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Anxiety disorders Flashcards

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1
Q

Neurotic, stress related and somatoform disorders of anxiety

A 
Generalised anxiety disorder (GAD)
Specific phobias
Panic disorder
Obsessive compulsive disorder (OCD) (no longer technically an anxiety disorder)
PTSD
Adjustment disorders
Dissociative disorders
Somatoform disorders (somatisation disorders)
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2
Q

Aetiology of anxiety (general)

A
  • Genetics - no spec genes, but relatives at higher risk, maybe associated with heritability of personality trait, neuroticism
  • Neuroticism - ppl with high neuroticism scores are more likely to experiences anxiety, guilt, depression and anger and feel easily overwhelmed by minor frustrations
  • Early experiences and life events
  • Neurochemical theories - central neurotransmitters serotonin, NA and GABA may be dysregulated in anxiety disorders; act as target of successful drugs (serotonin:SSRIs; NA:TCAs; GABA:benzos)
  • Behavioural and cognitive theories - classical conditioning: neutral stimulus with frightening result; negative reinforcement: repetition of behaviours that relieve anxiety are repeated –> stay fearful; cognitive: automatic repeating of worrying thoughts -> indiction+maintenance of anxiety; attachment theory: quality of child/parent attachment affects confidence as adults
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3
Q

Symptoms of anxiety

A

Psychological - fear/worry, poor concentration, irritability, feelings of unreality (depersonalisation, derealisation), insomnia, nigh terrors

Motor Sx - restlessness, fidgeting, feeling on edge, unable to relax

Neuromuscular - tremor/trembling, tension headache, muscle aches (esp neck and back), dizzy/light-headed/unsteady, tinnitus

GI - dry mouth, difficulty swallowing/lump in throat, nausea, indigestion/stomach pains, abdominal churning/butterflies, flatulence, frequent or loose motions

CV - chest discomfort, palpitations

Resp - difficulty inhaling, tight/constricted chest

Genitourinary - urinary frequency, erectile dysfunction, amenorrhoea

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4
Q

Generalised anxiety disorder: definitions

A

At least 4 of the following present most days for at least 6 months:

  • Autonomic arousal
  • Physical Sx
  • Mental state
  • General hot/cold, numbness/tingling
  • Sx of tension
  • Exaggerated response to being startles
  • Concentration difficulties

Not triggered by a specific stimulus; is continuous/persistent and generalised; not restricted to or strongly predominating in any particular environment/circumstance

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5
Q

Generalised anxiety disorder: Risk factors

A 
Female
FHx
Physical or emotional stress
Hx physical/emotional trauma
Chronic pain or physical illness
Hx substance abuse
Repeated visit with physical Sx that don't response to Tx
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6
Q

Generalised anxiety disorder: dominant symptoms

A 
Persistent nervousness
Trembling
Muscular tensions
Sweating
Lightheadedness
Palpitations
Dizziness
Epigastric discomfort
Often, fears that they/relative will shortly become ill or have an accident

Severe cases can have panic attacks

Sx present for at least 6 months (intensity may fluctuate)
May present with only physical Sx such as headaches, muscle tension, GI symptoms, back pain, insomnia

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7
Q

Differentials for generalised anxiety disorder

A

Organic causes:

  • Hyperthyroidism - continuous
  • Excess caffeine - continuous/episodic
  • Drug induced - beta blockers, salbutamol, theophylline, St Johns Wort, corticosteroids
  • Substance misuse - intoxication e.g. amphetamines, withdrawal e.g. benzos, EtOH
  • Arrhythmia - episodic
  • Hypoglycaemia - episodic
  • Phaeochromocytoma - episodic

Adjustment disorder

Depression - anxiety may be a feature; can Dx both; can be mixed anxiety and depression is there are low-levels of both Sx equally

Anxious (avoidant) personality disorder

Dementia

Schizophrenia - anxiety may occur in early SCZ, preceding delusions/hallucinations. Delusional mood may seem like anxiety

