MEDI3004 MENTAL HEALTH ROTATION -YEAR 3 MBBS. Topic 3 - Anxiety Disorder.docx

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University of Queensland
Associate Professor Jane Turner

ANXIETY DISORDERS  Anxiety serves as an adaptive mechanism to warn about an external threat by activating the sympathetic nervous system. It becomes pathological when o Fear is greatly out of proportion to the risk/severity of threat o Response continues beyond existence of threat or becomes generalized to other similar or dissimilar situations o Social or occupational functioning is impaired TYPES 1. Generalized Anxiety Disorder: constant worrying 2. Panic Disorders: discrete episodes of severe anxiety with somatic symptoms 3. Specific Phobias 4. Obsessive-compulsive disorder 5. Reactions to stress  Post traumatic Stress Disorder: anxiety Sx following an event outside normal human experience  Adjustment Disorders ETIOLOGY  Genetics: up to 20% of patients’ first degree relatives are affected  Physiological o Over activity of SNS with  adrenaline and noradrenaline. ACTH and cortisol are also  o Disordered activity of the limbic system of the brain involving  GABA (anxiolytic drugs enhance GABA) o 5-HT and NA is release is   Personality: sensitive or insecure personality  Events and stress may precipitate e.g. marital difficulties SYMPTOMS Mental Physical  Apprehension/worry – either  Cardiovascular Sx: tachycardia or palpitations general or focused  Resp Sx: dyspnea or chest pain  Poor concentration  GIT Sx: dry mouth, nausea, anorexia, dysphagia, diarrhea  Irritability  Muscle tension, tension headache  Insomnia – usually initial type  Fatigue  Dizziness  Sweating  Tremor  Frequency of micturition  Flushing of face and chest DDX  Personality Disorder  Other psychiatric illness e.g. major depression, psychosis  Medical illness e.g. thyrotoxicsosis, temporal lobe epilepsy  Substance misuse – alcohol, caffeine, other drugs  Stress reactions of normal degree Cardiovascular Post MI, arrhythmia, congestive heart failure, pulmonary embolus, mitral valve prolapse Respiratory asthma, COPD, pneumonia, hyperventilation Endocrine hyperthyroidism, pheochromocytoma, hypoglycaemia, hyperadrenalism, hyperparathyroidism Metabolic Vitamin B deficiency, porphyris 12 Neurologic Neoplasm, vestibular dysfunction, encephalitis Substance intoxication (caffeine, amphetamines, cocaine, thyroid preparations, OTC for colds/degongestants), withdrawal (benzodiazepines, alcohol) Other ψ Pyschotic disorders, mood disorders, personality disorders (OCPD), somatoform disorders INVESTIGATIONS Work up  Physical examination  FBC  Thyroid function test  Electrolytes  Urinalysis  Urine drug screen  Other: neurological examination, CXR, ECG, CT MANAGEMENT Pharmacological  Anxiolytic drugs o Benzodiazepine  best taken when Sx occur or before patient faces anxiety-provokign situation  tolerance and dependence occur if regularly used  Antidepressants o Tricyclics  e.g. trimipramine 25mg nocte regularly + 25mg mane PRN, trimipramine or mirtazepine  Hypnotic and anxiolytic properties are immediate and dose-related  Effective in panic disorder o MAOIs  tried if other classes are ineffective o SSRIs  Side effects: Can exacerbate anxiety, GIT upset  Sometimes covering of newly stared SSRI with trazodone or benzos  Beta blockers o E.g. propranolol o Can help control physical Sx of anxiety such as palpitations  Buspirone  Antihistamines o E.g. promethazine o Sedative properties  Antipsychotics o Low dose chlorpromazine or olanzapine o Side effects: extrapyramidal side-effects, weight gain Psychological  Cognitive Behaviour Therapy  Behaviour Therapy GENERALISED ANXIETY DISORDER  Physical and/or mental symptoms are present most of the time in the absence of real danger, and are ‘free-floating’ rather than focused on any particular stimulus  Acute episodes are precipitated by obvious stressors and respond to supportive interviews CRITERIA A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) B. The person finds it difficult to control the worry C. The anxiety and worry are associated with >3 of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months) *NB: only one item is required for children  Restlessness or feeling keyed up or on edge  Difficulty concentrating or mind going blank  Irritability  Muscle tension  Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep D. The focus of anxiety and worry is not confined to features of an Axis I disorder, such as panic disorder, social phobia, etc E. