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Anxiety Disorders (Specific disorders (Panic disorder (episodic paroxysmal…

- - - - Common in women
      - Most disabling
      - +/- panic disorder
      - 84% have at least one other psychiatric disorder
      - Anxiety and panic symptoms associated with places or situations where escape may be difficult or embarrassing, leading to avoidance
      - Treatment - antidepressants and BZDs in short term only (as may reinforce avoidance) and psychotherapy (CBT looking at exposure techniques and cognitive methods to teach about bodily responses).
    - - Fear of scrutiny of others in small groups
      - Avoidance of social situations
      - Symptoms of incapacitating anxiety, not secondary to delusional or obsessive thoughts and restricted to particular social situations, leading to a desire to escape or avoidance (which may reinforce the strongly held belief of social inadequacy)
      - Features
        
        Men1:women1
        
        Associated with fear of criticism and low self esteem
        
        Thought that genetic basis of interpreting situations as dangerous, while interpretation of social cues environmentally determined (conditioned fear response learned from watching parents).
        
        Increased activity within fear networks in brain during anxiety provoking tasks
        
        Response to antidepressants suggest dysregulation in 5-HT, NE or DA systems
      - Treatment
        
        Pharmacology
        
        B blockers for reducing autonomic arousal
        
        SSRIs
        
        Psychological
        
        CBT first line therapy utilising relaxation training, anxiety management, social skills training ad integrated exposure methods.
        
        90% response rate, especially when using combined approaches! Can be life-long chronic condition without treatment.
    - - Theory that phobia results from pairing specific object or situation with emotion of fear and panic
      - Features
        
        Twice as common in women
        
        5 subtypes
        
        Animals
        
        Aspects of natural environment
        
        Blood/injection/injury
        
        Situational
        
        Other
        
        Likelihood of developing another psychiatric disorder is 80% in lifetime
      - Recurrent excessive and unreasonable psychological or autonomic symptoms of anxiety in (anticipated) presence of a specific feared object or situation leading to avoidance.
      - Treatment
        
        Medication not advised unless in severe cases to reduce fear/avoidance, then BZDs can be used to allow engagement in exposure, however not as useful as anxiety may be inhibited during exposure. B blockers can be used for symptomatic relief but not subjective fear.
        Consider anti-depressant if clear secondary depression
        
        Psychotherapy
        
        Behavioural therapy - Wolpe's systemic desensitisation using relaxation and graded exposure
        
        Reciprocal inhibition
        
        Flooding
        
        Cognitive methods - Education and anxiety management and coping skills
    - - CBT - desensitisation, exposure therapy, flooding or self help
        
        Theory that anxiety is response learned from parental behaviour or classical conditioning
      - SSRIs
      - Psychodynamic psychotherapy
  - - - Pharmacological - 1st order treatment - SSRIs (benefit after 12 weeks on high dosage)
      - Psychotherapy - CBT (exposure and relaxation and control of hyperventilation) or emotional focused psychodynamic psychotherapy
    - - Step 1 - Maintain reassuring and calm attitude
      - Step 2 - Prompt use of BZDs for immediate anxiety relief
  - - - Generalised biological vulnerability
        
        Genetic
        
        Neurobiological - diminished autonomic nervous system responsiveness, HPA axis dysfunction, loss of regulatory control of cortisol (reduced suppression during dexamethasone suppression testing)
      - Generalised psychological vulnerability
        
        Diminished sense of control (following trauma or insecure attachment)
        
        Overprotective/ lack of warmth in parenting, leading to low perceived control over events
      - Specific psychological vulnerability
        
        Stressful life events
    - - Worries about the future
      - Comorbidity with other anxiety disorders
    - - ICD 10 classification - at least 4 of...
        
        Symptoms of autonomic arousal
        
        Palpitations/ tachycardia
        
        Sweating
        
        Trembling/shaking
        
        Dry mouth
        
        Physical symptoms
        
        Breathing difficulty
        
        Choking sensation
        
        Chest pain
        
        Generalised symptoms
        
        Hot flushes/ cold chills
        
        Numbness/ tingling
        
        Tension symptoms
        
        Muscle tension/ache
        
        Restlessness/ inability to relax/ feeling keyed up
        
        Other
        
        Exaggerated responses to minor surprises
        
        Concentration difficulties
        
        Persistent irritabilty
        
        Difficulty getting to sleep due to worry
        
        Mental state symptoms
        
        Dizziness
        
        Unsteadiness
        
        Feeling faint
        
        Fear of loosing control, passing out or dying
    - - Psychotherapy generally less effective than in other anxiety disorders
      - Pharmacological treatment aimed at predominant symptom
        
