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Psychiatry > Anxiety Disorders > Flashcards

Anxiety Disorders Flashcards

0
Q

Theories of anxiety

A

Genetics - some heritable element linked to trait neuroticism
Life events - linked to childhood adversity and difficult life events
Neurochemical - 5HT,NA and GABA are all dysregulated
Behavioural - classical conditioning & negative reinforcement
Cognitive - automatic thoughts & attachment theory

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1
Q

Epidemiology of anxiety disorders

A

Very common
Total incidence:18.1%
Total prevalence:28.8%
2:1 (women:men), except social phobia (1:1) and OCD (more men)

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2
Q

Classical conditioning

A

The simplest stimulus-response association
Repeated pairing of a neutral stimulus with a frightening one causes a fear response to the neutral stimulus
Little Albert

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3
Q

Negative reinforcement

A

The reinforcement of a behaviour by the removal of an unpleasant stimulus
Most commonly this reinforces avoidance or running away from a frightening stimulus

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4
Q

Cognitive theories of anxiety

A

Anxious thoughts are repeated in an automatic, ruminative way which induces and then maintains anxiety

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5
Q

Attachment theory

A

The quality of the attachment between children and their parents effects their confidence as adults
Insecurely attached children become anxious adults

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6
Q

Genetics of anxiety

A

Strong heritability but no specifically linked genes
Associated with trait neuroticism (Fullerton et al 2003)
Significant genetic overlap between anxiety and depression (Kendler 1996)

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7
Q

Generalised anxiety disorder GAD

A

Continuous, free-floating anxiety not triggered by anything
Symptoms may occur at any time with panic attacks if severe
For diagnosis symptoms must be present for 6months although symptoms may fluctuate
Incidence: 3.1% Prevalence: 5.7%

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8
Q

Differential diagnosis for GAD

A

Hyperthyroidism
Substance abuse (intoxication or withdrawal) -> excess caffeine
Depression, if severe diagnose both, if not ‘mixed anxiety & depressive disorder’
Anxiety may be an early symptom of dementia or schizophrenia
Consider anxious/avoidant PD if no recent increase in anxiety

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9
Q

Phobias (phobic anxiety disorders)

A

Intense anxiety in response to specific but ordinary stimuli
Patients will usually be avoidant and hypervigilent
Seriousness is defined by the level of disability the patient experiences
Incidence: 8.7% Prevalence : 12.5%

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10
Q

Agoraphobia

A

The fear of being unable to easily escape to a safe place (home)
This includes a fear of open, crowded and enclosed spaces
Onset in mid-20/30s, gradual or after sudden panic attack
Anxiety increases with distance, decreased by companion or car.
Incidence: 0.8% Prevalence: 1.4%

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11
Q

Differential diagnosis for phobic disorders

A

Depression -> can cause social/agoraphobia but may also be comorbidity or develop secondarily
Social phobia–> specifically a fear or scrutiny or humiliation
OCD -> rituals or germ fear may confine the patient at home
Schizophrenia -> either due to negative symptoms or paranoia

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12
Q

Social phobias

A

Centred around fear of criticism or humiliation by others
Can cope with an anonymous crowd (unlike agoraphobics) but small groups are very difficult - may have specific worry (eating)
Often self medicate with drugs/drink -> psychological avoidance
Incidence: 6.8% Prevalence: 12.1%

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13
Q

Differential for social phobia

A

A shy person -> for social phobia there must be ‘overt fear’
Agoraphobia -> specific fear of being away from home
Anxious/avoidant PD -> lifelong disabling shyness/anxiety
Poor social skills/ASD -> social skills poor even when relaxed
Benign essential tremor -> familial and worse in social situations

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14
Q

Blood, injury or needle phobias

A

Unusually for phobia these produces strong vasovagal reaction causing bradycardia and hypotension
May have evolutionary advantage of falling into recovery position when injured

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15
Q

Panic attacks

A

Episodic and ‘comes out of the blue’ with total anxiety with physical symptoms (difficulty breathing, palpitations, tightness)
Attacks are self-limiting (30mins) but may feel longer
The pt fears they will die, provoking further anxiety and engages in ‘safety’ behaviours (calling an ambulance, etc)

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16
Q

Panic disorder (episodic paroxysmal anxiety)

A

A disorder of intermittent panic attacks with little anxiety in between
For diagnosis the patient must have recurrent attacks, usually several in one month
Incidence: 2.7% Prevalence: 4.7%

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17
Q

Differential diagnosis for panic disorders

A

Another anxiety disorder -> GAD or agoraphobia
Depression -> if criteria for diagnosis are met it takes precedence
Alcohol/drug withdrawal -> anxiety mistaken for panic attacks
Organic causes -> cardio/resp conditions or pharochromocytoma

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18
Q

Calcium parasthesia

A

Hyperventilation blows off CO2 causing raised pH and hypocalcaemia which affects nerve conduction
This can cause parasthesia in the fingers, toes and around the mouth
In extreme cases this leads to carpopedal spasm of the fingers and toes

19
Q

Treatments for anxiety disorders

A

CBT
Exposure therapy
Pharmacological

20
Q

Cognitive behavioural therapy

A

Challenging the pt’s expectations of danger and the central beliefs involved in that using behavioural experiments & role play
Education about the physical and psychological aspects of anxiety, and coping strategies to counter them
Combating -ve automatic thoughts and vicious cycles of worry

