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Psychiatry > Anxiety > Flashcards

Anxiety Flashcards

1
Q

types of anxiety disorder

A

GAD
Phobia
Panic
PTSD
OCD

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2
Q

Neurosis

A

psychiatric disorder characterised by distress, that are non-organic and have discrete onset. Delusions and hallucinations are absent.

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3
Q

Definition of anxiety

A

an unpleasant emotional state involving subjective fear and somatic symptoms. If they become excessive or inappropriate = anxiety disorder

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4
Q

Yerkes Dodson Law

A

anxiety can be beneficial up to a plateau of optimal functioning. Can be helpful for motivation up to a point, then begins to hinder again.

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5
Q

Most common in order with 14% prevalence overall

A
  • Specific phobia
  • Social phobia
  • GAD
  • Agoraphobia
  • Panic disorder
  • OCD
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6
Q

ICD 10 classifications of anxiety

A
  1. Phobia anxiety disorders - agoraphobia (with or without panic disorder), social or specific phobia.
  2. Other anxiety disorders - GAD, mixed anxiety, depressive disorder, panic disorder
  3. OCD - obsessional thoughts
  4. Reaction to severe stress and adjustment disorders - PTSD, acute stress
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7
Q

Generalised symptoms

A

Psychological - Anticipatory fear, worrying, poor con, poor attention, depersonalisation and derealisation

Cardio - palpitations and chest pain

Resp - hyperventilation, cough and chest tightness

GI - Abdominal pain, loose stools n+v, dysphagia and dry mouth

GU - frequency micturition, failure of erection and menstrual discomfort

Neuro - Tremor, myalgia, headache, paraesthesia and tinnitus.

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8
Q

History points in Anxiety

A
  • Rate of onset
  • Duration
  • Severity
  • Spontaneous or situational?
  • Psychiatric or medical conditions in the past / present / family
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9
Q

Two types of anxiety and difference

A
  • Generalised - present most of the time and not associated with specific objects or situations. Normal life events and typically longer duration
  • Episodic / Paroxysmal - Abrupt onset and discrete episodes. Severe and short lived with strong autonomic symptoms.
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10
Q

GAD

A

Ongoing uncontrollable widespread worry about many events or thoughts that the patient recognises as excessive and inappropriate.

Symptoms must be present on most days for at least 6 months in duration.

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11
Q

Aetiology GAD

A

2-4% in general population. More common in females at ratio of 2:1

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12
Q

Neurophysiological pathophysiology of GAD

A

Dysfunction of autonomic nervous system, exaggerated responses in the amygdala and hippocampus. Alterations in GABA, serotonin and noradrenaline.

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13
Q

Predisposing factors for GAD

A

Genetics, Childhood, personality type and demands for high achievement. Being divorced, living alone or as a single parent and low SES

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14
Q

Precipitating factors GAD

A

Stressful life events such as domestic violence, unemployment and relationship problems

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15
Q

Maintaining factors of GAD

A

Continuing stress events and marital status. Living alone and ways of thinking which perpetuate anxiety.

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16
Q

Symptoms of GAD

A

WATCHERS

  • Worry
  • Autonomic hyperactivity
  • Tension in muscles / Tremor
  • Conc difficulty / chronic aches
  • Headache / Hyperventilation
  • Energy Loss
  • Restlessness
  • Startled easily or sleep disturbance
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17
Q

Chest and Abdo symptoms of GAD

A

Difficulty breathing, choking, chest pain, nausea, abdominal distress and loose motions

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18
Q

Brain symptoms of GAD

A

Dizziness, fear of dying, losing control and derealisations

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19
Q

General symptoms of GAD

A

Hot flushes, numbness or tingling and headache

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20
Q

Tension symptoms of GAD

A

Muscle tension, aches or pains, restlessness, on edge, difficulty swallowing and sensation of lump in throat

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21
Q

Non-specific symptoms of GAD

A

Being startled, concentration difficulty, persistent irritability, sleep problems.

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22
Q

MSE GAD

A

Appearance - worried, restless, sweaty, hyperventilating and lip biting or pallor with tense posture
Speech - trembling and slow
Mood - anxious
Thought - repetitive worrying thoughts
Perception - no hallucinations
Cognition - poor memory and reduced conc
Insight - may or may not have.

