29. Anxiety Flashcards
what anxiety states do you need to screen for?
Generalised anxiety disorder
Obsessive compulsive disorder
Panic
Phobias
Acute stress disorder
PTSD
symptom exploring anxiety
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?
what is GAD
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.
features required for making a diagnosis of GAD
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
fetaures of GAD
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,
Assessment ?anxiety
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
what medications can tirgger anxiety? DHx
Salbutamol, theophylline, corticosteroids, antidepressants and caffeine
Management of GAD
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
examples of low intensity psychological interventions GAD
(individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
examples of high intensity psychological interventions GAD
cognitive behavioural therapy or applied relaxation
what is OCD
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.
what are obsessions
an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
what are 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.
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.
what si the difference between conpulsiona dn delusion
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
how to classify OCD severity
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
management of ocd mild fucntional impairment
- Low intensity : CBT including ERP
- SSRI or high intensity CBT
management of ocd moderate functional impairment
SSRI or high intensity CBT including ERP
what is ERP in OCD management
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
management of ocd severe functional impairment
SSRI AND high intensity CBT including ERP
acute stress disorder vs PTSD
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.
management acute stress disorder
- trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
- 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
features of ptsd
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
management of PTSD
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
what secondary things should you screen for in ptsd
depression
drug or alcohol misuse
anger
unexplained physical symptoms
If SSRI treatment is effective for the treatment of OCD, how long should it be continued for to prevent relapse?
12 months
Management of panic disorder
- 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
if ?social anxiety disorder, how do you screen for this?
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
management of social anxiety disorder
- individual CBT for social anxiety disorder (based on the Clark and Wells model or the Heimberg model)
management of specific phobias
CBT with gradual exposure (desensitisation therapy)
what is agoraphobia
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.
