3. Anxiety Disorders Flashcards
What are the treatments for social anxiety disorder?
Self help
Psychological therapy - individual CBT (first line)
Medication - SSRI such as sertraline or escitalopram
What are the 2 types of PTSD?
- Simple PTSD - response to single traumatic event
- Complex PTSD - response to being exposed to repeated or multiple traumatic events over life e.g. slavery, genocide, DV, repeated childhood sexual/physical abuse.
What are the risk factors for PTSD?
- refugees/asylum
- first responders
- Military (increased length service, lower rank)
- prev psych disorder
- female
- chronic disease
- postnatal
- over avoidance of risk
what are the symptoms of PTSD?
* re-experiencing
- Flashbacks - as if event happening again
- nightmares
- reminders of the event provoke distress
* hyperarousal or emotional numbing (spectrum)
- hypervigilance
- exaggerated startle response
- irritable, difficulty concentrating
- sleep difficulty
- difficulty feeling emotion, detached from others
- giving up hobbies
- amnesia of main events
- negative self perception
* avoidance or rumination behaviour
-avoid people or situations that remind of event
- suppress memories
- why me?
What is the stepwise management for PTSD?
- 1st month - watchful waiting, unless severe symptoms then specialist referral
- treat PTSD before other co-morbid conditions e.g depression, alcoholism
- assess suicide/self harm risk
- if symptoms continue after 1 month of event - refer to specialist
Under specialist:
* trauma focussed CBT 1st line if within 3 months (CBT main focus in children)
* EMDR 1st line if >3 months from event
* Treatment can be effective at anytime after the event.
* Drug treatment 2nd line: venlafaxine or SSRI (sertraline, paroxetine)
* Short term benzo for insomnia
immediate debriefing is ineffective, can be harmful
depression will usually lift as the PTSD is treated.
When to diagnose GAD?
- excessive worry about several aspects of everyday life, or general worry about no particular circumstance
- with symptoms of physiological arousal:
- muscle tension/restlessness, headaches, back pain
- sympathetic overactivity - GI disturbance, palps, trembling,dry mouth, irritability
- difficulty concentrating
- sleep - difficulty falling or staying asleep
- symptoms persist several months
- distress or impairment of social life/work/education.
Can use GAD-7
What is Step 1 in the management of GAD?
- educate on diagnosis
- active monitoring
- manage comorbid conditions e.g depression/physical
What is step 2 in the management of GAD?
if symptoms not improved with education and active monitoring
Offer a low intensity psychological intervention:
* Individual self help (based on CBT principles) - written/electronic for person to work through over 6 weeks.
* Individual guided self-help -as above but telephone therapist led
* Psychoeducational groups - CBT principles with therapist.
What is Step 3 in the management of GAD?
or if severe impairment
if not improved with step 2
Offer either:
* Individual high intensity psychological intervention - CBT or applied relaxation (12 weeks) (1st line if pregnant)
* Drug treatment - sertraline 1st line. If sertraline not effective, alternative SSRI - paroxetine or escitalopram, Or SNRI - duloxetine or venlofaxine.
* Pregabalin if cannot tolerate SSRI or SNRI
* Do not offer benzo unless short term in a crisis
What is step 4 in the management of GAD?
complex, treatment failed, very marked impairment
or high risk self harm
- specialist referral
What are the options for a pregnant woman taking SSRI/SNRI/pregabalin for GAD?
- discuss risk benefits - relapse vs fetal risks
- currently no data that pregabalin causes malformations/ miscarriage/ fetal growth changes. There are risks with SSRI/SNRI (PPHN, withdrawal, unknown if teratogenic)
- option to switch to psych intervention
- lowest effective dose
- perinatal mental health specialist referral if uncertain/changing medication/starting medication
How soon should I review someone under the age of 30 receiving an SSRI/SNRI?
within 1 week
How soon should I review someone with GAD?
after 4-6 weeks of treatment.
(Unless under 30 and started SSRI/SNRI. Or they are High Risk)
How long should someone with GAD continue medication for if it is effective?
at least a year to reduce the risk of relapse
What are the features of social anxiety disorder?
- excessive fear of humiliation or embarrassment
- physical autonomic symptoms - palps, sweating, dry mouth, nausea, shaking
- Fear is followed by avoidance
How should OCD be classified?
- mild, moderate or severe
- recommend the use of the Y-BOCS scale
- ‘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
What is an obsession in OCD?
unwanted intrusive thought, image or urge that repeatedly enters the person’s mind
What is a compulsion in OCD?
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform.
overt -checking that a door is locked, covert mental act- repeating a certain phrase in one’s mind.
When should someone with OCD be referred?
- severe OCD
- high risk
- initial treatments not helped
- Age <18
How should OCD with mild functional impairment be managed?
referal to NHS talking therapies for low intensity CBT with Exposure Response Prevention (ERP)
Move to moderate management if not helped.
How should OCD with moderate functional impairment be managed?
Offer choice:
Intensive CBT with ERP or SSRI (escitalopram, fluoxetine, paroxetine, sertraline)
Clomipramine is an alternative to SSRI if person prefers or SSRI contraindicated - high toxicity in overdose
refer to psych if unsure or treatment not helped.
compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response
fluoxetine for Body dysmorphic disorder
continue meds for 12 months after remission.
How are children under age 18 with OCD managed by CAMHS?
guided self help (mild)
CBT incl ERP involving family and carers (if mod/severe)
How long should an SSRI be continued for panic disorder?
- the minimum duration is least 6 months after the optimal dose is reached.