Increased HR, BP and RR

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23
Q

Ix GAD

A

BT - FBC - infection or anaemia, TFT - Hyperthyroidism, Glucose - Hypoglycaemia

ECG - sinus Tachy

Questionnaires - GAD-2, Becks anxiety inventory and hospital anxiety / depression scale

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24
Q

Biological treatment GAD

A

1st line - SSRI - Sertraline

2nd Line - SNRI - Venlafaxine or duloxetine

3rd - Pregabalin

Benzodiazepines should NOT be offered unless short term during crises - issues with dependence

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25
Q

Psychosocial treatment GAD

A

Psychological - Psychoeducational groups / CBT / Applied relaxation

Social - Self help methods / Support groups / Exercise

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26
Q

Stepped care model of GAD

A
  1. Assessment and psychoeducation
  2. Low intensity psych interventions - self help and guided self help with. group based support
  3. Medication or CBT
  4. Multi agency teams and high specialist input. Combination of both medication and therapy. May need crisis team.
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27
Q

Ddx GAD

A
  • Panic disorder
  • Specific phobias
  • Schizophrenia
  • Personality disorder
  • Excessive caffeine or alcohol consumption
  • Withdrawal from drugs
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28
Q

What is a phobia

A

intense, irrational fear of a stimulus that is recognised as excessive or unreasonable

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29
Q

Agoraphobia

A

fear of public spaces - immediate escape would be difficult

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30
Q

Social phobia

A

Fear of social situations - humiliation, embarrassment or criticism

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31
Q

Isolated phobia

A

Fear of specific object or situation.
Arachnophobia
Haematophobia
Phobia of flying
Phobia of heights

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32
Q

RF of phobias

A
  • Aversive experiences
  • Stress and negative life events
  • other anxiety disorders
  • Mood disorders
  • Substance misuse disorders
  • Family History
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33
Q

Symptoms of phobias

A

Biological - Similar to GAD - Autonomic response with tachycardia. Some may lead to vasovagal response —> Syncope e.g. blood phobia.

Psychological - Anticipatory anxiety, inability to relax, urge to avoid situation and a fear of dying.

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34
Q

MSE of phobia

A

Appearance - restless wanting to escape, pale, sweaty and hyperventilating with or without syncope
Speech - trembling or speechless
Mood - anxious
Thought - unpleasant feelings towards threat, fear of situation or desire to escape
Insight - Poor when feared stimulus present. Good otherwise

Will be normal unless phobia is present / brought up

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35
Q

ICD-10 Agoraphobia

A

a. Marked and consistent fear in at least 2 of crowds / public spaces / travelling alone / travelling away from home
b. Symptoms of anxiety (2+)
c. Significant emotional distress
D. Symptoms restricted to situation

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36
Q

ICD - 10 Social Phobia

A

A. Marked fear of being focus of attention or embarrassment in social situations
B. At least 2 symptoms of anxiety plus blushing, vomiting, urgency or micturition / defecation
C. Significant emotional distress
D. Excessive or unreasonable
E. Symptoms restricted to the situation

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37
Q

ICD-10 Specific phobia

A

Marked fear / avoidance of specific subject
Symptoms of anxiety infrared situation
Significant emotional distress only when linked to situation.

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38
Q

IX for phobias

A

Minimal - maybe questionnaires but mainly on history

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39
Q

Treatment of Generic phobia

A

Good rapport
Avoidance of anxiety inducing substances - caffeine, alcohol
Co-morbidities - check for substance missuse or personality disorders
Specialist referral if concern for SH and Suicide.

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40
Q

Treatment of agoraphobia

A

CBT
Graduated exposure
SSRI

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41
Q

Treatment social phobia

A

CBT
Graduated exposure
SSRI or SNRI or MAOI - moclobemide (1/2/3)
Psychodynamic psychotherapy

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42
Q

Specific phobia Treatment

A

Exposure - self help or CBT
Benzodiazepines short term

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43
Q

Difference between GAD and Phobia

A

Symptoms of GAD occur most of the time whereas features of phobic anxiety disorders occur in response to particular situations

Commonly, agitation is an associated behaviour of GAD whereas avoidance of the particular situation typically occurs in phobic anxiety disorders

