Psychiatry SC074: I Feel Very Nervous: Anxiety Disorders Flashcards
Limbic system
- ***Amygdala
- ***Hippocampus
- Parahippocampal gyrus
- Medial frontal cortex
- Thalamus
- ***Hypothalamus
- ***Brainstem nuclei
- Cingulate gyrus
- Fornix
Amygdala based neurocircuit for Anxiety:
Amygdala (registration of emotional significance of stimuli + development of **emotional memory)
Interact with:
1. Medial prefrontal cortex (cognitive control of anxiety + manifestation of anxiety)
2. Hippocampus (cues to anxiety)
3. Brainstem nuclei (somatic manifestation of anxiety) —> **Neurological system
4. Hypothalamus (somatic manifestation of anxiety) —> ***Hormonal system
Neurochemical basis of Anxiety
- GABA system
- inhibitory neurotransmitter
- suppress other neurotransmitter e.g. serotonin, norepinephrine, dopamine etc. - Norepinephrine system
- autonomic arousal + somatic symptoms in anxiety - Serotonin system
- appetite, energy, sleep, mood, libido, cognitive function in anxiety
Dysregulation of these systems cause anxiety disorder
Clinical features of Anxiety disorders
- ***Psychological symptoms
- Worrying thoughts (Marked + Persistent + A lot)
- Fearful anticipation
- Irritability
- Feeling of restlessness
- Sensitivity to noise
- Difficulty in concentration
- Subjective poor memory -
**Physical symptoms (common, need to exclude **organic causes)
- GI tract —> dry mouth, swallowing difficulty, epigastric discomfort, excessive belching, frequent loose bowel motions
- Respiratory —> chest constriction, breathing difficulty, hyperventilation
- Cardiovascular —> palpitation, chest discomfort
- Genito-urinary —> frequency of micturition, erectile failure, lack of libido, increased menstrual discomfort
- CNS —> tinnitus, blurring of vision, dizziness, headache, muscle aches and stiffness, tremulous hands
- Others —> sleep disturbance, unpleasant dreams
NB: Co-morbidity is common
***Major Anxiety-related Disorders
- Generalised Anxiety Disorder (***No specific anxiety focus, Free floating anxiety, content can change from day to day) (廣泛性焦慮症)
- Panic Disorder (***Fear of imminent death, Fear of recurrence of panic attack) (驚恐症)
- Acute Stress Disorder / Post-traumatic Stress Disorder (***Fear of traumatic memory) (急性壓力症患 / 創傷後壓力症候群)
- Obsessive-Compulsive Disorder (***Fear of intrusive, obsessive ideas e.g. hands are dirty) (強迫症)
- Phobic Disorder (***Situational avoidance anticipation) (恐懼症)
- Specific (Specific fear animal, thunder, height etc.)
- Social (Fear of embarrassment)
- Agoraphobia (Fear of crowds, cannot escape)
Generalised Anxiety Disorder (廣泛性焦慮症)
Clinical features:
- Excessive worries and anxiety
- **Free floating anxiety
- **Apprehensive expectation
- Occur ***most of the time
DSM-5:
1. Excessive anxiety + worry, occurring more days than not for **>=6 months, about a number of events or activities
2. The person finds it **difficult to control the worry
3. Associated with **>=3 of following 6 symptoms:
- **Restlessness or feeling keyed up or on edge
- **Being easily fatigued
- **Difficulty concentrating or mind going blank
- **Irritability
- **Muscle tension
- ***Sleep disturbance
4. Causes clinically significant distress + functional impairment
5. Not due to the direct physiological effects of substance or general medical conditions
6. Not explained by another mental disorder
Comorbidity (**2/3 of GAD patients):
1. **Depression
2. ***Other anxiety disorders (e.g. panic, social anxiety)
3. Personality disorder (e.g. anankastic, paranoid, avoidant)
4. Alcohol + Drug abuse
Panic Disorder (驚恐症)
Clinical features:
1. Severe anxiety attack
- palpitation, chest pain, choking sensation, dizziness
- fear of ***dying, losing control, or going mad
- extremely uncomfortable
-
**Unpredictable + **Sudden onset
- not restricted to any particular situation
- no obvious precipitating factors - ***Recurrent
- Persistent fear of having another attack
- Impair function of patient (e.g. not go to work) - Subsequently avoid that situation
- May develop phobic symptoms
- May be agoraphobic if attack in various situations
- May be demoralised + depressed
DSM-5:
1. An abrupt surge of intense fear / intense discomfort that reaches a peak within **minutes, and during which time **>=4 of following symptoms occur:
- Palpitations, pounding heart, accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or heat sensations
