29. Anxiety

Question 1

what anxiety states do you need to screen for?

Answer 1

Generalised anxiety disorder
Obsessive compulsive disorder
Panic
Phobias
Acute stress disorder
PTSD

Question 2

symptom exploring anxiety

Answer 2

PC: anxiety. how long for? ADLs? What do you worry may happen?
cognitive: poor concentration, irritability
Phsycial: restless, concentration, muscle tension, sleep disturbance, panick attack /breathing…

AVOIDANCE

“When you get these thoughts, is there an end point to them? Can you reach a point and reassure yourself?”

Physical physcial: sweating, palpitations, weight loss, cold intolerance, tremor

ATSD/PTSD: Any triggers? stressful events? do thoughts centre around that experience?

Phobias: does sthis worry happen in a particualr situation? do you avoid stuff?
Do you find yourself avoiding social situations or activities?
Are you fearful or embarrassed in social situations?

OCD: do you have the same intrusive thoughts? do you ever need to perform certain behaviours? what would happen if you didnt?

Question 3

what is GAD

Answer 3

Chronic excessive worry for at least 6 months that causes distress or impairment. The worry is disproportionate to any inherent risk. The worry is not confined to features of another mental health disorder, a result of substance misuse or relating only to a physical health condition.

Question 4

features required for making a diagnosis of GAD

Answer 4

6 months

At least 3/6 req for diagnosis (DSM-5). ⅙ required in children
Restlessness or nervousness
Easily fatigued
Poor concentration
Irritability
Muscle tension (achy neck/shoulders, tension headaches)
Sleep disturbance

Question 5

fetaures of GAD

Answer 5

Restlessness or nervousness
Easily fatigued
Poor concentration
Irritability
Muscle tension (achy neck/shoulders, tension headaches)
Sleep disturbance

Other symptoms reported: (autonomic) sweating, lightheadedness, palpitations, dizziness, epigastric discomfort, dry mouth, tingles,

Question 6

Assessment ?anxiety

Answer 6

History
Screening: cold intolerance, weight loss,
DHx: Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Examination
GAD7 questionnaire
Pulse
Thyroid exam

TFT ?hyperthyroid
ECG ?arrythmia
24 hour urine for vanillylmandelic and metanephrines ?pheochromocytoma (exists with severe HTN or tachycardia)
Medication review

Question 7

what medications can tirgger anxiety? DHx

Answer 7

Salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Question 8

Management of GAD

Answer 8

step 1: education about GAD + active monitoring

step 2: low-intensity psychological interventions

step 3: high-intensity psychological interventions or drug treatment.

step 4: highly specialist input e.g. Multi agency teams

If using drugs to treat GAD:
1. Sertraline
2. Alternative SSRI or SNRI
3. Pregabalin
+ Beta-blockers such as propranolol are good for treating the somatic symptoms of GAD

Question 9

examples of low intensity psychological interventions GAD

Answer 9

(individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

Question 10

examples of high intensity psychological interventions GAD

Answer 10

cognitive behavioural therapy or applied relaxation

Question 11

what is OCD

Answer 11

Presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.
Obsession : an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Compulsions : repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Question 12

what are obsessions

Answer 12

an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.

Question 13

what are compulsions

Answer 13

repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Compulsions are driven by the belief that if they don’t complete the action, something bad will happen. They have insight into this whereby it is not a delusional belief but are still compelled to do it.

Question 14

what si the difference between conpulsiona dn delusion

Answer 14

in a compulsion they have insight into this whereby it is not a delusional belief but are still compelled to do it

Rule out command hallucinations
Check insight and shakability of beliefs

Question 15

how to classify OCD severity

Answer 15

NICE recommend classifying impairment into mild, moderate or severe
they recommend the use of the Y-BOCS scale
an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance

Question 16

management of ocd mild fucntional impairment

Answer 16

1. Low intensity : CBT including ERP
2. SSRI or high intensity CBT

Question 17

management of ocd moderate functional impairment

Answer 17

SSRI or high intensity CBT including ERP

Question 18

what is ERP in OCD management

Answer 18

exposure and response prevention

A psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Question 19

management of ocd severe functional impairment

Answer 19

SSRI AND high intensity CBT including ERP

Question 20

acute stress disorder vs PTSD

Answer 20

Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.

Question 21

management acute stress disorder

Answer 21

1. trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
2. benzodiazepines
   sometimes used for acute symptoms e.g. agitation, sleep disturbance
   should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation

Question 22

features of ptsd

Answer 22

re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

avoidance: avoiding people, situations or circumstances resembling or associated with the event

hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating

emotional numbing - lack of ability to experience feelings, feeling detached from other people

Question 23

management of PTSD

Answer 23

Psychological:
+/- trauma-focused cognitive behavioural therapy (CBT) or +/-eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases

Drug treatment (NOT 1st line)
1. venlafaxine or SSRI eg sertraline
2. risperidone

watchful waiting may be used for mild symptoms lasting less than 4 weeks

Question 24

what secondary things should you screen for in ptsd

Answer 24

depression
drug or alcohol misuse
anger
unexplained physical symptoms

Question 25

If SSRI treatment is effective for the treatment of OCD, how long should it be continued for to prevent relapse?

Answer 25

12 months

Question 26

Management of panic disorder

Answer 26

1. either cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

step 3: review and consideration of alternative treatments/referral to specialist mental health services

Question 27

if ?social anxiety disorder, how do you screen for this?

Answer 27

3-item Mini-Social Phobia Inventory (Mini-SPIN)
- fear of embarrassment stops you doing things
- avoid stuff where center of attention
- being embarrased or looking stupid are worst fears

score each 0-4

overall score>6 = ?social anxiety refer for more assessment

Question 28

management of social anxiety disorder

Answer 28

1. individual CBT for social anxiety disorder (based on the Clark and Wells model or the Heimberg model)

Question 29

management of specific phobias

Answer 29

CBT with gradual exposure (desensitisation therapy)

Question 30

what is agoraphobia

Answer 30

anxiety about being in places or situations from which escape might be difficult, embarrassing, or in which help may not be available in the event of having a panic attack.

This anxiety is said to typically lead to a pervasive avoidance of a variety of situations that may include: being alone outside the home or being home alone; being in a crowd of people; travelling by car, bus or place, or being on a bridge or in a lift.