Week 1 - G - Anxiety disorder - Generalised anxiety disorder, Panic, Phobias (agoraphobia, specific, social), Obsessive compulsive disorder Flashcards
What physical symptoms can anxiety present with?
- * Sweating, hot flushes or cold chills
- * Trembling or hsaking
- * Muscle tension or aches and pain
- * Numbness and tingling sensation
- * Feeling dizzy, unsteady, faint or lighthearted
- * Dry mouth
- * Feeling of chocking
- * A sensation of lump in the throat
- * Palpitations or accelerated heart rate
- * Nausea
- * Chest pain
What it is important to rule out as the causes of the dry mouth? What is the sensation of a lump in the throat known as?
It is important to rule out the dry mouth as a side effect of medication or dehydration out as a cause
A sensation in the lump of the throat such as a pill or some other obstruction when there is none is globus hystericus
What is thought to be released in anxiety causing the shakiness, dizziness and dry mouth?
It is thought that noradrenaline is released causing these symptoms - anything counteracting actelychoine will give dry mouth
Tricylics ie amitriptyline or imipramine are anticholinergics and cause this
What are some of the cognitive symptoms of anxiety?
Fear of losing control
Difficulty in concentrating - mind going blank
Feeling tense
Derealization and depersonalisation
Racing thoughts
Meta-worrying
Health anxiety
What is derealisation and depersonalisation? What is meta worrying?
Derealisation is where there is the feeling that some objects are not in fact real
Depersonalisation is where there is the feeling that the self is distant or not really present
Meta worrying - basically when the patient worries about everything and then continues to worry about worrying - seen in generalised anxiety disorder
What are some of the behavioural symptoms of anxiety?
Advoidance of certain situations which can lead to isolation
Reassurance seeking
Difficulty in sleeping because of worrying
Safety behaviours
Excessive use of drugs/alcohol
Restlessness and inability to relax
What is the stress response?
This is where exposure to stress results in instantaneous and concurrent biological responses to assess the danger and organise an appropriate response
What acts as the emotional filter of the brain for assessing whether sensory material relayed from where? requires a stress of fear response
The emotional filter of the brain for assessing whether sensory material relayed via the THALAMUS requires a stress or fear response is the AMYGDALA
Where is the amygadala found? The series of responses to stress happen far prior to the point at which the adrenal gland is stimulated to produce what?
The amygadala is found at the end of the tail of the caudate nucleus (part of the basal ganglia)
The sensory information is relayed to the thalamus and the amygdala will decide whether appropriate to send signals to the hypothalamus with the end result of the kidneys releasing cortisol
When someone experiences a stressful event, the amygdala, an area of the brain that contributes to emotional processing, sends a distress signal to the hypothalamus. How does the hypothalamus cause the release of cortisol?
Hypothalamus will produce corticotrphin releasing hormone (CRH) which will stimulates the anterior pituitary gland to release ACTH - adrenocorticotropic hormone which stimulate the adrenal glands to produce cortisol
acute stress leads to dose-dependent increase in catecholamines and cortisol What does cortisol act to mediate and where does it act upon?
Cortsiol acts to mediate (and shut down) the stress response
And it acts through negative feedback on the pituitary, hypothalamus and amygdala
These are the different sites that are responsible for the stimulation of cortisol release
Everyone can experience anxiety at times but anxiety disorder is when it is more extreme and this is a mental health disorder which is more extreme What is anxiety disorder?
Anxiety disorder occurs in two pathological processes
Extent - when the anxiety is more extreme than normal
Content - when there is anxiety in situations that are not ‘normally’ anxiety provoking
Typically speaking is the anxiety recognised by the individual as being excessive or not?
Typically speaking the anxiety is recognized by the individual as being excessive
Different types of anxiety disorders * Generalised Anxiety Disorder * Panic Disorder * Agoraphobia * Social Phobia * Specific Phobia * Obsessive Compulsive Disorder * PTSD - discussed in a different lecture
Describe generalised anxiety disorder?
This is anxiety that is generalised and persistent
It is not specific to any particular environment or situation and is not due to substane misuse or a medical condition
What are the dominant symptom that are typically associated with generalised anxiety disorder?
The symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, light headedness, palpitations and dizziness
What criteria do you have to meet to be diagnosed with generalised anxiety disorder?
GAD needs to be severe enough to be long lasting - at least most days for at least 6 months, is not controllable and causing significant distress and impairment in function and is typically associated with the dominant but variable symptoms mentioned on the previous card
GAD typically presents between 20 and 40 and what other psychiatric disorders is it associated with?
It is associated with depression, substance abuse and other anxiety disorders
What is the treatment option for GAD? 1st line, 2nd line and 3rd line What can be given if a crisis but only for short term?
1st line treatment for GAD is cognitive behavioural therapy
2nd line treatment for GAD is SSRIs, if they dont work, switch to a different SSRI or try an SNRI
3rd line - pregablin
For short term treatment only, can give benzodiazpeines eg diazepam
name example SSRI and SNRIs How do they work?
SSRI examples - citalopram, fluoxetine, sertraline, paroxetine - they selectively block serotonin uptake in the presynaptic terminals therefore more serotonin in synaptic cleft
SNRI examples - venlfafaxine, duloxetine - they block the reuptake of serotnonin and noradrenaline from the syapctic cleft into the presynaptic terminals
How does pregablin and benzodiazepines work?
