Anxiety disorders and management

Question 1

Biological (physical) symptoms of anxiety?

Answer 1

Sweating, hot flushes or cold chills
Trembling or shaking
Muscle tension or aches and pains
Numbness or tingling sensations
Feeling dizzy, unsteady, faint or lightheaded 
Dry mouth 
Feeling of choking
Sensation of a lump in throat 
Difficulty breathing
Palpitations or pounding heart
Chest pain or discomfort
Nausea or abdo distress

Question 2

What are the pathological cognitive symptoms of anxiety?

Answer 2

Derealization
Depersonalisation
Meta-worry

Question 3

Behavioural symptoms of anxiety?

Answer 3

Aviodance of certain situations
Exaggerated response to minor suprises or being startled
Difficulty in getting to sleep due to worry
Excessive use of alcohol/ drugs 
Restlessness and inability to relax
Persistent irritability 
Seek reassurance from family/ gp 
Checking behaviours

Question 4

What is the stress response?

Answer 4

Exposure to stress results in instantaneous and concurrent biological responses (to assess danger and organise an appropriate response)

Question 5

What is the emotional filter of the brain?

Answer 5

Amygdala; emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response
Modified by later-received cortically processed signals

Question 6

Which hormone is particularly active in stress?

Answer 6

Cortisol and catecholamines via adrenal gland

Question 7

Different types of anxiety disorders?

Answer 7

GAD
Panic disorder
Agoraphobia
Social phobia
Specific phobia
OCD

Question 8

What is generalised anxiety disorder?

Answer 8

Anxiety that is generalised and persistent but not restricted to, or even strongly predominating in any particular environmental circumstances (free floating)

Question 9

What is a buzzword for GAD?

Answer 9

Free-floating

Question 10

What are the dominant symptoms of GAD?

Answer 10

Persistent nervousness
Trembling
Muscle tensions 
Sweating 
Lightheadedness
Palpitations
Dizziness
Epigastric discomfort

Question 11

Criteria for diagnosis of GAD?

Answer 11

Long lasting; most days for at least 6 months
Not controllable
Causing significant distress/ impairment in function

Question 12

What is the lifetime prevalence of GAD?

Answer 12

9%

Question 13

Typical age of onset of GAD?

Answer 13

20-40

Question 14

Treatment of GAD?

Answer 14

1st line: CBT
2nd line: SSRI/SNRI
Long term anxiety disorder: pregabalin
Benzodiazepines (short term only)

Question 15

What is CBT?

Answer 15

An evidence based psychological treatment based on identifying an individual’s automatic thoughts, cognitive biases and schemas
Helps the individual identify thoughts, assumptions, misinterpretations and behaviours that reinforce and perpetuate the anxiety

Question 16

What is panic disorder?

Answer 16

Recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable

Question 17

Dominant symptoms in panic disorder?

Answer 17

Sudden onset of palpitations
Chest pain
Choking sensations
Dizziness
Feelings of unreality (depersonalization, derealization)
Secondary fear of dying, losing control or going mad

Question 18

What will panic order tend to occur with?

Answer 18

Agoraphobia
Direct physiological effects of a substance or general medical condition; hyperthyroidism, caffeine intoxication
Can get panic in depression

Question 19

What % of those with panic disorder will have concurrent agoraphobia?

Answer 19

50-67%

Question 20

What can trigger a panic attack in susceptible individuals?

Answer 20

Infusion of lactate

Re-breathing air (inc CO2)

Question 21

What can be seen on the PET scan of someone who has panic disorder?

Answer 21

Increased metabolism in the anterior pole of the temporal lobe; parahippocampal gyrus

Question 22

What is the treatment for a panic disorder?

Answer 22

1st line: CBT
2nd line: SSRI/SNRI/tricyclics
Benzodiazepines (short term only)

Question 23

What are the 3 types of phobia?

Answer 23

Agoraphobia
Social phobia
Specific phobia

Question 24

What is agoraphobia?

Answer 24

Well-defined cluster of phobia embracing fears of leaving home, entering ships, crowds and public places, or travelling along in trains, buses or planes

Question 25

Will people with phobias recognise that their phobia is irrational?

Answer 25

Yes

Question 26

What is a specific phobia?

Answer 26

Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation

Question 27

What is the treatment for a specific phobia?

Answer 27

Behavioural therapy; exposure Graded exposure/ systematic desensitisation Add in CBT if necessary SSRI/ SNRI if required

Question 28

What is a social phobia?

Answer 28

Persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others

Question 29

What are common anxiety symptoms of social phobia?

Answer 29

Blushing or shaking Fear of vomiting Urgency or fear of micturition or defecation

Question 30

When does social anxiety tend to start?

Answer 30

In school; results in poor school performance, school refusal, poor employment history

Question 31

What is the biological basis of social phobia?

Answer 31

Increased bilateral activation of the amygdala and increased rCBF to the amygdala (and related limbic areas) that normalizes on successful treatment (pharma or psychological)

Question 32

Treatment of social phobia?

Answer 32

CBT SSRI/ SNRIs Benzo (short term only)

Question 33

What are examples of obsessional thoughts?

Answer 33

Ideas, images or impulses entering the mind in a stereotyped way Recognised as the patients own thoughts Unpleasant, resisted and ego-dystonic

Question 34

Buzzword for obsessional thoughts?

Answer 34

Ego-dystonic

Question 35

What are examples of compulsive acts?

Answer 35

``` Repeated rituals or stereotyped behaviours Not enjoyable Not functional Often view as neurtralising Recognised as pointless Resistance may diminish over time ```

Question 36

Criteria for diagnosis of OCD?

Answer 36

Obsessional thought or compulsive acts must be present most days for at least 2 weeks AND be a source of distress and interference with activities Obsessions must be own thoughts Resistance must be present Rituals are not pleasant Obsessional thoughts/ images/ impulses must be repetitive

Question 37

What does OCD commonly co-exist with?

Answer 37

``` Schizophrenia Tourettes and other tic disorders Body dysmorphic disorder Eating disorders Trichtillomania ```

Question 38

Treatment for OCD?

Answer 38

CBT; including response prevention | SSRI/ clomipramine

Question 39

Mode of action of benzodiazepines?

Answer 39

Act on GABA-A receptor (inhibitory ionotropic receptor) to cause chloride influx and membrane hyperpolarisation and therefore inhibitory post-synaptic potential

Question 40

Problems with benzodiazepines?

Answer 40

Sedation and psychomotor impairment Dependency and abuse Alcohol interaction Can worsen co-morbid depression