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Anxiety Disorders Flashcards

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1
Q

What is Generalised Anxiety Disorder (GAD)?

A

Excessive and uncontrolled anxiety about everyday things i.e. money, health, family, work, relationships.

Must be:

  • Persistent
  • Excessive
  • Unreasonable
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2
Q

Describe the different severities of GAD

A

Mild > Normal social function
Severe > Difficulty with simple daily activities

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3
Q

What is the DSM-V diagnostic criteria for GAD?

A
  1. Excessive anxiety/worry about everyday issues for at least 6 months that is disproportionate to any inherent risk, and causes distress, or impairment
  2. Associated with 3 symptoms (1 in children)

Also - worry not due to mental disorder, substance abuse, other condition.

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4
Q

What is the aetiology of GAD?

A

Biological

  • Genetic predisposition

Psychosocial

  • Current stress, life events
  • Childhood experiences (separations, demands for high achievement, excessive conformity)
  • History of trauma
  • Divorced
  • Lone parent
  • Living alone
  • F > M
  • Begin <25yrs
  • Substance abuse
  • Chronic painful illnesses
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5
Q

What are the S/S of GAD?

A

Psychological

  • Frequent worry and tension
  • Restlessness / edginess / irritability
  • Impaired concentration / mind goes blank

Physical

  • Insomnia / difficulty sleeping
  • Muscle aches / pain / tension
  • Constipation / diarrhoea / nausea
  • Autonomic - palpitations / sweating / dry mouth / trembling / tachycardia / tachypnoea
  • Difficulty breathing / choking sensation / CP
  • Dizziness / light headedness / fear

> 3 required for diagnosis

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6
Q

What are the investigations for GAD?

A
  • GAD-7 questionnaire (5 = mild, 10 = moderate, 15 = severe)
  • Beck’s Anxiety Inventory
  • HADS
  • Bloods: FBC, U+Es, LFTs, Ca, TFTs
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7
Q

What is the management of GAD?

A

BIOPSYCHOSOCIAL stepwise approach

Step 1
Education & active monitoring

  • Written information on GAD
  • Online resources
  • Regular exercise

Step 2
Low-intensity psychological interventions:

  1. Non-guided self-help (individual) > 6 weeks
  2. Guided self-help (individual) > 6 weeks
  3. Psychoeducational groups > 6 weeks

Step 3
High-intensity psychological interventions +/- medication

  1. CBT > 12-15 weeks
  2. Applied relaxation > 12-15 weeks
  3. SSRI (1st line NICE = sertraline; only SSRI licensed = paroxetine)
    - Weekly follow-up due to increased risk of suicidal thinking / self-harm initially
  4. Switch to another SSRI (after 8 weeks in step 1)
  5. Switch to an SNRI (venlafaxine)
    - Weekly follow-up due to increased risk of suicidal thinking / self-harm initially
  6. Pregabalin (antiepileptic) > modulate VGCC

Step 4
Highly specialist input

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8
Q

What is a phobia?

A

An anxiety disorder defined by a persistent and excessive fear of a specific object or situation.

Leads to avoidance of the feared situation, and can lead to disability.

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9
Q

What are the S/S of a phobia?

A
  • Avoidance
  • Fear
  • Disability
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10
Q

What are the types of phobia?

A
  • Social
  • Specific
  • Agoraphobia
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11
Q

What is the aetiology of a phobia?

A
  • Genetics
  • Can occur following major life event in someone with dependent personality traits
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12
Q

What is the ICD-10 definition of agoraphobia?

A

A phobia embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes – literally means ‘fear of the marketplace’

Classified WITH or WITHOUT a panic disorder

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13
Q

What are some ‘problem situations’ for agoraphobia?

A

Travelling (trains, buses, etc.), queueing, supermarkets, crowds, parks

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14
Q

Describe the epidemiology of agoraphobia

A
  • Age of onset = 20-35yo
  • Onset often follows a precipitating event, which may be a panic attack, which leads to avoidance, or can be gradual
  • F>M
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15
Q

What are the S/S of agoraphobia?

