L11 Anxiety Disorders Flashcards
Explain what ‘anxiety disorders’ are.
Anxiety:
- Body’s response to stress results in BOTH psychological & physical (somatic) response
- Adaptive “fear, fight or flight” response to real / perceived threat/stimulus
Disorder: Severe, excessive, persistent anxiety & irrational fears that impairs functioning w/ everyday living
- Pathological in nature: anxiety is out of proportion to actual danger or threat of situation
- Persists long after original trigger disappeared; typically more than 6 months
- Increases risks for developing cardiovascular, cerebrovascular, gastrointestinal and respiratory disorders
Classification of all anxiety disorders can be categorised into mild, moderate & severe disorders. True or false?
False!!
There is NO such thing as ‘mild’ severity for ALL anxiety disorders!!
Which specific anxiety disorders are most amenable to pharmacological treatment?
Briefly describe each anxiety disorder listed.
1) Generalised anxiety disorder (GAD)
- Excessive anxiety & worries > 6 months
2) Panic disorder (PD)
- Anticipatory anxiety of recurrent panic attacks
3) Social anxiety disorder (SAD)
- Fear of being scrutinised or humiliated by others in public
4) Obsessive-compulsive disorder (OCD)
- Obsessional thoughts/impulses that causes anxiety, followed by compulsive behaviours to relieve that anxiety
5) Post-traumatic stress disorder (PTSD)
- Re-experiencing of trauma
- Persistent avoidance
- Increased arousal & negative cognitions after exposure to trauma
Which particular anxiety disorders are less amenable to pharmacological treatment?
Specific phobias & adjustment disorders
Explain the pathophysiology of anxiety disorders.
1) Circuits:
- Fear circuit & symptoms are regulated by amygdala
- Worry circuit & symptoms are regulated by cortico-striatal-thalamic-cortical (CSTC) loop
2) Neurochemical dysregulation:
(a) Defense system:
- Originates in amygdala of limbic system
- Responsible for “fear, fight or flight” responses -> physical (somatic) responses
- Responds to both learned & unlearned threats
(b) Behaviour inhibition system:
- Based in hippocampus & septum of limbic system
- Responsible for avoidance behaviour
(c) Neurotransmitters:
- Increased NE/NA in locus coeruleus projecting from brain stem to amygdala and CSTC loop
- Increased 5-HT due to overactivation of amygdala, which receives input from serotonergic neurons & thus inhibits its subsequent outputs due to overuse of 5-HT
- Lack of inhibitory GABA to result in adequate CNS depression against overactivation of excitatory synapses
What are some medical conditions associated with the manifestations of anxiety disorders?
1) Cardiovascular: Angina, arrhythmias, CHF, ischemic heart disease, MI
2) Endocrine: Cushing’s disease, hyperparathyroidism, hyperthyroidism, hypoglycemia
3) Metabolic: Hyponatremia, hyperkalemia, phrochromocytoma, Vit B12 or folic acid deficiencies
4) Neurological: Dementia, delirium, migraine, Parkinson’s disease, seizures, stroke, neoplasms, inadequate pain control
5) Pulmonary: Asthma, COPD, pulmonary embolism, pneumonia
6) Others: Anemias, SLE, vestibular dysfunction
Name some drug classes that may induce the manifestation of anxiety disorders.
1) Sympathomimetics: Pseudoephedrine
2) CNS stimulants
3) Methylxanthines: Caffeine & theophylline
4) Thyroid hormone: Levothyroxine (T4)
5) Corticosteroids
6) Antidepressants: SSRIs, TCAs esp. initiation or rapid dose escalation
7) Dopamine agonists: Levodopa
8) Beta-adrenergic agonists: Salbutamol (esp. systemic/PO)
Name some drug classes that may induce symptoms of anxiety upon abrupt withdrawal.
Caffeine, alcohol, sedatives, BZDs, antidepressants & nicotine
Name some drug classes that may induce symptoms of anxiety upon intoxication.
Anticholinergics, antihistamines & digoxin
Describe the clinical presentation of GAD.
1) Excessive anxiety & worry occurring more days than not, for at least 6 months, about a number of events or activities (e.g. work, school performance)
- Finds it difficult to control
2) Anxiety & worry are associated with at least 3 of the following C-FIRST symptoms:
- difficulty Concentration or mind going blank
- being easily Fatigued
- Irritability
- Restlessness or feeling keyed up or on edge
- Sleep disturbances (insomnia, restless unsatisfying sleep)
- muscle Tension
3) Smx cause significant functional impairment
4) Smx NOT caused by physiological effects of a substance or another mental condition
- Focus of anxiety/worry is not confined to features of another mental disorder
Describe the clinical presentation of a panic disorder.
