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Year 4 Psychiatry > Anxiety Disorders > Flashcards

Anxiety Disorders Flashcards

1
Q

What drugs may cause drug-induced anxiety?

A

Salbutamol
Theophylline
Corticosteroids
Antidepressants
Caffeine

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2
Q

Stepwise management of GAD?

A

step 1: education about GAD + active monitoring

step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.

step 4: highly specialist input e.g. Multi agency teams

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3
Q

Pharmacological management of GAD?

A

NICE suggest sertraline should be considered the first-line SSRI

if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (duloxetine, venlafaxine)

If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Busipirone (5HT1A¬ agonist) is suitable for short term management
Delayed onset of action
Diminished efficacy in previous benzo users
Side effects: dizziness, headache and nausea
Minimal sedation

Beta blockers such as propranolol can be used for somatic symptoms

Low dose antipsychotics can be considered

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4
Q

Management of panic disorder?

A

NICE recommend either cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

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5
Q

What is OCD, and what is meant by obsessions and compulsions?

A

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.

Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

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6
Q

Possible aetiological factors for OCD?

A

genetic
psychological trauma
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

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7
Q

What other psychiatric conditions are associated with OCD?

A

depression (30%)
schizophrenia (3%)
Sydenham’s chorea
Tourette’s syndrome
anorexia nervosa

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8
Q

How is OCD managed if functional impairment is low?

A

low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)

If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)

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9
Q

How is OCD managed if functional impairment is moderate?

A

offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)

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10
Q

How is OCD managed if functional impairment is severe?

A

offer combined treatment with an SSRI and CBT (including ERP)

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11
Q

What is post traumatic stress disorder?

A

Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse.

One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month.

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12
Q

Features of PTSD?

A

re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

avoidance: avoiding people, situations or circumstances resembling or associated with the event

hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating

emotional numbing - lack of ability to experience feelings, feeling detached from other people
depression

drug or alcohol misuse

anger

unexplained physical symptoms

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13
Q

Management of PTSD?

A

following a traumatic event single-session interventions (often referred to as debriefing) are not recommended

watchful waiting may be used for mild symptoms lasting less than 4 weeks

military personnel have access to treatment provided by the armed forces

trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases

drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

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14
Q

Examples of anxiety disorders?

A

Generalized Anxiety disorder
Phobias
Panic disorder
Obsessive Compulsive Disorder Post-traumatic Stress Disorder

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15
Q

Concept of neuroses

A

Symptoms that are both understandable and with which one can empathize

Insight is maintained - this is as opposed to delusions which are not understandable or cannot be empathised with

Neuroses are quantitively but not qualitatively different from normal

Neuroses different to ‘neurotic’ individuals who often suffer from lifelong personality difficulties

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16
Q

Social factors associated with anxiety disorders?

A

Lower social class
Unemployment
Divorced
Renting rather than owning
No educational qualifications
Urban living Aetiology

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17
Q

In which patients are anxiety disorders more common?

A

Females
Younger patients (from 35-40 years and older dx more likely to be depression or an organic pathology)

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18
Q

Psychological symptoms of anxiety?

A

Fears
Worries
Poor concentration
Irritability
Depersonalization
Derealisation
Insomnia
Night terrors

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19
Q

Motor symptoms of anxiety?

A

Restlessness
Fidgeting
Feeling on edge

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20
Q

Neuromuscular symptoms of anxiety?

A

tremor
tension headache
muscle ache
dizziness
tinnitus

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21
Q

GI symptoms of anxiety

A

Dry mouth
Trouble swallowing
Nausea
Indigestion
Flatulence
Frequent or loose motions

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22
Q

What ?CVS symptoms might anxiety present with

A

Chest discomfort, palpitation

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23
Q

What respiratory complaints might anxiety present with

A

Difficulty inhaling, Tight/constricted chest

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24
Q

What GU symptoms might anxiety present with?

A

Urinary frequency
Erectile dysfunction
Amenorrhoea

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25
Q

ICD-10 criteria for GAD

A

Generalized and persistent ‘free floating’ anxiety symptoms involving elements of:

Apprehension (worries about future misfortunes, feeling on edge, difficulty in concentrating)

Motor tension (restless fidgeting, tension headaches, trembling, inability to relax)

Autonomic overactivity (light-headedness, sweating, tachycardia, epigastric discomfort, dizziness etc)

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26
Q

Differential diagnoses for GAD?

