Anxiety Disorders Flashcards
What is hyperventilation syndrome?
A syndrome caused by excessive hyperventilation in response to a stressor, which provokes n exagerated respiratoyr respone. Individuals tend to use accessory muscles to breath, resulting in hyperinflated lungs and increased perceived effort. This creates anxiety, which leads to further exacerbation of what they are experiencing, leading to a vicious cycle.
What are cardiac signs/symptoms of HVS?
- Chest pain
- ECG changes
What are the respiratory signs/symptoms of HVS?
- Hyperpnoea
- Tachypnoea
- Dyspnoea
- Wheeze
What are the CNS signs/symptoms of HVS?
- Dizziness
- Weakness
- Confusion
- Agitation
- Depersonalisation
- Visual hallucinations
- Syncope/seizure (rarely)
- Paraesthesias
What are the GI signs/symptoms of HVS?
- Bloating
- Belching
- Flatus
- Epigastric Pressure - due to aerophagia
- Dry mouth
What metabolic changes might you seen in someone with HVS?
- Acute hypocalcaemia
- Hypokalaemia
- Acute hypophosphataemia
Why do metabolic changes occur in HVS?
Due to electrolyte disturbances secondary to respiratory alkalosis
If someone was showing signs/symptoms similar to those seen in HVS, what would be your differential diagnosis?
- Respiratory - ARDS, Asthma attack, Venous air embolism, Pleural effusion, Pneumonia, Pneumothorax, PE, COPD exacerbation, Smoke inhalation
- Cardiac - AF/atrial flutter, Cardiomyopathy, MI
- MSK - Costocondritis
- Endocrine/Metabolic - DKA, Hyperthyroidism, Metabolic acidosis
- Psychiatric - Panic disorder, Withdrawal syndrome
How would you investigate someone who was showing signs/symptoms suggestive of HVS?
- History/Examination
-
Exclude more serious causes
- Bloods - FBC, U+E, TFTs, glucose, Ca2+, PO4, ABG
- Pulse oximetry
- Toxicology
- D-dimer
- ECG
- CXR, maybe V/Q scan
What is a panic attack?
https://www.youtube.com/watch?v=YxELZyA2bJs
Period of intense fear characterised by a constellation of symptoms that develop rapidly, reach a peak of intensity in about 10 mintues, and generally do not last more than about 20-30 minutes. Attacks are either spontaneous, or situational. They can occur during sleep, and rarely can occur without the psychological component.
What are symptoms associated with a panic attack?
- Palpitations, racing heart
- Sweating/Chills/hot flashes
- Trembling/shaking
- Sense of SOB/Feeling of choking (globus hystericus)
- Chest pain/discomfort
- Nausea/abdominal distress
- Dizziness, unsteady, light-headed, faint
- Derealisation/depersonalisation
- Fear of dying (angor animus)
- Numbness/tingling
What is a panic disorder?
https://www.youtube.com/watch?v=YxELZyA2bJs
Recurrent and unexpected panic attacks (>2), which are not secondary to substance misuse, medical conditions, or another psychiatric disorder. The individuals also need to have persistent worry and change in behaviour due to the disorder
What is important to screen for from a psychiatric point of view when assessing someone with a suspected panic disorder/has panic attacks?
Thoughts of suicide/homicide - acute anxiety can lead to impulsive acts. This is more likely in those with comorbid depression and substance/alcohol misuse.
If someone was presenting with panic attacks, what would your differential diagnosis be?
- Panic disorder/Other anxiety or related disorder
- Substance/alcohol misuse
- Mood disorders
- Endorcine - Carcinoid syndrome, Cushing’s, Hyperthyroidism, Hypoglycaemia, Hypoparathyroidism, Phaeochromocytoma
- Anaemia
- Cardiac - Arrhythmias, Atypical chest pain, Mitral valve prolapse, MI
- Respiratory - COPD, Athma
- HVS
- Epilepsy - especialy TLE
How would you investigate someone with panic attacks/suspected panic disorder?
Basic investigations to exclude physical causes
- Bloods
- Toxicology
- ECHO
- EEG
How would you treat someone with panic disorder?
Pharmacological
- SSRI’s - citalopram, escitalopram, paroxetine, sertraline
- BDZ - for severe symptoms, only prescribe for short period in combination with antideprssants until antidepressants work
Psychological
- CBT
- Psychodynamic therapy
How would you treat an acute panic attack?
- Maintain a reassuring and calming attitude
- Severe symtpoms - BDZs
- Exclude medical causes - if first presentation
What is Agoraphobia?
Anxiety and panic symptoms associated with places or situations where escape may be difficult or embarassing (e.g. crowds, public places, travelling alone or away from home), leading to avoidance.
Falls under phobic anxiety disorders
What are specific phobias?
https://www.youtube.com/watch?v=PCOg2G797ek
Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety, in the anticipated presence of a specific feared object or situation, leading to avoidance wherever possible. DSM-IV distinguishes 5 main subtypes:
- Animals
- Aspects of natural environment
- Blood/injection/injury
- Situational
- Other
What is social phobia?
Symptoms of incapacitating anxiety (psychological +/- autonomic) that are not secondary to delusional or obsessive thoughts and are restricted to particular social situations, leading to a desire for escape or avoidance. This may reinforce the strongly held belief of social inadequcy.
What are signs/symptoms of social phobia?
