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Y5 Psychiatry > Anxiety Disorders > Flashcards

Anxiety Disorders Flashcards

1
Q

What is the biological aetiology of stress reaction disorders?

A
  • Neurochemical
    • Dysregulated serotonin, NA, GABA
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2
Q

What is the psychosocial aetiology of stress reaction disorders?

A
  • Threatening Early experiences/Life events
  • Behavoiral/Cognitive theories
    • Conditioning (i.e. little Albert)
    • Negative reinforcement
    • Cognitive theory – worrying NATs repeated
    • Attachment theory – insecurity as child - anxiety
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3
Q

What are the signs of and symptoms of stress reaction disorders?

A
  • Psychological
    • Worries
    • Insomnia
    • Night terrors
  • Motor
    • Restlessness
  • Neuromuscular
    • Tremor
    • Tension headache
  • Gastrointestinal
    • Dry mouth
    • Nausea
    • Flatulence
  • Cardiovascular
    • Palpitations
  • Respiratory
    • Tight chest
    • Dyspnoea
  • Genitourinary
    • Urinary frequency
    • Erectile dysfunction
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4
Q

What investigations are appropriate for suspected stress reaction disorders?

A

SEDATED - History and Physical Examinations

  • Symptoms of anxiety
  • Episodic or continuous
    • Continuous = GAD
    • Episodic = phobia, OCD, PTSD
  • Drink and drugs
  • Avoidance and escape
  • Timing and triggers
  • Effect on life
  • Depression
  • Collateral history
  • Rating Scales - Beck anxiety inventory, HADS
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5
Q

Name 4 stress reaction disorders?

A
  • Generalised anxiety disorder
  • Phobia
  • Panic disorder
  • Obsessive compulsive disorder (OCD)
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6
Q

Define Generalised Anxiety Disorder?

A

At least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk, and causes distress, or impairment in the absence of mental disorder, substance abuse, other condition

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7
Q

What are the symptoms of Generalised Anxiety Disorder?

A
  • Must have 3+ most of the time for a diagnosis
    • Restlessness/nervousness
    • Being easily fatigued
    • Poor concentration
    • Irritability
    • Muscle tension
    • Sleep disturbance
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8
Q

What are the risk factors for Generalised Anxiety Disorder?

A
  • Divorced
  • Lone parent
  • Living Alone
  • 35-54 years old
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9
Q

What are the protective factors for Generalised Anxiety Disorder?

A
  • Married
  • Co-habiting
  • 16-24 years old
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10
Q

What are the signs and symptoms of Generalised Anxiety Disorder?

A
  • Autonomic
    • Palpitations, sweating, trembling, dry mouth, tachypnoea
  • Chest/Abdomen
    • Difficulty breathing, choking sensation, chest pain, nausea
  • Brain/Mind
    • Dizziness, light headedness, derealisation/depersonalisation, fear of losing control, fear of dying/illness
  • Tension
    • Muscle tension/aches/pains, restlessness, lump in throat
  • General
    • Hot/cold flush/chill, numbness/tingling sensation
  • Other
    • Exaggerated startle response, difficulty concentrating, persistent irritability, difficulty sleeping
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11
Q

What are the appropriate investigations for suspected Generalised Anxiety Disorder?

A
  • GAD-7 questionnaire
    • 5 = mild, 10 = moderate, 15 = severe GAD
  • Beck’s Anxiety Inventory
  • Hospital Anxiety and Depressions Scale (HADS)
  • Urine drug screen, ECG (phaemo, arrythmia), TFTs
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12
Q

What is the management of Generalised Anxiety Disorder?

A
  • Step 1: Written information on GAD + Active monitoring + Regular exercise
  • Step 2: Low-intensity psychological interventions
    • (1) Self-help (individual, non-guided)
    • (2) Self-help (individual, guided)
    • (3) Psychoeducational groups
  • Step 3: High-intensity psychological interventions OR Medications stepwise approach
    • High-intensity psychological interventions
      • CBT
      • Applied relaxation
    • Medications stepwise
      • STEP 1: SSRI
      • STEP 2: Different SSRI after 8 weeks
      • STEP 3: SNRI (venlafaxine)
      • STEP 4: Pregabalin
      • STEP 5: Quetiapine (atypical antipsychotic) - unlicensed
        • Adjunct: propranolol for physical symptoms
        • Never give BDZ to people with anxiety
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13
Q

What is the severity of a phobia related to?