- Paresthesias
- Derealisation / Depersonalisation
- Fear of losing control or going crazy
- Fear of dying
- Recurrent unexpected panic attacks
- > =1 attacks has been followed by 1 month of one / both of the following:
- Persistent concern about having additional attacks or their consequences (Anticipatory anxiety: constantly worrying about next attack (self notes))
- A significant maladaptive change in behaviour related to the attacks - Not due to direct physiological effects of a substance or a general medical condition
- Not better accounted for by another mental disorder
Comorbidity:
1. Depression
2. Other anxiety disorders (e.g. Agoraphobia)
3. Alcohol + Drug abuse
DDx:
1. **Physical disorders
- **epilepsy, **thyroid disease, **cardiac disease, vestibular dysfunction, **pheochromocytoma
2. **Substance abuse
- intoxication / withdrawal
3. ***Other anxiety disorders
Phobic Disorder (恐懼症)
3 types:
1. Specific (items, situations etc.)
2. Agoraphobia
3. Social
2 major components of clinical features:
1. Anxiety
- Only in **particular circumstances
- Marked **anticipatory anxiety (i.e. **Predictable vs Panic Disorder (Unpredictable))
2. **Avoidance
Comorbidity:
1. Depression
2. Alcohol + Drug abuse
3. Panic disorder with Agoraphobia
DDx for Anxiety symptoms (記住):
1. **Physical disorders
2. **Substance abuse etc.
DDx for Avoidance features:
1. **Personality disorder (e.g. Asocial personality disorder (differ in that the person enjoy being alone))
2. **Depression
3. ***Psychosis (delusion of persecution, fear of being harmed)
Specific Phobia
- Anxiety is provoked in the presence / anticipation of specific object
- Animals, Heights, Thunders, Darkness, blood etc.
- Tendency to avoid the stimulus
- Severe distress / functional impairment
DSM-5:
1. **Marked fear or anxiety about a specific object or situation
2. The phobic object or situation almost **always provokes immediate fear or anxiety
3. The phobic object or situation is actively **avoided or endured with intense fear or anxiety
4. The fear or anxiety is **out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
5. The fear, anxiety, or avoidance is persistent, typically lasting for **>=6 months
6. The fear, anxiety, or avoidance causes clinically **significant distress or impairment in social, occupational, or other important areas of functioning
7. The disturbance is not better explained by other mental disorder
Agoraphobia
- Away from home
- In crowds or situations they cannot leave easily that provoke anxiety and avoidance
- Buses, Trains, MTR, Supermarket, Queue, Hairdresser’s chair, Cinema
- Need to be accompanied
- Severe: Housebound
Progression:
- Panic attack in public place (Panic Disorder)
—> Phobic Disorder (Fear of going to particular place)
—> still get panic attacks at other places
—> Agoraphobia (Fear of going to all places)
—> Depression (∵ Housebound) / Substance misuse
DSM-5:
1. Marked fear or anxiety about **>=2 of the following 5 situations:
- **Being in open spaces
- **Being in enclosed places
- **Using public transportation
- **Standing in line or being in a crowd
- **Being outside of the home alone
- The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.
- The agoraphobic situations almost always provoke fear or anxiety.
- The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
- The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
- The fear, anxiety, or avoidance is persistent, typically lasting for ***>=6 months.
- The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
- The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.
Social Phobia
- Anxious in situations (observed, criticized, embarrassment or humiliation)
- Speak in small group
- Introduced to stranger
- Eat in public, write in public
- Fear of angry, rejecting face, avoid eye contact
- Blushing and trembling
DSM-5:
1. Marked fear or anxiety about **>=1 social situations in which the individual is exposed to possible scrutiny by others.
2. The individual fears that he or she will act in a way or show anxiety symptoms tat will be negatively evaluated.
3. The social situations almost always provoke fear or anxiety.
4. The social situations are avoided or endured with intense fear or anxiety.
5. The fear or anxiety is out of proportion to the actual threat posed by the social situations and to the sociocultural context.
