Anxiety Disorders

Question 1

What are the general symptoms of anxiety

Answer 1

In anxiety disorders the normal anxiety response is exaggerated and triggered by a non-existent and trivial threat. This is often recognised by its physical symptoms

1. Psychological: feeling worried, poor concentration, irritability, depersonalization/ derealization, difficulty sleeping
2. Muscular: Tremor, headaches, muscle aches, restlessness
3. Cardiovascular: chest discomfort and palpitations
4. GI: Dry mouth, indigestion, flatulence, frequent/ loose motions
5. Respiratory: Tachypnoea/ hyperventilation, difficulty inhaling, chest constriction
6. Urogenital: Urinary frequency, erectile dysfunction, amenorrhea

Question 2

What are the most significant contributing factors to anxiety disorders

Answer 2

• There is a genetic contribution to the disease, supported by family and twin studies. There is a 4-6x higher risk in relatives of affected people and 30-50%
• Childhood and life events predispose people to anxiety disorders > by definition, PTSD is caused by extreme past trauma. The risk of developing PTSD is associated with the degree of exposure, proximity and human contribution to the traumatic event.

Question 3

Explain the neurotransmitter, neuroanatomical and psychological theories of anxiety disorders

Answer 3

• Neurotransmitter theories: The central neurotransmitters serotonin, NA, and GABA are underactive in anxiety disorders. As such: the drugs for anxiety disorders target these neurotransmitters > SSRIs, TCAs (target NA), Benzos (target GABA)
• Neuroanatomical theories: Functional hyperactivity of the amygdala is found in anxiety disorders. May also be associated with atrophy of the hippocampus (short-term memory) OCD is linked to damage in the basal ganglia by Sydenham’s chorea (could follow strep throatàPANDAS), encephalitis and Tourette’s.
• Psychological theories: May involve classical conditioning- neutral stimulus paired with frightening one, negative reinforcement- behaviours which relieve anxiety are repeated > habituation, attachement theory- poor attachment= anxiety, modelling.

Question 4

What are the outcomes for anxiety disorders

Answer 4

Overall a rule of 1/3rds exists for anxiety disorders: 1/3 recover completely, 1/3 improve partially and 1/3 fare poorly, suffering considerably with a poor quality of life.

Question 5

What is the definition of specific phobias. What is the lifetime prevalence and what is the mean age of onset. Does it commonly affect males or females

Answer 5

Fear out of proportion to the demands of the situation which cannot be reasoned away and is beyond voluntary control. In these disorders, intermittent anxiety occurs in specific, but ordinary circumstances. This fear leads to avoidance of the feared situation and can lead to disability. Patients generally only seek treatment once the condition has become debilitating. Commonly includes animals, storms, heights, illness, injury, death.

Epidemiology:

• F>M (2:1)
• Often starts in childhood (5-9)
• Lifetime prevalence: 5-10%

Question 6

What is agoraphobia? What are some differentials for agoraphobia

Answer 6

A fear of being in situations where escape might be difficult or that help wouldn’t be available if things go wrong. The onset is commonly in the twenties or mid-thirties and may be gradual or precipitated by a panic attack. May occur in both open & confined spaces. Avoidance of phobic situations must be prominent and often results in the patient becoming house-bound and dependent:

• DDx: organic causes (dementia often makes patients housebound), negative symptoms of psychosis, depression, social anxiety disorder, OCD, PD
• F>M (4:1). Lifetime prevalence 5 %, Onset 20s-mid 30s, 80% married. Nearly all unemployed or homemakers.
• Course is fluctuating but results in depression in 40% of cases.

Question 7

What is social phobia? What are some differentials? What is a common complication of social phobia

Answer 7

This generally develops in the late teenage years. Marked fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating (scrutinized, judged, or criticised) > can usually tolerate crowds since the focus isn’t on them. This may include everyday interactions such as public speaking, meetings, dates. Patients may seek help for ‘embarrasing’ symptoms that draw attention to their anxiety e.g blushing, sweating:

• This can be seen as more of a spectrum, DDx: shyness, poor social skills, autism, psychosis, depression, agoraphobia, PD
• F=M (3:2), Onset in late teens (17 – 30), 6 month prevalence 2-3/1000
• Generally present for life and can result in secondary depression
• Common complications include alcohol and drug dependence.

