Anxiety disorders Flashcards Preview

Psychiatry > Anxiety disorders > Flashcards

Flashcards in Anxiety disorders Deck (66):
1

Main differentials for OCD

  1. Depressive disorder: Obsessions common
  2. Psychosis: Delusions are 'believed' and seen as reality
  3. Anankastic (aka obsessive) personality disorder
  4. Hypochondriasis, body dysmorphia
  5. Other anxiety disorder

2

M:F ratio of OCD

1:1

3

Aetiological factors for OCD

Bio: Genetic vulnerability (3-7% of first degree relatives affected), dysregulation of 5-HT system, ?autoimmune cause (e.g. in Sydenham's chorea, encephalitis)

Psycho: Anankastic personality

Social: Stressful events precipitate OCD

4

Maintaining factors for OCD

Avoidance of situations triggering obsessions + performance of compulsions --> prevent habituation of anxiety

5

Core symptoms of OCD

Must cause distress/functional impairment (behaviours must take >1h per day)

Emotion: Anxiety around topic of obsessional thought

Cognition: Ego-dystonic (i.e. resisted) repetitive obsessional thoughts/images/ruminations/impulses

Behaviour: Compulsions/rituals (may be mental or physical, and may not be present). 

Somatic symptoms: Tension, esp if stopped doing compulsions

6

Age demographics of OCD

Mean age: 20yrs

70% onset <25

15% >35

7

Prevalence of OCD in general population

0.5-3%

8

Frequent co-morbidities for OCD

Depression (obsessions follow depression in MDD, and vv for OCD)

Eating disorder

Other anxiety disorder

Tics, Tourette's

9

Outcome for OCD

20-30% significant improvement within 1y

40-50% moderate improvement

20-40% chronic/worsening symptoms

10

Poor prognostic factors for OCD

Personal: Male, comorbid depression or PD

Illness: early onset, long duration, tics, acting on compulsions

11

Psychological treatment options for OCD

CBT + exposure-response prevention

12

Pharmacological treatment options for OCD

  1. First line: SSRI (fluoxetine, paroxetine, sertraline)
  2. Second line: Clomipramine

Continue for 12mo as maintenance

13

Important anxiety differentials to rule out in <18

ADHD

ASD

Substance misuse

Eating disorder

14

Important anxiety differentials to rule out in 18-35

Schizophrenia

Bipolar

Major depressive disorder

Substance misuse

Somatoform disorder

15

4 components of anxiety to assess

Cognition: What are you worried about? What is the nature? Any triggers?

Body sensations: Head to toe manifestation of symptoms

Behaviour: Anxious-avoidant behaviour that perpetuates anxiety disorder

Impairment: How has it affected your life? Can you put it out of your mind? --> become disorder

16

Typical duration of a panic attack

Peak at 10-15 min

Last 20-30 min

17

Definition of generalised anxiety disorder

Free-floating, excessive worry w/ psychic + physical tension causing functional impairment

18

ICD-10 symptoms criteria for generalised anxiety disorder

At least 4 of:

Autonomic arousal: E.g. palpitations, tachycardia, dry mouth

Physical symptoms: Difficulty breathing, chest pain, abdominal distress

Mental state: Dizziness, light-headedness, fear of dying/losing control/going mad, poor concentration, feeling on edge

Musculoskeletal: Tension, tingling/numbness, globus

Hypervigilance

Sleep disturbance: Nightmares, frequent waking, not EMW usually, that should alert to depression

 

19

Time criterion for generalised anxiety disorder

Most of the time for >=6mo, shorter --> likely adjustment

20

Prevalence of generalised anxiety disorder

lifetime: 5.4%

21

Demographic risk factors for anxiety disorder

Female

Unemployed

45-59yrs peak incidence

Marital/sexual disturbance or trauma

22

Biological aetiological factors for generalised anxiety disorder

Genetics: Shared heritability w/ depression, 5x more prevalent in first-degree relatives