6. The fear, anxiety, or avoidance is persistent, typically lasting for **>=6 months.
7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
8. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.
9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder
10. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Obsessive-Compulsive Disorder (OCD) (強迫症)
- ***Recurrent, compulsive nature
- Maintained **insight + Regarded as **senseless
- Presence of ***resistance (initial phase) until cannot resist due to high anxiety
Obsession:
- Thoughts, impulses, images, ruminations or doubts
- Themes: dirt, contamination, aggression, illness, religion
Compulsion:
- ***Stereotyped behaviour to calm one self
- Checking, cleaning, counting, slowness (to avoid making mistake)
4 Common presentations:
1. Contamination with **cleaning
2. Doubt with **checking
3. **Precision + **Symmetry with ordering, counting, repeating, hoarding, slowness
4. Religious, sexual, aggressive obsession
DSM-5:
1. Presence of obsessions, compulsions or both:
Obsessions as defined by (1) and (2):
(1) **Recurrent + **Persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as **intrusive + **unwanted, and that in most individuals cause **marked anxiety + distress
(2) The individual attempts to **ignore / **suppress such thoughts, urges, or images, or to **neutralise them with some other thought or action
Compulsions as defined by (1) and (2):
(1) **Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels **driven to perform in response to an obsession, or according to rules that must be applied **rigidly
(2) The behaviours or mental acts are aimed at **preventing / ***reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive
- **Time consuming (take >1 hour a day), or cause marked **distress, or impairment in social, occupational, or other important areas of functioning.
- Not due to the direct physiological effects of a substance
- The disturbance is not better explained by the symptoms of another mental disorder
(vs Obsessive-compulsive personality disorder (OCPD):
- OCD: has true obsessions + compulsions
- OCPD: pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, >=4:
—> preoccupied with details, rules, lists, order, organisation, schedules
—> perfectionism that interferes with task completion
—> excessively devoted to work + productivity
—> overconscientious, scrupulous, inflexible
—> unable to discard worn-out / worthless objects
—> reluctant to delegate tasks / work with others
—> adopts a miserly spending style (money viewed as sth to be hoarded for future catastrophes)
—> rigidity + stubbornness)
Treatment of Anxiety Disorders
- ***Supportive measures
- Explanation
- Reassurance
—> Stop vicious cycle of anxious thoughts - Psychological treatment
- **CBT
—> Based on fact that emotional response is affected by cognition / understanding / interpretation of environment
—> Identify abnormal thinking style (can be subconscious)
- **Mindfulness-based therapy - Medications
- **Antidepressants (e.g. SSRI, SNRI, TCA, MAOI etc.)
- Beta-blocker (e.g. Propranolol: not affect CNS: memory, concentration)
- **BDZ (central acting: memory, sleepy)
- Buspirone
- Pregabalin
Antidepressant
- SSRI
- Paroxetine, Citalopram, Escitalopram, Fluoxetine, Sertraline, Fluvoxamine - SNRI
- Venlafaxine, Duloxetine - TCA
- Imipramine: panic disorder
- Clomipramine: OCD - MAOI
- Phenelzine: phobia - Reversed Inhibitor of MAO-A (RIMA)
- Moclobemide: phobia
Psychotherapy
Panic Disorder:
1. **Interpretation of body sensation (e.g. understand muscle tension)
2. Understand physiological response to fear
3. **Relaxation techniques
Phobic Disorder:
1. Targeting the avoidance (hierarchy list)
2. **Exposure techniques
- Graduated, repeated, prolonged (need to stay with feared object until anxiety feeling subside), clear tasks
- Real-life, imaginal exposure
- Home-based, relative support
3. **Relaxation exercise
4. Social phobia
- ***Social skill training
- Cognitive treatment for fear of negative evaluation from others
OCD:
1. **Psychoeducation
2. Psychological support and reassurance
3. **Exposure and ritual prevention
4. **Thought stopping and distraction for rumination
5. Resistive thoughts only increase their occurrence
6. **Cognitive change
- “If I don’t do it perfectly, then I’ve done it horribly”
- “If something bad is going to happen, it is much more likely to happen to me or to someone I love about than to others”
7. Modifications of responsibility beliefs
8. To consider evidence for less threatening alternative explanation
