Anxiety Flashcards
S+S:
Mood and thought
What is depersonalisation?
What is derealisation?
Tension Agitation Fear of loss of control Dread Irritability Lack of concentration
Periods of feeling disconnected or detached from one’s body and thoughts
An alteration in the perception or experience of the external world so that it seems unreal.
S+S - Physical symptoms:
What is somatization?
GI symptoms? - 4
What is Globus Pharyngeus?
The physical (or body) expression of stress and emotions through the mind-body connection.
Bowel and bladder changes
Butterflies in stomach
Nausea
Lack of appetite
Feeling like there is a lump in their throat when in fact there is nothing there.
S+S - Panic attacks:
Physical signs? - 4
What is angor animi?
How long does it last?
Hyperventilation:
- You get tetany with it. What is it?
- What else do you get? - 3
- What type of metabolic disturbance can happen very acutely>
Palpitations
Sweating
Trembling
Hyperventilation
The fear of dying - common in panic attacks
Involuntary contraction of muscles, which may be caused by disorders that increase the action potential frequency of muscle cells or the nerves that innervate them.
Tingling
Paraesthesia
Chest pain
Respiratory alkalosis
Risk Factors:
What sex is at a higher risk for most anxiety disorders except OCD and social anxiety disorder?
What’s the age of onset for most anxiety disorders?
What’s the age of onset for GAD?
What screening tool can be used to evaluate the severity of the anxiety?
FH
Females
Teens and 20s but may be untreated for yrs
40s and 50s
GAD7 Anxiety Screening Tool
Generalised Anxiety Disorder (GAD):
2 keywords to define
GAD is not situational. What does this mean?
How long must it last for?
It is the most common anxiety disorder. Which sex is it more common in?
Generalised
Persistent
Not triggered by anything specific like a phobia
6 months
Females
Generalised Anxiety Disorder (GAD) - Management:
Psychological:
- First-line - 1
- Low-intensity - 2
- High intensity - 2 - who is this offered to? - 2
Psychoeducation for patients and families
6 weeks of self-help CBT or group psychoeducation
12 wks of weekly CBT or applied relaxation
Those with marked functional impairment or failure to improve on lower steps - drug Rx can also be alternative
Generalised Anxiety Disorder (GAD) - Management:
Biological - an alternative for those who need high-intensity psychological intervention:
- First-line
- Second-line
- Third-line - also used to treat nerve pain - P
How long will the drugs take to begin working?
What may happen before they start working?
What warnings should be given to the patient?
SSRI
Alternative SSRI or SNRI
Pregabalin
1 wk
Increased anxiety or agitation
Suicide risk
Warn against sudden cessation due to withdrawal effects
Generalised Anxiety Disorder (GAD) - Management:
Social interventions:
Peer support groups
Support with returning to work or training if needed
Panic disorder - S+S:
Define
How many attacks typically happen in a month?
How may people with panic attacks interpret their symptoms?
What may panic disorder lead to that starts with A?
Episodic and recurrent panic attacks which are not situational
Several
A physical health problem
Agoraphobia - now situational fear - they don’t fear being with people unlike a social phobia
Agoraphobia:
What is it?
What percentage of those with the panic disorder does it present in?
Fear of public places and fear that they will find it hard to escape from such places and/or have a panic attack.
50%
Rx IS THE SAME FOR BOTH
Panic disorder and agoraphobia - Management:
What type of Rx is done in primary care?
When is a secondary referral needed?
Psychological and biological
Failed at least 2 Rx
Panic disorder and agoraphobia - Management:
Psychological:
First-line
Second-line
Third-line
What specifically can be done for agoraphobia?
Psychoeducation for patient and family - including those presenting at A&E - CAN JUST BE SOME INFORMATION TO TAKE AWAY WITH THEM
CBT - Self-help or computerised
Individual CBT - 7-14 weekly sessions
Graded exposure therapy
Panic disorder and agoraphobia - Management:
Biological:
First-line
Second-line
How long should the drugs be used for if found to be effective with manageable side effects?
When are benzo’s needed?
SSRI - allow 12 wks for effect to be seen - counsel as always about side effects
TCA (imipramine or clomipramine)
6 months
Emergencies - A&E
Panic disorder and agoraphobia - Management:
Social Rx - 1
Peer support groups
Social anxiety disorder (social phobia):
What is it?
What sort of sign could you see? - eye
Psychological symptoms - 2
How may this present with children?
Fear and avoidance of meeting people and daily activities such as speaking by telephone, going to the shops, eating and drinking in company.
Poor eye contact
Low self-esteem and fear of criticism
Selective mutism
Social anxiety disorder (social phobia) - Management:
Psychological therapy before meds. CBT is done first. What is involved in the individual CBT?
Clark and Wells Modelis used for adults in CBT. What is it?
What type of CBT is useful in young people?
What is an alternative to individual CBT?
Individual CBT - involves psychoeducation and graded exposure either during sessions or as homework.
Video feedback to correct negative self-imagery, and shifting from self-focused to externally-focused attention.
Group CBT - useful in children and young people
Self-help CBT
Psychodynamic therapy
Social anxiety disorder (social phobia) - Management:
Biological:
- First-line
- Second-line
- Third-line
In who should drugs be avoided in?
SSRI - sertraline
A different SSRI or venlafaxine (SNRI)
MAOIs - moclobemide
Children and young people
Social anxiety disorder (social phobia) - Management:
Social - what difficult social situations which may be contributing to the condition, should be addressed?