A

Hyperthyroidism (look for goitre, tremor, tachycardia, weight loss, arrhythmia, exophthalmos)

Substance misuse (intoxication – amphetamines; withdrawal – benzo, alcohol)

Excess caffeine

Depression: anxiety common feature of depression and likewise. Which came first and which is currently more prominent are useful clues. If both, diagnose mixed anxiety and depressive disorder

Anxious (avoidant) personality disorder: patient describes themselves as an anxious person with no recent major increase in anxiety levels. (note this disorder can predispose)

Dementia (early)

Schizophrenia (early)

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27
Q

ICD-10 criteria for panic disorder?

A

Recurrent attacks of severe anxiety not restricted to any particular situation or set of circumstances and therefore unpredictable

Secondary fears of dying, losing control or going mad

Attacks usually last for minutes; often there is a crescendo of fear and autonomic symptoms

Comparative freedom from anxiety symptoms between attacks (but anticipatory anxiety is common)

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28
Q

Which patients are most greatly affected by panic disorders?

A

2-3x more common in females
Bimodal: peaks at 20yo and 50yo

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29
Q

What increases the risk of suicide in anxiety disorders?

A

comorbid depression, alcohol misuse or substance misuse

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30
Q

Concurrent agrophobia is common in which anxiety disorder?

A

Painic disorder

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31
Q

iClinical features of panic disorder?

A

Breathing difficulties

Chest discomfort

Palpitations

Tingling or numbness in hands, feet or around the mouth: Hyperventilation blows off CO2, raising pH, Calcium binds to albumin leads to hypocalcaemia. If extreme, carpopedal spasm (curling of fingers and toes can occur)

Shaking, sweating, dizziness

Depersonalization/ derealisation

Can lead to fear of situation where panic attacks occur or agoraphobia

Conditioned fear of fear pattern develops

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32
Q

Differential diagnoses of panic disorder?

A

Other anxiety disorders: GAD and agoraphobia

Depression (if depression precedes or criteria for depression fulfilled, it takes precedence)

Alcohol or drug withdrawal

Organic causes: CVS or respiratory disease.

Others: hypoglycaemia, hyperthyroidism.

Rarely: pheochromocytoma.

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33
Q

Physiological management of panic disorder?

A

Reassurance

CBT effective in 80-100%

CBT is first line

Initial education about nature of panic attacks and fear of fear cycles

Cognitive restructuring; detecting flaws in logic

Interoceptive exposure techniques such as controlled exposure to somatic symptoms(breathing in CO2 and physical exercise)

Secondary agoraphobic avoidance: treat by situational exposure and anxiety management techniques

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34
Q

Drug management of panic disorder?

A

SSRIs are first line drug treatment (but 2nd line to CBT)

Also, clomipramine (tricyclic with similar action on serotonin) is effective

Prognosis
50-60% remit with medication; 80-100% with CBT

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35
Q

Features of mixed anxiety and depressive disorder?

A

ICD-10 criteria: symptoms of anxiety and depression are both present but neither clearly predominates

Treat with counselling, cognitive therapy or psychotherapy, especially interpersonal therapy

Treating the depression usually relieves anxiety symptoms (SSRIs are best)

36
Q

Features of specific/isolated phobias?

A

ICD-10 criteria: restricted to highly specific situations such as proximity to particular animals, heights, thunder, flying, blood etc

Often clear in early adulthood

Result in avoidance

Phobias of blood and bodily injury lead to bradycardia and hypotension upon exposure

Severity depends on effect on quality of life ( pilots afraid of flying)

Always exclude co-morbid depression

37
Q

Features of agoraphobia?

