Anxiety

Question 1

Which features distinguish pathological anxiety from normal anxiety?

Answer 1

Autonomy: no or minimal environmental trigger
Intensity: exceeds patient’s capacity to bear the discomfort
Duration: symptoms are persistent
Behaviour: anxiety impairs functioning and/or results in disabling behaviours – avoidance or safety behaviours

Question 2

What are some of the normal fears which occur at each stage of development?

Answer 2

Birth-6m: Loud noises, loss of physical support, rapid position changes, rapidly approaching other objects
7-12m: Strangers, looming objects, unexpected objects or unfamiliar people
1-5yrs: Strangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet
6-12yrs: Supernatural, bodily injury, disease, burglars, failure, criticism, punishment
12-18yrs: Performance in school, peer scrutiny, appearance

Question 3

What is the epidemiology of anxiety disorders?

Answer 3

Most prevalent psychiatric disorders
11% in Primary Care populations,
Panic disorder: 1.7%
Obsessive Compulsive Disorder: 2.3%
Post-Traumatic Stress Disorder: 3.6%
All phobias: 8.0%
Generalised Anxiety Disorder:	2.8%

Question 4

What are the symptoms of anxiety?

Answer 4

Psychological arousal:
Worrying thoughts, Irritability, Sensitivity to noise, Restlessness, Fearful anticipation, Poor concentration
Sleep disturbance
Muscle tension (tremors, aches)
Autonomic arousal:
Dry mouth, diarrhoea, difficulty breathing, palpitations, chest discomfort, frequent and urgent micturition
Hyperventilation (dizziness, tingling numbness)

Question 5

What is generalised anxiety disorder (GAD)?

Answer 5

Generalised and persistent somatic (physical) and psychological symptoms of anxiety on most days for at least several weeks at a time and usually several months
Anxiety symptoms usually involve elements of
Apprehension
Motor tension
Autonomic overactivity
Characterised by free-floating anxiety that may fluctuate but neither situational nor episodic

Question 6

What is panic disorder (episodic paroxysmal anxiety)?

Answer 6

Several attacks within one month
In circumstances with no objective danger
Not confined to known or predictable situations
With comparative freedom from anxiety symptoms between attacks
Symptoms are of a sudden crescendo of severe anxiety, associated with intense awareness of threatening bodily sensations e.g. palpitations, choking, chest pain, dizziness.
Panic attacks are short-lived and most last less than 10 minutes

Question 7

What is agoraphobia?

Answer 7

Psychological and autonomic symptoms primarily manifestations of anxiety and not secondary to other symptoms, such as depression or delusions.
Anxiety must be restricted to at least two of the following: crowds, public places, travelling alone, travelling away from the home
Avoidance of the phobic situation must be a prominent feature.
ymptoms restricted to fearful situations or contemplation of feared situation
Avoidance is always present
Can occur with or without panic disorder

Question 8

What is social phobia?

Answer 8

Psychological, behavioural or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
The anxiety must be restricted to or predominate in particular social situations
The phobic situation is avoided whenever possible
Marked fear of being the focus of attention, of embarrassment or humiliation
Blushing or shaking
Fear of vomiting
Urgency or fear of micturition

Question 9

What is specific (isolated) phobia?

Answer 9

Psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
The anxiety must be restricted to the presence of the particular phobic object or situation
The phobic situation is avoided whenever possible

Question 10

What is obsessive-compulsive disorder?

Answer 10

characterised by obsessive symptoms (thoughts, impulses, images) and/or compulsive acts or rituals, present on most days for at least two weeks, causing distress and interfering with activities.
With lesser symptoms may have anankastic Personality Disorder, ego-synodic symptoms (symptoms do not usually distress the patient)

Question 11

What is the epidemiology of OCD?

Answer 11

Symptoms are common in childhood, and at this age, this is considered normal
M=F
Mean onset of symptoms to diagnosis is about 9 years (i.e. long delay)
Frequently symptoms coexist with
Schizophrenia
Tourette’s Syndrome
Depression

Question 12

What are obsessions?

Answer 12

Acknowledged as excessive or unreasonable
Repetitive
Intrusive and resisted by the patient (although the resistance may diminish in chronic OCD)
Unpleasant – i.e. the thought gives no pleasure
Originate in the mind of the patient and are not imposed by outside persons or influences (i.e. not thought insertion)
Cause distress and interfere with functioning

Question 13

What are impulsions?

Answer 13

Acknowledged as excessive or unreasonable
Repetitive
Intrusive and resisted by the patient, causing mounting anxiety
Unpleasant – i.e. the act itself gives no pleasure, but may relieve tension or anxiety.
The desire to carry out the act originates in the mind of the patient and are not imposed by outside persons or influences ie not a made act arising from psychosis.
Causes distress and interferes with functioning, usually due to wasting time.
Magical thinking can occur – eg. “if I touch this door frame five times, no harm will come to my family”.

Question 14

What are common medical conditions associated with anxiety?

