Anxiety disorders Flashcards
What is neurosis
Group of psychiatric disorders
Characterised by distress
Non-organic
Discrete onset
No hallucinations or delusions
What is anxiety
Unpleasant emotional state
Subjective fear
Somatic symptoms
Problematic when excessive and inappropriate
What are the psychological features of anxiety
Anticipatory fear of impending doom
Worrying thoughts
Exaggerated startle response
Restlessness
Poor concentration and attention
Irritability
Depersonalisation
Derealisation
What are the non-psychological features of anxiety
CVS
- Palpitations, chest pain
Resp
- Hyperventilation, cough, chest tightness
GI
- Abdominal pain, loose stools, nausea and vomiting, dysphagia, dry mouth
Urinary
- Frequency, failure of erection, menstrual discomfort
Neuromuscular
- Tremor, myalgia, headaches, paraesthesia, tinnitus
Behaviours
- Avoidant
What is generalised (free-floating) anxiety
Present most of the time
Not associated with specific objects or situations
Excessive/inappropriate worries about normal life events
Long duration
What is episodic (paroxysmal) anxiety
Abrupt onset
Discrete episodes
Severe
Strong autonomic symptoms
Short-lived
What are the conditions related to anxiety
Medical
- Hyperthyroidism, hypoglycaemia, anaemia, phaeochromocytoma, Cushing’s, COPD, heart failure, malignancy
Substance-related
- Intoxication, withdrawal, medication side-effect
Psychiatric
- Eating disorders, somatoform disorders, depression, schizophrenia, OCD, PTSD, adjustment disorders, anxious avoidant personality disorder
What is generalised anxiety disorder
Ongoing, uncontrollable, widespread worry about many events
Thoughts recognised by patient as being excessive and inappropriate
Most days for >6 months
What is the epidemiology of generalised anxiety disorder
2-4%
F>M
What are the risk factors for generalised anxiety disorder
Predisposing
- Genetics, upbringing, personality type, demand for high achievement, divorce, live alone, single parent, low socioeconomic status
Precipitating
- Stressful life event
Perpetuating
- Controlling stressful event, marital status, living alone, certain ways of thinking
What are the clinical features of generalised anxiety disorder
Chest and abdomen
- Difficulty breathing, feeling of choking, chest pain, nausea, abdominal pain, loose stools
Brain
- Dizzy, feeling of dying, fear of losing control, derealisation, depersonalisation
General
- Hot flushes, cold chills, numbness/tingling, headaches
Tension
- Muscle aches, restlessness, feeling on edge, difficulty swallowing, lump in throat
Non-specific
- Startled, difficulty concentrating, persistent irritability, sleep disturbances
What is the ICD-10 criteria for generalised anxiety disorder
> 6 months of prominent tension, worry, and feelings of apprehension about everyday events/problems
At least 4 symptoms, at least 1 of autonomic arousal (palpitations, sweating, shaking/tremor, dry mouth)
What are the investigations for generalised anxiety disorder
Bloods
- FBC TFTs, glucose
ECG
- Tachycardia
Questionnaires
- GAD-2, GAD-7, Beck’s anxiety inventory, hospital anxiety and depression scale
What are the differential diagnoses for generalised anxiety disorder
Neurotic disorders
- Panic disorder, specific phobias, OCD, PTSD
Depression
Schizophrenia
Personality disorders
- Anxious, dependent
Excessive caffeine/alcohol
Withdrawal from drugs
Organic
- Anaemia, hyperthyroidism, phaeochromocytoma, hypoglycaemia
What is the biological management for generalised anxiety disorder
First line: SSRI (sertraline)
SNRI (venlafaxine, duloxetine)
Pregabalin (if SSRI/SNRI not affective)
Continue for 1 year
Do not give benzodiazepines (only short term during crisis)
What is the psychological management for generalised anxiety disorder
Psychoeducation
CBT
Applied relaxation techniques
What is the social management for generalised anxiety disorder
Self-help methods
Support groups
Encourage exercise
What is the NICE stepped care model for generalised anxiety disorder
Step 1
- Identification and assessment
- Psychoeducation and active monitoring
Step 2
- Low intensity psychological intervention
- Self-help, psychoeducation, group-based therapy
Step 3
- High intensity psychological intervention
- CBT or applied relaxation
- Drug treatment
Step 4
- Highly socialised input
- Drug and psychological therapy
- Consider involving crisis team
What is a phobia
Intense, irrational fear of an object/situation/person/place
Recognised as excessive and unreasonable (out of proportion to threat)
What is agoraphobia
Fear of public spaces
Fear where immediate escape would be difficult
25-30s
Strongly linked to panic disorder
What is social phobia
Social anxiety disorder
Fear of social situations
Due to fear of humiliation, criticism, or embarrassment
Late adolescence
What is a specific (isolated) phobia
Fear of a specific object or situation
Conditioning event in early life
What are the risk factors for phobic anxiety disorders
Aversive experience
Stress and negative life events
Other anxiety disorders
Mood disorders
Substance misuse
Family history
What are the clinical features of phobic anxiety disorders
Biological
- Tachycardia, vasovagal response
Psychological
- Anticipatory anxiety, inability to relax, urge to avoid, may have fear of dying
What is the ICD-10 criteria for agoraphobia
Consistent fear and avoidance of at least 2 of: crowds, public spaces, travelling alone, travelling away from home
