxiety disorders - marked in PTSD and associated with atrophy of the hippocampus which plays a key role in short-term memory → distorted processing and storage of traumatic events may explain the reliving in PTSD
- Basal ganglia and OCD linked in illnesses such as: Sydenham’s chorea, encephalitis lethargica, and Tourette syndrome.
- Strep throat may be followed by Sydenham’s chorea; by OCD symptoms accompanied by anti-basal ganglia antibodies; and by PANDAS (paediatric autoimmune neuropsychiatric disorders associated with strep infection) → in which OCD develops suddenly in children
- OCD linked to frontal lobe inhibition, possibly explaining why obsessions are so hard to suppress
What are the psychological theories behind anxiety disorders?
- Classical Conditioning: repeatedly paring a neutral stimulus with a frightening one → fear in response to neutral stimulus
- Negative reinforcement: Behaviours which relieve anxiety (e.g. running away) are repeated. This prevents habituation (getting used to stimulus and calming down) → anxiety is maintained after escaping stimulus
- Cognitive theories: worrying thoughts are repeated in an automatic way → induced and maintains anxiety response
- Attachment theory: quality of attachment between children and their parents affect confidence as adults (insecurely attached children become anxious adults)
Describe the physical and psychological symptoms of anxiety.
The pattern, timing and trigger differ according to the particular anxiety disorder
Avoidance and escape are common to most anxiety disorders, and people may develop safety seeking behaviours (SSBs) → coping strategies, which temporarily reduce anxiety or seem to avert catastrophe (e.g. seeking reassurance)
Define Generalised anxiety disorder. How can we diagnose it?
In GAD, anxiety is continuous and generalized (‘free-floating’).
The person worries about anything and everything, e.g. work, health, relationships, past mistakes, imminent catastrophes.
Physical symptoms are often prominent (e.g. tension headaches). Panic attacks occur in severe cases.
To diagnose GAD, symptoms must be present for at least several months, although their intensity may fluctuate.
Define panic disorder.
Anxiety is intermittent and without an obvious trigger: it comes ‘out of the blue’.
What is a panic attack?
A panic attack is a sudden attack of extreme (‘100%’) anxiety, associated with physical symptoms, such as:
- Breathing difficulties.
- Choking sensations.
- Chest discomfort/ tightness.
- Palpitations.
- Pins and needles/ numbness (hands, feet, lips)
- Depersonalization/ derealization.
- Tremor
- Dizziness, fainting.
- Sweating.
People commonly think they’re having a heart attack or stroke, or fear they’ll die, ‘lose control’, or ‘go mad’. These alarming thoughts exacerbate panic, until they gain reassurance or engage in SSBs (e.g. calling an ambulance, taking aspirin). Panic attacks are self-limiting, usually lasting less than 30 minutes, although they can feel never ending
How can we diagnose panic disorder?
For a diagnosis of panic disorder, there must be recurrent panic attacks (several within a month). Between episodes, the person is fairly anxiety free.
What are phobias?
In these disorders, intermittent anxiety occurs in specific but ordinary circumstances. People characteristically avoid or escape feared situations, only seeking treatment when this becomes disabling.
DEFINITION
Definition of a phobia (Marks)
Fear out of proportion to the demands of the situation
It cannot be reasoned away
It is beyond voluntary control
Fear leads to avoidance of the
feared situation, and can lead to disability
What are specific phobias? Describe the epidemiology
Specific objects or situations trigger anxiety, e.g. spiders (arachnophobia).
F>M (2:1)
Often starts in childhood (5-9)
Lifetime prevalence: 5-10%
Environmental and injury
phobias: mid 20’s
Animals, storms, heights,
illness, injury, death
When do phobias tend to develop? What does the level of disability depend on?
Phobias often develop in childhood, although sometimes begin later, usually after a frightening experience. The level of disability depends on how easily the person can avoid the thing they fear, e.g. a doctor with haemophobia (blood phobia) would be severely disabled.