A

ICD-10 criteria: Fear not only open spaces but also of related aspects, such as the presence of crowds and difficulty of immediate easy escape back to a safe place, usually home (may occur with or without panic disorder)

Commonly in 20s or mid-thirties
May be gradual or precipitated by a sudden panic attack

Comorbid depression is common (be wary of drugs and alcohol to overcome)

Also higher incidence of sexual problems

38
Q

Agoraphobia differentials

A

Depression
Social phobia
Obsessive Compulsive Disorder
Schizophrenia (may stay because of social withdrawal or as a way of avoiding perceived persecutors)

39
Q

Features of social phobias

A

Most common anxiety disorder

ICD-10 criteria: Fear of scrutiny by other people in comparatively small groups (as opposed to crowds), leading to avoidance of social situations

Comparatively small = around 5-6 people (Usually 1-2 is fine)
May be specific (public speaking) or generalized (any social setting)

Physical symptoms: blushing, fear of vomiting

Symptoms include blushing (characteristic), palpitations, trembling, sweating

Can be precipitated by stressful or humiliating experiences, death of a parent, separation, chronic stress

Genetic vulnerability

May abuse alcohol or drugs (perpetuating problem)

Mental state examination: may appear relaxed as phobic object or situation not present

40
Q

Differentials for phobias

A

Shyness (in social phobia, there is fear)
Agoraphobia
Anxious personality disorder
Poor social skills/autistic spectrum disorders (will not show good skills when relaxed)
Benign essential tremor (familial, worse in social situations, responds to benzo and alcohol)

41
Q

Investigation of ?phobia

A

History and Examination
Rating scales of anxiety: Beck Anxiety Inventory and the HADs score (Hospital anxiety and Depression scale)
Social and occupational assessments for effect on quality of life
Collateral History

42
Q

Which phobias have the best outcome

A

Animal phobias

43
Q

Which phobias have the worst outcome?

A

Agoraphobias

44
Q

Management of phobias

A

Flooding (taking someone with fear of heights to a tower)

Modelling (individual observes therapist engaging with phobic stimulus)

Agoraphobia and panic disorders: CBT treatment of choice

Social phobia: CBT is the treatment of choice

Drug management
SSRIs and MAOIs (phenelzine) most useful in agoraphobia and social phobia
Tricyclic antidepressants best for those with depressive component

Agoraphobia + panic disorder: CBT first line and SSRI 2nd line

Benzodiazepines can be used before a phobic situation

B-blockers are effective if somatic symptoms predominate

45
Q

What can be used to help establish the sevrity of GAD diagnosis

A

The GAD-7 anxiety questionnaire can help establish the severity of the diagnosis

46
Q

Enviromental triggers/contributers for GAD

A

Family relationships
Friendships
Bullies/abuse
Work or school pressures
Alcohol and drug use

47
Q

The cycle of behaviours in OCD

A

The obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary improvement in the anxiety.

Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief.

This cycle continues and each time gets more engrained in the person’s behaviour.

Without doing the compulsions, the person feels they cannot get relief from their anxiety.

The obsessions and compulsions are present on a daily basis and are not something the person will enjoy or do willingly. They impact on other areas of life, such as their social life or other interests.

48
Q

What is meant by the term ‘anxiety’

A

Anxiety can be defined as a constellation of psychological and physiological responses to a potential/uncertain threat and is an essential function of the central nervous system (CNS).

It is analogous to pain in that it is an unpleasant experience which exists to automatically motivate us to avoid harm.

49
Q

What is ‘trait anxiety’?

A

“Trait anxiety” is your propensity to experience the anxiety response when exposed to a stressor.

It is a stable characteristic arising from a multitude of genetic and environmental factors, particularly adaptive responses to experiences of potential threat during development (for instance bullying, trauma, neglect or parental loss), as well as the nature of early attachment relationships.

These experiences ‘calibrate’ the CNS response to a threat in adulthood.

As you would expect, high trait anxiety confers a greater survival advantage

50
Q

State anxiety vs trait anxiety

A

“State anxiety” is simply the state of feeling anxious, as opposed to ‘trait anxiety’ which is the propensity to experience anxiety when exposed to a stressor

51
Q

Clinical signs that may be present in anxiety?

A

tachycardia,
tachypnoea,
tremor, sweating,
pallor,
pupil dilation

52
Q

What is rumination?

A

Rumination (continuously thinking about the same thing) occurs in various psychiatric disorders, and the process of recurrently thinking through possible catastrophic outcomes of one’s situation (also known as worrying) is another function of state anxiety which we can assume was useful in evolutionary terms; it is thought to represent an automatic attempt at problem-solving, which serves to maintain a state of vigilance for potential danger.

However, in the context of anxiety disorders, it may further increase state anxiety.

