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Anxiety Disorders

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Anxiety Disorders

  1. 1. Psychiatry
  2. 2. Anxiety Disorders • Anxiety is a normal response to stressors • It is considered pathological if it becomes so exaggerated, frequent and chronic that it impairs function • Anxiety is the main feature of anxiety disorders, but also seen in other psychiatric and mental disorders • Anxiety = a state consisting of psychological and physical symptoms brought about by a sense of apprehension at a perceived threat • Perceived threat can be many external like agoraphobia (wide spaces), social phobia and specific phobias OR internal as in panic disorder, generalised anxiety disorder and OCD • In each of these conditions there is a characteristic pattern of psychological and physical symptoms ICD 10: F40-48
  3. 3. Normal Anxiety • Known problem e.g. Exam, football match • Definable • External threat of some sort • Lasts a short period of time • If mild: helpful, If severe: harmful What is Pathological/clinical Anxiety? •Sense of fear •Not well defined •Threat not immediate/ unknown •May be an “internal” threat •Often chronic
  4. 4. Symptoms of Anxiety Psychological symptoms: • feelings of fear or impending doom, apprehension • Dizziness and faintness • Restlessness • Exaggerated startle response • Poor concentration • Irritability • Insomnia • Night terrors • Depersonalisation • Derealisation • Globus hystericus (lump in throat&gulp) • Themes of misfortune • Belief of inability to cope with stress • Unrealistic ideas of danger Physical Symptoms •Cardiovascular: palpitations, tachycardia, chest discomfort •GI: dry mouth, lump in throat, nausea, abdominal discomfort, diarrhoea •Resp: hyperventilation, difficulty catching breath, chest tightness •GU: urinary frequency, failure of erection, amenorrhoea •Other: hot flushes/cold chills, tremor, sweating, headache and muscle pains, numbness and tingling sensations around the mouth and in the extremities, dizziness and faintness
  5. 5. Symptoms • Behaviour: – reduced purposeful activity – Increased purposeless activity – Avoidance of some situations • Somatic: – Hyperventilation – Retro-sternal constriction (chest pain) – Muscle tension – Autonomic over-activity • Associated symptoms – Depersonalisation (feel they are not real/watching themselves/in a dream) – Derealisation (feel the world isn’t real) – Irritability – Low mood
  6. 6. Pathological Anxiety • Secondary to other psychiatric illnesses e.g. Psychotic and worried about being stabbed • Secondary to physical conditions e.g. Thyrotoxicosis, drug use (inc caffeine), drug withdrawal (BDZs), phaeochromocytoma, hypoglycaemia and alcohol • High trait anxiety (personality), worrier from childhood • Anxiety disorders – Personality traits – Childhood factors (loss/separation, abuse) – Stress: relationships – Social supports: families, less social support = more anxiety – Genetic/biological factors
  7. 7. Sleep Hygiene • Routine • Wind down • Exercise • Reading • Avoid caffeine • Warm, but not too warm room
  8. 8. Anxiety Disorders • Onset early adulthood generally, rarely middle age • May be misdiagnosed as a depressive or medical disorder • Female 2:1 Male • Social phobia and OCD, closer to 1:1 ratio • Depressive symptoms are common in anxiety disorders and vice versa • If the diagnostic criteria for depressive disorder and generalised anxiety disorder(GAD) are fulfilled a diagnosis of MIXED ANXIETY AND DEPRESSIVE DISORDER is made • Other psychiatric disorders are also common in anxiety disorders, including other anxiety disorders, personality disorders and substance misuse • Anxiety disorders: – Phobic anxiety disorders: agoraphobia, social phobias, specific phobias – Panic disorder – GAD – OCD – PTSD
  9. 9. Aetiology • Psychiatric and medical conditions: psychiatric - mood disorders, psychotic disorders, somatoform disorders and eating disorders. Medical: hyperthyroidism, Cushings, phaeochromocytoma, hypoglycaemia and drug/alcohol intoxication/withdrawal • Genetic Factors: predispose to anxiety disorders, may manifest as “neurotic” traits or neurotic clucter (cluster C) personality disorders • Neurochemical abnormalities: noradrenergic and serotonergic neurons act on limbic system to increase anxiety • Environmental factors: triggered/perpetuated by stressful events, especially those involving a threat. Can result from stressful/traumatic events in childhood • Psychological theories: inappropriate though processes. Psychoanalytical theory – loss or separation in childhood.
