Anxiety Disorders Flashcards
What are the symptoms of neurosis?
Neurosis is collective term for psychiatric disorders characterised by distress which is non organic and have a discrete onset. Hallucinations and delusions are not present. Depressive symptoms are also common.
Psychological-
Fear of impending doom, out of proportion, patient will start exhibiting avoidance behaviour.
Cardiovascular-
Increased HR, palpitations, chest pain.
Respiratory-
Hyperventilation, cough, chest tightness
GI-
Loose stools, butterflies, N+V, dry mouth, dysphagia
Genitourinary-
Increased frequency of micturition, failure of erection, menstrual discomfort
Neuromuscular-
Tremor, myalgia, headache, paraesthesia, tinnitus.
How are anxiety disorders classified?
Continuous- GAD (XS worry about normal life events, longe duration (days up to years)
Or
Paroxysmal- can be situation dependent or situation independent. Abrupt and discrete onset, lasting typically less than 1hr.
Situation dependent is a phobic anxiety disorder which can be specific phobia, agoraphobia or social phobia.
Situation independent is a panic disorder.
What are the differential diagnosis for anxiety?
Can occur alongside many conditions and so these can be considered as differentials.
Hyperthyroidism, hypoglycaemia, Cushings, COPD, CCF, intoxication (alcohol, caffeine, cannabis), withdrawal (alcohol, benzodiazepines, caffeine), side effects (thyroxine, steroids, adrenaline), eating disorders, depression, OCD, PTSD etc.
What is GAD?
Ongoing, uncontrollable, widespread worry which the patient recognises as excessive and inappropriate.
Present for most days for 6 months.
What is the pathophysiology of GAD?
Causes can be biological- genetic or neurophysiological (alterations in serotonin, GABA and noradrenaline.
Can be environmental- stressful life events I.e. divorce, childhood abuse, exposure to substances. Or can be due to substance dependence.
2:1 F:M
What are the clinical features of GAD?
Although many symptoms of anxiety are present I.e. palpitations, feeling of choking, chest tightness etc specific to GAD is WATCHERS.
Worry (excessive and uncontrollable) Autonomic hyper stimulation I.e. increased sweating, HR and pupil dilated Tense muscles/tremor Concentration difficulty/chronic aches Headache/hyperventilation Energy loss Restlessness Sleep disturbance/startled easily
How is GAD investigated?
Hx asking question related to the clinical features. What is a typical day for you? Do you ever feel anxious? Is this for most days? Have you noticed problems with your memory or concentration? Do you ever lie awake at night worrying or wake up intermittently? Etc
FBC (anaemia/infection), TFTs (hyperthyroidism), glucose (hypoglycaemia).
ECG- may show sinus tachycardia.
Questionnaires I.e. GAD-2, GAD-7, Hospital Anxiety and Depression Score etc
What are the differentials of GAD?
Other neurotic disorders I.e. panic disorder, specific phobias, OCD, PTSD. Depression Drug withdrawal XS caffeine/alcohol consumption Personality disorder
How is GAD managed?
Screen for depression and substance misuse.
Biopsychosocial model
Biological-
SSRI first line. Sertraline
SNRI second line. Duloxetine or venlafaxine.
Pregabalin third line.
Need to continue medication for a year.
Benzodiazepines should not be used long term as can cause dependence.
Psychological-
Low intensity- psychoeducational groups
High intensity- CBT and applied relaxation.
Social-
Self help methods I.e. writing out problem on paper and looking at it objectively.
Support groups
Exercise
Stepwise model-
Start with psychoeducation about GAD and monitoring.
Step up to low intensity psychological interventions
Step up to high intensity psychological interventions
Step up to high specialist input. Drug and psychological therapies. May need crisis team involved.
What is a phobia?
Intense irrational fear of a person, place, object, situation which is excessive and unreasonable.
What is agoraphobia?
Fear of public spaces in which immediate escape would be difficult in a panic attack.
Largely associated with panic disorder.
ICD 10-
Fear or avoidance of 2 of the following- crowds, public spaces, travelling alone, travelling away from home.
At least 2 symptoms of anxiety in the feared situation, where one should be an autonomic symptom.
Significant emotional distress due to avoidance/anxiety symptoms, recognised as unreasonable and excessive.
Symptoms restricted to feared situation.
What is social phobia?
Fear of social situations which could lead to criticism, humiliation or embarrassment.
ICD 10-
Fear or avoidance of being focus of attention, or fear of embarrassment/humiliation.
At least 2 symptoms of anxiety + 1 of the following; blushing, fear of vomiting, urgency/fear of micturition/defecation.
Significant emotional distress due to avoidance or anxiety symptoms.
Recognised as excessive or unreasonable.
Symptoms restricted to feared situation.
What is a specific isolated fear?
Fear restricted to a specific object or situation. This is through conditioning in early life.
ICD 10-
Fear or avoidance of specific object/situation (not including agoraphobia or social phobia)
Symptoms of anxiety in the feared situation.