        Psychic symptoms - buspirone
        
        Somatic symptoms - BZDs - lorazepam and diazepam
        
        Depressive symptoms - TCAs (clomipramine), SNRIs (duloxetine and venlafaxine)
  - - - Symptoms
        
        Daze
        
        Depression
        
        Anxiety
        
        Anger
        
        Dispair
        
        Overactivity
        
        Withdrawal
      - Transient disorder lasting hours or days, occurring immediately in response to exceptional stress, which is resolved after stressor removed. Stressor usually involves severe threat to security or physical integrity of the individual or loved person.
    - - Occuring within 1 month of a social stressor
    - - Other symptoms
        
        Flashbacks
        
        Dreams
        
        Numbness
        
        Emotional blunting
        
        Anhedonia
      - Predisposing factors
        
        Childhood trauma
        
        Personality traits
        
        Poor social support
        
        Female
        
        Recent stressful life change
        
        Excessive alcohol use
      - Treatment
        
        Watch and wait
        
        Pharmacolgical
        
        Antidepressants - paroxetine liscenced
        
        Mood stabilisers for intrusive thoughts (carbamazepine, valporate)
        
        BZDs for anxiety/ hyperarousal symptoms
        
        Psyhotherapy
        
        Psychodynamic psychotherapy
        
        Trauma focused CBT
        
        Eye movement desensitisation and reprocessing
      - Severe psychological disturbance following a traumatic event, characterised by involuntary re-experiencing of elements of the event, with symptoms of hyperarousal, avoidance and emotional numbing.
      - ICD-10 criteria
        
        Persistent remembering/ reliving of stressor in intrusive flashbacks, vivid memories or recurring dreams
        
        Avoidance of circumstances resembling/ associated with stressor
        
        Inability to recall some important aspects of stressor
    - - Ventilation exceeding metabolic demands, leading to haemodynamic and chemical changes causing dyspnoea, agitation, dizziness, atypical chest pain, tachyponea and paresthesia.
      - Caused by stressors e.g. emotional, sodium lactate, caffeine, CO2
      - Serious underlying pathology should be eliminated (ARDS, air embolism, asthma etc) and then reasurance given, benzodiazepines if anxiety is severe and establishment of a normal breathing pattern e.g. instructing to breathe more abdominally and exhale maximally.
    - - Type 1 trauma = single, dangerous and overwhelming event
      - Type 2 trauma = repeated and sustained ordeal stressors
    - - Overlap with acute stress reaction but with more emphasis on dissociative symptoms (disconnecting thoughts), with onset within 4 weeks and lasting 2-4 weeks (after which, classified as PTSD)
      - Treatment
        
        Simple practical measures such as support and advice
        
        Psychological
        
        Debriefing may help in some situations
        
        CBT
        
        Pharmacological
        
        TCA/ SSRI/ BDZs
    - - Normal
        
        Typical symptoms experienced after bereavement, including shock, numbness, disbelief, preoccupation with the deceased, disturbed sleep and apetite, weight loss and hearing the voice of the deceased.
        
        Lasting up to 12 months, but can be longer for child, spouse or partner
      - Abnormal
        
        Reaction very intense, prolonged, delayed/absent or symptoms outside of normal range (preoccupation with feelings of worthlessness, thoughts of death, excessive guilt, marked slowing of thought and movement, prolonged period of not being able to function normally, hallucinatory experiences (other than voice or image of deceased)
  - - - Obsessions = Ideas, images or impulsions entering individuals mind repetitively which are distressing and often resisted
      - Compulsions = Rituals of stereotyped behaviour that are repeated again and again and are not enjoyable apart from relieving anxiety
    - - Present most days for 2 weeks to be classified as OCD
    - - Psychological
        
        CBT
      - Pharmacological
        
        SSRIs - escitalopram, fluoxetine, sertraline, paroxetine
        
        Augmentation with antipsychotics (risperidone/ haloperidol) if accompanied by psychotic symptoms/ tics
      - Physical
        
        ECT if suicidal or severely incapacitated
        
        Psychosurgery to disrupt neuronal loop between orbitofrotnal cortex and basal ganglia
        
        Deep brain stimulation