Anxiety Disorders Flashcards
Define neurosis
Neurosis is a collective term for psychiatric disorders characterised by distress, that are non-organic, have discrete onset and where delusions & hallucinations are absent.
*Term neuroses used to refer to anxiety disorders
Anxiety is an unpleasant emotionastte involving subjective fear and somatic symptoms; every human experiences anxiety. When does it become illness?
Anxieties are either:
- Excessive
- Inappropriate
Discuss the Yerke’s-Dodson law and explain how it helps us to understand anxiety disorders
- Increase in anxiety/arousal improves performance up to a certain point
- After this point the anxiety/arousal becomes too great and performance declines
- Pt’s with anxiety disorders will therefore have decreased performance hence it can have a huge impact on life
Put the following anxiety disorders into order of prevalence:
- Agoraphobia
- Specific phobia
- OCD
- Social phobia
- Panic disorder
- Generalised anxiety disorder
*
- Specific phobia
- Social phobia
- Generalised anxiety disorder
- Agoraphobia
- Panic disorder
- OCD
What is the prevalence of anxiety disorders?
14%
State some symptoms of anxiety disorders, consider:
- Psychological
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Neuormuscular
ICD-10 classifies psychiatry disorders into 10 categories; one of these categories is neurotic, stress-related and somatoform disorders. State 4 sub-categories within this
Depressive symptoms are very common in pts with neuroses; true or false?
True (hence you should always screen for depression in pts presentng with anxiety)
Discuss how we can categoriese neuroses based on nature of anxiety and the circumstances in which anxiety arises
Compare generalised/free-floating/continuous anxiety with paroxysmal/episodic anxiety
Generalised
- Present most of time
- Not associated with specific objects or situations
- Excessive & inappropriate worry about normal life events
- Longer duration (months, years)
Paroxysmal/episodic
- Discrete episodes
- Abrupt onset
- Severe anxiety with strong autonomic response
- In respnse to specific threats
- Short lived ( <1 hour)
State some conditions that are associated with anxiety; ensure you include examples of medical, substance-related and psychiatric conditions
*NOTE: any chronic condition may cause anxiety & depression
Define generalised anxiety disorder (GAD)
Syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the pt recognises as excessive and inappropriate.
For what duration must symptoms be present for a pt to have GAD?
Most days for at least 6 months
What is the prevalence of GAD?
Is it equally common in both sexes?
What is common age of presentation for GAD?
- 2-4%
- F:M is 2:1
- ~30 years
The aetiology of GAD can be split into biological and environmental causes; state 2 biological & 2 environmental causes
State some predisposing, precipitating & perpetuating factors for GAD
State some clinical features of GAD, think about symptoms relating to:
- Cardiovascular
- Respiratory
- GI
- Brain & mind
- General symptoms
- Symptoms due to tension
- Non-specifi symptoms
WATCHERS is a mneumonic to help remember clinical features of GAD; state this mneumonic
- Worry
- Autonomic hyperactivity (sweating, increased HR, increased pupil size)
- Tension in muscles/tremor
- Concentration difficulties/chronic aches
- Headache/hyperventilation
- Energy loss
- Restlessness
- Startled easily/sleep disturbance
What is the typical pattern of sleep disturbance in GAD?
Difficulty getting to sleep with intermittent wakening & nightmares
Discuss the ICD-10 criteria for GAD
A. A period of at least 6 months with prominent tension, worry & feelings of apprehension about everyday events & problems
B. At least 4 of the following symptoms (see image) with at least one symptom of autonomic arousal (palpitations, sweating, shaking/tremor, dry mouth)
Example questions to ask in GAD history
Discuss potential findings on MSE for pt with GAD
What investigations might you do for a pt with supsected anxiety?
Structure your answer into bedside, bloods & imaging/other highlighting the reason for each investigation
Bedside
- ECG: if had palpitations to check for any arrhythmias
- Plasma glucose: hypoglycaemia can cause autonomic symptoms
- Questionnaires: e.g. GAD-7, Beck’s anxiety inventory
Bloods
- FBC: anaemia can cause tachycardia & hence palpitations aswell as lack of energy
- TFTs: hyperthryoidism can cause sympathetic nervous system symptoms e.g. sweating, tachycardia
State some differential diagnoses for a pt presenting with anxiety symptoms
*remember, think of other psychiatric conditions & organic causes
Management of GAD is based on biopsychosocial model; discuss the biological management of GAD
- First line= SSRI (sertraline recommended as it has anxiolytic effects)
- Second line= SNRI (e.g. venlafaxine, duloxetine)
- Third line: pregabalin
- Benzodiazepines ONLY in crises as short term measure
Medicaiton should be continued for at least a year to see if it improves symmptoms.