BOTH (1) & (2):
1) Recurrent unexpected panic attacks AND
- Panic attack: Discrete period of intense fear/discomfort developed abruptly that reaches a peak w/in 10 min (usually no more than 20-30 min), during which at least 4 smx occurs:
- e.g. palpitations, sweating, trembling, sensations of SOB, feeling of choking, chest pain/discomfort, nausea or abdominal distress, dizziness/lightheadedness/faint, derealisation/depersonalisation, fear of losing control, fear of dying, paresthesias (numbness or tingling sensations), chills/hot flushes
2) At least 1 of the panic attacks has been followed by at least 1 month of one of the following:
- Persistent anticipatory anxiety of having additional panic attacks
- Worry about implications of panic attack
- Significant change in behavior related to panic attacks
3) Smx cause significant functional impairment
4) Smx NOT caused by physiological effects of a substance or another mental condition
Describe the clinical presentation of a social anxiety disorder.
1) Marked & persistent fear of at least 1 social/performance situation of being scrutinised or humiliated/embarrassed by others in public lasting for at least 6 months
- Exposure to phobic stimulus almost invariable provokes an anxiety response
2) Feared social/performance situations are avoided or endured w/ intense anxiety/distress
- Avoidance, anxious anticipation or distress in the feared situation(s) significantly impairs functioning
3) Smx NOT caused by physiological effects of a substance or another mental condition
- DDx: Avoidant Personality Disorder
Describe the clinical presentation of OCD.
EITHER Obsessions OR Compulsions are classified under OCD:
Obsessions:
1) Recurrent & persistent thoughts/impulses/images that are experienced, at some time during the disturbances, as intrusive & inappropriate and caused marked anxiety/distress
2) Thoughts, impulses or images are NOT simply excessive worries about real-life problems
3) Person attempts to ignore or suppress such thoughts/impulses/images, or neutralise them w/ some other action/thought
4) Person recognises that the obsessional thoughts/impulses/images are a product of his own mind
Compulsions:
1) Repetitive behaviours or mental acts that person feels driven to perform in response to an obsession or according to rigid rules
2) Aimed at preventing/reducing distress brought about by obsessions BUT NOT connected in a realistic way to neutralise/prevent or are clearly excessive
- At some point, person recognises that obsessions/compulsions are excessive/uncontrollable.
- Significantly impairs functioning or distressing & time-consuming (at least 1 h/day)
- Smx NOT caused by physiological effects of a substance or another mental condition
Describe the clinical presentation of PTSD.
1) Exposure to actual or threatened death, serious injury or sexual violence directly or indirectly
2) Presence of at least one of the following intrusion smx post-trauma:
- Intrusive, recurrent & involuntary memories
- Traumatic nightmares
- Dissociative reactions (continuum from brief to complete loss of consciousness)
- Intense or prolonged distress post-exposure
- Marked physiological reactivity post-exposure
3) Persistent effortful avoidance of distressing trauma-related stimuli
4) Negative alterations in cognitions and mood associated w/ trauma (min. 2 of following smx):
- Inability to recall key features of trauma; dissociative amnesia
- Persistent, exaggerated negative beliefs/expectations about oneself/others
- Persistent, distorted blame of self or others causing trauma or resulting consequences
- Persistent negative emotional state (i.e. fear, horror, anger, guilt, shame)
- Markedly diminished interest or participation in pre-tramuatic significant activities
- Feelings of detachment or estrangement
- Persistent inability to experience positive emotions
5) Marked alterations in arousal or reactivity associated w/ trauma (min. 2 of following smx):
- Irritable or aggressive behaviour
- Self-destructive or reckless behaviour
- Hypervigilance
- Exaggerated startle response
- Problems in concentration
- Sleep disturbances
- Persistance of smx for at least 1 month for criteria 2-5.
- Significant functional impairment or distress
- Smx NOT caused by physiological effects of a substance or another mental condition
What are some of the more common examples of psychiatric rating scales used in clinical settings for anxiety disorders?
Clinician-rated: Hamilton Anxiety Scale (HAM-A)
- Recovery = HAM-A score < 7
- Significant anxiety = 18-20
- Response = 40-50% reduction in HAM-A score
Self-rated:
- Beck Anxiety Inventory (BAI): More specific for panic smx & distinguishes anxiety from depression
- Zung Self-rated Anxiety Scale: Good measure of severity but not used in children/adolescents