A
  • Panic attacks
  • Anxiety symptoms: palpitations, sweating, shaking, dry mouth, difficulty breathing, chest pain, nausea, dizziness, hot flushes, fear of losing control, fear of dying
  • The patient may feel better if accompanied by someone else
  • Becomes dependent on someone else
  • Avoidance of phobic situations ± isolation behaviour
  • Associated features: depressive/obsessional symptoms, social phobias

N.B. some agoraphobics may have little anxiety because they can avoid specific triggers well

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16
Q

What is the management of a phobia?

A

Step 1. = Education, reassurance and self-help

Step 2. = CBT with Exposure Response Prevention (ERP)

  • ‘Desensitisation approach’
  • (1) Pt. identifies goal (i.e. holding a slug) and constructs hierarchy of feared situations
  • (2) Pt. tackles hierarchy from least to most frightening
  • (3) Aim to stay in situation until anxiety subsided > challenges existing thoughts

Step 3. = Medication

  • SSRIs
  • Beta blockers
  • Short-course BZN (only in urgent situations e.g. high risk to self / others, or for certain specific phobias i.e. dental injections)

Also:

  • +/- Relaxation therapy and breathing techniques
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17
Q

What is a social phobia / social anxiety disorder?

A

Fear scrutiny by other people leading to avoidance of social situations - associated with low self-esteem

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18
Q

What is the difference between social phobia and agoraphobia?

A

People with SAD will tolerate anonymous crowds, unlike agoraphobics, but smaller groups may spike anxiety

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19
Q

What are the S/S of a social phobia / SAD?

A
  • Blushing, hand tremor, nausea or urinary urgency in social situations (i.e. explore situations)
  • Self-medicate with alcohol or drugs (to desensitise)
  • Panic attacks
  • Social withdrawal
  • Alcohol abuse more common
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20
Q

What is a specific phobia?

A

Phobias restricted to highly specific situations such as proximity to slugs or snails.

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21
Q

Describe the epidemiology of specific phobias

A
  • COMMON
  • Begin in childhood
  • F > M
  • May have a FHx of phobia (indicating a negative reinforcement as a child or classical conditioning)
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22
Q

What are the S/S of a specific phobia?

A
  • Contact can evoke panic (e.g. barricading bedroom, screaming at housemates)
  • Most phobias lead to tachycardia, but blood or injury phobia cause an initial tachycardia followed by vasovagal bradycardia and hypotension > may cause nausea and fainting
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23
Q

Should you treat anxiety/phobias with BZN or antidepressants?

A
  • NEVER treat anxiety with BZN as there is a high risk of dependence (short-term in specific phobia is ok)
  • Specific Phobias do NOT respond well to antidepressants
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24
Q

What is the definition of panic disorder?

A

Sudden, unexpected, recurrent panic attacks not triggered by a specific stimulus, which give rise to excessive and dysfunctional anxiety, even between attacks.

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25
Q

What are the S/S of a panic attack?

A
  • Fear of suffocating / dying
  • Hyperventilation
  • Sweating / dizziness / palpitations
  • Chest discomfort
  • Desire to flee
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26
Q

What are the S/S of panic disorder?

A
  • Sudden, unexpected onset of panic attack
  • Usually last ≤30 minutes (anywhere from 1 minute - 1 hour)
  • Several within a month
  • Alarming thoughts (i.e. I’m going to die) provoke further panic until reassurance or engagement in ‘safety behaviour’ occurs (i.e. call ambulance, take aspirin, etc.)
  • In between episodes, relatively fine with minimal anxiety

> Panic disorder should not be main diagnosis if a depressive disorder exists at the time attacks start

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27
Q

What are the investigations for panic disorder?

A
  • Good history & collateral history
  • Rule out organic causes (thyroid, alcohol/drug withdrawal)
  • Urine drug screen
  • Bloods: TFTs, LFTs, glucose
  • ECG
  • Rating scales of anxiety e.g. BAI and HADS
28
Q

What is the management of panic disorder?