Question 8

What factors give better prognosis in specific phobias

Answer 8

Simple phobias in childhood may continue for many years, whilst those starting in adult life after a stressor have a better prognosis (70-80% resolve with CBT.)

Question 9

How can specific phobias be managed

Answer 9

• CBT with exposure therapy: Done through desensitization, whereby there is repeated exposure to the stimulus without avoidance behaviour, which allows for habituation. Involves weekly sessions and homework > exposure tasks for agrophobia include gradually leaving the house and activities of daily living, for social anxiety disorder they might include stopping ‘safety-seeking behaviours’ (SSBs) during social situations.
• Medication can be used: SSRIs/Venlafaxine, Beta-blockers, Benzodiazepines (last resort)

Question 10

What is panic disorder, how does it present and when can it be diagnosed

Answer 10

‘Episodic paroxysmal anxiety’: Intermittent anxiety NOT triggered by a specific stimulus which can be very unpredictable:

• Presents as recurrent ‘panic attacks’ which occur out of the blue. These are sudden attacks of extreme anxiety, associated with the physical symptoms of anxiety (fear of suffocation, hyperventilation, sweating, palpitations, chest discomfort, desire to flee). Alarm at these physical manifestations e.g fearing that they are having a heart attack can often exacerbate the panic until they seek help or engage in SSBs (safety seeking behaviour).
• For a diagnosis of panic disorder there must be recurrent panic attacks (several within 1 month) and between these episodes they must be fairly anxiety free
• SSBs take the place of escape from stimulus (e.g calling an ambulance)
• Generally, occurs between 25-44, lifetime prevalence = 5%

Question 11

What are some differentials for panic disorder

Answer 11

organic causes including asthma, angina, stroke, hyperthyroidism, phaeo, intoxication, withdrawal, depression

Question 12

Investigations for panic disorder

Answer 12

• Rule out organic causes (incl. thyroid), alcohol & drug withdrawal (TFTs, UDS)
• Urine drug screen
• ECG > need to rule out alternative pathology, particularly in the case of palpitations etc.

Question 13

Management of panic disorder

Answer 13

• CBT (panic not perish)/ Relaxation training including breathing techniques
• Pharmacological intervention including SSRIs and Venlafaxine MR
• Benzos are not recommended due to the risk of tolerance and dependence (NICE)

Question 14

Generalised anxiety disorder definition and presentation. When can GAD be diagnosed

Answer 14

• Anxiety NOT triggered by a specific stimulus which is continuous, generalised, excessive and uncontrolled > The patient worries about anything and everything
• Continuous (present for most days over 6 months)> differentiates GAD from panic disorder
• Physical symptoms are often prominent: Motor tension, restlessness, irritability, somatic symptoms
• Often presents with comorbid depression, OCD, Panic disorder (often cannot distinguish between disorders)
• To diagnose GAD, symptoms must be present for at least several months, although intensity may fluctuate

Question 15

Differentials for GAD

Answer 15

• Organic causes including hyperthyroidism, dementia (can present with low level anxiety), intoxication (amphetamines, caffeine), withdrawal
• Psychosis (free floating anxiety can precede delusions)
• Depression
• PD

Question 16

When does GAD generally present, in whom is it more common and what are some risk factors for its development

Answer 16

• More common in 20’s, F>M (2:1), 1 yr prevalence 3-8%

Risk Factors:

• History of physical/emotional trauma though may be any type of trauma
• Low socioeconomic status (interestingly a greater risk factor even than past trauma)
• Substance abuse
• Chronic painful illnesses

Question 17

Investigations for GAD

Answer 17

Must first exclude physical causes for the presentation

• Screening using the GAD-7 questionnaire
• Hospital Anxiety and Depression Scale (HADS) for screening (used for all anxiety disorders)

Question 18

Management of GAD

Answer 18

• Step 1: Education & active monitoring
• Step 2: low-intensity psychological interventions > CBT focused on thinking errors such as catastrophising (jumping to the worst possible conclusion)
• Step 3: high-intensity psychological intervention with/without drug treatment
• Step 4: specialist assessment
• Medication: SSRI, SNRI, Pregabalin- an antiepileptic licenced for neuropathic pain and GAD. Alternatively could utilise TCAs where other anti-depressants are inadequate. Beta-blockers can be used to treat some physical symptoms.

