Anxiety Disorders Flashcards
Describe the areas of the brain that are involved in anxiety
- Amygdala: fight or flight response
- Hypothalamus: HPA axis activation, cortisol response
- Limbic system: emotions
- Cerebral cortex: thoughts, behaviours
Describe some of the symptoms of anxiety
- Psychological: worry, hyperarousal, irritability, difficulty concentrating, sleep disturbance
- Cardiopulmonary: ^ HR, RR, BP, palpitations
- GI: indigestion, diarrhoea
- Muscle: tension, headache, tremor
Define GAD, phobia, and panic disorder
- GAD: feelings of worry/fear that are present most of the time and not triggered by specific events, lasting for >6 months
- Phobias: episodes of intense fear triggered by a specific, ordinary situation
- Panic disorder: episodes of intense fear not triggered by any specific situation
Describe the presentation of phobias
- Episodes of anxiety + fear triggered by a specific but ordinary situation eg. social, heights, crowds
- May lead to avoidance behaviours
- Causes significant impairment
- Often present for long time
What are some examples of phobias? Explain them
- Agoraphobia: fear of being in situations where escape is difficult eg. crowds, public places, travelling
- Social phobia: fear of being the focus of attention/behaving in a way that will cause embarrassment or criticism
Which conditions commonly occur with agoraphobia?
Depression
Panic disorder eg. panic disorder when outside fuels the agoraphobia because they are now scared of leaving the house and provoking another panic attack
What are some differential diagnoses for agoraphobia?
Schizophrenia Personality disorder Social anxiety OCD Depression: social withdrawal
How can you differentiate agoraphobia vs social phobia?
What specifically are they afraid of when going outside? eg is it people looking at them or is it not being able to get away?
Does the place matter? eg small groups, large crowds
What are some differential diagnoses for social phobia?
Shyness Agoraphobia Avoidant PD Autism Schizophrenia
What can be used for assessing social phobia?
SPIN (social phobia inventory) or LSAS
How would you counsel someone that has been diagnosed with social phobia?
- Explain the diagnosis and check understanding
- Management: CBT, SSRIs in severe cases
- Advise to avoid using alcohol or drugs to cope, signpost for services
- Advise TCI if feeling worse, feeling very low in mood, etc
What is the management of social phobia?
- Bio: SSRIs second line
- Psych: CBT in Clark and Wells or Heimburg model. Self-guided if declined CBT.
What is the management of agoraphobia?
CBT with exposure and response prevention
SSRIs second line
Describe exposure and response prevention
A type of talking therapy where the patient is taught strategies to cope with fear and anxiety, then they are exposed to increasingly fear-inducing situations in order to cause habituation to the stimulus.
eg. fear of spiders: think about a spider, look at a picture of a spider, watch a video of a spider, etc.
What are some symptoms of panic attacks
- Intense fear/dread
- Chest constriction, difficulty breathing
- Hyperventilation
- Numbness and tingling in the fingers, mouth
- Sweating, dizziness
How is panic disorder diagnosed?
Recurrent panic attacks
What are some ways of assessing anxiety disorders?
GAD-7
Beck anxiety inventory
HADS
Specific eg. SPIN and LSAS for social phobia
What investigations would you do for someone with anxiety?
Usually only if GAD or panic disorder. Phobias have specific trigger
- Physical examination eg. pulse, heart
- Observations
- ECG
- Bloods: FBC, CRP, U+Es, TFTs
- Urine drug screen
Describe the management of GAD
Biopsychosocial
Mild-mod: individual guided self-help
2nd line or Mod-severe GAD: CBT or SSRI (12 week course)
When would you refer a patient with GAD to secondary care?
Treatment failure eg. trial of medications + CBT
High risk of suicide/self-harm
Self neglect
What is the management of panic disorder?
Biopsychosocial
Mild: individual self-help
Mod-sev: CBT -> SSRIs (12 week course) -> TCA (imipramine)
How should you follow-up someone newly prescribed Sertraline?
See within 2 weeks unless if <30 years, then see in 1 week to monitor for suicidal thinking
Define obsessions and compulsions
Obsessions: recurrent unwanted and intrusive thoughts, images, impulses
Compulsions: repeated and purposeful behaviours that the person feels compelled to do
How is OCD diagnosed?
Presence of obsessions and/or compulsions present for most days over 2+ weeks
Significant enough to cause distress
How are obsessions different to delusions?
Patients know that obsessions are irrational
What are some common examples of obsessions? Compulsions?
Obsessions: contamination/infection, harm
Compulsions: cleaning, counting, checking
What are the differential diagnoses for OCD?
Anankastic PD
Anxiety disorders
Autism
Schizophrenia
What is the management of OCD?
Biopsychosocial
- Mild: individual self-help with ERP
- Mod/2nd line: high intensity CBT with ERP or SSRIs
- Severe: CBT + SSRI
How long should an SSRI be continued in OCD?
12 months after remission
Define acute stress reaction
Transient disorder (<1 month) of significant severity which develops in an individual without a mental disorder is response to exceptional physical/mental stress.
What can cause acute stress disorder?
An event in which the person feared for their life eg.
- War/victim of terror or significant crime
- Rape
- Natural disaster
- Car crash
Define PTSD
Anxiety disorder that develops following traumatic events of exceptionally threatening nature, lasting longer than one month.
How does PTSD present?
Usually after a latent period eg 6 months following event
- Hyperarousal: hypervigilance, tension, irritability, easily startled, insomnia
- Re-experiencing: flashbacks, night terrors
- Avoidance
- Numbness, decreased interest, mood changes, low self-esteem
What is the management of PTSD?
Biopsychosocial
- Mainstay: Trauma focused CBT, EMDR (for non-combat) -> Venlafaxine or SSRIs
- Support groups
If someone presents with symptoms of PTSD and depression, which takes priority in management?
PTSD (unless the depression is preventing engagement with treatment or high risk of self-harm/suicide)
What is the management of acute stress disorder?
Reassure and support, watchful waiting or
Can offer cognitive processing therapy, narrative exposure therapy etc
Describe adjustment disorder
- Maladaptive reaction to a psychosocial stressor eg breakup, divorce, etc
- Onset within 1 month of the event, usually lasts <6 months
- Can be depression or mixed depression and anxiety
What is the management of adjustment disorder?
- Support, reassurance
- Counselling
- Can consider psych therapies if significant impairment
Define malingering and factitious disorders
- Malingering: deliberately feigning symptoms for specific purpose eg receive medication
- Factitious disorder: deliberately feigning symptoms for unconscious reasons
What are some causes of functional disorders?
- Initial pathology eg sprained ankle
- Somatisation (depression manifesting as pain)
- Increased attention to pain
- Past trauma -> conversion disorder
How are functional disorders managed?
- Thorough history with good active listening
- Investigate appropriately but not excessively
- Reassure the patient!! And give a positive diagnosis of functional syndrome. Validate their emotions and their symptoms while acknowledging no underlying pathology
- Encourage normal functioning
- Consider CBT +/- antidepressants