A

Biopsychosocial; stepwise

Step 1:
Education, reassurance and self-help

Step 2:
Low-intensity psychological intervention:

  1. Self-help (individual, non-guided)
  2. Self-help (individual, guided) > weekly therapist appointment

Step 3:
High-intensity psychological intervention ± medications

  1. CBT ± SSRI (Citalopram)
  2. (After 12w): Switch to TCA (imipramine)
    BZN not recommended due to risk of tolerance and dependance

Step 4:
Refer to specialist

29
Q

What is OCD?

A
  • Obsessions and/or compulsions, present on most days for ≥2 consecutive weeks
  • Must be a source of stress ± interfere with ADLs
30
Q

What is an obsession?

A

Recurrent and persistent unwanted intrusive thoughts/images/urges that repeatedly enters the person’s mind, despite attempts to resist them

  • Self recognised as a product of own mind
  • Thoughts of carrying out the act are not pleasurable
  • Thoughts must be unpleasantly repetitive
  • Themed commonly - contamination, aggression (to self or others), infection, sex, religion
  • Egodystonic (themes/ideas against that which the person associates with their ego)
31
Q

What are compulsions?

A

Repetitive behaviours or mental acts that the person feels driven to perform

  • Can be overt and observable by others (e.g. checking that a door is locked), OR
  • Can be a covert mental act that cannot be observed (e.g. repeating a certain phrase in one’s mind)
  • Compelled to perform in response to own obsessions or irrationally defined rules
  • Performed to reduce anxiety through irrational belief they will prevent a dreaded event
32
Q

What are some types of compulsions?

A
  • Cleaning
  • Repeating
  • Checking
  • Ordering & arranging
  • Mental rituals
33
Q

What are the differential diagnoses of OCD?

A

Obsessions & compulsions

  • Body dysmorphic disorder (appearance preoccupation)
  • Anankastic personality disorder

Mainly obsessions

  • Depressive disorder (Beck’s -ve triad, 50% OCD co-morbid)
  • Other anxiety disorders
  • Hypochondriacal disorders
  • Schizophrenia

Mainly compulsions

  • Habit and impulse control disorders
34
Q

What are the RFs for OCD?

A
  • Genetic / FHx
  • Psychological trauma
  • Paediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)
  • M > F (only anxiety disorder to affect men more than women)
  • Mainly <25yrs
35
Q

What conditions are associated with OCD?

A
  • Depression (30%)
  • Schizophrenia (3%)
  • Premorbid anankastic personality (25%)
  • Sydenham’s chorea
  • Tourette’s syndrome
  • Anorexia nervosa
  • Encephalitis lethargica
36
Q

What are the investigations for OCD?

A
  • Bloods: FBC, TSH
  • Rating scale (Yale-Brown OCD scale)
  • OCD screening questions… ask these to check for OCD

Do you wash or clean a lot?
Do you check the time a lot?
Is there any thought that keeps bothering you that you would like to get rid of?
Do your daily activities take a long time to finish?
Are you concerned about putting things in a special order or are you very upset by a mess?
Do these problems trouble you?

37
Q

What is the management of OCD?

A

If functional impairment is mild:

  • Low-intensity psychological treatments: CBT with ERP
  • If insufficient or can’t engage in psychological therapy, offer choice of SSRI or more intensive CBT (including ERP)

If moderate functional impairment:

  • SSRI or more intensive CBT (including ERP)

If severe functional impairment:

  • Combined treatment with an SSRI and CBT (including ERP)
38
Q

What is ERP?

A

CBT: Exposure and Response Prevention

  • CBT aims to prevent compulsive behaviour, allowing the tolerated anxiety to habituate
  • E.g. someone with obsessions about contamination is supported to touch something dirty and instead of immediately washing their hands, they are encouraged to experience anxiety and discuss it with the therapist
  • A hierarchy of feared situations is used
  • Effective in well-motivated patients
39
Q

What is the prognosis of OCD?

A
  • OCD has a chronic course with symptoms worsening at times of stress
  • Often disabling
40
Q

What is acute stress disorder/reaction?

A

A transient disorder of significant severity which develops in an individual without mental disorder in response to a severe stressor.