Pregablin - GABA analogue- blocks voltage gated calcium channels therefore decreased release of glutamate and substance P
benzodiazepines - they enhance the effects of GABA also
What are drugs that treat anxiety known as?
anxiolytics
What is panic disorder?
This is recurrent attacs of severe anxiety (panic) which are unpredictable and frequent
What are the dominant symptoms of panic disorder?
Palpitations, chest pain, choking sensation, dizziness and feelings of unreality (depersonalisation (feeling onself is distant or not really here) or derealization (objects are unreal))
there is also a secondary fear of losing control, dying or going mad
What can commonly present alongside panic disorder?
Agoraphobia can commonly present alongside panic attacks
Panic attacks can have triggers in certain susceptible individuals What do these biological triggers include?
Infusions of lactate - by product of muscular activity
Or re-breathing air ie increased CO2
What is the treatment of panic disorders? Similar to the treatment of generalised anxiety disorder
1st line - CBT - congitive behavioural therapy
2nd line - SSRIs/SNRIs/Tricylics
Usually would go for an SSRI or tricyclic
Benzodiazepines can only be used short term
name three types of phobia?
Agoraphobia
Social phobia
Specific phobia
Does agoraphobia or social and specific phobias typically present at a younger age? Majority of all 3 will have presented by the age of 30
It is typical for social and specific phobias to have presented by a younger age than agoraphobia
In phobias, does the individual understand that the fear is irrational? How do they generally self manage the phobia?
The individual recognises that the fear is irrational
They generally avoid and anticipate the anxiety to self manage themselves
What is agoraphobia?
This is a cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, travelling alone in trains, buses or planes.
In agoraphobia Avoidance of the phobic situation is often prominent, and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations. Agoraphobia can be primary or secondary.
Describe each and explain which one is more common.
A primary agoraphobia is when agoraphobia presents on its own
Secondary agoraphobia is when the agoraphobia comes along with or after another disorder eg panic disorder or depression
Secondary agoraphobia is much more common
What does agoraphobia often involve to avoid anxiety?
It often involves - getting others to do shopping - avoiding crowds drinking alcohol to overcome fear
Go shopping at night when quiet
Technology ie internet shopping
What are specific phobias?
This is where there is a marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation
Give examples of specific phobias?
Specific phobias - flying, heights, animals or insects, receiving an injection, dentists, intercourse
Does the person recognise that the fear is excessive or unreasonable in specific phobias?
The person recognises that the fear is unreasonable in specific phobias - the phobia situation is avoided or endured with intense anxiety or distress
What is the treatment of specific phobias?
Behavioural therapy - where the patient has graded exposure to the fear
Add in CBT if necessary
If required, can also add SSRIs and SNRIs
What is social phobia also known as? What is it defined by? Does social phobias typically occur in small or large settings?
Social phobia is also known as social anxiety disorder
It is where there is the persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny
Social phobias typically occur in relatively small settings
exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound panic attack. What are the common anxiety symptoms in social phobias?
Blushing or shaking
Fear of vomiting
Urgency or fear of micturition or defecation
What happens in the brain in social phobias?
There is increased bilateral activation of the amygdala and increased rCBF (regional cerebral blood flow) that normalizes on successful treatment
What is the treatment of social phobias?
CBT
SSRIs/SNRIs
Benzos short term only
Obsessive Compulsive Disorder Recurrent obsessional thoughts and/or compulsive acts What are examples of obsessional thoughts and compulsive acts?
Obsessional thoughts - ideads, images o impulses entering the mind in a stereotyped way, recognized as the patients own thoughts but unpleasant and resisted
Compulsive acts - repeated rituals or sterotyped behaviors that are not enjoyable and recongised as pointless
What is the criteria for obessive compulsive disorder? What must be present?
Obsessiona symptoms or compulsive acts must be present most days for at least 2 weeks and be a source of distress and interfere with activities
The obessions must be thee persons own thoughts
The resistance must be present
The rituals are not pleasant
The obsessive thoughts/images/impulses must be repetitive
What are the most common obsessions in OCD? What are the most common compulsive acts in OCD?
Obsessions - contamination from dirt and germs, fear of harm and excessive concern with order or symmetry
Compulsive acts - checking eg gas taps and light switches (rituals), cleaning/washing, repeating acts
Treatment of OCD?
This would be CBT including response prevention
SSRIs given as the 1st line medication
Clomipramine
What type of drug is clomipramine?
This is a tricylic antidepressant
Having talked about benzos so much, lets talk about how they work They work by enhancing the effect of GABA The GABA-A receptor is an inhibitory ionotropic receptor In the presence of GABA, what happens?
In the presence of GABA the ion channel allow choride ion influx causing membrane hyperpolarisation which results in inhibitory postsynaptic potentials
* Benzos are rapid acting, well tolerated and effacious but why are they not used long term?
Problems start to occur particularly if used for greater than two weeks - sedation and psychomotor impairment
Discontinuation / withdrawal problems
Dependency and abuse
Alcohol interaction
What is the treatment of GAD, Panic disorder, OCD, and the phobias?
GAD
- * 1st line CBT
- 2nd line SSRIs/SNRIs
- * 3rd line Pregablin
- Benzos short term only
Panic disorders -
- CBT, SSRI/SNRI/Trcicylcis
- 2nd line (benzos)
OCD
- * 1st line CBT
- * 2nd line - SSRIs / clompiramine
Specific phobia -
- behavioural therapy (gradual exposure) + CBT if needed, SSRI/SNRI if needed
Social phobia -
- CBT, SSRI/SNRI if needed (benzos short term)