  10. 10. Phobic Anxiety Disorders • Phobia: persistent, irrational fear that is usually recognised as such which produces anticipatory anxiety for and avoidance of the feared object, activity or situation • Exposure to the feared thing induces intense anxiety and even panic attack • 3 types • Agoraphobia • Social phobia • Specific phobias: fear of a specific object/location. Commonly enclosed spaces (claustro-), heights (acro-), darkness (achluo-), blood (haemato-). Begin in early childhood. Thought to be passed on to help future generations survive! Leads to avoidance. Rx: behavioural, SSRIs.
  11. 11. Agoraphobia • Fear of places that are difficult/embarrassing to escape from e.g. Crowd, alone at home, public transport • Linked to poor spatial orientation • Suffer acute anxiety attacks when in, or anticipate being in these situations • Actively avoid situation • Autonomic symptoms (at least 2 of GAD) • May respond to CBT e.g. Graded exposure and Antidepressants:SSRIs. BDZs short term. Self help groups • Behavioural therapy much better than drugs but normally both used • Relapse is common • 60% of all phobias • Onset 15-35. F2:1M.
  12. 12. Social Phobia • Extreme persistent fear of being judged and embarrassed/ humiliated in all/specific social situations. • Either – marked fear of being the focus of attention or fear of behaving in an embarrassing/humiliating way – Marked avoidance of being the focus of attention or situations that have the potential to be embarrassing/humiliating – Plus 2 of GAD – Plus blushing/shaking, fear of vomiting, urgency/fear of micturition or defaecation • Exposure provokes extreme anxiety • Fear recognised as unreasonable • Onset adolescence/childhood. CHRONIC COURSE. • Majority never get married • ?genetic predisposition • May respond to CBT e.g. Graded exposure and anxiety management and Ads - SSRIs. Alcohol/BDZ abuse more common.
  13. 13. Panic Disorder • Panic attack = Rapid onset of severe anxiety lasting 20-30mins. Recurrent, unexpected panic attacks (no specific stimulus) • Can occur in panic disorder, phobic anxiety disorder, GAD, OCD, PTSD, separation anxiety disorder, depressive disorders and organic disorders (drugs, hyperthyroidism) • In panic disorder, panic attacks occur RECURRENTLY AND UNEXPECTEDLY • F2:1M in younger group, equalises with age • Onset 30’s. >45 – investigate other causes!!! • There is fear of the implications of a panic attack • VICOUS cycle develops. Fear of attack triggers more! • Can develop 2ary agoraphobia to reduce risk of PAs • May respond to CBT, drugs: SSRIs, TCAs and BDZs • Must exclude epilepsy, drug/alchol use/withdrawal
  14. 14. Panic attack • A discrete episode of intense fear, characterised by acute development of several of the following symptoms, reaching peak severity within 10mins – Escalating subjective tension – Sweating/ chills – Chest pain/discomfort – Palpitations, tachycardia – Tremor, nausea – Dry mouth – Dizziness/feeling faint – Depersonalisation/derealisation – Feeling of choking – Fear of dying, loss of control
  15. 15. Generalised Anxiety Disorder • Characterised by long standing (more days than not for 6m), free-floating anxiety that may fluctuate but is neither situational (phobic anx disorders) nor episodic (panic disorder) • Apprehension about events very unlikely to occur • Onset early adulthood. F2:1M • Often co-morbid with other disorders e.g. OCD, dysthymia • May respond to counselling, cognitive and behavioural therapies, drugs: SSRIs, SNRIs, sedative Ads (amitriptyline and trazodone) and BDZs **drugs best as a short term thing in conjunction with psychological treatment - AD (SSRIs) and/or BDZ and/or busprione (relaxant) and/or Bblocker
  16. 16. Symptoms of GAD • At least four of: – Palpitations -poor concentration – Sweating -disturbed sleep – Trembling -muscle tension – Dry mouth -restlessness – Difficulty breathing -numbness – Feelings of choking -tingling – Chest pain -difficulty swallowing – Nausea -irritability – Dizziness -hot flushes – Derealisation -cold chills – Depersonalisation – Fear of losing control – Fear of dying
  17. 17. Features distinguishing 3 anxiety disorders Phobic anxiety Panic disorder Generalised Anxiety Disorder Occurrence of anxiety Situational Episodic Free-floating Associated cognitions Fear of situation Fear of symptoms Fear of future Associated behaviour avoidance escape inhibition
