4 - Anxiety Disorders Flashcards
What is neurosis and some examples of neurotic disorders?
Class of functional mental disorder involving distress but not delusions or hallucinations, where behavior is not outside socially acceptable norms
Anxiety, Depressional, Obsessive (not personality disorders)
What are some examples of anxiety disorders?
Exaggerated response to threat or danger that lasts more than 3 weeks and interferes with lives. Threat is often psychological and does not exist
- Panic disorders
- Phobias
- Generalised anxiety
- PTSD
- OCD
- SAD
What is the epidemiology of anxiety disorders and what are some co-morbidities associated with it?
10% of the population affected, predominantly female
Comorbidity: Depression, Substance misuse, Personality disorders
If individual presents after age 35-40 years, it is more likely due to depressive disorder or organic disease
What are some risk factors for anxiety disorders?
- Family history
- Childhood adverse events
- Life events
Associations: Lower social class, unemployment, divorced, renting rather than owning, no educational qualifications, urban living
What are some symptoms of anxiety?
- Psychological: Fears, worries, poor concentration, irritability, depersonalization, derealisation, insomnia, night terrors
- Motor symptoms: Restlessness, fidgeting, feeling on edge, tremor
- Neuromuscular: tremor, tension headache, muscle ache, dizziness, tinnitus
- GI: Dry mouth, nausea, indigestion, butterflies, flatulence, frequent or loose motions
- CVS: Chest discomfort, palpitation
- Respiratory: Difficulty inhaling, Tight/constricted chest
- GI: Urinary frequency, erectile dysfunction
What is the epidemiology of GAD and the risk factors for this?
3-5% of the population with 2x more females than males
Risk factors: Chronic Pain or Condition
What is the ICD-10 diagnostic criteria for GAD?
- Anxiety which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances
- Variable dominant symptoms: persistent nervousness, trembling, muscle tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort
- Apprehension: expression of fears such as that the person or a relative will shortly become ill or have an accident.
What are some differential diagnoses for GAD?
- Hyperthyroidism (look for goitre, tremor, tachycardia, weight loss, arrrythmia, exopthalmos)
- Substance misuse (intoxication – amphetamines; withdrawal – benzo, alcohol)
- Excess caffeine
- Depression
- Anxious (avoidant) personality disorder:
- Dementia (early)
- Schizophrenia (early)
What is a questionnaire you can use to aid diagnosis of GAD and how do you interpret the scores?
GAD-7
7 questions about the last 2 weeks
5, 10, 15, 20 cut off scores for mild, moderate, moderately severe, severe
What is the stepwise management for generalised anxiety disorder?
ASSESS SUICIDE RISK
Step 1: All known and suspected presentations of GAD
- Explain the diagnosis and its meaning to the patient. Provide written information
- Assess severity, duration and impact on normal life
- Assess for depression
- Chronic co-morbidities should be reviewed and management optimised
- Substance abuse issues that may exist must be addressed
- Sleep hygiene, exercise, meditation advice
Step 2: Diagnosed GAD that has not improved after step 1 interventions
Offer low-intensity psychological interventions e.g non-facilitated self-help, individual guided self-help and psychoeducational groups
Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions
Offer one of:
- High-intensity psychological intervention e.g CBT
- Pharmacological treatment
Step 4
Referral to specialist care particularly for those at risk of self harm or suicide, significant co-morbidities or self neglect. Also refer patients in whom the first three steps have not managed their symptoms
Benzodiazepines may be used for acute anxiety, what is the concern with prescribing these?
- Should not be prescribed for more than 10 days due to risk of dependency and sedation
- Use only to overcome symptoms so severe they obstruct initiation of more appropriate psychological treatment
- Diazepam preferred due to longer half life (less risk of withdrawal symptoms with neurotic symptoms)
What medication is used for GAD treatment?
Usually this or psychological intervention, no evidence that increased efficacy using them together
First line: SSRI or SNRI (Venlaxafine or Duloxetine)
Second Line: Pregablin
Monitor every 2-4 weeks for first 3 months then every 3 months thereafter
B-Blockers can be used for somatic symptoms (CI asthma and heart block)
What is the prognosis with GAD?
