Anxiety Disorders Flashcards
General anxiety affects X areas of the body
6:
- Brain
- Heart
- Lungs
- GIT
- GU system
- Muscles
Anxiety symptoms affecting the brain
Feeling of worry
Poor concentration
Depersonalisation
Derealisation
Irritability
Poor sleep
Anxiety symptoms affecting the muscles
Tremor
Headache
Muscle ache
Restlessness
Anxiety symptoms affecting the GIT
Dry mouth
Flatulence
Frequent/loose stools
Indigestion
Anxiety symptoms affecting the heart
Palpitations
Chest discomfort
Anxiety symptoms affecting the lungs
SOB - tachypnoea can cause pins and needles
Dizziness
Constricted chest
Anxiety symptoms affecting the GU system
Incontinence
Amenorrhoea
Erectile dysfunction
GAD typically affects X year olds
35-54
Other risk factors for GAD include
Divorced or lone parent
Living alone
Female
Low SES
Poor education
Unemployment
Protective factors for GAD include
Cohabiting
16-24 year old
Marriage
The main tool we use to assess GAD in PC is the
GAD-7
Other tools we may use to assess GAD include
HADS
Becks anxiety Inventory
GAD-7 scoring
0-21
5-9 = Mild anxiety
10-14 = Moderate anxiety
15+ = Severe anxiety
The NICE stepwise approach to managing GAD
1 - Psychoeducation + active monitoring
2 - Low level psychological intervention
3 - High level psychological intervention + drug intervention
4 - Referral for specialist assessment
Low intensity psychological interventions include
Individual non-guided self help - 6 weeks
Individual guided self help for 6 weeks
Psychoeducational groups for 6 weeks
High intensity psychological interventions include
CBT for 12-15 weeks
Applied relaxation
Skip straight to step 3 of GAD management if
Marked functional impairment at presentation or pregnant woman with GAD
First line drug treatment for GAD
Sertraline
If sertraline doesn’t work in GAD, we should switch to
alternative SSRI or SNRI
If SSRI/SNRI isn’t tolerated well in GAD, offer
pregabalin
SSRI/SNRI use in pregnant women
after week 20 of pregnancy it will increase the risk of PPHN therefore aim to treat with lowest effective dose
When should <30 year olds be reviewed if started on SSRI/SNRI
After 1 week due to increased suicide risk - everyone else should be reviewed 4/6 weeks after starting.
In what anxiety disorders are males = females epidemiologically
OCD
BDD
Social anxiety disorder
How long does stress after trauma need to last to be PTSD - when does it need to occur
Needs to occur within 6 months of the trauma, needs to last more than 1 month to be called PTSD. Onset is typically delayed (latency period)
What are the 3 key domains of PTSD symptoms
Re-experiencing
Avoidance
Hyperarousal
PTSD re-experiencing symptoms include
Flashbacks
Memories
Repetitive thoughts/nightmares
PTSD avoidance includes
Avoiding people/situations related to trauma
PTSD can also cause negative cognition such as
Self harm, substance abuse
Depression and anxiety
Numbness, anhedonia
Headaches, dizziness, GI upset
PTSD hyper-arousal includes
Easy to startle
Insomnia
Hypervigilance
Irritable/restless
PTSD investigation
Trauma screening questionnaire
PTSD sub threshold management
Watchful waiting if mild symptoms within a month of trauma
Arrange within 1 month - add follow up at 1 month to see progress
PTSD mainstay management
- Trauma focused CBT
- EMDR used in more severe cases
- Drug treatment if psychological therapy declined/not responded to
PTSD drug managment
SSRI or venlafaxine. Last resort = antipsychotics e.g. risperidone if non responsive.
Acute stress reaction vs PTSD
Much more rapid onset than PTSD.
Doesn’t last longer than 1 month.