21
Q

CBT is particularly useful for

A

GAD - testing predictions of worry and errors in thinking as well as terminating avoidance/reassurance behaviours
Panic disorder - education about their symptoms to remove the need for safety behaviours

22
Q

Exposure therapy

A

This a part of CBT which is useful where avoidance and escape behaviours are central parts of a disorder (phobias)
In the absence of physical symptoms the body can only maintain anxiety for about 45mins before it habituates, reducing anxiety to extinction-> this involve increasing exposure to a phobic stimulus forcing them to habituate to it

23
Q

SSRIs for anxiety

A

Useful and can be combined with CBT
therapeutic dose for anxiety is higher than depression and there is a longer delay before effect (6-8 weeks)
Suddenly stopping SSRIs can cause reflex anxiety symptoms

24
Q

Tricyclic antidepressants

A

Clomipramine, imipramine

Used if patients don’t tolerate/respond to SSRIs

25
Q

Buspirone

A

A serotonin partial agonist
Not addictive but unpopular because of:
Delayed action
Dysphoric side effects

26
Q

Benzodiazepines

A

Bind to GABAa receptor to increase transmission - Eg diazepam
Useful in the short term and are very effective but rapidly develop tolerance/dependence (2-4 weeks)
Side effects –> amnesia, ataxia, respiratory depression, especially in elderly/co-morbid patients

27
Q

Beta-blockers

A

Used to treat the adrenergic symptoms that are particularly difficult in social phobia (tremor & palpitations)
Eg atenolol
BUT … Have many contraindications to use

28
Q

OCD (obsessive compulsive disorder)

A

Unpleasant, intrusive thoughts relating to particular obsessions which cannot be ignored.
The anxiety produced is relieved by performing compulsive rituals
Linked to basal ganglia and frontal lobe damage.
Usually a chronic disorder but can be treated with SSRIs/CBT

29
Q

Obsessional thoughts in OCD

A

Unpleasant, intrusive thoughts relating to particular themes (contamination, harming self/others, infection, religion/morality)
which cannot be ignored.
Patient recognises them as irrational and their own, and may be ashamed/embarrassed.

30
Q

Compulsions in OCD

A

Repeated, stereotyped rituals, which while purposeful often lack a link to the obsession
Normally cleaning, counting, checking or ordering
These can become a significant restriction on life and reduce quality of life.

31
Q

Aetiology of OCD

A

Heredity –> 3x higher risk in relatives
1/4 pt with OCD previously had anankastic traits (rigidity, orderliness) and stress may precipitate OCD
Basal ganglia and frontal lobe deficits are associated

32
Q

Brain changes in OCD

A

Basal ganglia -> diseases which effect the BG show an increased risk (sydenham’s chorea, encephalitis lethargica, Tourette’s)
Anti-BG antibodies have been found in pts with OCD secondary to strep throat infections
Imaging indicates reduced frontal lobe inhibition in OCD pts

33
Q

Management of OCD

A

Education and self help is important for improving functionality
CBT -> compulsions can be addressed in the same ways a escapes in phobias, and thus pts can be helped to habituate
This is effective in well-motivated patients
SSRIs –> effective in OCD, as well as clomipramine

34
Q

Extreme Stress reactions

A

Adjustment disorders
Acute stress reaction
Post traumatic stress disorder (PTSD)

35
Q

Acute stress reaction

A

A ‘state of shock’ following a traumatic event resolving in hours to days (3days max)
Pt will be anxious, dazed, amnesic, may depersonalise/derealise –>can be agitated, irritable or aggressive
Benzos may help in the short term but formal psych debriefing may increase the risk of later PTSD

36
Q

PTSD - post traumatic stress disorder

A

Following a ‘life-threatening’ traumatic event
Symptoms usually begin after six months and include re-experiencing, avoidance of reminders of the event and hyperarousal.
May also show emotional detachment or depression

37
Q

Re-experiencing symptoms in PTSD

A

Flashbacks - vividly reliving the trauma, feeling as though it is happening all over again
Nightmares
Intrusive memories relating to the event

38
Q

Avoidance

A

Avoiding reminders of the event as they will trigger flashbacks
Avoiding places or situations which are similar

39
Q

Hyper-arousal

A 
Persistent inability to relax
Hypervigilence - the patient feels that they always on red alert
Enhanced startle reflex
Insomnia 
Poor concentration/irritability
40
Q

Other changes after traumatic events

A 
Emotional detachment (numbness)
Decreased interest in activities
Powerful emotions including anger, loss of control, shame and crying
41
Q

Differential diagnosis of PTSD

A

Depression or anxiety disorders - both common responses to severe stress
Adjustment disorders

42
Q

Psychological Management for PTSD

A

Psychological treatments - CBT - testing and challenging thoughts of vulnerability after the event
EMDR - Eye movement desensitisation and reprocessing - focusing on a moving finger while reliving the event helps reduce stress

43
Q

Pharmacological management of PTSD

A

SSRIs - first line combined with psychological therapies

44
Q

Adjustment disorders

A

Life changes require adaptations to cope with
Often people can appear to cope with these changes easily will still show transient symptoms of anxiety or depression
In adjustment disorders a persons response is considered greater than expected but not enough to classify as a full disorder
Symptoms start within a month and resolve within 6 months

Psychiatry (18 decks)

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