SPIN is used for initial assessment and to monitor Rx response. What does it stand for?
How should appointments be planned?
What should be done if you find the person is also depressed?
Bullying in school
Family problems
Social Phobia Inventory
Offer clinic at less busy times
Private waiting areas if possible
Home-based appointments and Rx
Treat that first
Simple or specific phobia:
What is it?
What does the person do to compensate?
Management:
What is done in CBT?
Anxiety which is situational (specific to objects or situations)
Anticipatory avoidance and anxiety - panic attacks may occur
Graded exposure therapy and anxiety management
OCD:
What does it stand for?
What type of thoughts do they have?
What does it mean by compulsive acts?
What may co-exist with it? - 3
Obsessive compulsive disorder
Obsessional thoughts (e.g. around contamination, security)
Repetitive behaviours which provide temporary relief but don’t give pleasure
Depression, substance misuse or eating disorders
OCD - Management:
Psychological:
In their CBT, they undergo ERP. What does it stand for and mean?
Low-intensity CBT is 1st line for mild disease:
- What type is used? - 2
What is alternative to SSRI’s as the 1st line in moderate disease?
What combo can be done for severe disease?
Exposure and response prevention
Subjects confront the stimuli for their obsessions and are encouraged to resist acting out their compulsions (e.g. touching something ‘dirty’ and not washing their hands).
Self-help CBT
Group CBT
High-intensity individual CBT
Combo of CBT and SSRIs
OCD - Management:
Biological:
First-line?
When should meds only be used in children?
When should the dose be increased if there is no response?
How long should it be continued for if there is a response?
SSRIs - fluoxetine, paroxetine, sertraline
Only if Rx fails, and monitor carefully due to the risk of suicidality.
4-6 wks
OCD - Management:
Biological:
- Second line
- Third line
What can be used for suicidal or severely incapacitated patients?
Switch to another SSRI or clomipramine (TCA) but try adding CBT to SSRI
Antipsychotic
ECT
OCD - Management:
Social:
Who might need support in adult patients?
What support is needed for employment?
MDT approach - What does an OT and social worker do?
Children especially if it is affecting the patient’s ability to care for them.
Support regarding return to work and benefits if employment is affected
OT can help return to normal activities
Social workers - advice on childcare and benefits
PTSD:
What does it stand for?
What is it?
When does it present?
Risk factors
Post-traumatic stress disorder
Psychological distress following an extreme traumatic event, often involving a threat to life or physical integrity.
(e.g. assault, trauma, rape - can also be after childbirth)
6 months after the event
Females
Refugees
First responders
PTSD:
Key features mneumonic HARD:
Other features - what might they do to certain aspects of the event?
What does PTSD lead to?
Co-morbid conditions?
Hyperarousal/hypervigilance - autonomic arousal leading to:
- poor sleep
- irritability
- angry outbursts
- extreme startle response
- poor concentration
Avoidance of reminders of events - certain people or places
Re-living - flashbacks, dreams or vivid memories of events, accompanied by distress
They forget or blank out them
Functional and/or social impairment
Substance abuse, depression, anxiety
PTSD - Management:
Trauma-focused CBT - what does this include?
****Eye movement desensitisation and reprocessing (EMDR) is used. What is it?
Psychoeducation
Anxiety and anger management
Breathing techniques
Exposure to triggers in a controlled environment (ERP_
—————————–
During EMDR therapy sessions, you relive traumatic or triggering experiences in brief doses while the therapist directs your eye movements.
EMDR is thought to be effective because recalling distressing events is often less emotionally upsetting when your attention is diverted. This allows you to be exposed to the memories or thoughts without having a strong psychological response.
PTSD - Management:
If preferred, meds can be used instead.
What meds can be used if mild?
What meds can be used if severe?
When should BZDs be used?
SSRI (sertraline) or SNRI (venlafaxine)
Antipsychotics (risperidone)
ONLY IN EMERGENCIES
Acute Stress Disorder:
What is it?
Onset?
Symptoms?
Management - 2
PTSD-like symptoms within 1 month following extreme stress (e.g. car accident, assault) with onset typically in minutes to days.
Dissociation and PTSD symptoms (hypervigilance, avoidance, intrusive thoughts, low mood)
Trauma-focused CBT or active monitoring
Adjustment disorder:
Why is it different from PTSD and acute stress disorder?
They have impaired functioning without meeting the full diagnostic criteria for those or other mental disorders.
Benzodiazepines - Anxiolytics:
Lorazepam has a rapid-onset and is short-acting. What else can it do if given IV?
An example which begins with O
Diazepam - what is the difference between this and lorazepam? - what else can it do if given IV/PR?
Lorazepam - anticonvulsants
(Oxazepam) has a rapid-onset and is short-acting
Diazepam - Anticonvulsants
Benzodiazepines - Sedatives:
Nitrazepam - onset? how long does it last?
Temazepam - onset? how long does it last?
Rapid onset - long-acting
Slow onset - short-acting
Benzodiazepines - Others:
Midazolam is rapid-onset and short-acting sedative.
- When is it used? - 3
- By what route is it an anticonvulsant? - 2
Chlordiazepoxide - what type of withdrawal is it used in?
Procedures
ICU
Palliative care
Alcohol withdrawal
Benzodiazepines:
Side effects - 2
What situations are they used for?
Tolerance and dependency
Drowsiness and weakness
Severe, disabling anxiety or insomnia