May fluctuate in severity:
- The more chronic the condition, the worse the prognosis
- Comorbidity with depression is poor prognosis
- Stable premorbid personality good prognostic sign
- 50% recover with SSRI treatment
What is the epidemiology of panic disorder and what are some symptoms of this?
- 1-2% in general population with 2-3x more common in females
- Bimodal: peaks at 20yo and 50yo
- Agorophobia occurs in 30-50%
Symptoms
- Breathing difficulties
- Chest discomfort
- Palpitations
- Tingling or numbness in hands, feet or around the mouth
- Shaking, sweating, dizziness
- Depersonalization/ derealisation
- Can lead to fear of situation where panic attacks occur or agoraphobia
- Conditioned fear of fear pattern develops
Why may someone with panic disorder have tingling/numbness in their hands and feet?
Hyperventilation blows off CO2, raising pH
Calcium binds to albumin leads to hypocalcaemia. If extreme, carpopedal spasm (curling of fingers and toes can occur)
What is the ICD-10 criteria for panic disorder?
- Recurrent attacks of severe anxiety (panic) not restricted to any particular situation or set of circumstances and therefore unpredictable
- Secondary fears of dying, losing control or going mad
- Attacks usually last for minutes often there is a crescendo of fear and autonomic symptoms
- Freedom from anxiety symptoms between attacks (but anticipatory anxiety is common)
What are some differential diagnoses for panic disorder?
- Other anxiety disorders: GAD and agoraphobia
- Depression (if depression prescedes, it takes precedence)
- Alcohol or drug withdrawal
- Organic causes: CVS or respiratory disease
- Others: hypoglycaemia, hyperthyroidism
- Phaeochromocytoma
What is the management of panic disorder?
ALWAYS OFFER CBT BEFORE SSRIS
Step 1 – recognition and diagnosis
- Provide written information
- Support groups
Step 2 – treatment in primary care
- Low intensity intervention (telephone CBT, support groups)
- Exercise and sleep hygiene
Step 3 – review and consideration of alternative treatments
If moderate to severe then offer CBT or Antidepressants (SSRI, SNRI, TCAs, Clomipramine)
Step 4 – review and referral to specialist mental health services
If 2 interventions have not worked
What is the prognosis with panic disorder?
80-100% remission with CBT
50-60% remission with medication
What is mixed anxiety and depressive disorder?
- ICD-10 criteria: symptoms of anxiety and depression are both present but neither clearly predominates
- Treat with counselling, cognitive therapy or psychotherapy, especially interpersonal therapy
- Treating the depression usually relieves anxiety symptoms (SSRIs are best)
What are phobic disorders?
Anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread
Becomes a disorder when they cause marked distress and/or significantly impair a person’s ability to function
Examples: Agoraphobia, Social Phobia, Specific Phobias
What is Agoraphobia?
ICD-10 criteria: Fear not only open spaces but also of related aspects, such as the presence of crowds and difficulty of immediate easy escape back to a safe place, usually home (may occur with or without panic disorder)
- Commonly in 20s or mid-thirties
- May be gradual or precipitated by a sudden panic attack
What is social phobia?
Most common anxiety disorder
- ICD-10 criteria: Fear of negative evaluation by other people in comparatively small groups (around 5-6 people, usually 1-2 or crowds is fine), leading to avoidance of social situations
- Physical symptoms: blushing, fear of vomiting, palpitations, trembling, sweating. Symptoms can progress to panic attacks
- Patients think secondary manifestations are the primary problem
What investigations should you do for phobias?
- History and Examination
- Rating scales of anxiety: Beck Anxiety Inventory and the HADs score
- Social and occupational assessments for effect on quality of life
- Collateral History
How are phobias managed?
