Anxiety Disorders Flashcards
(44 cards)
What is anxiety?
-Anxiety and fear are normal responses to threatening circumstances. excessive worry about a number of different events associated with heightened tension
-Anxiety is often productive and can improve performance. However, high levels of anxiety can impair function.
-Anxiety consists of two components: thoughts about the potential threat and physical signs / symptoms
What are the anxiety disorders?
-Generalised (free floating): not associated with a specific external threat or situation, slow rate of onset, mild to moderate severity, long duration
-Paroxysmal: abrupt onset, occurs in discrete episodes and tends to be quite severe, shorter duration, phobia and panic
-OCD and stress-related
What to determine for differential diagnosis of anxiety
-The rate of onset, severity, duration
-Lifelong or acquired
-Whether anxiety is in response to specific threat or arises spontaneously (unprovoked)
-Whether the anxiety only occurs in context of pre-existing psychiatric or medical condition
-Do you sometimes wake up feeling anxious and dreading the day ahead? (any form of anxiety)
-Do you worry excessively about minor matters on most days of the week? (generalized anxiety)
-Have you ever been so frightened that your heart was pounding and you thought you might die? (panic attack)
-Do you avoid leaving the house alone because you are afraid of having a panic attack or being in situations (like being in a crowded shop or on a train) from which escape will be difficult or embarrassing? (agoraphobia)
-Do you get anxious in social situations, like speaking in front of people or making conversation? (social phobia)
-Do some things or situations make you very scared? Do you avoid them? (specific phobia)
-Onset after life event
=Stressful but not traumatic (adjustment disorder)
=Symptoms resolve within 3 days (acute stress reaction)
=PTSD
-Onset unrelated to life event
=Unpredictable, lengthy, mild-moderate periods of anxiety (>6 months): GAD
=Unpredictable but short intense periods of anxiety: panic
=Clear trigger, external event or situation (phobia)// intrusive thought or image (OCD
What is generalised anxiety disorder?
Excessive free-floating anxiety and worry about everyday events and problems occurring most of the time
- Apprehension
- Motor tension (restlessness, fidgeting, tension headaches, inability to relax)
- Autonomic overactivity
What is paroxysmal anxiety disorder?
-Panic Disorder – severe short-lived episodes of anxiety (panic attacks)occur unpredictably. Covered in a separate lecture.
-Phobias – anxiety occurs in response to a specific trigger, e.g. fear off lying. Covered in a separate lecture.
Epidemiology of anxiety disorders
-Anxiety disorders are the most common of all the psychiatric disorders.
-Prevalence for having an anxiety disorder is 12-17% per year.
-Only a third of people in the UK with a clinically significant anxiety disorder are receiving any kind of treatment.
-Specifically, GAD has a 1-year prevalence of 3% and occurs 2-3 times more frequently in females
-GAD can present at any time throughout childhood and adult life.
ICD-10 criteria for GAD
-6 month history of generalised anxiety plus:
-Four symptoms from the following list (at least one of which must indicate autonomic arousal):
=Autonomic Arousal - Palpitations/Tachycardia, Sweating, Trembling/Shaking or Dry Mouth.
=Physical Symptoms – Difficulty Breathing, Feeling of Choking, Chest Pain, Nausea/Abdominal Distress, Light-Headedness, Dizziness/Light-headedness, Hot Flushes/Cold Chills, Numbness/Tingling Sensations.
=Symptoms of Tension – Muscles Tension/Aches, Restlessness/ Inability to Relax, Feeling on Edge, Sensation of a Lump in the Throat, Exaggerated Startle Response.
=Psychological symptoms - Derealisation/Depersonalisation, Fear of Losing Control/ Going Crazy/Passing Out or Fear of Dying, Difficulty Concentrating, Persistent Irritability, Difficulty Getting to Sleep.
-Not explained by any other mental or physical disorder, or the effects of medication/substances
-Impairment in daily life
Aetiology of anxiety disorders
-Genetic factors=Anxiety disorders have a heritability of 30-50%
=Considerable genetic overlap with depression
=Different environmental stimuli can lead to those vulnerable individuals to experience depression, anxiety or both
-Biological factors
=Noradrenaline, serotonin and GABA are the 3 neurotransmitters most implicated
-Social and psychological factors
=Anxiety disorders are often linked to stressful life events
=Cognitive behavioural models suggest symptoms are a consequence of inappropriate thought processes and overestimation of dangers – considered to be maladaptive patterns of thinking that exacerbate and maintain symptoms
Differential diagnosis for anxiety
-Anxiety disorder:
=Generalised anxiety disorder
=Panic disorder
=Phobia
=Reaction to stress (e.g. Acute stress reaction / PTSD)
=Obsessive-compulsive disorder
-Secondary to other psychiatric disorder:
=Depression (major differential!), psychosis, personality disorder, neurodevelopmental disorder.
-Secondary to a physical condition: hyperthyroidism, cardiac disease, medication-induced anxiety (salbutamol, theophylline, corticosteroids, antidepressants, caffeine)
-Secondary to psychoactive substance use (esp. alcohol)
Medical conditions and substances associated with anxiety
Medical
-Causing dyspnoea:
=Congestive cardiac failure
=Pulmonary embolism
=Chronic obstructive pulmonary disease
=Asthma
-Causing increased sympathetic outflow
=Hypoglycaemia
=Pheochromocytoma
-Causing pain
=Malignancies
-Other
=Cerebral trauma
=Cushing disease
=Hyperthyroidism
=Temporal lope epilepsy
=Vitamin deficiencies
Side effects of prescribed drugs
-Antidepressants (e.g. SSRIs and tricyclics in first 2 weeks of use or following rapid discontinuation (particularly of Paroxetine or Venlafaxine))
-Corticosteroids
-Sympathomimetics
-Thyroid hormones
-Compound analgesics containing caffeine
-Anticholinergics
-Antipsychotics (akathisia)
Assessment of anxiety disorders
-History
=Establish how frequently they suffer from anxiety (generalised vs paroxysmal)?