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8
Q

Generalised anxiety disorder: investigations

A

Assess severity using GAD-7 questionnaire

  • Mild: 5-9
  • Moderate: 10-14
  • Severe: >15

Ask about OTC meds that can cause anxiety: salbutamol, theophylline, b-blockers, steroids, St Johns Wort; and alcohol/substance use

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9
Q

NICE management GAD

A

Assess severity
Treat comorbid disorders

Step 1:

  • Identification: and communicate Dx asap
  • Assessment: number/severity/duration Sx; degree of distress/impairment; consider comorbid issues/Hx
  • Education about GAD
  • Active monitoring

Step 2: diagnosed GAD not improved after active monitoring + education

  • Low intensity psychological interventions: individual non-facilitated/guided self-help, psychoeducational groups
  • Based on principles of CBT

Step 3: GAD with marked functional impairment or unimproved after step 2

  • Individual high-intensity psychological intervention OR drug treatment
  • High-intensity psych interventions: CBT, applied relaxation; 12-15 weekly sessions
  • Drug Tx: 1st line Sertraline; if ineffective 2nd line: other SSRI or SNRI; 3rd line if SSRI/SNRI not tolerable: pregabalin
  • Risks of SSRIs - bleeding, suicidality, withdrawal syndrome, overdose risk
  • Monitor - within 1st week, every2-4 weeks for 3 months, every 3 months
  • Benzos not offered except as short term measure during crises
  • If not responded to drug Tx- high intens psych intervention,; if partial response- ad psych intervention

Step 4: Complex, Tx-refractory GAD and very marked functional impairment or high risk of self harm

  • specialist assessment
  • Tx by specialist: combo psycho and drug Tx
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10
Q

Phobic anxiety disorders definitions and characteristics

A

Group of disorders: anxiety evoked only/predominantly in certain well defined situations that are not dangerous; situations are characteristically avoided or endured with dread

Pt concern focuses on individual Sx like palpitations or feeling faint and is often associated with secondary fears of dying, losing control or going mad

Contemplating entry to the phobic situation usually generates anticipatory anxiety

Phobic anxiety and depression often coexist

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11
Q

Agoraphobia features

A

Cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains/buses/planes; Key feature: being unable to easily escape to safe place (usually home)

Includes fear of open places AND fear of situations that are confined and difficult to leave without attracting attention

Common problem situations: travelling on train/plane/bus; queueing; supermarkets; large crowds; parks; sitting in middle row of cinema

Overwhelming urge to return home safely
Panic disorder is a frequent feature in present/past eps

Onset common in 20s/mid 30s; may be gradual or precipitated by a sudden panic attack
Worst-affected may become house dependent or dependent on those close to them

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12
Q

Differentials for agoraphobia

A

Depression: can cause social withdrawal
Social phobia
OCD: time consuming rituals can confine people to home
Schizophrenia: social withdrawal; persecutory delusions

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13
Q

Social phobia features

A

Fear of scrutiny by other people leading to avoidance of social situations
Can be associated with low self-esteem and fear of criticism
May complain of blushing, hand tremor, nausea, urinary urgency - pt can be convinced the 2ndary Sx is the primary problem
Tolerate and anonymous crown but small groups e.g. dinner parties/meeting, can be very intimidating
May have specific worries e.g. eating in public
May progress to panic attacks
Onset in late teens

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14
Q

Differentials for social phobia

A

Shyness: naturally shy, but no overt fear
Agoraphobia
Anxious (avoidant) personality disorder: lifelong Hx of shyness and anxiety
Poor social skills/autistic spectrum disorders
Benign essential tremor: familial tremor that is worse in social situations and responds to benzos and EtOH
Schizophrenia/psychosis

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15
Q

Specific (isolated) phoibias

A

Phobias restricted to highly specific situations (animals, heights, thunder, dark, flying, closed spaces, public toilets, certain foods, sight of blood)
Often develop in childhood but can be later (after a frightening experience)
If blood/injury/needle phobia, can be strong vasovagal reaction; lay pts flat before taking blood

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16
Q

NICE diagnosis of Social anxiety disorder

A

3 item Mini-social phobia inventory (mini-SPIN)
OR ask 2 qs: do you find yourself avoiding social situations or activities? Are you fearful or embarrassed in social situations?