Possible presentation of acute stress reaction
Initial state of daze (tunnel vision, not responding to stimuli, disorientation), followed by either further withdrawal or a state of agitation/anxiety - can get autonomic features of anxiety e.g. flushing, can also get partial amnesia
Management of acute stress reaction
- Support and reassurance
- Trauma focused CBT
- Benzodiazepnes may be used for short term distress
Self limiting condition - benzos don’t prevent PTSD
X is not recommended for management of acute stress reaction
Psychological debriefing following trauma - can increase the risk of developing PTSD
When does adjustment disorder need to occur
Within 3 months of change, doesn’t last more than 6 months.
Adjustment disorder management
Support, reassurance - maybe psychotherapy in the form of CBT or group therapy.
Symptoms of adjustment disorder
Symptoms of anxiety and depression may coexist but they will be subclinical so that neither diagnosis can be made.
OCD investigation
Yale brown obsessive compulsive scale
mild OCD management
Low intensity psychological interventions: brief CBT (10 hours- either individual self-guided or group), including ERP
moderate OCD management
More intensive CBT including ERP or can use drugs - SSRI
What does ERP involve?
Aims to allow anxiety to habituate: we trigger anxiety through introducing the obsession/thought to the patient, instead of engaging in the compulsion, they experience the anxiety. They learn to adjust to this and then we scale up the obsession trigger.
What pharmacotherapy is recommended in OCD
SSRI = first line. If they don’t work after 12 weeks we can trial alternative SSRI or clomipramine (TCA)
How does pharmacotherapy differ in OCD compared to depression
SSRI requires 12 weeks opposed to 4-6 weeks to see effects in OCD, larger dose also required therefore weaning of SSRIs in OCD needs 12 months rather than 6
Panic disorder investigations
- TFT - hyperT
- Depression screen - if depression precedes, it is not panic disorder
- UDS - substance use
- ECG - MI
- BM - hypo
Panic disorder management
- Recognition and diagnosis
- (mild-moderate). Primary care treatment: individual self help and information about support groups
- (moderate-severe): CBT + SSRI.
- 2nd line = imipramine or clomipramine (trial for 12 weeks)
- Refer to specialist MHS if 2 interventions trialled
Phobias, encompass [1,2,3] represent a cluster of anxiety disorders characterized by excessive and irrational fears.
Specific phobia, social anxiety disorder (SAD), and agoraphobia
What is needed for OCD diagnosis
- Presence of obsessions, compulsions, or both.
- Time-consuming (more than one hour a day) or causes significant impairment.
- Not attributed to another medical or mental disorder.
What are obsessions
Unwanted intrusive thoughts or images that are egodystonic and cause distress
What are compulsions
Repeated stereotyped rituals that the individual feels the need to do in order to suppress their anxiety - they can be covert or overt.
OCD prognosis
Runs a chronic course, with symptoms worsening at times of stress. Without treatment, it is disabling; 50% of cases have comorbid depression.
What are phobias
Intermittent anxiety occurs in specific but ordinary circumstances. People characteristically avoid or escape feared situations, only seeking treatment when this becomes disabling.
What is agoraphobia
Fear of large open spaces where you are unable to get to safe place (home)
Agoraphobia onset
20s- mid 30s - may be gradual or precipitated by sudden panic attack
Typical presentation of bad agoraphobia
Patient is housebound with close circle of family and friends. Comorbid depression = common
What is social phobia
Social anxiety disorder = fear of being judged by others. People worry that they will embarrass themselves in public.
Social phobia vs agoraphobia
- With social phobia, patients can cope in the agoraphobia situations e.g. large crowds, as long as attention is not on the. ∴ they tolerate smaller situations e.g. dinner parties less well. Patients often worry about particular symptoms e.g. blushing.
- Social phobia also has a slightly earlier diagnosis than agoraphobia.
What is the main symptom of phobias
Avoidance is the main symptom, where this is not possible, the person experiences disabling anxiety.
What is the mainstay of phobia management
Graded exposure therapy
What is graded exposure therapy
Utilizes systematic desensitization, based on the principle that anxiety habituates and doesn’t last more than 45 minutes ish. There you build up a tolerance over sessions with an increasing stimulus of the phobia
How is social phobia usually managed
Normally the patient engages in SSBs and active monitoring to avoid embarassment. Therapy focuses on dropping SSBs and confronting (exposure therapy) social situations that challenge assumptions.