Question 19

Acute stress reaction definition and presentation

Answer 19

• A transient disorder which develops in response to exceptional physical and/or mental stress, and which usually subsides within hours or days.
• There is no delay in the development of symptoms> Immediate causal temporal relationship with the trigger event so symptoms appear Immediately/ within minutes of stressor.
• ‘daze’, depression, anxiety, despair, over activity, and withdrawal may all be seen variably
• Examples include: Natural disaster • Motor vehicle accident • Mild traumatic brain injury • Burn • Industrial accident • Witnessing a mass shooting (trigger must be exceptional)
• Prevalence: 5% – 20%, F>M
• Risk Factors: History of a previous trauma, psychiatric disorder, female, trauma severity, neuroticism, avoidant coping

Question 20

Management of an acute stress reaction

Answer 20

The condition is self-limiting and will subside in hours or days, the management is supportive only

Question 21

Adjustment disorder definition and presentation

Answer 21

A maladaptive reaction to a psychosocial stressor - it is maladaptive because it interferes with the affected person’s social or occupational functioning. The disorder is expected to remit when the stressor recedes. The psychological stressors are not extreme as for an acute stress reaction and the reaction is deemed greater than is usually expected for the situation.

• Most people experience fleeting symptoms of anxiety, low mood, irritability or sleeplessness.
• Onset is usually within one month of the stressful event or life change
• Any age of onset, young single women are over represented, medical/ surgical patients= 5% of admissions, psychiatric patients> 10% of admissions

Question 22

How can the different presentations of adjustment disorder be classified

Answer 22

• Brief depressive reaction> transient mild depression, duration < 1 month
• Prolonged depressive reaction> mild depression in response to chronic stressor, duration < 2 years
• Mixed anxiety and depressive reaction

Question 23

Management of adjustment disorder

Answer 23

• Psychological
  
  • Group therapy: may reinforce positive coping strategies
  • Individual therapy: must be time limited to prevent dependence
  • Crisis counselling: is of doubtful benefit except in those with no other supports
• Pharmacotherapy
  
  • Short courses of medications may be useful for brief symptom relief such as insomnia

Question 24

What is a prolonged grief reaction and when can it be diagnosed

Answer 24

• Persistent and pervasive grief response
• Longing for the deceased/persistent preoccupation with the deceased
• Accompanied by intense emotional pain (e.g. sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to experience positive mood, emotional numbness, difficulty in engaging with social or other activities)
• Persists >6 months
• Clearly exceeds expected social, cultural or religious norms for the individual’s culture and context.
• Causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning

Question 25

PTSD ICD10 classification

When must PTSD present in the context of the stressor and how long should symptoms last

Answer 25

“An event of exceptionally threatening or catastrophic nature likely to cause pervasive distress in anyone: - ICD-10

• E.g. sexual assault, war, natural disasters, accidents, torture, terrorism
• Prevalence: One year = 1-3 %. Lifetime = 6.8% • F>M
• Usually begins within 6 months of the trauma and is considered where the symptoms experienced are prolonger and disabling
• Symptoms should last for longer than 1 month

Question 26

What causes PTSD, what are some predisposing factors

Answer 26

• Occurs in 10% of people who have experienced severe trauma
• Degree of exposure and proximity to stressor influence the risk along with continuous exposure to trauma or stressors and Memory formation dysfunction
• Predisposing traits include neuroticism, FHx of psych disorders, childhood abuse, poor early attachment

Question 27

What are some differentials for PTSD

Answer 27

• psychosis (flashbacks can resemble hallucinations but should relive past experiences)
• depression
• ASD
• adjustment disorder