If scores 6+ on mini-SPIN or answers yes x2 -> refer for comprehensive assessment

More comprehensive tools include SPIN and LSAS

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17
Q

NICE treatment of social anxiety disorder

A

1st line: Individual CBT

  • specific to social anxiety disorder, based on Clark and Wells model or Heimberg model
  • Up to 14 sessions, 90 mins
  • Not group CBT
  • If CBT declined; offer CBT based supported self help

2nd line: pharmacological treatment

    1. SSRI: escitalopram or sertraline
    1. Fluvoxamine/paroxetine/SNRI
    1. MAOi e.g. phenelzine
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18
Q

Panic disorder features

A

AKA episodic paroxysmal anxiety
Essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation/set of circumstances and are unpredictable

Intermittent anxiety; comes out of the blue
Sudden onset of palpitations, chest pain, choking sensations, dizziness and feelings of unreality (depersonalisation or derealisation)

Breathing difficulties
Tingling (pins and needkes) or numbness in hands, feets or around mouth
Shaking
Dizziness/faints
Sweating

Often secondary fear of becoming incontinent, dying, losing control or going mad
Alarming thoughts provoke further panic -> pt engages in safety behaviours (actions to avery catastrophe)

Panic attacks are self limiting; last no more than 30 mins

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19
Q

Differentials of panic disorder

A

Other anxiety disorder: GAD/agoraphobia
Depression: depression dx takes precedence if Sx precede
Alcohol and drug withdrawal
Organic causes: CV and resp disease; phaeochromocytoma

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20
Q

Investigations for panic disorder

A

Hx - rule out preceding depressive Sx; confirm recurrent panic attacks and anxiety free in between eps
Assessment tools: HADS;GAD-7
If acute pres in A&E - minimum Ix to exclude acute physical problems; refer to primary care, offer educational info/local groups

21
Q

NICE guidelines panic disorder

A

Step 1: recognition and Dx

Step 2: mild-moderate

  • Individual non-facilitated/facilitated self-help
  • Offer support groups (F2F/telephone conference)
  • Discuss benefits of exercise

Step 3: moderate-severe

  • CBT or anti-depressant (if long standing/not benefitted from psych intervention)
  • CBT- 1-2hrs/week; 7-14 hrs total
  • Medication - 1st line SSRI (review in 2/4/6/12 wks to decide if effective/continue); 2nd line imipramine or clomipramine (if SSRI not suitable or no improvement after 12 wks)

Step 4: If two interventions (psych/meds/bibliotherapy), but still significant Sx
- Refer to specialist MH service

Step 5: holistic assessment and shared care plan made
- prev Tx, substance use, comorbids, functioning, social networks, chronic stressors

22
Q

Investigations for anxiety disorders

A

Good Hx/exam, focus on ruling out organic causes; collateral Hx

Rating scales of anxiety - to assess severity or provide baseline scores

  • Beck Anxiety Inventory
  • Hospital Anxiety and Depression Scale (HADS)

Social and occupational assessments for effects on QoL

Ruling out organic causes:
TFTs
LFTs/MCV (alcohol)
Urine drug screen
ECG/24 hr ECG (arrhthymias)
Glucose
24 hr urine for VMA (phaeochromocytoma)
23
Q

Pharmacological options in anxiety disorders

A 
SSRIs
TCAs
Buspirone
Benzos
B-blockers
24
Q

OCD defining features

A

Essential feature: recurrent obsessional thoughts or compulsive acts

Obsessional thoughts: ideas, images or impulses that enter pts mind again and again in a stereotyped form; distressing; pt unsuccessfully tries to resist
- Recognised as own thoughts even though are involuntary/repugnant