HPA axis: Reduced cortisol responsiveness to DMST

NA/5-HT/BDZ axis: Dysregulation

23

Psychological aetiological factors for generalised anxiety disorder

Diminished sense of control: Trauma or insecure attachment to primary caregivers --> intolerance of uncertainty

Parenting: Overprotective or lacking warmth

Personality: Esp anxious-avoidant

24

Social aetiological factors for GAD (aka specific psychological vulnerability)

Trauma: war/parental loss/abuse

Dysfunctional family/marital relationships

25

Medical conditions associated w/ anxiety-like symptoms

Cardio: Arrhythmia, ischaemic heart disease, mitral valve disease, heart failure

Resp: COPD/asthma, PE

CNS: vestibular nerve disease, temporal lobe epilepsy

Endocrine: Hyperthyroidism, hypoparathyroidism, hypercalcaemia, phaeochromocytoma, carcinoid, hypoglycaemia

26

Prognosis for generalised anxiety disorder

Generally poor

30% remission at 3 years

68% residual symptoms at 6 years

27

Management for generalised anxiety disorder

Step 1: Psychoeducation - breaking cycle of anxiety + treat any co-morbidity

Step 2: Facilitated/independent self-help - computerised CBT, problem-solving techniques, relaxation techniques

Step 3a: CBT 

Step 3b: Pharmacology: sertraline, other SSRI (e.g. paroxetine, escitalopram for social), pregabalin (take longer to be more effective)

28

Demographic risk factors for panic disorder

Female

Widowed, divorced, separated

Physical/sexual abuse

Early parental loss

15-24yo or 45-54yo

29

Symptoms of panic attacks

Palpitations, tachycardia, chest pain

Sweating

Trembling/shaking

Hyperventilation, shortness of breath, fealing of choking

Psych: Fear of dying, dissociative symptoms

Paroxysmal: No trigger, or triggered in site of earlier attacks

30

Common comorbidity for panic disorder

Agoraphobia (esp if untreated)

Substance misuse

Major depressive disorder (should not Dx panic if depressive disorder present at start of panic attacks)

Bipolar disorder

31

Emergency management of panic attack

Reassurance

Exclude medical cause if first presentation

BDZs if severe

Psychiatric referral if recurrent (i.e. panic disorder)

32

Prognosis of panic disorder

Functional recovery in 25-75% at 1 yr

10-30% at 3 years (chronic course)

If attacks present for >6mo --> will run a prolonged, fluctuating course

33

Management of panic disorder

1st line: Self-help

2nd line: CBT and/or SSRI (e.g. sertraline, paroxetine, citalopram)

3rd line: TCA (e.g. imipramine, clomipramine)

34

Aetiological models for panic disorder

NAergic/5-HTergic: Hypersensitivity

Lactate/CO2: brainstem hypersensitivity

GABA: Reduced activity

Cognitive: Hypersensitivity to autonomic cues

 

 

35

Clinical features of agoraphobia

Emotional: Situational anxiety, in open spaces where escape may be difficult or embarrassing

Cognitive: Thoughts of collapsing/having panic attack in public, inability to escape (c.f. fear of scrutiny in SA)

Behaviour: leading to avoidance --> risk of self-neglect

Somatic: +/- panic attacks (i.e. agoraphobia with(out) panic disorder)

36

Aetiological factors for agoraphobia

Bio: Genetic (first degree relatives have higher incidence of alcohol dependence, MDD, other anxiety disorder)

Psycho: Fear/loss of confidence due to previous panic attack/trauma/physical frailty --> learned response

37

Differential for agoraphobia

Presence of panic disorder, other anxiety disorder (esp GAD, social)

Presence of delusions in psychotic disorder

Major depressive disorder

 

38

Management of agoraphobia

Psychological: CBT, esp exposure therapies

Pharma: SSRIs for panic disorder (e.g. paroxetine, citalopram)

Prognosis: Present for >1year, likely to persist for at least 5y

39

Definition of simple phobia

Recurring, excessive, unreasonable fear in presnce (or anticipation of) specific stimulus/situation

