Anxiety Disorders

Question 1

Explain the difference between pathological and normal anxiety?

Answer 1

• Anxiety disorders are pathological in EXTENT – i.e. the anxiety is more extreme than normal and/or pathological in CONTEXT – i.e. anxiety is present in situations that are not “normally” anxiety provoking
• Anxiety disorders cause significant distress and impairment of social/ occupational/ other function
• The stress response: exposure to stress results in instantaneous and concurrent biological responses
• The amygdala acts as the emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response (ms), this is modified by the later received cortically processed signal (i.e. act first, think later)
• In pathological anxiety there is an initial response and then cognition kicks in to perpetuate the response

Question 2

Define generalised anxiety disorder?

Answer 2

• Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in any particular environmental circumstances
• Persistent and chronic (fluctuating course)
• The anxiety is not about a particular thing but many things

Question 3

What are the dominant symptoms and feelings patients may have in GAD?

Answer 3

• Dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness and epigastric discomfort
• Typically associated with restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind goes blank, irritability, muscle tension, sleep disturbance

Question 4

What is the criteria to diagnose GAD?

Answer 4

• It is NOT due to any other disorder (i.e. they don’t have GAD due to hyperthyroid because if hyperthyroid is treated the anxiety gets better)
• Needs to be severe enough to be long lasting (most days for at least 6 months), not controllable and causing significant distress/ impaired function

Question 5

What is the typical age of onset for GAD?

Answer 5

• Typical age of onset = 20-40 (it is odd for someone to present with GAD later and other causes should be ruled out)

Question 6

Step management for GAD?

Answer 6

Step 1 (for everyone): education, self help, active monitoring
Step 2 (for those not improved by step 1): low intensity CBT, self help, self help groups
Step 3 (GAD causing functional impairment/ not responded to step 2): high intensity CBT and/or drug treatment
Step 4 (refractory/ risk of self harm/ marked functional impairment): refer for highly specialised help

Question 7

Define panic disorder? Explain how it differs from GAD?

Answer 7

• Essential feature is recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
• The anxiety is more severe than GAD but is short lasting, and the person feels fine after the episode (this is in contrast to GAD where there is a constant level of background anxiety)

Question 8

What are the dominant symptoms of panic disorders?

Answer 8

• Dominant symptoms: sudden onset chest pain, palpitations, choking sensations, dizziness and feelings of unreality, also secondary feelings of fear of dying, losing control or going mad

Question 9

What is the most common type of anxiety disorder?

Answer 9

GAD

Question 10

Management of panic disorder?

Answer 10

• In mild offer self help and education, next step is CBT, next is SSRI (or other antidepressant but SSRI is first line), then refer to mental health services if still not improving

Question 11

Presentation of agorophobia?

Answer 11

• Avoidance of the phobic situation is often prominent and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
• Often involves other people, alcohol or technology to avoid anxiety e.g. others do shopping, drink before going out to overcome panic, internet shopping

Question 12

Management of agoraphobia?

Answer 12

• CBT and exposure therapy is first line
• SSRIS/ SNRIS if needed
• Benzodiazepines are used short term only

Question 13

Define specific phobias?

Answer 13

• A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation e.g. flying, heights, animals, insects, blood

Question 14

Signs/ symptoms of specific phobias?

Answer 14

Even talking about the phobia can cause distress
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response akin to a panic attack
AnticipatoryAnxiety
The person generally has good insight – they are aware that the fear is excessive and/ or unreasonable

Question 15

Management of specific phobias?

Answer 15

Treatment is with behavioural therapy and graded exposure, add in CBT if necessary, SSRIs/ SNIRs if required can be helpful to augment behavioural therapy

Question 16

Define social anxiety / phobia?

Answer 16

A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
Typically occurs in small social settings (vs agoraphobia which occurs in large crowds)

Question 17

Signs/ symptoms of social phobia?

Answer 17

• Common anxiety symptoms are: blushing or shaking, fear of vomiting, urgency or fear of micturition or defaecation
• Tends to come on early in life resulting in poor school performance, school refusal and poor employment history

Question 18

Management of social phobia?

Answer 18

CBT is treatment of choice, may add SSRI/ SNRI, benzodiazepines short term only

Question 19

Explain what OCD is?

Answer 19

• Recurrent obsessional thoughts and/ or compulsive acts
• Obsessional thoughts may be ideas, images or impulses entering the mind in a stereotyped way, they are recognized as the patient’s own thoughts but are unpleasant, resistant and ego-dystonic (not in harmony with self)
• Involves repeated rituals, stereotyped behaviours, that are not enjoyable or functional and recognized as pointless

Question 20

Criteria for OCD?

Answer 20

Obsessional symptoms or compulsive acts must be present most days for at least 2 weeks (moving away from a timeline in ICD 11) AND be a source of distress and interference with activities:
 Obsessions must be individuals own thoughts
 Resistance must be present
 Rituals are not pleasant
 Obsessional thoughts/ images/ impulses must be repetitive

Question 21

Management of OCD?

Answer 21

CBT is the main treatment, then may add SSRIs

Question 22

Explain why benzodiazepines should not be used long term in anxiety disorders?

Answer 22

Most anxiety disorders are chronic conditions so patients will simply become reliant on them

Question 23

Define hypochondriasis/ illness anxiety disorder?