Compulsive acts/rituals: stereotyped behaviours that are repeated again and again; not inherently enjoyable/resulting in completion of useful tasks; function to prevent unlikely event (harm to or by pt)

  • Recognised as pointless/ineffectual; repeated attempts to resist
  • Anxiety present; worsens if compulsive acts are resisted
25
Q

OCD subclassifications

A

Predominantly obsessional thoughts or ruminations

Predominantly compulsive acts (obsessional rituals)

Mixed obsessional thought and acts

Other OCD

OCD, unspecified

26
Q

OCD aetiology

A

Relatives x3 increased risk
1/4th pts have premorbid anakastic personality traits (rigidity, orderliness)
Stress may trigger OCD
Basal ganglia implicated: affected by illnesses that are RFs for OCD (Sydenham’s chorea, encephalitis lethargica, Tourette’s) (Anti-basal ganglial Abs have been shown in those who develop OCD following strep throat; step also causes Syndenhams)
Neuroimaging: associates OCD with deficit in frontal lobe inhibition

27
Q

Clinical features of OCD

A

Obsessions: thoughts are unpleasant but pt recognises them as irrational and their own (unlike delusions/thought insertion)
Themes usually: contamination, aggression (harm to self or others), ifection, morality (sex, religion)

Pt feels acutely uncomfortable or anxious

Compulsion common examples: cleaning, counting, checking and ordering objects

Can severely affect QoL

Resistance to obsessions/compulsions may decrease/disappear in chronic cases

28
Q

Differentials of OCD

A

Anxiety disorders: less obsessional Sx, more anxiety Sx
Depression: 50% OCD pt experience have depress S; depress takes priority if meets criteria
Illness anxiety disorder (hypochondriasis)
Body dismorphic disorder
Anankastic personality disorder: lifelong personality of rigidity, with high standards or orderliness, hygiene etc; pattern of obsessions and compulsions is absent unless OCD is superimposed
Schizophrenia: beliefs are delusional, not obsessional
Organic causes: rare e.g. Sydenham’s chorea

29
Q

Investigations for OCD

A

In Hx: pts describing obsessions may say ‘i know its silly but’, delusional pts don’t describe like this
May present with physical Sx: dermatological, genital or anal, general stress or doubts about contracting HIV
Assess for comorbidities

NICE:

  • Screening questions: e.g. do you wash/clean a lot etc
  • Determine if mild/moderate/severe: depends on degree of distress and functional impairment
  • Yale-Brown Obsessive-Compulsive Scale (Y-BCOS) - how much day fort thoughts/acts, intereference with social/work/school/relationships, distress, anxiousness, effort to resist, control over thoughts, drive of compulsions
30
Q

Management of OCD - overview

A

Education and self help
CBT/ERP: exposure and response prevention; aims to prevent compulsive behaviours and work through anxiety
SSRIs: effective in OCD; Clomipramine (TCA) also effective

Prognosis: chronic course, with Sx worsening in stress times; often disabling; comorbid depression is common

31
Q

NICE guidelines OCD

A

Primary care: provide informative leaflets

Mild functional impairment:

  • Low-intensity psych intervention via IAPT
  • Low intensity CBT (including exposure and responsive prevention) + individual/group CBT

Moderate functional impairment (or above ineffective):

  • Intensive CBT including ERP OR
  • SSRI: escitalopram, fluoxetine, fluvoxamine, paroxetine or sertraline; needs higher/longer dose than depression; also needs monitoring
  • Consider clomipramine as alternative or if prev effective

Severe functional impairment

  • Refer to secondary care mental health team for assessment
  • Consider combined SSRI + CBT with ERP OR Clomipramine while awaiting assessment

Children/young ppl:

  • Mild impairment - guided self help + support adn info to family,; consider referral to CAMHS is ineffective
  • Moderate-severe functional impairment -> refer to CAMHS
  • SSRI can be prescribed by a specialist (not primary care)
32
Q

Acute Stress Reaction definition

A

Transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress that usually subsides within hrs or days
- Individual vulnerability and coping capacity affect occurrence and severity

33
Q

Acute stress reaction clinical features

A

-SX Start within minutes of event and disappear within 2-3days maximum (often hours)

  • Sx typically mixed and changing picture
  • Initial state of daze with some constriction of consciousness/attention
  • May be followed by further withdrawal from surrounding situation OR by agitation and over activity (flight reaction or fugue)
  • Autonomic signs of panic (tachycardia, sweating, flushing)

Often disoriented and agitated, sometimes irritable, panicky or aggressive
After event, may experience amnesia, depersonalisation and derealisation

34
Q

Acute stress reaction clinical features

A

-SX Start within minutes of event and disappear within 2-3days maximum (often hours)

  • Sx typically mixed and changing picture
  • Initial state of daze with some constriction of consciousness/attention
  • May be followed by further withdrawal from surrounding situation OR by agitation and over activity (flight reaction or fugue)
  • Autonomic signs of panic (tachycardia, sweating, flushing)

Often disoriented and agitated, sometimes irritable, panicky or aggressive
After event, may experience amnesia, depersonalisation and derealisation

35
Q

Management of acute stress reaction

A
  • Exclude injury
  • Support and reassurance usually all thats required
  • Benzos can alleviate short term distress, but don’t prevent later PTSD
  • Formal, immediate, psych debriefing, like describing the trauma/emotional response may increase chance of PTSD
36
Q

Post-Traumatic Stress Disorder - definition, predisposing factors, onset

A

Arises as delayed response to a stressful event/situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in anyone

Predisposing factors: personality traits (compulsive, asthenic), prev Hx neurotic illness

Sx last >1 month; onset within 6 months of event; usually delayed onset/latency period

37
Q

Post-Traumatic Stress Disorder - definition, predisposing factors, onset

A

Arises as delayed response to a stressful event/situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in anyone

Predisposing factors: personality traits (compulsive, asthenic), prev Hx neurotic illness

Sx last >1 month; onset within 6 months of event; usually delayed onset/latency period; most recover, chronicity can lead to personality change

38
Q

Aetiology of PTSD

A

Multifactoral:

  • Form of trauma: degree of exposure, proximity and human design
  • Why some people develop, others don’t:
    Heritability
    Impaired sensitivity of HPA axis
    Reduced hippocampal volume (memory storage)
    Hyperactive amygdala (emotional processing)
- RFs:
Personality: neurotic traits
Personal/F pysch Hx
Childhood abuse
Poor early attachment
  • Survivors guilt and continual exposure to the trauma/other stressors can worsen
39
Q

Clinical features

A
  • Eps of reliving the trauma in intrusive memories (flashbacks), dreams or nightmares
  • Persisting background of sense of numbness and emotional blunting, detachment from other people, unresponsiveness to surrounding, anhedonia and avoidance of activities that remind of trauma
  • State of autonomic hyper-araousal with hyper-vigilance, enhanced startle reaction and insomnia
  • Fluctuating
  • Most recover, some follow chronic course with eventual transition to enduring personality change

Four key features:

  • Re-experiencing - vivid flashbacks, recurring memories, reccurring dreams
  • Hyperarousal - insomnia, irritability/outbursts of anger, difficulty concentrating, exaggerated startle response, hypervigilance
  • Avoidance - efforts to avoid thoughts/feeling/activities/places/people associated with trauma; feeling detached; reduced interest in activities
  • Negative alterations in cognitions and mood: neg emotions of self/others/world; persistent neg emotional states; diminished interest in significant activities; inability to experience positive emotions
40
Q

