Anxiety and Obsessions Flashcards
What are the types of anxiety disorders?
Anxiety disorders are characterised by the feeling of anxiety which is the most severe and prominent symptom. This occurs alongside physical symptoms, and in the absence of organic brain disease or another psychiatric symptom. There are three main types of anxiety disorders, which share many features, but have key differences:
- Generalised Anxiety Disorder (GAD) is characterised by continuous anxiety although it may fluctuate in intensity.
- Specific phobias are characterised by intermittent anxiety arising in particular circumstances.
- Panic disorder is characterised by intermittent anxiety that can arise unrelated to any circumstance.
What are the behavioural and cognitive theories for anxiety disorders?
- Classical conditioning - the repeated pairing of a neutral stimulus with a frightening one results in a fear reaction to the neutral stimulus.
- Negative reinforcement - behaviours that relieve anxiety (e.g. running away) are repeated. This prevents habituation (desensitisation) so escaping from a fearful stimulus maintains the fear response.
- Cognitive theories - Various stressors can contribute to a state of anxiety in a person who has high trait anxiety or is particularly predisposed. This state of anxiety causes hyperarousal which perpetuates anxiogenic automatic thoughts, which are repeated in an automatic way. The state of anxiety also causes avoidant behaviour, which is repeated due to negative reinforcement.
- Attachment theory - the quality of attachment between children and their parents affects their confidence as adults: insecurely attached children become anxious.
What are the features of generalised anxiety disorder?
How long does it need to last for in order to be classified as a disorder?
In GAD, anxiety is not triggered by a specific stimulus, but is instead continuous and free-floating (generalised). Life is a worry - past mistakes and future imagined catastrophes occupy the mind endlessly.
The ICD-10 criteria require symptoms to last for at least 6 months, although severity may fluctuate.
What are the differential diagnoses for generalised anxiety disorder?
Differential diagnoses
- Hyperthyroidism
- Substance misuse: intoxication of amphetamines, withdrawal of benzodiazepines or alcohol
- Excess caffeine
- Depression: anxiety is a common feature of depression. Diagnose mixed anxiety and depressive disorder if both full-blown depression and GAD are present.
- Anxious (avoidant) personality disorder
- Dementia
- Schizophrenia
What are the features and types of phobic disorders?
In these disorders, anxiety occurs intermittently in relation to specific but quite ordinary circumstances. Patients characteristically exhibit avoidant behaviour to these situations and anticipatory anxiety; the seriousness of the phobia depends on the resultant disability.
Phobic anxiety disorders are split into:
- Agoraphobia
- Social phobia
- Specific phobias
What are the features of agoraphobia?
Agoraphobic patients are anxious when they are away from home, in crowds, or in situations that they cannot leave easily. There are three sets of symptoms:
- Avoidance behaviours to these situations
- Anxiety when anticipating these situations
- Other symptoms such as depression.
The anxiety they feel is similar to other phobic disorders, however they can also experience panic attacks either spontaneously or in response to stimuli, and have anxious thoughts about fainting and losing control.
Common problem situations include: travelling on trains, planes, buses, queuing, supermarkets, large crowds, parks and sitting in the middle row of a cinema.
What are the features of social phobia?
Onset is normally in late teens, with men and women being equally affected. The core fear in social phobia is one of being scrutinised or criticised by other people, and patients often worry they will embarrass themselves in public. They may tolerate an anonymous crowd, but become anxious in dinner parties, board meetings etc.
Alcohol dependence is common and perpetuates the problem as it offers psychological avoidance.
What are the differential diagnoses for social phobia?
Differential diagnoses should include:
Normal shyness - some people are naturally shy
Agoraphobia - in agoraphobia, the need to get somewhere safe is more important than the fear of scrutiny.
Anxious (avoidant) personality disorder
Poor social skills/autism spectrum disorder
What are the features of specific phobic disorders?
These phobias are restricted to a single, specific situation (e.g. spiders = arachnophobia). They often develop in childhood, although sometimes begin later, usually after a frightening experience. Phobias result in avoidance and, in severe cases, disability.
What are the features of panic disorder?