53
Q

What are the neurophysiological changes underpinning anxiety?

A

Reduced functional connectivity between the prefrontal cortex and the limbic system (especially the amygdala and anterior cingulate cortex): these connections are thought to subserve conscious control/awareness of emotional states.

Single nucleotide polymorphism variations in 5-HT (serotonin) transporter, resulting in diminished 5-HT signalling: this is the basis of the “Monoamine Hypothesis” of anxiety and depression and is the target of the most widely used antidepressants, the selective serotonin reuptake inhibitors.

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis: this is the term used to describe the self-regulating neuronal and hormonal interaction between the hypothalamus, the pituitary gland and the adrenal glands, which is a central component of the physiological response to stress (see here for more information).

54
Q

To meet the criteria for any anxiety order, what features of symptoms must be present?

A

Persist for several months, on more days than not
Result in significant impairment (in personal, family, social, educational, occupational, or other important areas of functioning)
Not be a manifestation of another health condition or the effects of a substance/medication

55
Q

Common features of GAD?

A

Subjective experience of nervousness
Difficulty maintaining concentration
Muscular tension or motor restlessness
Sympathetic autonomic over-activity
Irritability
Sleep disturbance.

56
Q

Common features of phobic anxiety disoders

A

Anticipatory anxiety (about exposure to precipitant, and about anxiety itself)
Somatic symptoms (e.g. palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, chills, hot flushes)

57
Q

Characteristic features of anxiety disorders?

A

A crescendo of anxiety, usually resulting in exit from the situation
Somatic symptoms (e.g. palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, chills, hot flushes)
Secondary fear of dying/losing control (often related to the somatic symptoms)

58
Q

Stepwise general treatment of anxiety disoders?

A

Psychoeducation, sleep hygiene, and self-guided cognitive-based therapy (CBT)/ relaxation techniques: it may be helpful to acknowledge that these can appear basic/low intensity, but emphasise their evidenced effectiveness for mild/moderate anxiety if done regularly.

CBT: identifying then gradually unlearning the maladaptive patterns of thought/behaviour which are perpetuating symptoms. A CBT practitioner may employ techniques such as exposure therapy (allows extinction of erroneously learned fears) and applied relaxation.

Pharmacological (equal 1st line with CBT). SSRI (e.g. escitalopram or sertraline), SNRI (e.g. duloxetine or venlafaxine) or atypical antidepressant (e.g. Mirtazapine) with the choice depending on side-effect profile.

59
Q

When might benzodiazepines be suitable to manage anxiety disorders?

A

They can be used for transient causes of anxiety (ie. fear of flying) or in crisis only, maximum of 2 weeks prescription advised.

60
Q

HARD - charecteristic features of PTSD?

A

Hyperarousal: persistently heightened perception of current threat (may include enhanced startle reaction)

Avoidance of situations/activities reminiscent of the events, or of thoughts/memories of the events

Re-experiencing the traumatic events (vivid intrusive memories, flashbacks, or nightmares).

Distress: strong/overwhelming fear and physical sensations when re-experiencing

61
Q

What is C-PTSD

A

C-PTSD is a disorder that may develop following exposure to series of extremely threatening/horrific events, commonly prolonged or repetitive situations from which escape is difficult (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

C-PTSD can be thought of as a constellation of significant modifications to a person’s automatic threat response, occurring because of having to adapt to prolonged/repetitive trauma.

62
Q

Criteria for C-PTSD?

A

Characteristic features of C-PTSD include all diagnostic requirements for PTSD (above), plus:

Severe and persistent problems in affect regulation

Severe and persistent low self-worth, accompanied by feelings of shame/guilt/failure related to the traumatic events

Severe and persistent difficulties in sustaining relationships and in feeling close to others.

63
Q

Obsessive-compulsive or related disorders are a group of disorders characterised by repetitive thoughts and behaviours, including what?

A

Obsessive-compulsive disorder (OCD)
Body dysmorphic disorder (BDD)
Body-focused repetitive behaviour disorders (ie. trichotillomania, dermatillomania)
Hypochondriasis (health anxiety disorder)
Hoarding disorder

64
Q

What is acute distress disorder and how does it differ from PTSD?

A

Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc).

This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.