Management of GAD is based on biopsychosocial model; discuss the psychological management of GAD
- Low intensity psychological intervention
- Psychoeducation groups
- Individual self-help courses
- High intensity psychological interventions
- CBT
- Applied relaxation
Management of GAD is based on biopsychosocial model; discuss the social management of GAD
- Support groups
- Encourage exercise
- Sleep hygiene
- Encourage them to engage in self-help exercises (e.g. write down worrying thoughts)
We have already discussed the biopsychosocial management of GAD; however, NICE recommend a stepped care model. Discuss this model
*NOTE: if someone has marked functional impairment go to step 3
If a pt has both anxiety and a comorbid depressive disorder or other anxiety disorder which should you treat first?
Most severe first, as this is more likely to improve overall functioning.
When should you, in a GP setting, refer a pt with GAD to psychiatrist?
- Severe anxiety and marked functional impairment
- GAD that has not improved following step 3 interventions
- Risk of self-harm, suicide, self-neglect or significant comorbidiy e.g. substance misuse, personality disorder, complex physical health problem
Discuss the prognosis of GAD
- Chronic condition that may fluctate in intensity
- Full recovery (all symptoms gone) occurs in some but not all people- still risk of relapse
- GAD with comorbid depression is known to have the worst prognosis, with more associated symptoms and disability than depression or anxiety disorders alone
Define a phobia
Intense, irraitonal fear of an object, situation, place or person that is recognised as excessive or unreasonable
Define agoraphobia
Fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the evnet of a panic attack
Define social phobia (social anxiety disorder)
Fear of social situations which may lead to humilation, criticism or embarrassment
Define specific (isolated) phobia
Fear restricted to a specific object or siutation (excluding agorophobia and social phobia)
State some common causes of specific phobias (where possible include the prefix given)
For agorphobia, discuss:
- Prevalence
- Age of onset
- Male to female ratio
- 0.4%
- Early adulthood (25-30yrs)
- M:F is 1:2
For social phobia, discuss:
- Prevalence
- Age of onset
- Male to female ratio
- 1.2%
- Adolescence
- M:F is 1:1
For specific phobia, discuss:
- Prevalence
- Age of onset
- Male to female ratio
- 3.5%
- Childhood but can develop later in life
- M:F is 1:1
Discuss the proposed aetiology for:
- Agoraphobia
- Social phobia (social anxiety disorder)
- Specific phobia
State some risk factors for phobias
Clinical features of phobias are similar to those of GAD, remind yourself of some of symtoms of GAD
- Urge to avoid feared situation
- Inability to relax
Tachycardia is the usual autonomic response in anxiety disorders however there are some circumstances in which a vasovagal response is produced; state some of these situations
Phobias of blood, injection & injury
Vasovagal response- which produces bradycardia- commonly leads to syncope
Alongside usual anxiety symptoms, what other symptoms may a person with social phobia present with?
- Blushing
- Hand tremor
- Nausea
- Urgency of micurition/defecation
Social phobias can be discrete (restricted to certain social situations) or diffuse (involving almost all social situations outside family circle). State some common discrete social phobias
- Eating in public
- Public speaking
- Encounters with opposite sex
- Using public toilets
Which of agoraphobia, social phobia and specific phobia is strongly linked to panic disorder?
Agoraphobia. ICD-10 divides agoraphobia into:
- Agoraphobia with panic disorder
- Agoraphobia without panic disorder
Discuss the ICD-10 criteria for agoraphobia
All of the following criteria should be fulfilled for a definite diagnosis:
(a) the psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts
(b) the anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, travelling away from home, and travelling alone
(c) avoidance of the phobic situation must be, or have been, a prominent feature.
* *clarify difference in book & ICD*
Discuss the ICD-10 criteria for social phobia
All of the following criteria should be fulfilled for a definite diagnosis:
(a) the psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
(b) the anxiety must be restricted to or predominate in particular social situations
(c) the phobic situation is avoided whenever possible.