  18. 18. PTSD • Protracted and sometimes delayed response to a highly threatening or catastrophic experience (within 6m) • Commonly combat in males and sexual assault in women • Characterised by numbing, detachment, flashbacks, nightmares, partial or complete amnesia for the event avoidance of and distress as reminders of the event and prominent anxiety symptoms • Depressive disorders common, as well as anxiety disorders and alcohol/substance misuse • May respond to supportive psychotherapy, CBT, group therapy and Ads: SSRIs, TCAs • BDZs should be avoided due to dependence risk • Prognosis good but may persist for years
  19. 19. Obsessions • Recurrent, persistent ideas/thoughts/images that enter the mind again and again in a stereotyped form • Patient regards them as alien and absurd and recognises them as products of their own imagination • Almost invariably distressing and attempts are made to ignore/suppress them Compulsions • Voluntary, stereotyped behaviours which are reluctantly performed again and again despite being regarded as alien or absurd • Act is performed with a subjective sense of compulsion and desire to resist it • If resisting is attempted there is increasing anxiety which is only yielded by giving in • Function is to prevent some unlikely event (objectively) which they fear will occur • Usually recognised as pointless/ineffectual • Can be normal in childhood or adulthood
  20. 20. Obsessive-Compulsive Symptoms • Obsessive compulsive disorder • Depression • Anankastic (obsessional) personality disorder • Schizophrenia • Early dementia & other organic brain disorder • Gilles de la Tourette’s syndrome • Anxiety Obsessions •Contamination 45% •Pathological doubt 42% •Somatic 36% •Need for symmetry 31% •Aggressive impulse 28% •Sexual impulse 26% •Obsessional slowness 3-4% Compulsions •Checking 63% •Washing 50% •Counting 36% •Need to ask/confess 31% •Symmetry and precision 28% •Hoarding 18%
  21. 21. Obsessive Compulsive Disorder • 3 classifications: – Predominantly obsessional thoughts – Predominantly compulsive acts – Mixed obsessional thoughts and acts • Obsessional thought: recurrent idea, image or impulse that is perceived as being senseless, that is unsuccessfully resisted amd that results in marked anxiety and distress • Product of ones own mind (not thought insertion) • Commonly involve doubt, contamination, orderliness and symmetry, safety, physical symptoms, aggression and sex • Compulsive act: recurrent stereotypical behaviour that isn’t useful or enjoyable but that reduces anxiety and stress • Perceived as being senseless but unsuccessfully resisted • Commonly washing, cleaning, arranging and ordering, checking, counting or repeating a phrase • Rx: SSRIs, TCAs, psychological: graded exposure etc
  22. 22. OCD • A mental disorder characterised by recurrent obsessional thoughts or compulsive acts (rituals) • Frequently accompanied by depression • Males have worse prognosis • Aetiology: – partly genetic – Abnormalities of brain circuits linking pre-frontal cortex, striatum, thalamus and back to pre-frontal cortex – Hypersensitivity of post-synaptic serotonin receptors Tourette’s Syndrome •Neuropsychiatric disorder •Multiple motor and vocal tics •Onset 5-8 •Commoner in boys •Up to 80% have obsessional symptoms •Treat with dopamine blocker e.g. haloperidol PANDAS •Associated with Sydenham’s chorea •B haemolytic streptococcus •Cross immunity with basal ganglia •OCD symptoms and motor disorder
  23. 23. Treatment • Benzodiazepines: Diazepam (valium), temazepam, nitrazepam, lorazepam, clonazepam – Uses: anxiety, sleep disorders (zopiclone), muscle spasticity, epilepsy, pre-meds before an operation, alcohol withdrawl, myoclonus, akathisia – A/Es: drowsiness, dizziness, psychomotor impairment. Dry mouth, blurred vision, GIT upset, ataxia, headache, hypotension. RARE: amnesia, restlessness and skin rash. – Problems: active metabolites causing prolonged effects e.g. Hangover effect. Tolerance. Psychological dependence. Physical dependence. – PRESCRIBED WITH CAUTION. Reserved for more severe cases. Lowest effective dose should be used. Prescribe for 2 weeks. 4 at most. Avoid “repeat” prescriptions. Warn pts about risk of dependence • SSRIs – fluoxetine

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