Anxiety and neuroses Flashcards
GAD diagnosis
a) Core symptom
b) Plus how many added symptoms (physical, autonomic or mental state)
- tip: no. symptoms required same as for depression
a) Excessive anxiety and worry (apprehensive expectation) with loss of control
- Occurring more days than not for at least SIX months
- About a wide range of events or activities (i.e. generalised)
b) At least 4 other symptoms
GAD symptoms:
a) Core - Mnemonic: AND I CREST…
b) Autonomic
c) Chest/abdomen
d) Mental state
e) General
a) - Anxiety,
- No control,
- Duration > 6m,
Irritability, Concentration impairment, Restlessness, Energy depleted, Sleep impaired, Tense muscles
b) Autonomic arousal symptoms: Palpitations, tachycardia, sweating, trembling or shaking, dry mouth
c) Difficulty breathing. Feeling of choking. Chest pain or discomfort. Nausea or abdominal distress (such as churning in stomach).
d) Feeling dizzy, unsteady, faint, or light-headed.
derealisation, depersonalisation. Feeling of losing control, ‘going crazy’, or passing out. Fear of dying.
e) - Hot flushes or cold chills.
- Numbness or tingling sensations.
- Muscle tension or aches and pains.
- Restlessness and inability to relax.
- Feeling keyed up, on edge, or mentally tense.
- A sensation of a lump in the throat or difficulty in swallowing
GAD-7: score cutoffs
5 - mild, 10 - moderate, 15 - severe
Stepped care model of GAD management:
a) Outline the steps 1 - 4
b) Who is suitable for each step?
Step 1: Assess, monitor, educate
(for all newly diagnosed)
Step 2: Low-intensity psychotherapy, self-help, facilitated sessions
(if not improved after step 1)
Step 3: CBT/applied relaxation or drug treatment
(if inadequate response to step 2 or marked functional impairment)
Step 4: Specialist drug and/or psychological treatment, multiagency team, crisis intervention, OP/IP care (Treatment resistant GAD, very marked functional impairment, risk of neglect/self-harm)
CBT for GAD
a) Optimal duration
b) Brief CBT
a) 16 - 20 hours delivered as weekly 1-2 hour sessions
b) 8 - 10 hours
Relaxation and exposure therapy for GAD
Relaxation involves practising techniques that lead to muscular or bodily relaxation.
Exposure entails (over a period of time) graded, repeated confrontation (through visualisation, image, or the stimulus) with a stimulus that causes anxiety
Drug management of GAD (stage 3):
a) 1st line
b) Alternative
c) Should beta-blockers and MAOIs be used for GAD?
d) If rapid response is required, what class may be prescribed? (for max 4 weeks)
a) Sertraline (SSRI)
b) Venlafaxine (SNRI)
c) No
d) Benzodiazepines
Causes of anxiety:
a) Drug classes
b) Other substances
c) Medical conditions
a) Penicillins, sulfonamides, beta-agonists, and steroids
b) Caffeine, nicotine, marijuana, and stimulants
- Alcohol, opioid and benzodiazepine withdrawal
c) Hyperthyroidism, hypoglycemia, anaemia, cardiac arrhythmias, and pulmonary insufficiency
Panic attack:
a) define
b) symptoms
c) mnemonic: PANIC
a) Panic attack:
- Episode of intense subjective fear,
- Rapid onset and peaking within 10 minutes
- With 4+ of symptoms below
b) At least 4 of:
- Sweating. Trembling or shaking. Dry mouth.
- Feeling short of breath, choking, chest pain, discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, light-headed or faint.
- Derealisation or depersonalisation.
- Fear of losing control or ‘going crazy’.
- Fear of dying.
- Numbness or tingling sensations.
- Chills or hot flushes
c) • Features of a panic attack (PANIC) Peak within 10 minutes of onset Autonomic (sweating, trembling, shaking) Nausea (and abdominal upset) Intense fear (of losing control, dying, impending doom) Chest pain/ Choking
Panic disorder: define
- commonly coexists with what disorders?
Panic disorder is defined as recurrent unexpected panic attacks. Commonly coexists with:
- Agoraphobia
- social phobia
- GAD
- depression
- substance misuse
Cancer causing flushing, diarrhoea and vomiting?
- due to excessive release of what chemical?
Carcinoid tumours (a type of NET, commonly GI)
- Excessive serotonin release (5-HT)
- 24 hour urinary excretion of 5-hydroxyindoleacetic acid (5-HIAA) confirms diagnosis
- Rx: resection +/- octreotide
Panic disorder: stepped care (1 - 4)
- 1st line drug?
- 2nd line drug?
- Guidance on use of benzos/beta-blockers
Step 1: identify, monitor, educate
Step 2: CBT, self-help (exercise, abdominal breathing, identify and target triggers like caffeine and substance misuse), Drugs (SSRI first line)
Step 3: 2nd line drugs (e.g. TCAs) and further management
Step 4: Consider referral to psychiatry if 2 or more interventions have failed to control panic attacks
Don’t use BBs or BZDs
Social anxiety disorder:
a) Define
b) 2 types
c) Main physical symptoms
d) Main psychiatric symptoms
e) 2 screening questions. 1 screening tool
f) 1st and 2nd line management
a) It is persistent fear and anxiety about one or more social or performance situations
b) Generalised social anxiety which affects most, if not all areas of life. Performance social anxiety, where these feelings only occur in a few specific situations such as public speaking, eating in public, vomiting in public (emetophobia) or dealing with figures of authority
c) Trembling, sweating, palpitations, tremor, flushing
d) Fear, insecurity, avoidance, dread social occasions, ruminate and obsess afterwards, low self esteem
e) Do you find yourself avoiding social situations or activities? Are you fearful or embarrassed in social situations? Mini-SPIN (Social phobia inventory)
f) CBT/self-help, 2nd line: SSRI
Agoraphobia
- PHOBIC (2 of these)
a) A fear of open spaces, especially those in which getaway may be difficult, which leads to avoidance of the situation
b) - Public transportation - e.g, travelling in cars, buses, trains, ships or planes.
- Home - outside of
- Open spaces - e.g, parking lots, market places or bridges.
- Being in shops, theatres or cinemas.
- In a queue
- Crowded places
Agoraphobia: management
- Same as for social phobia, stepped care approach
Step 1: identify, monitor, educate
Step 2: CBT, self-help (exercise, abdominal breathing, identify and target triggers like caffeine and substance misuse), Drugs (SSRI first line)
Step 3: 2nd line drugs (e.g. TCAs) and further management
Step 4: Consider referral to psychiatry if 2 or more interventions have failed to control panic attacks
Don’t use BBs or BZDs