Cannot be reasoned away, beyond voluntary control

Causes impairment

40

Mean age of onset for simple phobias

15yo, 7-8 for animal/needle and 20 for situational

41

Comorbidities in simple phobias

Mood or other anxiety

>80% lifetime comorbidity

42

Management of simple phobias

Exposure therapy (rarely use BDZs to allow engagement in exposure therapy)

43

Aetiology of simple phobias

Genetic vulnerability (esp in non-situational)

Learned response (perpetuated by avoidance)

44

Clinical features of social anxiety

Cognition: Fear of being judged (not harmed) by others, anticipatory anxiety

Bodily sensations: Embarrassment, blushing, hand tremor, nausea, sweating

Behaviour: Avoidance

Associations: Substance misuse, suicidality, low self-esteem, perfectionism, 80% co-morbidity w/ other condition

45

Aetiology of social phobia

Bio: Minor genetic component (MZ:DZ 24:15)

Psycho: Learned responses e.g. from previous social trauma, learned from parents, overprotective parenting

46

Management of social phobia

Assessment: Mini Social Phobia Inventory (Mini-SPIN)

First line: CBT or CBT-based self-help book with telephone guidance. >90% response + reduces relapse. Includes behavioural/exposure therapy. May be combined with medication (see below)

Second line: SSRI (sertraline, citalopram are licensed)

Third line: Alternative SSRI, venlafaxine

47

Neuroses not more prevalent in women (i.e. equal prevalence)

Social phobia

OCD

Panic disorder (equivocal)

48

Comparison of panic disorder, phobic anxiety, and generalised anxiety, onset

Panic: Paroxysmal

Phobic: Situational

Generalised: Persistent

49

Comparison of panic disorder, phobic anxiety, and generalised anxiety, behaviour

Panic: Escape (e.g. agoraphobia)

Phobic: Avoidance

Generalised: Agitation

 

50

Comparison of panic disorder, phobic anxiety, and generalised anxiety, cognition

Panic: Fear of symptoms/dying

Phobic: Fear of situation/stimulus

Generalised: Worry

51

Mechanism of action of buspirone

5-HT agonist --> overall decrease in synaptic 5-HT levels + increase in DA/NA

52

Short-term management of acute anxiety

Benzodiazepines

Buspirone

Review after 2-4w max! 

53

Mechanism of action of benzodiazepines

Allosteric modulators of GABA receptors

54

Timecourse for withdrawal symptoms from benzodiazepines

Up to 3 weeks after stopping if long-acting, within a day if short-acting

More likely with short-acting

 

55

Symptoms of benzodiazepine withdrawal

Tremor, perspiration, seozures

Tinnitus, perceptual disturbances

Low appetite +/- weight loss

Insomnia, anxiety

 

56

Common classes of hypnotics

Benzodiazepines

Z-drugs (zopiclone, zolpidem)

Antihistamines (esp promethazine)

57

Common side effects of benzodiazepines

Mental state: Depression, confusion, drowsiness, 'hangover effect', suicidal ideation

Neuro: Ataxia, dizziness, headache, tremor, muscle weakness, vision disorders

Other: Dysarthria, fatigue, GI disturbance, respiratory depression

58

Timecourse to tolerance of hypnotics

3-14d, should not be used long-term!

59

Indications for buspirone

Non-sedating anxiolytic, for use in generalised anxiety

60

Age distribution for GAD

15-30 and 40-60 (bimodal)

61

Age distribution for agoraphobia

15-30 and 70-80 (bimodal)

62

Age distribution for social phobia

Childhood - 30years

63

Age distribution for panic disorder

15-25 and 40-60

64

Age distribution for OCD

Generally onset in teenage years

65

Differentials for GAD

Withdrawal from drugs/alcohol

Drugs: e.g. bronchodilators, antiarrhytmics, thyroxine, psychotropics

Dementia

Depression

SCZ

Physical illness

66

Poor prognostic factors for GAD

Severe symptoms, agitation

Derealisation

Conversion symptoms

Suicidal ideation

Concurrent depressive illness