What is the phobia in social anxiety disorder? When do they tend to appear? What is the epidemiology?
Core fear = being scrutinised or criticised by other people and a worry of embarrassing themselves in public.
Onset is normally in the late teens, with men and women equally affected
Patients struggle with situations where the focus is potentially on them: dinner parties, board meetings, dating, public speaking.
F=M (3:2)
Onset in late teens (17 – 30)
Continuous course
6 month prevalence 2-3/1000
What are the SSBs in social anxiety disorder?
Self-medication with alcohol/drugs perpetuates problem as offers psychological avoidance
Patients may seek help for embarrassing sx e.g. blushing, trembling, sweating and urinary frequency
What is the phobia is agoraphobia?
Uniting fear is of being unable to easily escape to a safe place (usually home). It includes fear of open place and fear of situations that are confined and difficult to leave without attracting attention. Common examples include
- Travelling on trains, planes or buses
- Queuing
- Supermarkets
- Large crowds
- Parks
- Sitting in the middle row of a cinema
When is the onset of agoraphobia?
20s – mid thirties, may be gradual or precipitated by a sudden panic attack
How disabling is agoraphobia?
The overwhelming urge is to return home to safety.
The prospect of leaving home generates anxiety, the severity increasing with distance from home or difficulty returning.
Access to a dependable companion (or sometimes a car) can increase the person’s geographical range and makes situations more bearable.
Those worst affected become housebound, dependent on a small circle of family or friends
What are obsessions?
Obsessions are unwanted, unpleasant, and intrusive, repeatedly entering the mind despite attempts to resist them.
What obsessions do patients with OCD tend to have?
They can be:
- Thoughts, e.g. ‘I’m dirty!’
- Images, e.g. imagining your parents having sex.
- Impulses, e.g. the urge to shout ‘bomb’ in an airport.
- Doubts, e.g. ‘Did I turn off the oven?’
Obsessions are egodystonic (conflict uncomfortably with the person’s self- image) and are in no way enjoyable.
Common themes include:
- Contamination/ illness, e.g. catching HIV.
- Sex, e.g. fear of being a paedophile (when this feels repugnant, not enjoyable).
- Harming self or others, e.g. through violence, accidents, or mistakes.
- Sacrilege/ immorality, e.g. urges to shout something blasphemous in a mosque.
- Need for order or symmetry, e.g. to feel ‘right’, be ‘lucky’, or prevent harm.
How do patients feel about the obsession?
Although generally the sufferer recognizes that obsessions are irrational or untrue, they cause deep discomfort or anxiety, often because they bring a terrible feeling that something bad might happen.
This anxiety is ‘neutralized’ with a compulsion
What are compulsions?
Compulsions are repeated, stereotyped and seemingly purposeful rituals that the patient feels compelled to carry out, even though they are irrational and lack any obvious link to the obsession
o Examples include
- Cleaning
- Counting
- Checking
- Ordering objects
Define body dysmorphic disorder
In BDD, people are excessively worried about their appearance, believing that part of their body is ugly or abnormal, often focusing on their face, head, or skin.
The flaw is either imagined or extremely minor (e.g. slightly crooked nose), but they can’t stop thinking about it.
What behaviours are associated with body dysmorphic disorder?
Behaviours include recurrent checking (via photos, mirrors, measuring, or touch); protracted and excessive grooming; or using make-up or clothing to camouflage or cover the area.
They may try to ‘correct’ the perceived defect, e.g. taping back ears, cosmetic surgery, or desperate self-surgery (e.g. cutting their ears with scissors).
Define PTSD.
PTSD follows a traumatic event that is often experienced as ‘life-threatening’
The event suffered must be ‘an event of exceptionally threatening or catastrophic nature, likely to cause pervasive distress in anyone’
PTSD is considered when symptoms are prolonged and disabling.