Differentials of PTSD

A

Depression
Anxiety disorder
Adjustment disorder

41
Q

Investigations for PTSD

A

Hx and RISK ASSESS

Assess for comorbids: Alcohol abuse/dependence, drug misuse, MDD, physical health problems more prevalent than genpop

42
Q

Management of PTSD

A

Watchful waiting with social support (in mild/moderate) in first 4/52; follow up in 1 month

Trauma focused CBT

  • Offered to all pt with >1month Sx
  • Examine and test shattering of prev beliefs
  • Cognitive processing therpay; narrative exposure therapy; prolonged exposure therapy
  • Can retraumatise the pt

Eye movement desensitisation and reprocessing (EMDR)

43
Q

Management of PTSD

A

Watchful waiting with social support (in mild/moderate) in first 4/52; follow up in 1 month

Trauma focused CBT

  • Offered to all pt with >1month Sx
  • Examine and test shattering of prev beliefs
  • Cognitive processing therpay; narrative exposure therapy; prolonged exposure therapy
  • Can retraumatise the pt

Eye movement desensitisation and reprocessing (EMDR)

  • PTSD/clin Sx adults presenting >3months after non-combat related trauma
  • Original trauma re-experienced via details, while fixing eyes on therapists finger as quickly passes side to side
  • Can be any left-ride movement instead of eyes (finger tapping)
  • Aids memory processing

Pharmacological Tx

  • Consider SSRI (paroxetine and sertraline) or venlafaxine for adults
  • Consider antipsychotics (risperidone) in addition to psych therapies if they have failed to respond to other drug Tx or have disabling Sx (e.g. hyperarousal)
44
Q

NICE guidelines

A

Active monitoring of ppl with subthreshold Sx within 1 month of trauma

Do NOT offer psychologically focuses debriefing for prevention/Tx of PTSD

Offer individual trauma-focussed CBT to adults exposed to 1+ trauma within last month

  • Cognitive processign therapy
  • Cognitive therapy for PTSD
  • Narrative exposure therapy
  • Prolonged exposure therapy

Consider EMDR for non-combat related trauma presenting 1-3 months; offer EMDR for non-combat >3 months

Consider supported trauma focussed computerised CBT at altrantive

Drugs considered if pt preference:
1st line: verlafaxine or SSRIU e.g. sertraline
2nd line: consider antipsychotic eg risperidone with psych Tx if disabling Sx/behaviour or not responded to anything else

If PTSD +depression - Tx PTSD first

45
Q

NICE guidelines PTSD: children

A

Children and young people:
Prevention - active monitoring/individual/group trauma CBT within 1 month
Treatment - consider trauma CBT ages5-6 presenting >1 month; consider trauma CBT ages7-17 presenting 1-3 months; offer trauma CBT age 7-17 presenting >3 months

46
Q

Adjustment disorder

A

Difficulty coping with a stressful life event or situation

State of subjective distress and emotional disturbance, usually interfering with social functioning and performance arising in period of adaptation to a significant life change or a stressful life event

Stressor examples:

  • Social network change - bereavement, separation
  • Wider social support/values - migration, refuge
  • Developmental transition - going to school/university, becoming a parent, retirement
47
Q

Diagnosis of adjustment disorder

A

Development of emotional or behavioural Sx in response to identifiable stressor occurring within 3 months; marked distress that is in excess of what would be expected

Impairment of social or academic function

Stress related disorder does not meet criteria for another mental disorder

Once stressor or consequences has terminated, the Sx do not persist for more than 6 additional months

48
Q

Clinical features of adjustment disorder

A

Depressed mood, anxiety or worry
Feeling of inability to cope, plan ahead or continue in present situation
Some degree of disability in performing of daily routine
Persons reaction is deemed greater than usually expected for the situation but not severe enough to diagnose anxiety or depression
Sx start within month of stressor and resolve within 6 months

49
Q

Management of adjustment disorder

A

Support, reassurance and problem-solving

Y5 Psych (11 decks)

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