Anxiety

Question 1

What is anxiety?

Answer 1

Excessive worry about a widespread variety of things + heightened tension

Question 2

What is yerkes-dodson law?

Answer 2

Arousal performance is an inverted U shaped curve, optimal performance at medium arousal/anxiety

As arousal goes between medium - high, person becomes more anxious

Question 3

What questions would you ask in an anxiety history?

Answer 3

Rate of onset?
Duration?
Severity?
Spontaneous? or Stimulus?
Other psychotic conditions?

Question 4

What symptoms may be indicative of an anxiety disorder?

Answer 4

Psychological:

• Irritable
• Worry
• Early startles
• Impending doom
• Poor Concentration

GI - loose stools, butterfly’s, N&V
Genitourinary - increased micturition, erection failure
Neuromuscular - headaches, tremor
Cardioresp - Palpitations, tachycardia, chest pain, hyperventilate

Question 5

What differentials would you consider for anxiety disorders?

Answer 5

Hyperthyroidism
Cardiac disorders

Salbutamol
Theophylline
Steroids
Caffeine

Psychiatric:

• Eating disorders
• Depression
• Schizophrenia
• OCD
• PTSD
• Somatoform disorders

Question 6

What are the types of phobic anxiety disorder? Briefly describe these

Answer 6

Specific phobia - fear of a specific object or situation

Agoraphobia - fear of public spaces that you cannot escape from

Social phobia - fear of social situations in which you may become embarrassed or criticised

Question 7

What is generalised anxiety disorder?

Answer 7

Syndrome of ongoing uncontrollable widespread worry about events/thoughts ongoing for most days for at least 6 months.

Patient realties thoughts are excessive and worries about being worried

Question 8

What are the steps of managing generalised anxiety disorder?

Answer 8

Step 1 - psychoeducation and active monitoring

Step 2 - self help, group psychoeducation therapy

Step 3 - CBT +/- SSRI (1. sertraline 2. venlafaxine or duloxetine 3. pregabalin)

Step 4 - Highly specialist team combining psychological and pharmacological interventions

Question 9

What are the risk factors for phobic anxiety disorder?

Answer 9

Prior bad experience
Other anxiety disorder
Mood disorder
Substance misuse
Family history

Question 10

How is phobic anxiety disorder managed?

Answer 10

CBT + Graded Exposure + SSRI

Psychodynamic therapy can also be used
Benzodiazepines can be used in the short term

Question 11

What is panic disorder?

Answer 11

Recurrent episodic severe panic attacks which are unpredicatable

Question 12

How may panic disorder present?

Answer 12

Sense of dread
Nausea
Shaky
Feel faint
Wobbly legs
Chest pain
Rapid HR

Question 13

How is panic disorder managed?

Answer 13

1. Self help - education, support groups
2. CBT +/- Sertraline
3. TCA (imipramine) if no improvement after 12 weeks SSRI
4. specialist services

Question 14

What is PTSD?

Answer 14

Post-traumatic stress disorder

Intense prolonged delayed reaction following an exceptionally traumatic event - >1 month

Question 15

How may patients with PTSD present?

Answer 15

Re-live the event - intrusive and involuntary flashbacks or vivid memories or nightmares

Avoidance - people or location, inability to recall trauma

Hyperarousal - irritability and outbursts, difficulty concentrating/sleeping, easily startled

Emotional numbing - detach from others, give up enjoyable activities, low mood

Question 16

What is acute stress disorder and how is it managed?

Answer 16

Reaction (like PTSD) occurring within the first 4 weeks of an acutely stressful event

Watchful waiting

Question 17

How are patients with PTSD managed?

Answer 17

Trauma focussed CBT

EMDR - eye movement desensitization and randomisation

2. Sertraline or venlafaxine

Risperidone in severe cases
Benzodiazepines for short term agitation and sleep disturbance

Question 18

What are the stages of bereavement?

Answer 18

Denial
Anger
Bargaining
Depression
Acceptance

Question 19

What is atypical grief reaction? What are the risks for this?

Answer 19

• Delayed onset - >2wks
• Reaction more intense
• Prolonged - up to and beyond 12 months

Risks: women, sudden/unexpected, complex relationship, poor support

Question 20

What is OCD?

Answer 20

Recurrent obsessional thoughts or compulsive acts or both

Question 21

Describe the cycle seen in OCD

Answer 21

Obsessive though –> Anxiety –> Compulsion –> Temporary Relief

Question 22

What differentials would you consider for OCD?

Answer 22

Eating disorders
Anankastic personality disorder - OCPD
Body dysmorphia
Other anxieties
Hypochondriacal
Schizophrenia

Question 23

What are obsessions (in OCD)?

Answer 23

Unwanted intrusive thoughts, images or urges that repeatedly enter the individuals mind

They are recognised as absurd

Question 24

What are compulsions (in OCD)?

Answer 24

Repetitive behaviours or mental acts that the person feels driven to perform

Overt - observable by others
Covert = mental acts eg repeating a phrase

Question 25

How is OCD managed?

Answer 25

CBT including exposure & response prevention therapy (ERP)

+/- SSRI depending on severity

Question 26

Which SSRI is used for body dysmorphic disorder?

Answer 26

Fluoxetine

Question 27

What is insomnia? What defines it as being chronic?

Answer 27

Trouble falling asleep, staying asleep or waking early

Chronic: 3 nights/week for 3 months

Question 28

How is insomnia managed?

Answer 28

Sleep hygiene
Identify cause
1 prescription only of zopiclone
Diazepam if linking to daytime anxiety

?CBT referral