2+ symptoms of anxiety in feared situations
Significant emotional distress
Symptoms restricted to feared situations
What is the ICD-10 criteria for social phobia
Marked fear of being the focus of attention, or embarrassment
2+ symptoms of anxiety and one of: blushing, fear of vomiting, urgency
Significant emotional distress
Symptoms restricted to feared situation
What is the ICD-10 criteria for specific phobia
Marked fear of specific object/situation
Symptoms of anxiety in feared situation
Significant emotional distress
Symptoms restricted to feared situation
What investigations are needed for phobic anxiety disorders
Social phobia inventory
Liebowitz social anxiety scale
What is the management for phobic anxiety disorders
Establish good rapport
Avoid anxiety-inducing substances (caffeine…)
Urine drug screen
Thorough risk assessment
Agoraphobia
- CBT, gradual exposure, SSRIs
Social phobias
- CBT, gradual exposure, SSRIs/SNRIs, psychodynamic psychotherapy
Specific phobias
- CBT, gradual exposure, benzodiazepines (short term use)
What is panic disorder
Recurrent, episodic, severe panic attacks
Unpredictable, not restricted to a particular situation
What are the causes for panic disorder
Biological
- Genetic, linked to serotonin/adrenaline, stimulation of sympathetic nervous system
Cognition
- Misinterpretation of somatic symptoms
Environment
- Life stressors
What is the epidemiology of panic disorder
1% prevalence
3 times more likely in females
Onset in late adolescence
What are the risk factors for panic disorder
Family history
Major life event
Recent trauma
Other mental disorders
White ethnicity
Asthma/cigarette smoking
Benzodiazepine withdrawal
What is the ICD-10 criteria for panic disorder
Recurrent panic attacks not associated with a specific situation
Often occur spontaneously
Peak in a few minutes
Last a few minutes
At least one symptom of autonomic arousal
What is the management for panic disorder
First line: SSRIs
- If no improvement in 12 weeks, give imipramine or clomipramine
Do not give benzodiazepines
CBT
Self-help methods
Support groups
Encourage exercise
What is the NICE stepped care approach for panic disorder
Step 1
- Recognition and diagnosis
Step 2
- Psychological therapies, medications, self-help methods
Step 3
- Alternative treatment (if initial one failed)
Step 4
- Refer to specialist
Step 5
- Care in specialist mental health setting
What is PTSD
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
What are the causes of PTSD
Exceptionally stressful life event
Genetic
Failure to process emotions
What is the epidemiology of PTSD
25-30% of those who have been through a traumatic event
F>M
More common in certain professions (medics, military…), refugees, asylum seekers
What are the risk factors for PTSD
Pre-trauma
- Previous abuse, history of mental illness, low socioeconomic background, childhood abuse
Peri-trauma
- Severity of trauma, perceived threat to life, adverse emotional reaction during/straight after event
Post-trauma
- Concurrent life stressors, lack of social support
What are the clinical features of PTDS
Develop within 6 months of event
Reliving situation
- Persistent, intrusive, involuntary thoughts
- Flashbacks, vivid memories, nightmares
Avoidance
- Avoid similar situations, inability to recall certain parts of event
Hyperarousal
- Irritability, outbursts, difficulty sleeping, hypervigilance, exaggerated startle response
Emotional numbing
- Negative thought about self, difficulty expressing emotions, detachment from others
What are the stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
What investigations are needed for PTSD
Questionnaires
Consider CT head
What is the management for PTSD
<3 months since trauma
- Watchful waiting (if mild trauma)
- Trauma-focussed CBT
- Short-term sleep medication (zopiclone)
- Thorough risk assessment
> 3 months since trauma
- Trauma-focussed CBT
- Eye movement desensitisation and reprocessing
- Drug treatment (paroxetine, mirtazapine, amitriptyline, phenelzine)
What is OCD
Recurrent obsessional thoughts and compulsive acts
Obsessions
- Unwanted intrusive thoughts, images, or urges
- Distressing to individual
- Not able to resist them
- Recognise them as absurd
Compulsions
- Repetitive, stereotyped behaviour or mental act that the person feels driven to perform
What are the causes of OCD
Biological
- Low serotonin, genetic, childhood group A strep infection
Behavioural
- Operant conditioning
Strongly linked with other psychiatric disorders
What are the epidemiology and risk factors for OCD
Mostly in early adulthood
M=F
Carrying out compulsions exacerbates obsessions
Neglect, abuse, bullying, social isolation
What is the ICD-10 criteria for OCD
Symptoms most days for 2 weeks
Cause distress or interfere with functioning
What are the clinical features of OCD
Failure to resist
Originate from person’s mind
Repetitive or distressing
Carrying out compulsions is not pleasurable (but reduces anxiety)
OCD cycle (obsession, anxiety, compulsion, relief)
What is the management for OCD
CBT (cause anxiety, prevent them from carrying out action)
Medication (SSRIs)
Education, distraction techniques, self-help groups
Thorough risk assessment
Mild OCD
- Low intensity psychological intervention
Moderate OCD
- SSRIs or high intensity psychological intervention
Severe OCD
- Combined SSRIs and CBT