Discuss the ICD-10 criteria for specific phobias
All of the following should be fulfilled for a definite diagnosis:
(a) the psychological or autonomic symptoms must be primary manifestations of anxiety, and not secondary to other symptoms such as delusion or obsessional thought
(b) the anxiety must be restricted to the presence of the particular phobic object or situation
(c) the phobic situation is avoided whenever possible.
Discuss potential MSE for a patient with phobia (imagine they are exposed to stimulus for phobia as otherwise MSE mostly normal)
Diagnosis of phobias is usually straight forward with investigations not required; state some example questionnaires you could use for social phobia
- Social phobia inventory
- Liebowitz social anxiety scale
Three features can separate phobic anxiety from GAD; state these
(SS, AA, AA)
- Anxiety occurs in specific situation
- There is anticipatory anxiety if risk of encountering feared circumstance
- There is attempted avoidance of the feared circumstance
Discuss the management of social phobia
*Structure as first line, second line etc… Think about biopsychosocial model
First line= CBT (includes graduated exposure and desensitisation. Offer individual as opposed to group)
Second line if refuse CBT: CBT-based supported self help
Third line= SSRI (sertraline, escitalopram)
Fourth line (if only partially responsed to either of above)= both SSRI and CBT
Fifth line= SNRIs (venlafaxine)
Sixth line= MAOI (moclobemide)
Other management:
- Avoid anxiety inducing agents e.g. caffeine
- Screen & treat comorbidities
- Refer to specialist if risk of self-harm, suicide, self-neglect or significant co-morbidity
Discuss the management of agoraphobia
- CBT (includes graduated exposure)
- SSRIs
Other management:
- Screen & treat comorbidities
- Refer to specialist if risk of self-harm, suicide, self-neglect or significant co-morbidity
- Self-help techniques (E.g. focus on watch, breathe deeply, creative visualisation)
- Avoid anxiety inducing agents e.g. caffeine
- Support groups e.g. MIND
Discuss the management of specific phobias
- Self help (based on CBT- focuses on exposure)
- CBT (focuses on exposure)
- Benzodiazepines may be used in short term e.g. if caustrophobic pt needs CT scan
Other management:
- Screen & treat comorbidities
- Refer to specialist if risk of self-harm, suicide, self-neglect or significant co-morbidity
- Avoid caffeine
- Support groups e.g. MIND
Discuss the prognosis of phobic disorders
Most phobias are curable; some may need a combination of treatments
What is panic disorder?
Characterised by recurrent, episodic, severe panic attacks which are unpredicatable and not restrictedto any particular situation or circumstance
Discuss epidemiology of panic disorder, include:
- Prevelance
- Age of onset
- Male:female ratio
- 1%
- More common in women (3:1)
- Late adolesence
Discuss pathophysiology/aetiology of panic disorder, include following factors:
- Biological
- Cognitive
- Environmental
Biological
- Genetics
- Neurochemical: post synaptic hypersensitivity to serotonin & adrenaline
- Sympathetic nervous system: fear or worry stimulates SNS to increase CO which leads to further anxiety
Cognitive
- Misinterpretation of somatic symptoms e.g. fear that palpitations will lead to heart attack
Environmental
- Life stressors
State some risk factors for panic disorder
Discuss clinical features of panic disorder (include duration of symptoms)
*HINT: think PANICS Disorder
Symptoms only usually last for minutes
Discuss the ICD-10 classification for panic disorders
For a definite diagnosis, several severe attacks of autonomic anxiety should have occurred within a period of about 1 month:
(a) in circumstances where there is no objective danger
(b) not confined to known or predictable situations
(c) with comparative freedom from anxiety symptoms between attacks (although anticipatory anxiety is common).
State some differential diagnoses for panic disorder
Discuss the management of panic disorder (think about NICE stepped care approach)
If mild-moderate, first line is to try:
- Self help materials based on CBT
- Self help methods e.g. bibliotherapy, exercise, support groups
- Support groups
If moderate to severe:
- CBT
- SSRIs (first line pharmacological agent)
- Try SNRIs or TCAs (if SSRI don’t work)
Compare GAD, panic disorder & phoic anxiety, include:
- Age of onset
- When it occurs
- Associated behaviour
- Cognition (what they fear/worry about)
- Associations
Discuss prognosis of panic disorder
Treatment is effective in most pts (80%)
What is PTSD?