A
  • Level of disability
    • Pilot fearing flying is a severe disability
  • Social phobia and agoraphobia have the biggest impact on life
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14
Q

Name 3 types of phobia?

A
  • Agoraphobia
  • Specific
  • Social
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15
Q

Define agoraphobia.

A
  • A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes
    • Literally means ‘fear of the marketplace’
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16
Q

What are the signs and symptoms of agoraphobia?

A
  • Uniting fear
    • Inability to escape to safe place causes an overwhelming urge to return home to safety
  • Panic attacks
    • Particularly if associated with panic disorder
  • Avoidance of phobic situations ± isolation behaviour
  • Associated features: depressive/obsessional symptoms, social phobias
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17
Q

What is the management of agoraphobia?

A
  • Education, reassurance and self-help
  • Exposure Response Prevention (ERP)
    • Therapy = ‘Desensitisation approach’
        1. Patientt identifies a goal and constructs hierarchy of feared situations
        1. Patient tackles hierarchy from least to most frightening
        1. Aim to stay in situation until anxiety subsided
  • CBT
    • ​Reduce patient’s expectation of threat, and the behaviours that maintain threat-related beliefs
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18
Q

What are the risk factors for agoraphobia?

A
  • 20-35 years old
  • Female
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19
Q

Define social phobia.

A

Fear of scrutiny by other people leading to avoidance of social situations

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20
Q

What are the risk factors for social phobia? What is associated with social phobia?

A
  • No really risk factors - ONLY anxiety disorder to affect genders equally (others are more common in females)
  • Associated with:
    • Low self-esteem
    • Fear of critism in general
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21
Q

What are the signs and symptoms of social phobia?

A
  • Complaints of blushing, hand tremor, nausea or urinary urgency in social situations
  • Self-medicate with alcohol or drugs in order to desensitise
  • Panic attacks
  • Some will tolerate anonymous crowds, unlike agoraphobics, but smaller groups may spike anxiety
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22
Q

What is the management of social phobia?

A
  • Education, reassurance and self-help
  • Exposure Response Prevention
  • CBT
  • SSRIs
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23
Q

Define Specific Phobia.

A

Phobias restricted to highly specific situations such as proximity to slugs or snails

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24
Q

What are the signs and symptoms of specific phobia?

A
  • Isolating oneself away from the stimulus
    • Barricading bedroom/Screaming at housemates
  • May have a FHx of phobia
    • Indicates a negative reinforcement as a child or classical conditioning
  • Tachycardia
    • Blood or injury phobia causes an initial tachycardia followed by vasovagal bradycardia and hypotension - can cause nausea and fainting
25
Q

What is the management of specific phobia?

A
  • Education, reassurance and self-help
  • Avoidance if possible
  • Exposure Response Prevention (ERP)
  • Relaxation therapy and breathing techniques
  • Short-term BDZ for certain specific phobias (i.e. dental injections)
    • Never long-term
26
Q

Define Panic disorder.

A

Recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable

27
Q

What are the signs and symptoms of panic disorder?

A
  • Classical Anxiety
    • Palpitations
    • Chest tightness/Choking sensation
    • Pins and needles
    • Depoersonalisation
    • Shaking
    • Dizziness/faints
    • Sweating
  • Several episodes within a month
    • In between episodes, relatively fine with minimal anxiety
  • Sudden onset with no warning signs
  • Episodes typically last ≤30 minutes
  • Alarming thoughts provoke further panic until reassurance or engagement in ‘safety behaviour’ occurs
    • i.e. Think they are going to die - call ambulance, take aspirin
28
Q

What is the management of panic disorder?

A
  • Education, reassurance and self-help
  • Step 1 = Low-intensity psychological intervention
    • Self-help - guided or unguided
  • Step 2: High-intensity psychological intervention ± medications
    • 1st line = CBT ± SSRI (Citalopram)
    • 2nd line = Change SSRI to TCA or add BDZ (not exceeding 2-4 weeks)
    • Psychodynamic psychotherapy
  • Step 3 = Psychiatry/Tertiary referral
29
Q

What is the prognosis of panic disorder?

A
  • 65% achieve complete remission
  • 10-20% continue to have significant symptoms
30
Q

Define OCD.