65
Q

Features of acute stress disorder

A

intrusive thoughts e.g. flashbacks, nightmares

dissociation e.g. ‘being in a daze’, time slowing

negative mood

avoidance

arousal e.g. hypervigilance, sleep disturbance

66
Q

Management of acute stress disorder

A

trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line

benzodiazepines
- sometimes used for acute symptoms e.g. agitation, sleep disturbance
- should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation

67
Q

Acute stress reaction vs adjustment disorder?

A

The key difference between these conditions is that an acute stress reaction will typically follow a highly stressful event, whereas with adjustment disorder, the stressor need not be severe or outside the “normal” human experience.

For example, the difference between seeing a fatal car accident vs being made redundant.

68
Q

What is adjustment disorder?

A

A state of emotional distress and disturbance usually interfering with social functioning arising in a period of adaptation to a significant life change or stressful life event such as bereavement or separation

69
Q

What is the definition of a neurotic disorder?

A

Neurosis refers to a class of functional mental disorder involving distress but not delusions or hallucinations, where behavior is not outside socially acceptable norms

70
Q

When does autonomic response cause anxiety disorders

A

Symptoms and pathological response/arousal remain increased disproportionate to the treat

71
Q

Phobias

A

Anxiety in particular cirumstances, leading to avoidance
Anticipatory anxiety, cannot be reasoned away
Crowds, living things, natural phenomena
Self help, medication, CBT

72
Q

Common triggers for agoraphobia

A

Distance from home
Crowding
Open space
Social situations

73
Q

Peak of onset of agoraphobia?

A

20s and 30s

74
Q

SSRIs - advantages

A

SSRIs are widely used due to their relatively little effect on other neurotransmitters including dopamine, noradrenaline, histamine, and acetylcholine. This limits the side-effect profile and improves concordance.

75
Q

Which anxiety disorder is not more common in women?

A

Social phobias - gender mix

76
Q

What is a social phobia commonly associated with

A

Substance misuse

77
Q

Phobia vs panic disorders?

A

Phobia - trigger, symptoms only related to specific trigger

Panic - no trigger

78
Q

According to NICE, if a person presents in A&E with a panic attack, they should:

A

be asked if they are already receiving treatment for panic disorder

undergo the minimum investigations required to exclude acute physical problems

not usually be admitted to a medical or psychiatric ward

be reffered to primary care for subsequent management even if assesment has been undertaken in a and e

be offered appropriate written information about sources of support, including local and national voluntary self-help groups

79
Q

What are Egodystonic thoughts

A

Unpleasent/distressing thoughts

80
Q

Thoughts in OCD

A

Thoughts - reccurent ideas, images, impulsion
Distressing
Patient tries to resist, recognises thoughts as their own — insight

81
Q

OCD pathophysiology

A

Cortical-subcortical re-entrant circuits and recurrent behaviour

Recurrent symptoms occur as a result of incoordination between phasic subcortical inputs and synaptic gating processes in cortical-subcortical circuits.

Excess arousal

82
Q

Which part of the brain is responsible for the flight of fight response

A

The amygdala

83
Q

GAD risk and protective factors?

A

Risk factors for the development of GAD include;

Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent

Protective factors include;

Aged 16 - 24
Being married or cohabiting

84
Q

What is a diphasic response

A

Vaso-vagal syncope caused by an overcompensating rebound parasympathetic activation following sympathetic arousal

Most anxiety responses involve sysmpathetic drive , with an increase in heart rate, etc. that is not going to lead to fainting (syncope). Blood-injury phobia is the classical exception an syncope (vaso-vagally mediated) can occur due to a biphasic response. (NOTE: not everyone with blood-injury phobia faints)

85
Q

Psychological therapy for PTSD

A

“Consider EMDR for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented between 1 and 3 months after a non-combat-related trauma if the person has a preference for EMDR.
Offer EMDR to adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a non-combat-related trauma.”

86
Q

Cognitive theory suggests what as the most significant underlying factor in anxiety disorders?

A

Catastrophic misinterpretation (usually of somatic symptoms) is the key component in panic disorder (and is vital to explain the mechanism of panic). In other anxiety problems patients tend to have a higher perception of threat and of an adverse outcome (i.e. they forsee the worst happening in the future)

Year 4 Psychiatry (18 decks)

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