Significant emotional distress due to avoidance or anxiety symptoms, recognised as excessive or unreasonable.
Symptoms restricted to the feared situation.
What are the RF for phobias?
Intense experience Stress and negative life events FHx Mood disorders Substance misuse disorders Other anxiety disorders
What are the clinical features of phobias?
Biological- includes all other anxiety symptoms. Main,y get tachycardia, but in phobias of blood, injury or injections patients get bradycardia, demonstrate a vasovagal response and faint.
Psychological- distress from anxiety, anticipatory anxiety, inability to relax, fear of dying, urge to avoid situation.
How are phobias investigated?
Hx- asking questions to find specific symptoms.
What situation cause you anxiety/embarrassment? (Specific)
Do you get symptoms in places where escape would be difficult? (Agoraphobia)
Do you ever worry what people think of you? (Social)
Do you avoid situations because you will feel panicky? (Anticipatory)
Diagnosis can squally be made without aid of investigations. May still use some questionnaires.
What are the differentials for phobias?
Other anxiety disorders or organic causes I.e. cushings, hyperthyroidism, hypoglycaemia, COPD, substance intoxication/withdrawal etc.
How are phobias managed?
Advice on avoidance of anxiety inducing substances I.e. caffeine
Screen for substance misuse, personality disorders
Refer to specialist if risk of self harm, suicide, self-neglect or significant co-morbidity
How is agoraphobia managed?
CBT
Gradual exposure I.e. walking increasing distance from their house everyday
SSRIs are first line pharmacologically
How is social phobia managed?
CBT.
Gradual exposure, both in session and at home.
SSRIs (sertraline) or SNRI (venlafaxine). If no response then MAOIs.
If decline CBT or medication then psychodynamic psychotherapy
How are specific phobias managed?
Exposure through self help or CBT.
Can use benzodiazepines in short term I.e. if need CT but claustrophobic.
What is panic disorder?
Unpredictable, recurrent, episodic severe panic attacks which are not restricted to a particular situation or circumstance.
Characterised by all of the following:
Discrete episode of intense fear/discomfort
Starts abruptly
Crescendos within minutes (peaks at 10 mins)
Lasts a few mins (never more than 1hr)
At least one symptom of autonomic arousal I.e. palpitation, sweating, shaking
Other symptoms of anxiety present
What is the pathophysiology of panic disorder?
Biological: One of most heritable anxiety disorders.
Neurophysiological: Increased sensitivity to serotonin or noradrenaline.
Cognitive: Misinterpretation of somatic symptoms I.e. palpitations will lead to heart attack then death.
Environmental: Presence of life stressors.
What are the RF for panic disorder?
FHx White Female Early 20s-30s Life stressors Recent trauma Asthma Major life events/recent trauma Cigarette smoking Medications I.e. benzodiazepines withdrawal
How is panic disorder investigated?
Hx-
Are you generally an anxious person or are there periods you are anxiety free? (Episodic)
Can you predict when these attacks will come on? (Unpredictable)
Have you ever felt so frightened you thought you might die? (Intense fear and anxiety)
Are you worried about anything in your life right now? (Major life stressors)
FBC (anaemia/infection), TFTs (hyperthyroidism), glucose (hypoglycaemia),
ECG sinus tachycardia
Questionnaires I.e. GAD-2, GAD-7, Hospital Anxiety and Depression Score
What are the differentials for panic disorder?
Other anxiety disorders
Organic causes I.e. hyperthyroidism, hypoglycaemia, Cushings, phaeochromocytoma, alcohol/substance withdrawal etc.
How is panic disorder managed?
SSRIs first line. If not suitable or no effect after 12 wks then TCAs (imipramine or clomipramine)
CBT
Self help methods I.e. providing information on panic disorder and how to overcome it, support groups, exercise.
What is PTSD?
A prolonged, delayed, intense reaction following exposure to an exceptionally traumatic event.
ICD 10-
A) Exposure to extremely traumatic event
B) Persistent remembering (reliving)
C) Actual or preferred avoidance of the similar situations
D) Either; inability to recall important accepts of the exposure OR persistent symptoms of increased psychological sensitivity/arousal
B, C, D all occur within 6 months of the stressful event or the end of a period of stress.
What is the pathophysiology of PTSD?
Exposure to an extremely stressful event either involved or witnessed.
Not everyone will develop PTSD from the same event and so could be genetic vulnerability.
Cognitive theories suggest failure to process the event, results in unprocessed memories which can intrude on the conscious awareness.
What are the risk factors for PTSD?
Female 2:1 Professions such as armed forces, police, doctors, fire fighters. Refugees, asylum seekers Previous trauma Mental illness Childhood abuse Low socioeconomic background Life stressors
What are the clinical features of PTSD?
Must occur within 6 months of the event.
1) Reliving the situation I.e. flashbacks, vivid memories, nightmares, distress if in similar circumstance.
