Anxiety Disorders

Question 1

What are the symptoms of neurosis?

Answer 1

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.

Question 2

How are anxiety disorders classified?

Answer 2

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.

Question 3

What are the differential diagnosis for anxiety?

Answer 3

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.

Question 4

What is GAD?

Answer 4

Ongoing, uncontrollable, widespread worry which the patient recognises as excessive and inappropriate.
Present for most days for 6 months.

Question 5

What is the pathophysiology of GAD?

Answer 5

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

Question 6

What are the clinical features of GAD?

Answer 6

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

Question 7

How is GAD investigated?

Answer 7

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

Question 8

What are the differentials of GAD?

Answer 8

Other neurotic disorders I.e. panic disorder, specific phobias, OCD, PTSD.
Depression 
Drug withdrawal
XS caffeine/alcohol consumption
Personality disorder

Question 9

How is GAD managed?

Answer 9

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.

Question 10

What is a phobia?

Answer 10

Intense irrational fear of a person, place, object, situation which is excessive and unreasonable.

Question 11

What is agoraphobia?

Answer 11

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.

Question 12

What is social phobia?

Answer 12

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.

Question 13

What is a specific isolated fear?

Answer 13

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.

Question 14

What are the RF for phobias?

Answer 14

Intense experience
Stress and negative life events
FHx
Mood disorders
Substance misuse disorders
Other anxiety disorders

Question 15

What are the clinical features of phobias?

Answer 15

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.

Question 16

How are phobias investigated?

Answer 16

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.

Question 17

What are the differentials for phobias?

Answer 17

Other anxiety disorders or organic causes I.e. cushings, hyperthyroidism, hypoglycaemia, COPD, substance intoxication/withdrawal etc.

Question 18

How are phobias managed?

Answer 18

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

Question 19

How is agoraphobia managed?

Answer 19

CBT
Gradual exposure I.e. walking increasing distance from their house everyday
SSRIs are first line pharmacologically

Question 20

How is social phobia managed?

Answer 20

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

Question 21

How are specific phobias managed?

Answer 21

Exposure through self help or CBT.

Can use benzodiazepines in short term I.e. if need CT but claustrophobic.

Question 22

What is panic disorder?

Answer 22

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

Question 23

What is the pathophysiology of panic disorder?

Answer 23

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.

Question 24

What are the RF for panic disorder?

Answer 24

FHx
White
Female
Early 20s-30s
Life stressors
Recent trauma
Asthma
Major life events/recent trauma
Cigarette smoking
Medications I.e. benzodiazepines withdrawal

Question 25

How is panic disorder investigated?

Answer 25

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

Question 26

What are the differentials for panic disorder?

Answer 26

Other anxiety disorders

Organic causes I.e. hyperthyroidism, hypoglycaemia, Cushings, phaeochromocytoma, alcohol/substance withdrawal etc.

Question 27

How is panic disorder managed?

Answer 27

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.

Question 28

What is PTSD?

Answer 28

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.

Question 29

What is the pathophysiology of PTSD?

Answer 29

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.

Question 30

What are the risk factors for PTSD?

Answer 30

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

Question 31

What are the clinical features of PTSD?

Answer 31

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.

Question 32

How is PTSD investigated?

Answer 32

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

Question 33

What are the differentials for PTSD?

Answer 33

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

Question 34

How is PTSD managed?

Answer 34

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.

Question 35

What is OCD?

Answer 35

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.

Question 36

What is the pathophysiology of OCD?

Answer 36

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.

Question 37

What are the clinical features of OCD?

Answer 37

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.

Question 38

How is OCD investigated?

Answer 38

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)

Question 39

What are the differentials of OCD?

Answer 39

Eating disorders
Body dysmorphia
Anxiety disorders 
Depressive disorder 
Dementia
Epilepsy
Head injury

Question 40

How is OCD managed?

Answer 40

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)