41
Q

What are examples of severe stressors?

A

War, natural disaster, threatened death, death of a relative, serious injury e.g. road traffic accident, sexual assault etc

42
Q

What is the duration of ASD?

A
  • Onset of symptoms is within minutes
  • DSM-V says symptoms must last for ≥3 days (usually subsides within hours/days)
  • If symptoms last >1 month, consider diagnosis of PTSD

Typical case – someone has just been told their family has died in a plane accident and they go into an acute stress reaction

43
Q

What are the differences between ASD and PTSD?

A

Although ASD and PTSD both begin with an acute stressor, ASD differs from PTSD in…

  • PTSD is diagnosed based on symptoms in clusters, not in totality
  • PTSD has a dissociative sub-type however, in ASD, depersonalisation and derealisation are symptoms
  • PTSD includes non-fear-based symptoms (i.e. risky behaviour) whereas ASD does not
44
Q

What are the S/S of ASD?

A

Key Features:

  • Initial state of daze (may manifest as stupor)
  • Constriction of consciousness field
  • Narrowing of attention
  • Inability to comprehend stimuli; disorientation

Other symptoms:

  • Autonomic signs of panic (fight or flight) – occur in minutes of stimulus and disappear in hours/days
  • Tachycardia, tachypnoea, sweating, hypertension, hyperactive
  • Partial or complete amnesia may be present
  • Depersonalisation
  • Derealisation
  • Intrusive thoughts e.g. flashbacks, nightmares
  • Negative mood
  • Avoidance
  • Arousal e.g. hypervigilance, sleep disturbance
45
Q

What are the investigations for acute stress disorder?

A
  • Full history (and MSE if indicated) and collateral history
  • Exclude injury
  • Must be a clear history between stressor and reaction
46
Q

What is the management of acute stress disorder?

A
  • Self-limiting
  • Support and reassurance
  • Trauma-focused CBT is usually used first-line
  • BZN may alleviate short-term distress / sometimes used for acute symptoms e.g. agitation, sleep disturbance

> BZN do not prevent later PTSD

47
Q

What is adjustment disorder?

A

ICD-10: States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event

Typical case = student just moved to university and has feels so homesick they’re unable to make friends or do anything however, there is no impact on sleeping, appetite, energy levels and no suicidal ideation, etc.

48
Q

What is the duration of adjustment disorder?

A
  • Beginning within 1 month of the stressful event
  • Not lasting longer than 6 months
49
Q

What are the RFs for adjustment disorder?

A
  • Divorce, unemployment, starting uni etc
  • ~20% of patients attending a psych OPD could be diagnosed with adjustment disorder
50
Q

What are the S/S of adjustment disorder?

A

Consider an associated conduct disorder… (esp. in adolescents)

  • Precipitated by a psychological stressor
  • Depressed mood (without biological sx of depression)
  • Anxiety (not severe enough to diagnose anxiety/depression)
  • Feeling of inability to cope
  • Disability in the performance of daily routine
  • May have increased autonomic arousal (increased BP / HR)
  • May be preoccupation with the event
  • Concentration may be poor
51
Q

What is grief reaction?

A

Can be normal or abnormal and/or prolonged…

Normal = recognisable sequence of stages that can last up to 2 years

Abnormal / Prolonged = delayed onset, greater intensity of symptoms or prolongation of the reaction

  • Preoccupation with negative thoughts, suicidal ideations, hallucinatory experiences
  • More likely when relationship with deceased was problematic or there was a sudden death
52
Q

What are the 5 stages of grief?

A
  1. Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
  2. Anger: this is commonly directed against other family members and medical professionals
  3. Bargaining
  4. Depression
  5. Acceptance
53
Q

How is grief reaction distinguished from depression?

A
  • The sadness and symptoms are focussed around the person that was lost
  • In depression, the symptoms are more free-floating and not focussed on anything in particular
54
Q

What are the investigations for adjustment disorder?

A
  • Full history and collateral history
  • MSE (if indicated)
55
Q

What is the management of adjustment disorder?