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
State some examples of traumatic events that may result in PTSD
Discuss prevelance of PTSD, include:
- % of adults in England that suffer
- What % of people who have traumatic event develop PTSD
- More common in male or female
- Age of onset
- 3%
- 25-30%
- More common females (2:1)
- Any age
Discuss the aetiology/pathophysiology of PTSD
State some risk factors for PTSD, think about:
- Exposure to major traumatic event
- Pre-trauma
- Peri-trauma
- Post-trauma
PTSD symptoms can be divided into four categories, state some examples of symptoms in each:
- Reliving the situation (persistent, intrusive, involuntary)
- Avoidance
- Hyperarousal
- Emontional numbing
Reliving situation: flashbacks, vivid memories, nightmares, distress when exposed to similar circumstances as stressor
Avoidance: avoid situations/people/objects/activities that remind them of the trauma, will not talk about traumatic event
Hyperarousal: irritability or angry outburts, exaggerated startle response, difficutly sleeping, difficulty concentrating, hypervigilence
Emotional numbing: negative thoughts about oneself, difficulty experiencing emotions, feeling of detachment from others, giving up previously enjoyed activities
Discuss ICD-10 classification for PTSD
- Symptoms must arise within 6 months of traumatic event.
- Must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams.
- ***Emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are often present but are not essential for the diagnosis*
- *DSMIV state symptoms must be present for 1 month*
- *Consultant says doesn’t have to have been within 6 months if clear PTSD*
Example questions for PTSD history
State two questionnaires that can be used to screen for PTSD
- Trauma screening questionnaire
- Post-traumatic diagnostic scale
Discuss potential MSE for patient with PTSD
Discuss the management of PTSD
- Consider active monitoring for people with subthreshold symptoms of PTSD within 1 month of a traumatic event. Arrange follow up within 1 month.
- Psychological therapies:
- Trauma focused CBT
- EMDR (consider in pts who present 1-3 months after non-combat related trauma if pt has preference for EMDR. Offer to pts presenting more than 3 months after non-combat related trauma)
- Pharmacological treatment:
- Can be considered if little benefit from psychological therapy, patient does not wish to engange in psychological therapy, there is comorbid depresssion or hyperarousal that would not benefit from psychological therapy. Drugs used include:
- SSRIs (No evidence for different efficacy but only paroxetine & sertraline licensed)
- Venlafaxine
- Z-drugs e.g. zopiclone may be used in short term for management of sleep disturbance
- Can be considered if little benefit from psychological therapy, patient does not wish to engange in psychological therapy, there is comorbid depresssion or hyperarousal that would not benefit from psychological therapy. Drugs used include:
- Social treatement:
- Support groups e.g. combat stress, rape crisis england & wales
What is acute stress disorder?
State some features
What is the management?
- Acute stress reaction that occurs in first 4/52 after a person been exposed to a traumatic event (in contrast to PTSD which is diagnosed after 4/52)
- Features (similar to PTSD):
- Intrusive thoughts e.g. flashbacks, nightmares
- intrusive thoughts e.g. flashbacks, nightmares
- dissociation e.g. ‘being in a daze’, time slowing
- negative mood
- avoidance
- arousal e.g. hypervigilance, sleep disturbance
- Management:
- First line: trauma focused CBT
Define OCD
OCD is characterised by recurrent obsessional thoughts and/or compulsive acts.
Define obsessions
Define compulsions
- Obsessions: unwanted, intrusive thoughts, images or urges that repeatedly enter individual’s mind. They are distressing for individual who tries to resist them and recognises them as egodystonic and a product of their own mind.