BEHAVIOURAL THERAPY IS BEST
Exposure techniques to reach systematic desensitization
- Exposure therapy: Flooding or Modelling (individual observes therapist engaging with phobic stimulus)
- CBT for agoraphobia, panic and social phobia
Drug management
- Agorophobia + panic disorder: CBT first line and SSRI 2nd line
- SSRIs and MAOIs most useful in agoraphobia and social phobia
- Tricyclic antidepressants best for those with depressive component
- Benzoodiazepines can be used before a phobic situation
- B-blockers are effective if somatic symptoms predominate
What is the prognosis with phobic disorders?
- Early diagnosis and treatment better prognosis
- Animal phobias have the best outcome
- Agorophobias do worse
What is OCD?
Presence of obsessions and/or compulsions that may cause functional impairment
What is the epidemiology of OCD and what are some risk factors?
1-3% prevalence
More common in males
Risk Factors:
- Family history
- Age (onset normally between 10-21)
- Emotional/stress triggers
- Pregnancy and post-natal period
- Childhood abuse and neglect
- Secondary to neurological disease
What are some useful questions to ask someone about OCD symptoms as they are often embarrassed to disclose symptoms?
- Do you wash or clean a lot?
- Do you check things a lot?
- Is there any thought that keeps bothering you that you would like to get rid of, but cannot?
- Do your daily activities take a long time to finish?
- Are you concerned about putting things in a special order, or are you upset by mess?
- Do these problems trouble you?
What is the ICD-10 diagnostic criteria for OCD?
Presence of recurrent obsessional thoughts or compulsive acts
Obsessional thoughts are:
- Ideas, images, or impulses that enter the person’s mind again and again
- Distressing, and the person often tries unsuccessfully to resist them
- Recognised as person’s own thoughts, even if they are involuntary or repugnant
Compulsive acts or rituals are:
- Stereotyped behaviours that are repeated again and again
- Not enjoyable or useful tasks
- Performed to prevent some objectively unlikely event, often involving harm to, or caused by, the person, which he or she fears might otherwise occur
- Recognised as pointless or ineffectual and repeated attempts are made to resist them
Anxiety present; if compulsive acts are resisted the anxiety gets worse
What are some differential diagnoses for OCD?
- Obsessive-compulsive personality disorder
- Autism spectrum disorder
- Body dysmorphic disorder
- Delusional disorder
- Substance-induced OCD
- Medication-induced OCD
- Trichotillomania (hair pulling)
How is OCD managed?
- Evaluate severity: Yale–Brown Obsessive-Compulsive Scale (Y-BOCS)
- Screen for other mental health disorders
- Provide written information
Mild functional impairment: refer for low intensity psychological intervention. CBT with Exposure and Response Prevention (ERP) is commonly offered
Moderate functional impairment: patients should be offered intensive CBT with ERP or an SSRI. Clomipramine may be used as second-line therapy
Severe functional impairment: refer for specialist input. Consider an SSRI (e.g escitalopram) combined with CBT in the interim. Clomipramine may be used as second-line therapy
What resources can you signpost people with OCD to?
- Mind
- OCD UK
What is the prognosis with OCD?
If OCD is untreated, the course is usually chronic, often with waxing and waning symptoms. Without treatment, remission rates among adults are approximately 20%.
What is included in the Yale-Brown Obsessive-Compulsive Scale?
- How much of your day is occupied by obsessive thoughts or spent performing compulsive acts (mild, less than 1 hour; moderate, 1–3 hours; severe, more than 3 hours)?
- How much do your obsessive thoughts or compulsive behaviours interfere with your social or work/school functioning (including relationships)?
- How much distress do your obsessive thoughts cause you? How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
- How much of an effort do you make to resist the obsessive thoughts or compulsions?
- How much control do you have over your obsessive thoughts? How strong is the drive to perform the compulsions?
How long do you need to be on SSRIs for OCD?
12 months with no symptoms
What is an acute stress reaction?
Transient disorder that develops in an individual with no other apparent mental disorder in response to exceptional physical and/or mental stress; usually subsides within hours or days. It should last no more than one month
Symptoms: “daze”, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation. Usually appear within minutes of stressful stimulus or event, and disappear within two to three days. Partial or complete amnesia may be present.
What is an adjustment disorder?