Question 28

What are the defining symptoms of PTSD

Answer 28

• Reliving- flashbacks, recurrent nightmares or intrusive memories
• Hyperarousal/vigilance- unable to relax, hypervigilance, enhanced startle reflex, insomnia, poor concentration, irritability
• Avoidance due to perceived fear of re-exposure (avoiding reminders of the event)
• Other- emotional detachment, comorbid Depression, comorbid substance misuse, suicidality

Question 29

What is the management of PTSD

Answer 29

• Watchful waiting may be considered if subthreshold symptoms of PTSD within 1 month of a traumatic event- should then arrange a follow-up within 1 month
• Psychological
  
  • Trauma focused CBT (attempts to challenge belief system which is developed after exposure to trauma) or EMDR (Eye movement desensitisation and reprocessing)
• Pharmacological
  
  • Mirtazapine / SSRI (likely paroxetine) / Venlafaxine
  • MDMA trials = 80% cure rate at 12 weeks (MAPS)

Question 30

Presentation of complex PTSD, when can it be diagnosed

Answer 30

Complex PTSD occurs following exposure to an event/events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met and in addition, the patient with have:

• Problems in affect regulation
• Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event
• Difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Question 31

Definition of obsessions

Answer 31

Obsessions: recurrent, unwanted and intrusive thoughts/images/impulses/doubts in one’s mind, despite attempts to resist them. They are egodystonic (conflict with the individual’s self-image) and are in no way enjoyable. Common themes include contamination/illness, sex (fear of being a paedophile), harming self or others, fear of sacrilege or immorality, need for order/symmetry

Question 32

Definition of compulsions

Answer 32

Compulsions: repeated and seemingly purposeful rituals that are carried out to end the anxiety caused by an obsession. They are neither pleasant or inherently useful. May be ‘overt’ or ‘covert’

Question 33

When can a diagnosis of OCD be given

Answer 33

• Symptoms must be present on most days for at least two successive weeks, and be the source of distress or interference with activities.
• Symptoms must be recognized as the individual’s own thoughts or impulses

Question 34

What is the prevalence of OCD, in whom is it more common

Answer 34

• Prevalence: 1%, F=M, Neurodevelopmental subtype more common in males

Question 35

Differentials for OCD

Answer 35

• organic causes including Tourette’s, Huntington’s, sydenham’s chorea
• psychosis (though in OCD patients recognize their obsessions as being irrational on some level)
• depression (50% of OCD sufferers have depression)
• agoraphobia
• Anankastic PD (rigidity, infelxibilty, liking of order)
• autism spectrum disorder

Question 36

What is the most signficant risk factor for OCD, what other factors predispose

Answer 36

• Genetic component: often associated with a family history of the disease- 35% of 1st degree relatives also have OCD, MZ: DZ = 50-80 %
• Between 11-80 % of Tourette’s patients have obsessional symptoms, 20% of OCD patients suffer from tics
• Personality traits: anankastic
• Stress
• Neurodevelopmental abnormalities: Basal ganglia defects and Frontal lobe abnormalities

Question 37

Management of OCD

Answer 37

• 1^st line> low intensity psychological therapy (brief individual or group CBT including ERT), 2^nd line SSRI, 3^rd line> (after 12 weeks) Clomipramine or alternative SSRI
• Exposure and response prevention CBT- expose to stressor and support them not to use compulsion
• Mindfulness
• SSRIs (high dose) or Clomipramine (TCA which is highly serotonergic)> Clomipramine is GOLD STANDARD
• Psychosurgery is rare- anterior cingulotomy

Question 38

Summary

Answer 38

Question 39

Panic disorder vs panic attacks

Answer 39

Panic disorder lacks triggers whilst panic attacks can mark severity in any other disorder which has triggers

Question 40

Panic disorder vs agoraphobia

Question 41

Social anxiety vs agoraphobia

Answer 41

Both can cause social withdrawal. ask which they’d dislike more: being in the middle of a crowd, or having to speak to a small group of strangers

Question 42

OCD vs agoraphobia

Answer 42

Compulsions can make someone house bound, need to ask why they are secluded

Question 43

Personality disorder vs Anxiety disorder

Answer 43

personality presents from early adulthood onwards and is pervasive across all situations rather than a later onset and relapsing-remitting course and triggers.