Panic disorder, also known as episodic paroxysmal anxiety is characterised by intermittent and extreme anxiety (panic attacks) without an obvious trigger - comes out of the blue. Often patients dear a serious medical consequence such as a heart attack. For a diagnosis of panic disorder, there must be recurrent panic attacks and relative freedom from anxiety in between episodes.
The symptoms provoke further panic as patients fear a serious medical consequence, and continue until the patient receives reassurance of engages in safety behaviours such as taking aspirin. Panic attacks are self-resolving lasting no more than 30 minutes.
People often have avoidance symptoms, such as not leaving the house. Many patients with panic disorder may have an element ofagoraphobia, so panic disorder is sometimes presented as panic disorder +/- agoraphobia.
What are the symptoms of a panic attack?
A panic attack is a sudden attack of extreme anxiety with accompanying physical symptoms such as:
- Breathing difficulties/choking feeling
- Chest discomfort/tightness
- Palpitations
- Tingling or numbness in hands, feet, or around the mouth
- Depersonalisation/derealisation
- Shaking
- Dizziness/faints
- Sweating
What are the investigations for anxiety disorders?
- A good history and physical examination to rule out an organic cause, or which may prompt further investigations.
- Rating scales of anxiety include Beck Anxiety Inventory and the HADS (Hospital Anxiety Depression Scale). These can assess severity and provide ‘baseline scores’ against which to measure treatment response.
- Social and occupational assessments for effect on quality of life. They may involve social services or occupational therapists.
- Collateral history
Describe the management approach for anxiety disorders
All patients with anxiety disorders should receive support in form of:
- Psychoeducation - important to help patients understand their illness. Written information should be provided with the nature of the disorder and it’s treatment options. Good leaflets exist from NICE and Royal College of Psychiatrists.
- Assess patients and treat patients for co-morbid conditions such as depression, and substance misuse.
For GAD, NICE recommends a step-wise approach, however patients can skip to step 3 if severe enough:
- Identification and assessment: education about GAD and treatment options; active monitoring.
- Low-intensity psychological interventions: pure self-help and guided self-help, group psychoeducation. Self-help material is often CBT based and involves books and computer programs. Also encourage people to rely on their
- Choice of a high-intensity psychological intervention or a drug treatment. The choice between psychological intervention or drug treatment should be guided by the patient’s preference, as there is no evidence that one is more effective than the other in the treatment of anxiety.
- Refer for specialist treatment (complex drug and psychological regimens): input from multiagency teams, crisis services, or day hospitals.
Describe the high-intensity psychological therapies for anxiety disorders
High intensity psychological therapies include:
- Cognitive Behavioural Therapy (CBT) to reduce patient’s expectation of threat and the behaviours that maintain threat-related beliefs. Over time, more adaptive coping mechanisms replace unhelpful behaviours such as avoidance behaviours.
- Applied relaxation provides the patient with relaxation techniques. This relies on the theory of reciprocal inhibition: it is not passive to both panic and relax at the same time, so practised relaxation can negate panic.
- Exposure therapy can be applied to agoraphobia, social phobia and specific phobias. In the absence of harm, the body can only remain extremely anxious for a relatively short period (~45 mins) before habituation occurs and anxiety levels drop. Habituation is getting used to fear, so anxiety decreases until the fear dies out (extinction). Exposure is usually through the gradual approach called desensitisation. The therapist helps the patient identify a goal and then construct a hierarchy of feared situations for which patients experience until they become habituated. This courageous tiptoeing can result in a complete cure.
What are the pharmacological treatments for anxiety disorders?
- SSRIs such as fluoxetine and paroxetine can be used to treat anxiety disorders. Therapeutic doses are generally higher than for depression, and response takes longer.
- TCAs can be used if patients don’t tolerate or respond to SSRIs.
- Buspirone is a serotonin partial antagonist, which is non-dependency-forming but unpopular due to delayed action and dysphoric effects.
- Benzodiazepines can be used to manage short-term anxiety, which are very effective, but patients quickly become dependent.
- Beta-blockers are sometimes used to treat the adrenergic symptoms that social phobia patients find so disturbing such as tremor and palpitations.
