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Q.11 GENERALIZED ANXIETY & MIXED ANXIETY-DEPRESSIVE DISORDER CLINICAL PICTURE, DIAGNOSIS, DIFFERENTIAL DIAGNOSIS AND TREATMENT
Terms in this set (26)
Fear = response to a known, external, definite, or non-conflictual threat
Anxiety = response to an unknown, internal, vague, or conflictual threat.
1)Panic disorder->Episodic paroxysmal anxiety.(high peaks, full remission in between)
2)Generalized anxiety disorder(Free-floating anxiety, no peaks, no periods of remission)
3)Mixed anxiety and depressive disorder
4) Other mixed anx. disorder
5)other specified anx. disorder
6)anx disorder unspecified)
General anxiety disorder
-Free floating anxiety with constant irritability and tension.
-Excessive worry about everyday situations and problems
-Difficult to control the worries and its associated somatic symptoms.
ans, cog, discomf, tension, ass?
-Autonomic: Dyspnea, palpitations, sweating, GIT
-Cognitive: irritation, concentration,sleep, dizziness, derealization, depersonalization(distant self, not "here")
-Tension(psychosomatic) Shaking, restlessness, headache
-Often coexist with other anxiety or depressive disorders
-Genetic predisp.+ environmental stressors.
-Mediators-> NE, 5HT, GABA, DA
-Prefrontal cortex, limbic system, amygdala, hippocampus.
Onset: early adulthood
lasting for at least three weeks (according to ICD-10) or six months or longer (according to DSM-IV-TR
-Duration: >6 months of sustained excessive anxiety, tension and worry.
-Accompanied by physiological symptoms, interfering with daily function. (ans, cogn,disc,tension)
-Easily fatigued, mind going blank, sleep(early waking)
-Focus of anxiety and worry is not confined to features of panic disorder, social phobia etc.
-Patient seeks medical care for SOMATIC problems.
Criteria for GAD (>3 >6months)
-Assess suicide risk
DDx Medical disorders
Medical disorders(often presents as paroxysmal anxiety)
-Neurological disease(epilepsy, stroke, tumor, cerebrovascular)
-Endocrine disease(hypoglc, pheochromocytoma)
-Drug intoxication(amph, coca)
DDx Mental disorders
Mental-> GAD emerges slowly.
-Panic disorders of phobias
-other mixed anxiety disorders
-Major depressive disorders
-Obsessive compulsive disorders
-Avoid caffeine, alcohol, drugs, nicotine
-List of worries
-Exposing, relaxation/breathing techniques
-Cognitive reconstruction, problem solving.
2)Support->Discuss with physician
3)Detection of anxiety provoking situations->change environment
4)Psychodynamic therapy-> increased anxiety tolerance
2-6 week duration->1-2 week tapering->discontinue
- Risk of dependence
-+SSRI if comorbid
Partial 5HT agonist
Cognitive > somatic symptoms
Effective after 2-3 weeks.
Mixed anxiety-depression disorder
Patient has symptoms of both anxiety and depression, but the criteria are not met for either an anxiety disorder or mood disorder
Seen in 1% of the general population.
Result in significant functional impairment.
Combination of biological, social and environmental factors.
50-60% of patients with depression have also anxiety disorder
18% with GAD also have depression.
Symptoms of anxiety and depression + autonomic symptoms
-Sub-syndromal for diagnosis of other disorders
-Duration >1 month
-Dysphoria for 4 weeks + more than four of the following:
1)Difficulty concentrating/impaired memory
2) Sleep disturbance, fatigue
3) Irritability, worrying
4)Tired/lack of energy
7)expecting the worst
8)Feelings of worthlessness
9)Low self esteem.
bear drinking syrup, hadina in stairs, war in the stairwell, hallway full of tires, marius crying, thea hope, exen på kjøkkenet, st johns worth på badet, steam på rommet
-Mood disorder-> depression, cyclothymia, dysthymia, bipolar 2
-Somatoform disorders(may cause bodily symptoms, esp. pain)
-Personality disorder(avoidant, dependent, obsessive compulsive)
Pharmacotherapy-> antidep and anxiolytics. SSRI + BZD short term.
Criteria for both met??
When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used
Yerkes Dodson curve
-Anxiety can be beneficial up to a plateu of optimal function, but deteriorates after.
-Low levels of GABA
-Frontal cortex and amygdala undergo structural remodelling induced by stress of maternal separation and isolation
-Also associated with abuse, separations, demands for high acheivement, and excessive conformity.
• CBT and SSRIs are the recommended rst-line treatments. • CBT (self-help material or face to face) for GAD seeks to:
° identify morbid anticipatory thoughts and replace them with more realistic cognitions
° distraction, breathing and relaxation exercises.
• Benzodiazepines should not usually be used beyond two to four weeks. Other pharmacological treatments include:
° serotonin noradrenaline reuptake inhibitors (SNRIs) ° buspirone
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