Usually begins within 6 months of the trauma, although there is often a delay before symptoms appear (latency period)
Describe the epidemiology. What are the symptoms of PTSD
EPIDEMIOLOGY
- Prevalence: One year = 1-3 %. Lifetime = 6.8%
- F>M
CORE SYMPTOMS
• Re-experiencing
o Flashbacks
o Nightmares
o Intrusive memories
• Avoidance
o Avoiding reminders of the event
o Trying not to think about the trauma
• Hyperarousal
o Inability to relax
o Hypervigilance
o Enhanced startle reflex
o Insomnia
o Poor concentration
o Irritability
• Other changes
o Emotional detachment
o Decreased interest in activities
o Powerful emotions including anger, depression, shame and uncontrollable crying.
o Suicidality
What is complex PTSD?
Severe and disabling condition, resulting from inescapable, repeated or prolonged trauma e.g. childhood sexual abuse, slavery, torture.
Chronic symptoms: difficulties regulating emotion, pervasive negative views of self, and problems trusting people and maintaining close relationships.
What is the differential diagnosis of anxiety disorders?
Organic:
• Hyperthyroidism
o Goitre, tremor, tachycardia, weight loss, arrhythmia, expothlamos
• Substance misuse
o Intoxication e.g. amphetamines
o Withdrawal e.g. benzodiazepines, alcohol
Excess caffeine
Depression
o Often comorbid
o Common feature of depression
o Generally, diagnose the disorder which came first and is most prominent but don’t be afraid to diagnose both if criteria are met:
o You can diagnose mixed anxiety and depressive disorder if low level symptoms of both affect the patient equally, neither justifying diagnosis alone.
Another Anxiety disorder - anxiety disorder can be hard to distinguish. Diagnosis is based on the most important and disabling features
Common mix-ups include:
- Panic disorder vs panic attacks (panic disorders lack triggers)
- Panic disorder vs agoraphobia
- Social anxiety disorder vs agoraphobia - both can cause social withdrawal
- OCD vs agoraphobia - time consuming compulsions or contamination fear can make people housebound
- OCD vs BDD - repetitive rituals common in both
- BDD vs social anxiety disorder - fear of scrutiny is shared
- PTSD vs acute stress reaction
• Personality disorder - Cluster C personality disorders - traits of negative affectivity, anankastia, or detachment are key differentials for anxiety disorders
•Dementia
• Psychosis
o Anxiety can occur before delusions and hallucinations
What is adjustment disorder? What are the symptoms of it? How should we manage it?
- Life changes include going to university, breaking up with a partner or moving house
- Most people experience fleeting symptoms of anxiety, low mood, irritability or sleeplessness
- Adjustment disorder: reaction is deemed greater than usually expected for situation but not sever enough to diagnose an exited or depressive disorder
- Symptoms start within a month of the stressor and resolve within six months
- Support, assurance and problem-solving are often all that is needed
What are the investigations for anxiety disorders?
Hx and physical examination - exclude organic causes
Rating scales of anxiety
o Beck Anxiety Inventory
o HADS: hospital anxiety and depression scale
Collateral hx
How does CBT use exposure therapy?
o Used as part of the CBT approach when there are strong elements of avoidance and escape
o In the absence of actual harm, the body can only remain extremely anxious for a short time (usually < 45 mins) before habituation occurs and anxiety levels drop
o Habituation is characterised by a decrease in anxiety until fear dies out (extinction)
o Exposure is usually through a gradual (or graded) approach called desensitisation
o The patient identifies a goal (e.g.being able to hold a slug) and constructs a hierarchy of feared situations
o The patient tackles it from least frightening to most frightening
o The aim is to stay in the situation until the anxiety has subsided to induce learning and challenge existing thoughts
o Agoraphobia can be treated using this strategy
How does CBT help in GAD?
- Main feature is continuous worry with no discernable trigger
- Therapy involves testing predictions of worry with behavioural experiments and looking at errors in thinking
How should a diagnosis of PTSD be explained to a patient?
What is chronic fatigues syndrome? How can it be managed?
Describe the reattribution model.
What is the management of GAD?
