5. Anxiety, Phobia & Stress-Related Disorders Flashcards
What is Generalised Anxiety Disorder?
A sensation of persistent worry and apprehension about common day problems and events, associated with chest, abdomen, mental state, general symptoms
- “free-floating” anxiety
Common signs and symptoms of GAD
Autonomic
- Palpitations
- Tachycardia
- Diaphoresis
- Dry mouth
- Tremors
Chest/Abdo:
- Chest pain
- SOB
- Nausea
- Stomach churning
- Choking sensations
Mental
- Giddiness
- Derealisation/Depersonalisation
- Fear of losing control and going crazy
- Feelings of death
General
- Numbness/tingling
- Muscle aches
- Restlessness
- Feeling on edge
- Feeling hot or cold
Others
- Persistent irritability
- Poor sleep
- Poor concentration
DSM-5 Criteria for GAD
Individuals must have had experienced excessive anxiety and worries for most everyday events for at least 6 months in duration.
- excessive worries are difficult to control
- cause functional impairment
- associated with at least 3 of the following symptoms:
1. Restlessness
2. Easily tired
3. Attentional and concentration difficulties
4. Muscle tension
5. Sleep difficulties
MR TICS
Muscle tensions
Restlessness
Tired
Irritable
Concentration poor
Sleep difficulties
Differential diagnosis of GAD
Panic disorder
Panic disorder with agoraphobia
Substance-induced anxiety
Hyperventilation syndrome
Stress-related disorder
Phobia
Mixed anxiety and depression
CHECK: Hyperthyroidism
Management of GAD
SSRIs (1st line)
CBT
Panic attack, Panic disorder and agoraphobia (comorbid)
Single attack = Panic attack
-> multiple build up of stress to hit threshold for panic attack
-> activates sympathetic drive
Recurrent and frequent panic attacks over a period of time (episodic) with symptom-free periods between attacks = panic disorder
Common sign and symptoms of panic disorder
Autonomic
- Palpitations
- Tachycardia
- Diaphoresis
- Dry mouth
- Tremors
- Feeling hot and cold
Chest/Abdo:
- Chest pain
- SOB
- Nausea
- Stomach churning
- Choking sensations
Mental
- Giddiness
- Derealisation/Depersonalisation
- Fear of losing control and going crazy
- Feelings of death
General
- Numbness/tingling
- Muscle aches
- Restlessness
- Feeling on edge
DSM-5 diagnostic criteria for panic disorder
Sudden onset of intense fear that peaks within mins
+ following symptoms might occur:
Physical symptoms
1. Palpitations
2. Diaphoresis
3. Tremors
4. SOB
5. Chest pain
6. Choking sensations
7. Abdominal discomfort
8. Dizziness
9. Feeling hot or cold
Mental symptoms
1. Derealisation
2. Depersonalisation
3. Feelings of losing control and going crazy
4. Feelings of death
At least one of the attacks must be followed by at least 1 month of either:
1. Persistent concerns about having additional attacks or
2. Marked changes in behaviour in relation to the attacks
For panic disorder, at least one of the panic attacks must be followed by at least 1 month of either:
- Persistent concerns about having additional attacks or
- Marked changes in behaviour in relation to the attacks -> avoidant behaviour
DSM-5 diagnostic criteria for agoraphobia
Significant anxiety and fear in at least 2 of the following situations:
+ preoccupation of worries that escape might be difficult / help not available
- Being alone outside of home
- Being in a crowd
- Bring in enclosed space
- Being in open spaces
- Using public transport modalities
+ affected functioning for at least 6 months
+/- panic disorder
Management of panic disorder
SSRIs (1st line)
CBT (2nd line)
*effect of CBT is as efficacious as SSRI
What is social phobia / social anxiety disorder?
Marked fear brought about by social situations (eg. being the focus of attention or fear of behaving in a manner that will be embarrassing), leading to avoidance of being the focus of attention
DSM-5 diagnostic criteria for social phobia
Significant anxiety about 1 or more social situations -> worry about being evaluated negatively by others -> tend to avoid these situations
*lasted for at least 6 months + functional impairment
Management for social phobia
SSRIs
- paroxetine
- continued for at least 6 months after recovery
CBT
DSM-5 diagnostic criteria for Specific Phobia
- Significant anxiety about a particular object or situation
- Encounters with the object or situation always cause marked anxiety
- The specified object or situation is avoided
- The anxieties and worries are excessively out of proportion in consideration of the actual threat posed
At least 6 months + functional impairment
Pathophysiology of OCD
Lesion in the orbital-frontal cortex and basal ganglia
What is an obsession?
Obsessions are persistent, intrusive thoughts, recognised to be the patient’s own, which cause the patient significant distress.
These thoughts can be doubts, images or ruminations.
