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Anxiety disorders Flashcards

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1
Q

Main differentials for OCD

A
  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
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2
Q

M:F ratio of OCD

A

1:1

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3
Q

Aetiological factors for OCD

A

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

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4
Q

Maintaining factors for OCD

A

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

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5
Q

Core symptoms of OCD

A

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

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6
Q

Age demographics of OCD

A

Mean age: 20yrs

70% onset <25

15% >35

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7
Q

Prevalence of OCD in general population

A

0.5-3%

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8
Q

Frequent co-morbidities for OCD

A

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

Eating disorder

Other anxiety disorder

Tics, Tourette’s

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9
Q

Outcome for OCD

A

20-30% significant improvement within 1y

40-50% moderate improvement

20-40% chronic/worsening symptoms

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10
Q

Poor prognostic factors for OCD

A

Personal: Male, comorbid depression or PD

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

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11
Q

Psychological treatment options for OCD

A

CBT + exposure-response prevention

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12
Q

Pharmacological treatment options for OCD

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

Continue for 12mo as maintenance

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13
Q

Important anxiety differentials to rule out in <18

A

ADHD

ASD

Substance misuse

Eating disorder

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14
Q

Important anxiety differentials to rule out in 18-35

A

Schizophrenia

Bipolar

Major depressive disorder

Substance misuse

Somatoform disorder

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15
Q

4 components of anxiety to assess

A

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

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16
Q

Typical duration of a panic attack

A

Peak at 10-15 min

Last 20-30 min

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17
Q

Definition of generalised anxiety disorder

A

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

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18
Q

ICD-10 symptoms criteria for generalised anxiety disorder

A

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

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19
Q

Time criterion for generalised anxiety disorder

A

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

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20
Q

Prevalence of generalised anxiety disorder

A

lifetime: 5.4%

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21
Q

Demographic risk factors for anxiety disorder

A

Female

Unemployed

45-59yrs peak incidence

Marital/sexual disturbance or trauma

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22
Q

Biological aetiological factors for generalised anxiety disorder

A

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

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23
Q

Psychological aetiological factors for generalised anxiety disorder

A

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

Parenting: Overprotective or lacking warmth

Personality: Esp anxious-avoidant

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24
Q

Social aetiological factors for GAD (aka specific psychological vulnerability)

A

Trauma: war/parental loss/abuse

Dysfunctional family/marital relationships

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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

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