Anxiety disorders

Question 1

Define anxiety

Answer 1

NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’

Question 2

physical differentials for GAD

Answer 2

alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety, phaemochromocytoma, paroxysmal tachycardia, meniere’s disease, demetnia, MS, lupus, infection, anaemia

Question 3

medications that can trigger anxiety

Answer 3

salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Question 4

management of GAD

Answer 4

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. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams

Question 5

first line pharmacological tx of GAD

Answer 5

sertraline
other options - SNRI (duloxetine, venlafaxine), pregablin

Question 6

sertraline risks <30 yr patients

Answer 6

weekly follow up for first month

Question 7

management of panic disorder

Answer 7

CBT or drug therapy
SSRI’s first line, then <12 weeks, imipramine/clomipramine

Question 8

types of anxiety disorders

Answer 8

• continuous/GAD
• Phobia anxiety disorder -> specific isolated phobia, social phobia, agorophobia
• Panic disorder/episodic
• Agoraophobia with panic
  -PTSD
• Health anxiety (hypochondriasis)
• OCD
• Body dysmorphic disorder

Question 9

prevalence of anxiety disorders

Answer 9

common
most severe condition - GAD as half of pts require tx
younger women
phobias - younger onset

Question 10

GAD sx

Answer 10

apprehension, difficult concentrating, motor tension (restless, fidget, tension headaches),
autonomic overactivity - dry mouth, loose stools, tight chest, palpitation, mictruition urgent, erectile dysfunction, amenorrhoea, tremor, tinnitus, insomnia

Question 11

define panic disorder - with or without agoraophobia

Answer 11

a fear of your own physiological and psychological reactions
bodily changes = impending collapse, insanity or death
if then avoid situation - ie: outside world = agoraphobia

Question 12

GAD

Answer 12

maintained by belief worry is useful

Question 13

social anxiety disorder

Answer 13

fear of negative evaluation by others…avoidance, safety behaviours

Question 14

OCD

Answer 14

unwanted recurring distressing intrusive thoughts or images = obsessions….attaching significance to an intrusive thought
- ego dystonic -> not fit with individuals moral and personality…‘thinks harming patients’
to neutralise distress = compulsions (overt - washing, covert - counting in head)

Question 15

Body dysmorphic disorder

Answer 15

preoccupation with an imagined defect in appearance…time consuming behaviours

Question 16

prevalence OCD

Answer 16

103% of population

Question 17

risk fx for OCD

Answer 17

family history
age: peak onset is between 10-20 years
pregnancy/postnatal period
history of abuse, bullying, neglect

Question 18

severity of OCD

Answer 18

Y-BOCS scale
mild, mod or severe
severe - >3 hrs a day

Question 19

treatment OCD

Answer 19

mild - CBT in exposure and response prevention
SSRI or more intense CBT
moderate - SSRI or clomipramine
severe - refer to secondary care mental health for assessment + SSRI + CBT
NOTE - SSRI’s usually require higher dose than for depression

Question 20

SSRI choice for body dysmorphic disorder

Answer 20

fluoxetine

Question 21

CBT with ERP

Answer 21

psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Question 22

PTSD cause

Answer 22

can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse. It

Question 23

PTSD diagnostic criteria

Answer 23

symptoms have been present for more than one month.

Question 24

features of PTSD

Answer 24

re-experiencing - flashbacks, nightmares
avoidance - people, situations
hyperarousal - hypervigilance for threat, exagerrated response, sleep problem
emotional numbing

other features
- depression
- drug/alcohol misuse
- anger
- unexplained physical sx

Question 25

PTSD management

Answer 25

<4 weeks - watchful waiting
military personnel - tx by armed force
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy - more severe cases
drug treatments for PTSD should not be used as a routine first-line venlafaxine or a selective serotonin reuptake inhibitor (SSRI),. In severe cases, NICE recommends that risperidone may be used

Question 26

benzodiazepines

Answer 26

can be used in PTSD alongside SSRI when waiting to work
generally avoid as dependence

Question 27

benzodiazepine mechanism

Answer 27

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

Question 28

benzodiazepines uses

Answer 28

sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant

Question 29

how long prescribed benzo

Answer 29

2-4 weeks

Question 30

benzo withdrawn

Answer 30

The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight
—> insomnia, irritability, anxiety, tremor, loss of appetite, tinnitus, perspiration, perceptual disturbances, seizures

Question 31

benzo v barbiturates mechanism

Answer 31

benzo - frequency
barbit - duration
FREQUENCY BEND - DURING BARBEQUE

Question 32

acute stress disorder

Answer 32

first 4 weeks after person has been exposed to a traumatic event
- negative mood, flashbacks, dissociation
tx with trauma focused CBT or benzo