A

Recurrent obsessional thoughts and/or compulsive acts that are present on most days for ≥2 consecutive weeks, a source of stress and interfere with ADLs

31
Q

Define obsessions.

A
  • Involuntary thoughts, images or impulses which are:
    • Self-recognised as a product of own mind (≥1 thought or act resisted unsuccessfully for diagnosis)
    • Thoughts of carrying out the act are not pleasurable
    • Thoughts must be unpleasantly repetitive
    • Themed commonly
      • Contamination, aggression (to self or others), infection, sex, religion
    • Egodystonic - themes/ideas against that which the person associates with their ego
32
Q

Define compulsions.

A
  • Repetitive mental operations or physical acts
    • Compelled to perform in response to own obsessions or irrationally defined rules
    • Performed to reduce anxiety through irrational belief they will prevent a dreaded event
33
Q

What are the differential diagnoses for OCD?

A
  • Obsessions and compulsions
    • Body dysmorphic disorder - appearance preoccupation
    • Anankastic personality disorder - lifelong personality (rigid, orderliness, hygienic)
  • Mainly obsessions
    • Depressive disorder - Beck’s -ve triad, 50% OCD co-morbid
    • Other anxiety disorders
    • Hypochondriacal disorders
    • Schizophrenia (if also delusional)
  • Mainly compulsions:
    • Habit and impulse control disorders
34
Q

In what situation can panic disorder not be the main diagnosis?

A

If a depressive disorders exists at the time attacks start

35
Q

If a patient has OCD and depression simultaneously, which one should be prioritised?

A
  • Prioritise what developed first
    • If the order is unknown = depression is the priority
36
Q

What are the risk factors for OCD?

A
  • Male
  • <25 years old
  • Genetics/Relatives = 3x the risk
  • Neurological
    • Basal ganglia inplicated/affected by
      • Sydenham’s chorea
      • Encephalilits lethargica
      • Tourette’s
  • Infection - Streptococcal throat/Strep A = anti-BG Abs
  • Psychosocial = 25% have a premorbid anankastic personality
    • Rigid and orderliness
37
Q

What are the signs and symptoms of OCD?

A
  • Obsessional thoughts
  • Compulsions/Rituals that are repeated
    • Tension/discomfort often neutralised by compulsion (these are not inherently enjoyable)
  • Anxiety (which gets worse the longer they ignore the compulsion)
38
Q

What are the appropriate investigations for suspected OCD?

A
  • Bloods: FBC, TSH
  • Rating scale (Yale-Brown OCD scale)
  • OCD screening questions
    • Do you wash or clean a lot?
    • Do you check the time a lot?
    • Is there any thought that keeps bothering you that you would like to get rid of?
    • Do your daily activities take a long time to finish?
    • Are you concerned about putting things in a special order or are you very upset by a mess?
    • Do these problems trouble you?
39
Q

What questions might you ask in an OCD screen?

A
  • Do you wash or clean a lot?
  • Do you check the time a lot?
  • Is there any thought that keeps bothering you that you would like to get rid of?
  • Do your daily activities take a long time to finish?
  • Are you concerned about putting things in a special order or are you very upset by a mess?
  • Do these problems trouble you?
40
Q

What is the management of OCD?

A
  • Mild functional impairment: CBT with ERP (Exposure and Response Prevention)
    • CBT aims to prevent compulsive behaviour as a tool to reduce obsessions allowing the tolerated anxiety to be habituated and eventually, extinguished
  • Moderate functional impairment: Intensive CBT with ERP or SSRI:
    • Intensive CBT with ERP
    • SSRI (continue for 12m after remission) - Fluoxetine > Sertraline (licenced)
      • Depression = 20mg
      • Anxiety = 40mg
      • OCD, Bulimia Nervosa = 60mg or 80mg
  • Severe functional impairment: Referral
41
Q

What are the 4 phases of cognitive therapy for OCD?

A
42
Q

What is the epidemiology of Agoraphobia?

A
  • 20-35 years old
  • 4:1 F:M
  • 80% are married
    • Most of these are unemployed or homemakers
43
Q

Define Acute Stress Disorder.

A

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days

  • DSM-V says symptoms must last for ≥3 days
  • If they last >1 month consider PRSD
44
Q

What are the causes of Acute Stress Disorder?

A
  • Death
  • War
  • RTA
  • Physical/Sexual Assault
45
Q

What are the signs and symptoms of Acute Stress Reaction?