Answer 23

• Hypochondriasis is characterised by persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses
• The preoccupation is accompanied by either: repetitive and excessive health-related behaviours, such as repeatedly checking of the body for evidence of illness, spending inordinate amounts of time searching for information about the feared illness, repeatedly seeking reassurance (e.g. arranging multiple medical consultations); OR maladaptive avoidance behaviour related to health (e.g. avoids medical appointments)
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning

Question 24

Define somatisation disorder/ somatic symptom disorder/ bodily distress disorder?

Answer 24

• Diagnosed when a person has a significant focus on physical symptoms e.g. pain, weakness, shortness of breath to a level that results in major distress and/ or problems functioning
• The individual has excessive thoughts, feelings and behaviours relating to the physical symptoms
• The physical symptoms may or may not be associated with a diagnosed medical condition but the person is experiencing symptoms and believes they are sick (not faking the illness)
• Diagnosis is based on the extent of the thoughts, feelings and behaviours related to the illness being out of proportion or excessive, the emphasis is not on the fact that a medical cause cannot be identified for their physical symptom

Question 25

In somatic symptom disorder what is diagnosis based on?

Answer 25

is based on the extent of the thoughts, feelings and behaviours related to the illness being out of proportion or excessive, the emphasis is not on the fact that a medical cause cannot be identified for their physical symptom

Question 26

Treatment of somatic symptom disorder?

Answer 26

usually CBT

Question 27

Treatment of hypochondriasis?

Answer 27

CBT plus/minus SSRI

Question 28

Difference between hypochondriasis and somatic symptom disorder?

Answer 28

• Somatic symptom/ bodily distress the focus is on the symptoms and the thoughts that go with it
• Hypochondriasis is about being fixated on diagnosis and the possibility of having serious life threatening illnesses, can have a fixation on normal feelings being serious symptoms

Question 29

Define factitious disorder?

Answer 29

(AKA Munchausen syndrome) involves intentional production of physical or psychological symptoms (also by proxy where carer makes the person they are caring for appear sick)

Question 30

Define conversion disorder?

Answer 30

– motor or sensory loss, not consciously feigning the symptoms or seeking gain

Question 31

Define dissociative disorder?

Answer 31

separating off certain memories from normal consciousness

Question 32

Define malingering?

Answer 32

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Question 33

What are the types of trauma?

Answer 33

INDIVIDUAL: intentional or unintentional
COMMUNITY: manmade or natural

TYPE 1: single events, sudden and unexpected
TYPE 2: repetitive trauma, 3x risk of PTSD vs type 1 trauma

Question 34

Under threat brain activity shifts from the ______ to the ___________

Answer 34

from the prefrontal cortex to the brainstem (superior colliculus and PAG)

Question 35

In PTSD there is increased activation of _______

Answer 35

amygdala and other limbic areas?

Question 36

Why may people struggle to talk about traumatic memories?

Answer 36

Deactivation of broca’s area occurs in trauma

Question 37

Why may there be timeless quality of traumatic memory?

Answer 37

right hemispheric lateralisation

Question 38

Is PTSD is a normal adaptation to severe traumatic stress?

Answer 38

no - it is maladaptive

Question 39

Is PTSD a stress response?

Answer 39

not really - more an overwhelming of the stress response

Question 40

Is PTSD an inevitable response to trauma? Is it the only response?

Answer 40

no and no

Question 41

Do most trauma exposed people develop PTSD?

Answer 41

no

Question 42

3 essential PTSD symptoms?

Answer 42

1) Re-experiencing the traumatic event or events in the form of vivid intrusive memories, flashbacks or nightmares
2) Avoidance of thoughts and memories of the event/ events or avoidance of activities, situations, or people reminiscent of the event
3) Persistent perceptions of heightened current threat, for example hypervigilance

Question 43

Additional PTSD symptoms?

Answer 43

• General dysphoria
• Dissociative symptoms
• Somatic complaints
• Suicidal ideation and behaviour
• Social withdrawal
• Excessive alcohol or drug use
• Anxiety symptoms
• Guilt, anger, shame, sadness, humiliation, survivor’s guilt

Question 44

How is PTSD different from acute stress reaction?

Answer 44

• Normal acute reactions to traumatic events can include all PTSD symptoms but they subside fairly quickly e.g. within 1 week or within 1 month if case of ongoing stressors
• In PTSD there can be a delay in symptoms too, ASR occurs straight after event, is normal and goes away quickly

Question 45

Management of PTSD?

Answer 45

• 1st line= CBT
• 2nd line= eye movement desensitisation and reprocessing therapy (the superior colliculus stores trauma and is also responsible for movement in response to visual stimuli so eye movements can help reprocess trauma)
• CBT tends to be more effective for simple cases
• Need alternative options to CBT because CBT is top down processing (how thoughts influence feelings) so it will not address brainstem led responses to trauma
• Talking therapy can also be difficult if deactivation of Brocas area
• There is not much evidence for use of medication but it can be used for specific symptoms or for treatment of comorbidity
• Benzodiazepines are not advised, if person is keen for medication can try venlafaxine or a SSRI, can consider antipsychotics e.g. risperidone if adults have hyperarousal and psychotic like symptoms

Question 46

Define agoraphobia?

Answer 46

• A fairly well defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places or travelling alone in trains, buses or planes

Question 47

What does NICE recommend for PTSD drug treatment if required?

Answer 47

SSRI or venlafaxine