The patient attempts to ignore or suppress these thoughts.
What is a compulsion?
Repetitive behaviours or mental acts usually associated with an obsession; they serve to reduce the distress caused by the obsessions
Carrying out the compulsive act should not be pleasurable to the patient
DSM-5 diagnostic criteria for OCD
Presence of (a) obsessions and (b) compulsions that have caused functional impairment
Obsessions must be:
1. repetitive thoughts, urges or images that are experienced recurrently, found to be intrusive and result in significant anxiety
2. efforts made to try to suppress these thoughts, urges or imagines with other thoughts or actions
Compulsions must be:
1. repetitive behaviours or mental acts that the individual feels obliged to perform as a response to the underlying obsessive thoughts
2. performed in order to reduce the anxiety experienced, or to prevent some dreadful event from happening
Questionnaire for OCD
Yale-brown obsessive compulsive scale
OCD spectrum disorder (to be assessed when taking an OCD history)
- body dysmorphic disorder
- hoarding disorder
- trichotillomania
Management of OCD
SSRIs (2-3x higher than dose for treating depression)
TCA: clomipramine
- trial of at least 1 SSRI found to be ineffective
- SSRI is poorly tolerated
- patient’s preference
- previous good response to clomipramine
Psychotherapy
- Behaviour therapy: Exposure response-prevention therapy***
- Danger ideation reduction therapy for contamination themes
Social
- Psychoeducation
Poor prognostic factors for OCD
- male
- childhood onset
- strong conviction about the rationality of obsession
- comorbid depression
- comorbid tic disorder
- inability to resist compulsions
- bizarre compulsions
- long duration of untreated illness
- need for hospitalisation
- presence of overvalued ideas
DSM-5 diagnostic criteria for hoarding disorder
- Difficulties disposing items, regardless of actual value
- Pre-occupied with needing to save the items, and the distress associated with disposing
- Leads to accumulation of items that clutter person living space and functional impairment
DSM-5 diagnostic criteria for Acute Stress Reaction
The following symptoms must be fulfilled within a duration of 3 days to 1 month after experiencing the traumatic event:
- Exposure to a severe or threatened death, serious injury or sexual violence
- Intrusive symptoms: repetitive, intrusive, distressing memories of the traumatic event
- Negative mood: inability to experience positive emotions
- Dissociative symptoms
- Avoidance symptoms
- Hyperarousal symptoms: sleep difficulties, irritable mood, on edge, issues with concentration, easily getting startled
DSM-5 diagnostic criteria for Adjustment disorder
Behavioural or emotional symptoms that have occurred within 3 months from the onset of the stressor (major change in life situation)
Symptoms cause functional impairments + out of proportion in terms of severity and intensity to what is normally expected of the stressors
Should resolve within 6 months after removal of stressors
Post-traumatic stress disorder
Acute stress disorder could become PTSD if symptoms persist for more than 1 month
- Develops within 6 months after traumatic event
Symptoms include:
- Re-experiencing (ie. flashbacks)
- Avoidance
- Hyperarousal
- Emotional numbing/detachment
DSM-5 diagnostic criteria for PTSD
- Repetitive, intrusive, and distressing memories of the traumatic events
- Marked efforts to avoid distressing memories and external reminders
- Dissociative amnesia towards important aspects of the traumatic event
+ marked impairment
Management of autonomic hyperarousal
Beta blockers
Operant conditioning
Organisms learn by operating on the environment
- Positive reinforcer will strengthen response
- Negative reinforcer will strengthen removing/avoiding stimulus
Risk factors for PTSD
- Recent stressful life events
- Childhood trauma
- Inadequate family support
- Low premorbid intelligence
- Female
- Previous exposure to trauma/psychiatric disorders
Management for PTSD
Pharmacotherapy: SSRIs
- Paroxetine, sertraline, fluoxetine
Psychotherapy
- Trauma-focused CBT
- Eye movement desensitisation and reprogramming
Acute treatment of panic attack
Benzodiazepines
Specific phobia most typically develops during which age period?
Childhood
- children are unable to discern the risks of the object/animal
Management of agoraphobia
Graded exposure to MRT train without coping avoidance
Should debriefing be done for patients who witnessed a traumatic event?
No, its ineffective or harmful
Treatment for specific phobia
Psychotherapy with systemised desensitisation
Meaning of ‘free floating anxiety’
No specific triggers for the anxiety
During hyperventilation, what phenomenon can be observed?
Carpopedal spasms
What are signs and symptoms of carpopedal spasms?
Peri-oral numbness
Acral numbness
Cramping of hands and legs Forced adduction of thumb Flexion of metacarpophalangeal joint and wrists
Extension of fingers on bilateral hands
Favourable prognostic factors in OCD
- good premorbid social and occupation status
- episodic symptoms
- less avoidant symptoms