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning F. The disturbance is not due to the direct physiological effects of a substance of a GMC and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder DIFFERENTIAL DIAGNOSIS  Overlap between GAD and other anxiety disorders, major depressive disorder and dysthymic disorder  With middle aged or older patients first present with anxiety symptoms, depression or dementia should be excluded  Organic disease e.g. thyrotoxicosis, caffeine intoxication, psychostimulant use, alcohol/drug discontinuation syndrome, adverse effects of prescribed or OTC meds.  Adjustment disorder with anxious mood MANAGEMENT Psychological  Primarily nonpharmacological Mx recommended  Educate, reassurance and identify precipitating or exacerbating factors such as any stressors  Relaxation techniques and coping skills  Cognitive behavioural therapy  Avoid caffeine and alcohol  Sleep hygiene Medication  If symptoms are more severe  Acute exacerbations: diazepam 2-5mg  Long term:  First line (SSRIs): paroxetine 10mg or sertraline 25mg  Second line: imipramine 25mg (TCA) or venlafaxine 75mg (SNRI)  Third line: buspirone 5mg tds (anxiolytic) PANIC DISORDER  Panic attacks are intermittent episodes of acute anxiety with marked physical symptoms  May be misdiagnosed as a MI or epileptic fit  First attacks often occur without apparent reason, but return to the situation can precipitate further attacks and set up a pattern of avoidant behavior  Panic disorder with agoraphobia o Anxiety about being in places or situation from which escape might be difficult or embarrassing or where help may not be available in the event of having an unexpected panic stack. Fears commonly involve situations such as being out alone, being in a crowd, standing in a line ro travelling on a bus o Situations are avoided, endured with anxiety or panic or require a companion o Mx as per panic disorder CRITERIA STUDENTS FEAR CCC A. (1) recurrent unexpected panic attacks: a discrete period of intense fear or discomfort, in which > 4 of Sweating the howlloing symptoms develop abruptly and reach a Trembling peak within 10 minutes Uunsteadiness & Dizziness Depersonalisation, Derealisation  palpitations, pounding heart or accelerated Elevated HR & palpitations heart rate Nausea  sweating  trembling or shaking Tingling  sensations of SOB or smothering FEAR of dying FEAR of losing control  feeling of choking FEAR of going crazy  chest pain or discomfort Chest pain  nausea or abdominal distress Chills  feeling dizzy, unsteady, lightheaded, or faint Choking  derealisation (feelings of unreality) or depersonalization (being detached from oneself)  fear of losing control or going crazy  fear of dying  paresthesias (numbness or tingling sensations), chills or hot flushes (2) at least one of the attacks has been following by 1 month or more of >1 of the following  persistent concern about having additional attacks  worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, going crazy)  a significant change in behavior related ot the attacks B. absence of agoraphobia C. the panic attacks are not due to the direct physiological effects fo a substance of general medical condition D. the panic attacks are not better accounted for by another mental disorder, such as Social Phobia, Obsessive-Compulsive Disorder, Post-Trasumatic Stress Disorder, Separation Anxiety Disorder MANAGEMENT Psychological  Explanation, support and stress management advice e.g. deep breathing ( arterial CO2concentration  slow respiration)  Cognitive behavior therapy (treatment of choice) – panic control treatment (exposure to ‘threat’, controlled slow breathing) Medications  When CBT not available or not effective  First line (SSRIs): citalopram 10mg, fluoxetine 10mg, fluvoxamine 50mg, paroxetine 10mg, sertraline 25mg  Second line: Venlafaxine 75mg (SNRI), clomipramine 50-75mg (TCA), imipramine 50-75mg (TCA), clonazepam 0.25-2mg (Benzo), phenelzine (15mg
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