Concerning cognition, there is constant worry about everyday life events in patients with GAD whereas patients with phobic anxiety disorders only worry about or fear a particular situation

THINK
SS - specific situations
AA - anticipatory anxiety
AA - attempted avoidance

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44
Q

Panic disorder

A

Recurrent, episodic and severe panic attacks which are unpredictable and not restricted to any particular situation or circumstance

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45
Q

Aetiology panic disorder

A

3 x more common in females

Late adolescent onset

1% general prevalence

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46
Q

Pathophysiology of Panic disorder

A

Genetics - Heritability

Neurochemical - Post synaptic hypersensitivity to serotonin and adrenaline

SNS - Fear or worry stimulates the SNS —> Inc cardiac output which can lead to further anxiety

Cognitive - Misinterpretation of somatic symptoms - e.g. fear of palpitations leading to a heart attack

Environmental - Life stressors

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47
Q

RF panic disorder

A
  • FHx
  • Major life events
  • 20-30
  • Recent trauma
  • Females
  • Other mental disorders
  • White
  • Asthma
  • Cigarette smoking
  • Medication - benzodiazepine withdrawal
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48
Q

Symptom of panic disorder

A

PANICS Disorder

Palpitations

Abdominal distress

Numbness / Nausea

Intense fear of death

Choking feeling / Chest pain

Sweating, Shaking, SOB

Depresonalisation or derealisation.

Panic symptoms peak within 10 minutes and rarely last longer than an hour.

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49
Q

Classification ICD-10 Panic disorder

A

ICD-10

  • Recurrent panic attacks that are not consistently associated with a specific situation or object and occur spontaneously
  • All of the following
    • Discrete episode of intense fear or discomfort
    • Starts abruptly
    • Crescendo within a few minutes
    • Autonomic arousal
    • Other symptoms of GAD
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50
Q

Ix Panic disorder

A

Hx - Same as GAD, but appearance and behaviour may be more intense - hyperventilating - in case of panic attack

BT - FBC - infection or anaemia, TFT - Hyperthyroidism, Glucose - Hypoglycaemia

ECG - sinus Tachy

Questionnaires - GAD-2, Becks anxiety inventory and hospital anxiety / depression scale

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51
Q

Treatment panic disorder

A
  • SSRI
  • If not suitable after 12 weeks then switch to TCA - imipramine or clomipramine
  • NO BENZO
  • CBT
  • Self help methods
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52
Q

Stepwise approach to panic disorder

A
  1. Recognition and diagnosis
  2. Treatment in primary care
  3. Review and consider alternative treatments
  4. Specialist mental health
  5. Care with specialist mental health services - hospitalisation
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53
Q

Ddx panic disorder

A
  • Other anxiety disorders
  • Organic - phaechormocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndrome, arrythmias, substance withdrawal
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54
Q

Age of onset for GAD, panic and phobia

A

Variable / Late adolescence / Childhood to late ado

55
Q

Occurrence of GAD, panic and Phobic

A

Persistent
Episodic
Situational

56
Q

Associated behaviour of GAD, panic and Phobic

A

Agitation
Escape
Avoidance

57
Q

Cognition of GAD, panic and Phobic

A

Constant
Fear of symptoms
Fear of situation

58
Q

Associations of GAD, panic and Phobic

A

Depression
Depression, agoraphobia and substance misuse
Substance misuse

59
Q

PTSD

A

Intense, prolonged and delayed reaction following exposure to an exceptionally traumatic event

60
Q

Abnormal Bereavement

A

Delayed onset, is more intense and prolonged >6 months

61
Q

Acute stress reaction

A

Abnormal reaction to sudden stressful events

62
Q

Adjustment disorder

A

Significant distress accompanied by an impairment in social functioning.

63
Q

Cognitive pathophysiology of PTSD

A

failure to process emotionally charged events causes memories to persist in an unprocessed form and can intrude on conscious awareness.