Answer 14

Endocrine: Thyroid dysfunction, Phaeochromocytoma
Metabolic: Acidosis (e.g. diabetic ketoacidosis), Hyperthermia or hypothermia
Hypoxia: CHF, angina, COPD, anaemia
Neurological: seizures, vestibular dysfunction
Cardiac: arrhythmias
Drug withdrawal: alcohol/opiates
Drug intoxication: caffeine, amphetamine, cocaine

Question 15

What is the step care approach for management of anxiety?

Answer 15

Step 1: Psychoeducation and active monitoring
Step 2: Guided self-help and low-intensity psychological interventions (primary care psychological services: IAPT)
Step 3: High-intensity psychological intervention (CBT) or drug treatment (primary care)
Step 4: Referral to secondary care - complex drug or psychological treatment regimes; input from multi-agency teams

Question 16

Which components should be included in psychoeducation?

Answer 16

Definition and nature of illness
Explaining cycle of anxiety for this diagnosis
Precipitating and maintaining factors
Treatment (medications and psychological)
CBT approach
Social interventions
Prognosis

Question 17

What is graded exposure/systematic desensitisation CBT?

Answer 17

Main approach for anxiety
Useful for treatment fo phobias
Identifying the fear
Setting treatment aims in a series of manageable steps (hierarchy), ranging from triggers causing mild anxiety to more severe anxiety
Starting with situations causing milder anxiety
Requires repeated exposure to anxiety causing stimuli
with repeated and graduated exposure, the anxiety extinguishes with time
Move up the hierarchy once feeling confidence to tackle anxiety

Question 18

What is the pharmacological management for anxiety disorder?

Answer 18

Antidepressants (anxiolytics, possible brief increase in anxiety in initial period)
Beta blocker
Benzodiazepines (Lorazepam (short half life), diazepam (longer half life)). Can be addictive used short term (4 weeks max). Can reduce efficacy of psychological treatment
Antipsychotic in severe cases

Question 19

What is acute stress reaction?

Answer 19

A brief response (up to a month) to severely stressful events
Anxiety and depression
numbness, detachment, poor concentration, derealisation, insomnia, restlessness, anger, autonomic symptoms​
Coping strategies: avoidance, denial, not remembering, alcohol excess

Question 20

What is the management for acute stress reaction?

Answer 20

Reduce emotional response – talking to friends/family or professionals.
Encouraging, but not forcing, recall (debriefing)
Learning effective coping skills
Anxiolytic only if severe anxiety (beware of addictive potential of benzodiazepines)
Hypnotics if severe sleep disturbance
78% go on to PTSD (those that get formally diagnosed)

Question 21

What is adjustment disorder?

Answer 21

Psychological reaction to adapting to a new set of circumstances
Starts within 3 months and must be understandably related to and in proportion to the stressful event.
These criteria are often met when in response to bereavement, the onset of terminal illness or sexual assault and medicalisation of these circumstances is avoided where possible
Anxiety, worry, depression, irritability
Occasional outbursts of dramatic or aggressive behaviour
Sometimes abuse of alcohol or drugs
Onset more gradual than acute stress reaction, and it takes a more prolonged course
Palpitations, tremor

Question 22

What is the management for adjustment disorder?

Answer 22

If possible, help resolve the change of circumstances e.g. support to make changes at work or put in touch with support groups when dealing with personal difficulties/illness
Help the natural process of adjustment, prevent avoidance and denial, encourage problem-solving to seek solutions and assess +/- of various courses of action.
Relieve anxiety by encouraging to talk and express associated feelings
Consider referring for talking therapy in primary care if the patient wishes for this

Question 23

Which symptoms indicate an abnormal response to grief?

Answer 23

Guilt about things other than actions taken or not taken by the survivor at the time of the death
Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person
Morbid preoccupation with worthlessness
Significant psychomotor retardation (e.g., it’s hard to get moving, and what movements there are slow)
Prolonged and serious functional impairment
Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person

Question 24

What is PTSD?

Answer 24

This is a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, likely to cause pervasive distress in almost anyone
The onset of symptoms follows the trauma usually with a latency period of a few weeks to a few months, but rarely exceeds six months. Symptoms must persist beyond six months after the event
sometimes arise much later in life, sometimes decades after the index trauma, often as a result of a more minor secondary trauma that reactivates older memories.
More common if internal perceived control, i.e. if the traumatic event was caused by someone or could have been prevented (for example, a victim of a stabbing) rather than an act of nature (for example, hit by lightening).

Question 25

What are the symptoms of PTSD?

Answer 25

Core triad of symptoms
Hyperarousal – persistent anxiety, irritability, insomnia, poor concentration
Re-experiencing – ‘flashbacks’, recurrent distressing dreams, inability to recall stressful events at will
Avoidance – of reminders of event, detachment, numbness, loss of interest in activities.
Depressive & guilt symptoms common
Substance use as a coping strategy common
Symptoms may begin quickly after, rarely >6 months after

Question 26

What is the management of PTSD?

Answer 26

Psychological treatment
psychoeducation
Trauma-focused CBT
Eye Movement Desensitization and Reprocessing (EMDR)
Biological:
antidepressants (e.g. SSRI)
Social – educate family, support in reintegration to the environment, avoid alcohol
Around 50% recover within first year
Poorer prognosis if co-morbid mental illness