A
  • Key Features:
    • Initial state of daze (may manifest as stupor)
    • Constriction of consciousness field
    • Narrowing of attention
    • Inability to comprehend stimuli; disorientation
  • Other symptoms:
    • Autonomic signs of panic (fight or flight) – occur in minutes of stimulus and disappear in hours/days:
      • Tachycardia
      • Tachypnoea
      • Sweating
      • Hypertension
      • Hyperactive
      • Partial or complete amnesia may be present
    • Depersonalisation
    • Derealisation
46
Q

What is the management for suspected Acute Stress Reaction?

A
  • Support and reassurance
  • Benzodiazepines for short-term distress - does not prevent later PTSD
47
Q

What are the complications of Acute Stress Reaction?

A

PTSD - in the future/progression to

48
Q

Define Adjustment Disorder.

A

Maladaptation to subjective distress and emotional disturbance (leading to anxiety, depression without biological symptoms), usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event.

  • Beginning within 1 month of the stressful event
  • Not lasting longer than 6 months
49
Q

What are the signs and symptoms of Adjustment Disorder?

A
  • Depressed mood
  • Anxiety and worry
  • Feeling of inability to cope
  • Disability in the performance of daily routine
  • Consider an associated Conduct Disorder (if in adolescents)
50
Q

What is the management of Adjustment Disorder?

A
  • Psychological – Group therapy or Crisis counselling
  • Pharmacotherapy – short course of treatment of insomnia ect
51
Q

Define Abnormal/Prolonged Grief Reaction.

A

Delayed onset, greater intensity of symptoms or prolongation of the reaction, preoccupation with negative thoughts, suicidal ideations, hallucinatory experiences

  • Depressive features are focused around the person that was lost
52
Q

What increases the chance for Abnormal/Prolonged Grief Reaction?

A
  • If the relationship with the deceased was problematic
  • It was a sudden death
53
Q

What is the management of Abnormal/Prolonged Grief Reaction?

A
  • Biological - antidepressants
  • Psychosocial - supportive counselling
54
Q

Define PTSD.

A
  • Arises as a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone
    • Must last >1 month
    • Often begins within 6 months of the trauma - often within a month
55
Q

What is the aetiology of PTSD?

A
  • 10% who have experienced severe trauma
  • F>M with a lifetime prevalence of 6.8%
56
Q

What are the signs and symptoms of PTSD?

A
  • Re-experiencing intrusive memories - flashbacks, nightmares, repetitive images, physical sensations
  • Avoidance of triggers
  • Hyperarousal - hypervigilance, enhanced startle reflex, insomnia, irritability, cannot relax
  • Other:
    • Mental health problems – depression, anxiety, phobias
    • FHx of Mental Health Problems
    • Self-harming or destructive behaviour – drug or alcohol misuse
    • Physical symptoms – headaches, dizziness, chest pain, stomach aches
    • Anhedonia/Emotional numbing
    • Survivor guilt
    • Memory formation dysfunction
57
Q

What investigation should be carried out for suspected PTSD?

A

Trauma Screening Questionnaire

  • 10 questions
  • Measure re-experiencing
  • Arousal symptoms
58
Q

What is the management of PTSD?

A
  • Mild PTSD - symptoms <4 weeks
    • Watchful waiting + treat co-morbid conditions (i.e. depression)
  • Moderate to Severe
    • CBT with “Trauma-focus” – the best evidence base for PTSD
    • Eye Movement Desensitisation and Reprocessing (EMDR) – less of an evidence base but still useful…
      • Patient recalls experience in as much detail as possible in a state of relaxation, whilst their eyes are fixed on the therapist’s finger as it moves from side to side
      • Aids memory processing by overstimulating the brain causing emotional blurring
    • Pharmacological management (not routinely recommended):
      • 1st line: SSRIs (sertraline) or SNRI (venlafaxine)
      • 2nd line: Atypical antipsychotics
    • CBT “generic” (helps deal with other problems in PTSD, such as anxiety)
59
Q

Define Complex PTSD.

A
  • All criteria for PTSD in addition to:
    • Problems around affect regulation
    • Beliefs that oneself is worthless accompanied by feeling of shame/guilt surrounding the trauma
    • Difficulties sustaining relationships and feeling close to others

Y5 Psychiatry (11 decks)

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