64
Q

Examples of traumatic events

A
  • Severe assault
  • Major natural disaster
  • Serious RTA
  • Civilian disaster
  • War
  • Freak occurrences - near drowning when on holiday etc
  • Physical torture
  • Prisoner of war or hostage
  • Violent or unexpected death
65
Q

RF of PTSD

A
  • Exposure to a major traumatic event
  • Pre trauma - previous, history of mental illness, low SES, childhood abuse
  • Peri-trauma - severity, perceived threat to life, adverse emotional reaction
  • Post-trauma - Concurrent life stressors, absence of social support
66
Q

Symptoms PTSD

A
  1. Reliving the situation - Flashbacks, vivid memories, nightmares, distress when thinking of similar situations
  2. Avoidance - Avoiding reminders of trauma and excessive. Inability to recall some events
  3. Hyperarousal - Irritability or outbursts, insomnia or hypersommnia and exaggerated startle response
  4. Emotional numbing - negative thoughts of oneself, difficulty controlling and expressing emotions, detachment
67
Q

MSE PTSD

A

Appearance - hyper vigilance
Speech - slow and trembling
Mood - anxious
Thought - pessimistic
Perception - No hallucinations and may have illusions
Cognition - poor attention and concentration
Insight - Good

68
Q

ICD-10 PTSD

A
  • Exposure to traumatic event
  • Persistent remembering
  • Avoidance of similar situations
  • Inability to recall some important aspects OR increased psychological sensitivity or arousal
  • Within 6 months of stressful event or at end of period of stress.
69
Q

Ix PTSD

A
  • Trauma screening questionnaire TSQ
  • Post traumatic diagnostic scale
  • CT head - if head injury is suspected
70
Q

Treatment PTSD >3 Months

A
  • CBT or Eye movement desensitisation and reprocessing (EMDR)
  • Drug - if little benefit from therapy, pt choice to not undergo therapy or co-morbid depression or severe hyperarousal
  • Paroxetine, mirtazapine, amitriptyline and phenelzine
71
Q

PTSD treatment <3 months

A

Within 3 months

  • Watchful waiting
  • Trauma-focused CBT - 8-12 sessions
  • Short term drug treatment - sleep disturbance - zopiclone
  • RA
72
Q

Ddx PTSD

A
  • Adjustment disorder, acute stress or bereavement disorder.
  • Dissociative disorder
  • Head injury or alcohol / substance misuse.
73
Q

Stages of grief

A

DABDA

Denial

Anger

Bargaining

Depression

Acceptance

74
Q

Consideration for diagnosis of PTSD

A

Pt may present with loss of loved one. Bereavement is a unique traumatic stress which is a normal human experience and not unnatural. It should not extend over 6 months and if it does think bereavement disorder or adjustment disorder - NOT PTSD

75
Q

OCD

A

recurrent obsessional thoughts or compulsive acts

76
Q

Compulsions

A

Repetitive stereotyped behaviours or mental acts that a person feels driven to performing. Either overt or convert.

77
Q

Pathophysiology of OCD

A

Biological - Dec serotonin and abnormalities in the frontal cortex and basal ganglia.

PANDAS - Childhood group A beta-haemolytic streptococcal infection can have a role as damages basal ganglia.

Psychoanalytic - filing the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness

Behavioural - Compulsive behaviour by operant conditioning.

77
Q

Obsession

A

Unwanted intrusive thoughts that repeatedly enter individuals mind. Distressing

78
Q

RF OCD

A
  • Other psychiatric disorders - depression, anorexia nervosa, Tourettes and sydenhams chorea
  • Early adulthood and equal among genders
  • Developmental factors - neglect, abuse or bullying / social isolation
  • Carrying out compulsive act is a maintaining factor.
79
Q

Symptoms of obsessions

A

contamination, fear of harm, excessive concern with order and symmetry, sex violence or blasphemy

80
Q

Symptoms of compulsions

A

Checking gas taps, cleaning, repeating acts or arranging objects, mental compulsions, hoarding

81
Q

Symptoms and Cycle of OCD

A

FORD Car

Failure to resist

Originate - from pt mind

Repetitive

Distressing

Carrying out obsessive thought is not pleasurable.

OCD Cycle:

Obsession —> Anxiety —> Compulsion —> Relief

82
Q

MSE OCD

A

Pt may be easily startled or visibly worried

Anxiety

Thoughts are unwanted and intrusive

Obsessions leading to poor concentration

Insight is usually very good.