2) Avoidance of similar situation or anything which could remind them I.e. people involved, location, failure to recall information about the trauma etc.
3) Emotional numbing- negative towards self, difficulty experiencing emotions, feeling detached from others, giving up previously enjoyed activities.
4) Hyperarousal- very vigilant, unable to sleep, difficulty concentrating, outbursts/irritable with others.
How is PTSD investigated?
Hx-
Has there been any traumatic event recently which could explain how you’re feeling? (Exposure)
Do you every get flashbacks or vivid memories of the event? (Reliving)
Do you find yourself constantly thinking about the same thing? (Rumination)
Have you ever had problems with sleep since? Do you get startled easily? (Hyperarousal)
Questionnaires- Trauma Screening Questionnaire, Post-traumatic diagnostic scale.
CT if suspecting head injury
What are the differentials for PTSD?
Adjustment disorder- non-catastrophic stressor I.e. divorce/redundancy. Symptoms start within 1 month and finish before 6 months.
Acute stress reaction- exposure to exceptional physical/mental stressor i.e. RTC. Symptoms onset within 1hr (immediate). They should stop within 8hrs (if transient stressor) or 48hrs (if continued stressor)
Bereavement- natural human response, grief cycle DABDA.
Abnormal bereavement- late onset, lasting >6 months
Anxiety disorders
Head injury
Alcohol/substance misuse
How is PTSD managed?
Symptoms present within 3 months of trauma-
Watchful waiting if <4wks and mild.
Trauma focused CBT- once a wk for 8-12 sessions
Zoplicone short term to help with sleep
Risk assessment to observe risk of neglect or suicide
Symptoms are present for >3 months after trauma-
Trauma focused psychological intervention:
a) CBT
b) EMDR- reduces stress in the shortest period of time. One technique involves moving the eyes to help the brain process traumatic events
Only consider drugs when; poor response to psychotherapies, patient prefers nots to engage in psychotherapies or co-morbid depression/severe Hyperarousal which would benefit from intervention.
Paroxetine, mirtazapine, amitryptiline, phenelzine. Paroxetine and mirtazapine used the most due to evidence present.
What is OCD?
Recurrent obsessional thoughts or compulsive acts or both.
Obsessions- unwanted, intrusive thoughts/images/urges that repeatedly enter the mind. They are distressing for the patient who resists them and recognises them as a product of their own mind.
Compulsions- repetitive mental/physical acts a person feels driven to do.
ICD 10
Obsessions/compulsions or both for most days for 2wks.
All clinical features of obsessions and compulsions must be present.
The O and C cause distress and interfere with a persons individual/social functioning due to wasting time.
What is the pathophysiology of OCD?
Biological- genetic aspect. Also child Group A beta haemolytic strep infection can cause damage to the basal ganglia (involved in OCD).
Psychoanalytic- fill the mind eith intrusive thoughts to prevent undesirable ideas entering consciousness.
Behavioural- operant conditioning. Don’t like the anxiety created by the obsession, since the patient learns this is reduced through the compulsion, the compulsion is maintained.
Associated with depression, anorexia nervosa, schizophrenia etc.
What are the clinical features of OCD?
Common obsession is getting contaminated, common compulsion is checking, followed by washing/cleaning.
Other obsessions: fear of harm (door locks not safe), excessive concerns with order or symmetry, sex, violence, blasphemy.
Other compulsions: repeating acts I.e. counting (covert), arranging objects, mental compulsion (special words repeated in a specific manner), hoarding etc.
Compulsions and obsession must have ALL four of the following:
FORD Car
Failure to resist
Originate from patients own mind, and they recognise this
Repetitive and distressing
Carrying out the obsessive thought or compulsion is not pleasurable but reduces the anxiety.
How is OCD investigated?
Hx-
Do you have distressing thoughts enter your mind, despite resisting them? (Obsessions)
Do you repeatedly check things you have already done? (Compulsions)
Do your daily activities take a long time to finish? (Carrying out the compulsions)
Yale-Brown obsessive-compulsive scale (10 items)
What are the differentials of OCD?
Eating disorders Body dysmorphia Anxiety disorders Depressive disorder Dementia Epilepsy Head injury
How is OCD managed?
CBT (exposure and response prevention- ERP)
Patient exposed to the situation causing anxiety I.e. dirt and then prevented from performing the compulsion I.e. washing hands. There anxiety will increase initially but will gradually die down.
SSRI I.e. fluoxetine, sertraline, citalopram.
Can use clomipramine which can be combined with citalopram, can also be combined with an antipsychotic. Can combine an antipsychotic with and SSRI too.
Psychoeducation and self help
Assess and manage any suicide risks
Identify and treat any co-morbid depression
Mild OCD- Low intensity psychological intervention (<10hrs therapist input)
Moderate OCD- SSRI or high psychological intervention input
Severe OCD- SSRI + CBT (with ERP)