A

Support, reassurance and problem-solving are often all that is required…

  • Biological = antidepressants, anxiolytics/hypnotics
  • Psychosocial = group or individual therapy (teaching about coping mechanisms and problem- solving techniques)
56
Q

What is the management of abnormal/prolonged grief reaction?

A
  • Biological = antidepressants
  • Psychosocial = supportive counselling
57
Q

What is the prognosis of adjustment disorder?

A
  • Short-term interruption to life
  • Symptoms usually improve after resolution of cause
58
Q

What is PTSD?

A

Serious anxiety disorder arising in response to a stressful event of an exceptionally threatening/catastrophic nature, which is likely to cause pervasive distress in almost anyone.

59
Q

What is the duration of PTSD?

A
  • Must last >1 month
  • Often begins within 6 months of trauma (often within the 1st month of the trauma)
60
Q

What are the RFs for PTSD?

A

BIO

  • FHx
  • Female
  • Genetics
  • Neuroanatomy

PSYCHOSOCIAL

  • Traumatic events
  • Neurotic personality type
  • Low social class
61
Q

What are the S/S of PTSD?

A

Key areas:

  1. Intrusive memories / reliving (flashbacks, nightmares, repetitive images, physical sensations)
  2. Avoidance of triggers (activities and situations reminiscent of the trauma)
  3. Hyperarousal (hypervigilance, enhanced startle reflex, insomnia, irritability, cannot relax, tense)
  4. Negative thinking & mood (about themselves and others, emotionally numb, lack of interest, unable to function)

Other:

  • Mental health problems – depression, anxiety, phobias
  • Self-harming or destructive behaviour / drug or alcohol misuse
  • Physical symptoms – headaches, dizziness, chest pain, stomach aches
62
Q

What are the investigations for PTSD?

A
  • Full history
  • Trauma Screening Questionnaire (10 questions; measure re-experiencing and arousal symptoms)
  • Screen for co-morbid psychiatric disorders and conduct risk assessment (suicide neglect)
63
Q

Can PTSD be prevented?

A

If the event occurred <1m to presentation, PTSD can be prevented with:

  • Cognitive processing therapy
  • Cognitive therapy for PTSD
  • Narrative exposure therapy
  • Prolonged exposure therapy.
64
Q

What is the management of PTSD?

A

Begin by classifying level of functional impairment as: mild, moderate or severe

N.B. immediate post-trauma formal debriefing actually increases future risk of PTSD, so not recommended

1. Watching waiting

  • Offered for mild PTSD (symptoms <4 weeks)
  • Treat co-morbid conditions (i.e. depression)
  • Arrange follow up in 1 month

2. Trauma-focused CBT with ERP

  • Offered for moderate-severe PTSD or presenting >1m
  • Traumatic event can shatter previous belief systems (e.g. the world is an unsafe place, I am vulnerable)
  • These thoughts can be examined and tested
  • Exposure therapy is important (support the patient to work through their memories)
  • Usually 8-12 regular session
  • Can be computerised if the patients would prefer not to do it F2F

3. Eye Movement Desensitisation and Reprocessing (EMDR)

  • Offer if moderate-severe PTSD or >3m after non-combat-related event
  • Patient recalls experience in as much detail as possible in a state of relaxation, whilst their eyes are fixed on the therapist’s finger as it moves from side to side > aids memory processing

Pharmacological management: (not routinely recommended)

  • 1st line: SSRIs (sertraline) or SNRI (venlafaxine)
  • 2nd line: Consider atypical antipsychotics (e.g. risperidone) in addition to psychological therapies if they have failed to respond to other drug treatment or have disabling symptoms/behaviours (e.g. hyperarousal)
  • Avoid BZNs

Group Therapy
Involves meeting and speaking with other people who have had similar experiences

65
Q

What is the management of chronic fatigue syndrome?

A
  • Graded exercise (scheduled and gradually increasing activity)
  • Patients need realistic goals and should not do more activity than planned
  • CBT improves fatigue and physical functioning
66
Q

What is the mechanism of action of BZNs?

A

Enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.

67
Q

What is a SE of BZN?

A

Anterograde amnesia

Psych (18 decks)

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