83
Q

Sub categories of OCD

A
  1. Predominantly obsessional thoughts
  2. Predominantly compulsive acts
  3. Mixed obsessional thoughts and acts
84
Q

ICD-10 OCD

A

ICD-10

  • Obsessions or compulsions present on most days for at least 2 weeks
  • Obsessions or compulsions share a number of features all of which must be present
  • The obsession or compulsions cause distress or interfere with the subjects social or individual functioning.
85
Q

Treatment OCD

A
  1. CBT - including ERP (exposure and response prevention)
  2. Pharmacology - SSRI - fluoxetine or sertraline or citalopram
    1. Clomipramine or antipsychotic in case of needing adjustment
  3. Psychoeducation, distratcing techniques and self-help books
  4. RA for suicide risk
  5. Treatment of co-morbidities - depression
86
Q

Ddx OCD

A
  • AN and BN ED
  • Anankastic personality disorder
  • Body dysmorphic disorder
  • Primary obsessions or compulsions - anxiety / depression / tourettes
  • Kleptomania
  • Organic - dementia, epilepsy or head injury
87
Q

What are somatoform disorder

A

group of disorders whose symptoms are suggestive of a physical disorder but in the absence of physiological illness - presumed to be caused psychologically.

88
Q

Causation Types of somatoform disorder

A
  • Multifactorial - for primary or secondary gain.
  • Biological - neuroendocrine genes
  • Psychological - a high proportion of those with PTSD / association to physical or sexual abuse
  • Social - adopting the sick role in order to gain relief from stress
89
Q

RF of somatoform disorders

A

CRAMPS

Childhood abuse

Reinforcement of illness behaviours

Anxiety disorders

Mood disorders

Personality disorders

Social stressors

90
Q

Dissociation

A

Separating if certain memories from normal consciousness as a psychological defence mechanisms used to cope with emotional conflict distressing for the patient

91
Q

Conversion

A

distressing events are transformed into physical symptoms.

92
Q

Dissociative amnesia

A

Amnesia for partial or complete for recent events that were traumatic. Too extensive to be ordinary forgetfulness.

93
Q

Dissociative fatigue

A

Unexpected physical journey away from usual surroundings followed by amnesia for the journey.

94
Q

Dissociative stupor

A

Profound reduction in or absence of voluntary movements speech and normal responses to stimuli.

95
Q

Trance and possession disorder

A

Trance = temporary alteration in state of consciousness. Possession = absolute conviction by the patient that they have been taken over by spirit or power or person.

96
Q

Dissociative motor disorders

A

Loss of ability to perform movements that are under voluntary control or ataxia.

97
Q

Dissociative convulsions

A

Sudden, unexpected spasmodic movements that resemble epilepsy without loss of consciousness

98
Q

Dissociative anaesthesia and sensory loss

A

Partial or complete loss of cutaneous sensation, vision, hearing or smell.

99
Q

Types of dissociative disorder

A

Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and Possession disorders
Dissociative motor disorders
Dissociative convulsions
Dissociative anaesthesia and sensory loss.

100
Q

MSE Somatoform disorders

A
  • Appearance and behaviour reflects underlying mood or anxiety disorders
  • Thoughts will show preoccupation to a physical disorder and symptoms
  • Insight into having psychiatric illness will probably be clouded.
101
Q

Ix somatoform disorder

A
  • Normally a disorder of exclusion
  • A thorough physical examination and investigations rule out an organic cause
  • BT - FBC, U+E, TFT and CRP all normal
  • Symptoms are investigated depending on system affected.
102
Q

Classifications of somatoform disorder

A

ICD-10

PUSHy SOMATOFORM

  • Persistent somatoform pain disorder
  • Undifferentiated somatoform disorder
  • Somatization disorder
  • Hypochondriacal disorder
  • Somatoform Autonomic Dysfunction
103
Q

Somatisation disorder

A
  • Briquets syndrome
  • Requires all 4 of
    • At least 2 years duration of physical symptoms that cannot be explained by any physical detectable disorder
    • Preoccupation with symptoms causes physical distress
    • Continuous refusal by patients to accept reassurance
    • Six or more symptoms :
      • Abdo pain / N+ V / Bloating / Regurgitation / Loose bowel motions
      • Chest pain / breathlessness / palpitations
      • Dysuria / Frequency / Incontinence / Vaginal discharge
      • Discolouration or itching / Arthralgia / Headaches / Visual disturbances
104
Q