=Is there a specific trigger(s)?
=Do you avoid certain situations that worry/scare you to reduce anxiety symptoms?
-Examination
=Basic physical exam including a thorough neurological and endocrine review
-Investigations
=Let the history guide further investigations e.g. tachycardia and heat intolerance may suggest thyrotoxicosis and TFTs would be used to exclude this
=Always consider substance misuse and alcohol withdrawal
Management of mild to moderate anxiety disorders
-Psychological therapies are first-line (usually CBT).-Helping the patient to overcome their maladaptive ways of thinking through psychoeducation is one of the most important steps in managing an anxiety disorder.
-In very mild cases, self-help programmes may be offered first.
Management of moderate cases (or cases not alleviated by psychotherapy)
-Pharmacological therapy is first-line.
-SSRIs are first-line pharmacological therapy for most anxiety disorders.
-Higher doses are usually required in anxiety treatment than in depression.
-Anxiety and agitation may increase initially with medication: warn patient they should alert their GP if any increased thoughts of self-harm or suicide occur.
-Slower titration can sometimes prevent this and improve concordance with medication.
-Other options (SNRIs, TCAs and MAOIs) can be effective but are mostly used only when SSRIs have not helped due to increased risk of side effects.
Management of severe cases of anxiety
Combined pharmacological and psychological therapy
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above
=if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
=compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response
Management of GAD
-Applied Relaxation - Patient learns breathing exercises and progressive muscle relaxation. Can be of added benefit in those with GAD with marked autonomic arousal / hyperventilation.
-Venlafaxine is an SNRI licensed for use in GAD as an alternative to SSRIs
-Step 1: education about GAD + active monitoring
-Step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
-Step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
-Step 4: highly specialist input e.g. Multi agency teams
-NICE suggest sertraline should be considered the first-line SSRI
-If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)
examples of SNRIs include duloxetine and venlafaxine
-If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
-Interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
Prognosis of GAD
-GAD commonly has a chronic, fluctuating course.
-It is normally worsened during times of stress e.g. starting anew job, bereavement etc.-GAD can cause significant distress and functional impairment, and as a result good, early management is very important.
Clinical presentation of panic attack disorders
-Panic Disorder: unpredictable occurrence of discrete episodes of extreme anxiety (“panic attacks”), unrestricted to a specific situation or presence of potential danger. Often there is little to no baseline anxiety outside of the panic attacks.
-Anticipatory anxiety: occurs secondary to panic attacks as the patient becomes anxious about having further attacks due to their distressing nature.
-Presenting features:
=Sudden onset feelings of intense anxiety
=Accompanied by the classic autonomic features of anxiety
=Often coexists with agoraphobia (see phobia lecture)
Epidemiology of panic disorder
-Panic disorder has a 1-year prevalence of 4%
-It is 2-3 times more common in females
-It commonly begins in late adolescence up till mid-30s
-95% of patients presenting with agoraphobia will have a previous or current diagnosis of panic disorder
Aetiology of panic disorder
-Panic disorder is one of the most heritable anxiety disorders, with more than 1/3 of patients having a first-degree relative with the same diagnosis
-Cognitive modelling suggests that a panic attack may be initiated when a susceptible individual misinterprets a normal bodily stimulus i.e. becoming aware of one’s heartbeat and becoming concerned that this represents something being wrong
=This can lead to an anxiety-related increase in heart rate and which creates a positive feedback loop ultimately causing a full blown panic attack
Assessment of panic disorder
-History
=Have you ever been so frightened that your heart was pounding and you thought you might die?
=Do you ever become aware of your breathing or heartbeat and feel that something is wrong causing you to panic?
=Do you feel anxious all the time?
=Do you worry about having further panic attacks?
-Examination and investigations to exclude potential alternative causes(physical / psychiatric / substance-related).
Management of panic disorder
-In CBT the focus is often on breaking the false association that the normal bodily function is truly worrisome or pathological in nature. This in turn helps to gradually breakdown the cycle of thoughts and behaviour that lead to a panic attack.
-Licensed SSRIs for panic disorder (first line): escitalopram, citalopram, paroxetine and sertraline (“start low and go slow” due to possible exacerbation of symptoms).
=If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
-Benzodiazepines can be used to manage acute crises in patients with severe illness. Longer term use should be avoided due to the risk of dependence
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Prognosis of panic disorder
-Up to half of patients with panic disorder are symptom free after 3 years
-1/3 will have chronic symptoms that negatively affect their quality of life
-Panic attacks are central to the development of agoraphobia, which usually develops within a year of the onset of recurrent attacks
Clinical presentation of phobic disorders
-Phobia: an intense, irrational fear of a neutral object, activity or situation that would not commonly cause distress, or excessive fear of an inherently aversive stimulus (beyond that experienced by most people).
-Presenting features:
=Sudden onset intense anxiety when faced with a particular stimulus.
=Accompanied by autonomic features of anxiety.
=Little to no baseline anxiety when not around the feared stimulus.
=Avoidance of the distressing stimulus, which can affect functioning.
=If severe, may present with frank panic attacks, or the patient becoming housebound
What is agoraphobia?
-Fear of entering crowded public places, usually where escape or seeking help may be difficult.
-Patients may refuse to leave the house if severe