- Compulsions: repetitive, stereotyped behaviours or mental acts that a person feels driven into performing. They can be overt (observable by others) or covert (mental acts not observable)
Discuss epidemiology of OCD, include:
- Prevalence
- Age of onset
- Male to female ratio
- 1-3%
- Bimodal (10yrs & 21yrs)
- Equally common in males & females (in childhood males more commonly affected, in adulthood females more commonly affected)
Discuss the aetiology of OCD, include:
- Biological factors
- Behavioural factors
- Psychoanalytic factors
Biological
- Genetics
- Decreased serotonin
- Abnormalities of frontal cortex & basal ganglia
- PANDAS
Behavioural
- Compulsive behaviour is learnt & maintained by operant conditioning
Psychoanalytical
- Filling mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness
State some risk factors for OCD
- Adverse/stressful life event e.g. exams
- Bullying
- Social isolation
- Neglect
- Abuse (emotional, physical, sexual)
- Substance abuse
- Pregnancy (can arise during pregnancy & obsessions/compulsions related to worrying about baby)
Describe the OCD cycle
OCD is strongly associated with other psychiatric disorders; state some of these
- Depression
- Schizophrenia
- Body dysmorphic disorder
- Anorexia nervosa
- Tourette’s syndrome
- Sydenham’s chorea
State some examples of common obsessions & compulsions
Most common obsession is being contaminated
Most common compulsion is checking closely followed by washing/cleaning
Obsessions and/or compulsions must have all of the following features… (4)
*HINT: think FORD CAR
- Failure to resist
- Orginate in patients mind
- Repetitive & distressing
- Carrying out the obsessive thought (or compulsive act) is not in itself pleasurable
Example of how can ask questions in OCD history
Discuss ICD-10 criteria for OCD
A.Either obsessions or compulsions (or both) present on most days for at least 2 weeks
B.Obsessions or compulsions share a number of features (FORD CAR)- all of which must be present
C.Obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning
**Diagnosis can be specified as predominantly obsessional thoughts or ruminations, predominantly compulsive acts or mixed obsessional thoughts & acts
What questionnaire can you use to assess OCD severity?
Yale-Brown obsessive compulsive scale
- 10 questions
- Each question graded 0-4
- Example questions: time (including how much time compulsions take up), distress, interference in daily activities, resistance, control etc…
Discuss potential MSE of pt with OCD
State some differential diagnoses for OCD
NICE reccomends using a stepped approach to the management of OCD; discuss this in detail (including specific drugs etc..)
Psychological Treatment
- All psychological interventions are CBT with ERP (exposure & response prevention)
- Low= max 10 therapist hrs. Use self-help materials, over phone or group CBT
- High= individual
Biological
- First line= SSRIs (e.g. fluoxetine, sertraline, paroxetine)
- Alternative first line= clomipramine
- Second line= alternative SSRI or clomipramine
- Other options:
- Adding antipsychotic to SSRI or clomipramine
- Clomipramine + citalopram
*if biological treatments effective continue for at least 12 months
Social
- Support groups e.g. OCD UK
- Educating & supporting family
- Support with e.g. finances
Alongside biopsychosocial management of OCD, state some other aspects of management
- Suicide & self harm risk
- Psychoeducation
- Driving
- Treatment of comorbid conditions e.g. depression, substance misuse
- Safeguarding
Define/describe an acute stress response
Exposure to an excpetional physical or mental stressor (e.g. physical assault, RTA) followed by immediate onset of symptoms (within 1 hour). Possible symptoms include:
- Anxiety symptoms
- Nanrrowing of attention
- Apparent disorientation
- Anger or verbal agression
- Despair or hopelessness
- Uncontrollable or excessive grief
Symptoms must begin to diminish within 8hrs (tranisent stressors) or 48hrs (continued stressors)
Define abnormal bereavement
Remind yourself of the Kubler-Ross stages of grief
Abnormal bereavement: delayed onset, is more intense and prolonged (>6 months). Impact of loss overwhelms individuals coping capacity.
Define/describe adjustment disorder
When a person has difficulty coping with one or more significant and stressful events or life changes. The symptoms present within 3 month of stressor. Symptoms vary; they may have depressive, anxiety or behavioural symptoms. Symptoms present <6 months.
Discuss the epidemiology of adjustment disorder, include:
- Age of onset
- Male to female ratio
- Varies but tends to be at times of transition e.g. adolescence, mid or later life
- Males & females affected equally
State some clinical features of adjustment disorder
- Low mood
- Anxiety symptoms
- Socially withdrawn
- Behavioural changes
- Decline in performance (e.g. academic, work)
- Difficulty with ADLs
- Physical symptoms: e.g. insomnia, headaches, abdo pain, chest pain, tiredness
Discuss ICD-10 criteria for adjustment disorder
Diagnosis depends on a careful evaluation of the relationship between:
(a) form, content, and severity of symptoms
(b) previous history and personality
(c) stressful event, situation, or life crisis
* *If stressor is minor or temporal sequence cannot be found (symptoms <3 months after stressor) then look for alternative*
Discuss management of adjustment disorder
- Psychological therapies
- Guided self-help centred around CBT
- CBT
- Counselling
- Interpersonal therapy
- Pharmacological
- Antidepressants
- Social
- Exercise
- Leisure activites
- Sleep