State of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event
>1 month but <6 months
Symptoms: depressed mood, anxiety, a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine
What is the management of an adjustment disorder?
What is PTSD?
Arises as a delayed or prolonged response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
Typical features:
- Episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”), dreams or nightmares
- Background of a sense of “numbness” and emotional blunting
- Detachment from other people
- Unresponsiveness to surroundings
- Anhedonia
- Avoidance of activities and situations reminiscent of the trauma
What is the prognosis with PTSD?
- Fluctuating course
- Recovery expected in majority of cases within a year
- Small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change
What is the ICD-10 diagnostic criteria for PTSD?
Should last for at least one month but onset should be not more than six months after stressor:
- Delayed and/or prolonged response to stressful event or situation of threatening or catastrophic nature, likely to cause distress in anyone
- Episodes of repeated reliving of the trauma (flashbacks) in memories or dreams
- Sense of ‘numbness’ and detachment from other people
- Avoidance of activities and situations reminiscent of trauma
- Usually autonomic hyperarousal with hypervigiliance, enhanced startle reaction and insomnia, poor concentration
Simplified as: trauma, flashbacks, numbness, avoidance, arousal
How may PTSD present in children?
- Dreams of the trauma, which may then change into nightmares of monsters
- Re-living the trauma in their play
- Sleeping problems (secondary enuresis or separation anxiety)
- Losing interest in things that they previously enjoyed
- Expressing the belief that they will not live long enough to grow up
What is the management of PTSD?
ASSESS SUICIDE RISK
Access to support groups (e.g CRUSE, Rape Crisis), sleep hygiene, identify other family members who may have experienced trauma too, written information
First line: Trauma-focused treatments
- Trauma focused CBT
- Eye movement desensitization and reprocessing (EMDR)
Second Line: Drugs
- SSRIs (Paroxetine)
- SNRIs (Venlaxafine)
- Second-generation antipsychotics (Risperidone)
How does EMDR work?
Bilateral stimulation (eye movements, taps, and tones) while the person focuses on memories and associations
Thought to help the brain process flashbacks and to make sense of the traumatic experience
What is depersonalisation and derealisation?
Depersonalisation: disturbed perception in which people, or the self, or parts of the body are experienced as being changed (‘as if made of cotton wool’), becoming unreal, remote, or automatised (‘replaced by robots’).
Derealisation: Detachment or estrangement from our surroundings. Objects appear altered: buildings may metamorphose in size and colour. The patient acknowledges the unreality of these ideas
What are two types of dissociation?
- Amnesia
- Derealisation (out of own body)
What is body dysmorphic disorder?
Form of anxiety that interferes with your life
What is some differential diagnoses for all anxiety disorders?
If considering anxiety always think is depression present too?
What is Lang’s three system model?
If someone presents with anxiety what are some important things to think about?
If considering anxiety always think is depression present too?
What happens in ERP CBT for OCD treatment?
Modelling, Flooding, Desensitisation
What is the difference between somatisation and Hypochondriasis?
- Duration of disorder
- Number of body systems included
What is the most common OCD compulsion?
Checking then cleaning
What does cognitive theory think is the main factor behind anxiety disorders?
Catastrophisation
What is the psychological treatment of choice for PTSD?
Trauma Focused CBT
A 21 year old woman has a fear of injections and has presented as she wishes to become pregnant and knows she will probably then need to have some blood taken. You think that she has a phobic disorder and try to explain principles of exposure therapy, with a view to referring her for CBT. She says this (exposure) won’t work for her, because if she sees a needle coming towards her she faints and therefore cannot habituate to the anxiety. What is the explanation for the alleged fainting episodes?
This is vasovagal syncope due to a diphasic response in blood-injury phobia
Use applied tension to overcome (tensing muscles to raise BP)
What psychological disorder are the following scenarios demonstrating?
- 46 year old nurse who won’t go near her patients when she is carrying sharp objects for fear that she will stab them
- 39-year old woman who has stopped going to the shop as she fears losing control of her bowels, (although she has never soiled herself)
- OCD
- Panic disorder