Hypochondrical disorder

A
  • Misinterprets normal bodily sensations which leads them to non-delusional preoccupation that they have a serious physical disease.
  • Refuse reassurances from doctors
  • Dysmorphophobia - excessive preoccupation with barely noticeable or imagined defects in their physical appearance.
105
Q

Somatoform autonomic disorder

A
  • Symptoms related to autonomic nervous system in multiple systems
  • E.g. cardiovascular - palpitations / chest pain / sweating
  • Some symptoms may be objective - sweating, tremor or Subjective - pain and paraesthesia
106
Q

Persistent somatoform pain disorder

A
  • Persistent >6 monts and severe pain that cannot be fully explained by a physical disorder.
  • Psychosocial stressors or emotional difficulties attribute to symptoms
  • Differs from somatisation disorder in that pain is the primary feature and multiple symptoms from different symptoms are not present.
107
Q

Ddx somatoform disorder

A
  • Somatoform disorders
  • Dissociative conversion disorder
  • Factitious Disorder
  • Malingering
  • Other psych - mood, psychotic or PD
  • Multisystemic disease - CT disorder or IBD.
108
Q

Malingering

A

patient seeks advantageous consequences of being diagnosed with a medical condition

109
Q

Factitious disorder

A

Adopt the sick role in order to receive care and for internal emotional gain.

110
Q

Management somatoform disorder

A

Biological -

  • SSRI
  • Physical exercise - dysmorphophobia

Psychological -

  • CBT

Social -

  • Stress relieving activities - medication and long walks.
  • Interview family members who serve to reinforce the sick role
111
Q

Explaining a somatoform disorder

A

Explanation - Many people like yourself have symptoms that we cannot find a reason for. Medically unexplained symptoms

Placing a positive spin - There are still ways we can help. We can train body to feel normal again but not able to pin point an exact cause

Relate to a disorder - We know physical illness can get worse dependent on patients mood - e.g. stress making asthma worse - so we can try to work with mood stabilisation that may help some symptoms.

112
Q

Munchausens syndrome

A

In both malingering and factitious disorder - Munchausens syndrome - physical and psychological symptoms are intentionally produced - Faked.

113
Q

Repression

A

involuntarily withholding an idea or feeling from conscious awareness

114
Q

Displacement

A

Redirection of emotions or impulses to a neutral person or object

115
Q

Suppression

A

Intentionally and temporarily withholding an idea or feeling from conscious awareness (vs repression which is involuntary)

116
Q

Psychotic defences

A

Denial
Distortion
Splitting

117
Q

Immature defences

A

Projection
Acting out
Projective identification

118
Q

Neurotic defences

A

Displacement
Reaction formation
Repression
Intellectualisation
Dissociation
Isolation
Regression
Rationalisation
Undoing

119
Q

Mature defences

A

Altruism
Sublimation
Suppression
Humour
Identification

120
Q

Projection

A

Attributing uncomfortable thoughts or feelings to others

121
Q

Projective identification

A

the object of projection invokes in that person precisely the thoughts, feelings or behaviours projected

122
Q

Reaction formation

A

Acting in the opposite way to the thought or feeling

123
Q

Intellectualisation

A

Focusing on details in an effort to avoid painful thoughts or emotions

124
Q

Dissociation

A

Temporary drastic modification of one’s personal identity or character to avoid emotional distress

125
Q

Regression

A

Reverting back to an earlier stage of development when faced with an unpleasant thought or emotion

involuntarily turning back the maturational clock and going back to earlier modes of dealing with the world

126
Q

Rationalisation

A

The creation of false but credible justifications

127
Q

Undoing

A

An attempt to take back an unpleasant thought or emotion

128
Q

Altruism

A

Lessening negative feelings by providing constructive service/generosity to others

129
Q

Sublimation

A

Redirecting negative thoughts or feelings into a more positive form

130
Q

Suppression

A

Process of consciously avoiding thinking about something for example by distracting oneself

131
Q

Identification

A

The unconscious modelling of one’s self upon another person’s character and behaviour

132
Q

BDD IV criteria

A

Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive

The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)

133
Q
A

Psychiatry (17 decks)

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