- Blushing
- Trembling
- Dry mouth
- Perspiration
- Excessive fear of humiliation, embarrassment, or others noticing how anxious they are
What characteristics do those with social phobia normally have which can potentially feed into their phobia?
- Overly self-critical
- Perfectionism
How would you manage someone with social phobia?
Pharmacological
- Beta-blockers
- SSRIs
- Consider - SNRIs, MAOIs
Psychological
- CBT - individual or group
What is the first line for treatment of social phobia?
CBT with SSRI’s/MAOIs
What is generalised anxiety disorder?
https://www.youtube.com/watch?v=9mPwQTiMSj8
Exessive worry (generalised fre-floating persistent anxiety) and feelings of apprhension about everyday events/problems, with symptoms of muscle and psychic tension, causing significant distress/functional impairment.
What are the signs/symptoms of generalised anxiety disorder?
At least 3 out of:
- Restlessness
- Easy fatiguability
- Concentraion difficulties
- Irritability
- Muscle tension
- Sleep disturbance
How long must symptoms of GAD be present before a diagnosis of GAD is made?
Present most days for at least 6 months (90 or more days out of 180 days)
How many of the symptoms outlined in the DSM-V symptom criteria for GAD need to be present in children for a diagnosis of GAD to be made?
1 or more
What are the general criteria outlined in DSM-V for the diagnosis of GAD?
- Excessive anxiety present on most days > 6 months
- Hard to control anxiety
-
Age dependent criteria
- Adult - 3 or more symptoms
- Children - 1 or more symptoms
- Impairment of daily life
- Not caused by drugs, medication
- Not caused by other psychiatric disorder
What would be you differential diagnosis for someone who predented with symptoms similar to GAD?
- Normal worries
- GAD
- Depression
- Other anxiety disorders
- Drug/alcohol problems
- Medical conditions
- Side-effects of medications
How would you manage someone with GAD?
Pharmacological
- Buspirone - psychic symptoms
- BDZs - somatic symptoms
- TCAs - depressive symptoms
- Beta-blockers - cardiovascular/autonomic symptoms
- SSRIs
Psychological
- CBT
What is obsessive compulsive disorder?
https://www.youtube.com/watch?v=I8Jofzx_8p4
A common, chronic condition, often associated with marked anxiety and depression, characterised by obsessions and compulsive acts or rituals. These must cause distress or interfere with the person’s social or individual functioning (usually by wasting time), and should not be the result of another psychiatric disorder. At some point, the individual recognises the symptoms to be excessive or unreasonable
What sort of obsessions/compulsions are often present in OCD?
- Checking
- Washing
- Contamination issues
- Doubting
- Bodily fears
- Counting
- Insistence on symmetry
- Aggressive thoughts
What is thought top be the main aetiological cause of OCD?
Dysregulation of the 5-HT system
What are the DSM-V criteria for the diagnosis of OCD?
- Obsessions, compulsions, or both present
- Time consuming behaviour
- Not physiological effect of medications or drugs
- Not caused by another psychiatric disorder
What would be your differential diagnosis of obsessive/compulsive traits?
- Normal
- Schizophrenia
- Phobias
- Depressive disorders
- Hypochondriasis
- Body dysmorphic disorder
- Trichotillomania
How would you manage someone with OCD?
Psychological
- CBT
- Behavioural therapy
Pharmacological
- SSRI’s
- Clomipramine - TCA
Physical
- ECT
- Psychosurgery
What is an acute stress reaction?
A transient disorder lasting hour or days that may occur in individuals as an immediate (within 1 hr) response to exceptional stress (e.g. natural disaster, major incident, serious assualt etc.) The stressor usually involves severe threat to the security or physical integrity of the individual or of a loved person
What are signs/symptoms of an acute stress reaction?
Initial daze, followed by:
- Depression
- Anxiety
- Anger
- Despair
What is post-traumatic stress disorder?
https://www.youtube.com/watch?v=hzSx4rMyVjI
Severe psychological disturbance following a traumatic event, characterised by involuntary re-experiencing of elements of the event, with symptoms of hyperarousal, avoidance and emotional numbing, and re-experiencing phenomena.
How does the DSM-V define PTSD?
Symptoms of acute stress response persist for over a month
What are signs/symptoms of PTSD?
Arise within 6 months of traumatic event, and present for at least 1 month
-
2 or more of:
- Difficulty falling asleep/staying asleep
- Irritability/outbursts of anger
- Difficulty concentrating
- Hyperarousal - Exaggerated startle response
- Hypervigilance - always on guard
-
Plus:
- Re-experience phenomena
- Avoidance
- Inability to recall stressful event
What are symptoms which indicate hyperarousal in PTSD?
- Persistent anxiety
- Irritability
- Insomnia
- Poor concentration
What are re-experience phneomena in PTSD?
- Flashbacks
- Dreams/Nightmares
- Intrusive thoughts
What are symptoms of avoidance in PTSD?
- Emotional numbing
- Cue avoidance
- Diminished interest
- Recall difficulties
How would you manage someone with PTSD?
Psychological
- Trauma-focused CBT
- EMDR - eye-movement desensitization and reprocessing
- Psychodynamic therapy
- Stress managment
Pharmacological
- SSRI’s
- TCAs
- Symptom specific treatment
What is eye-movement desensitization and reprocessing (EMDR)?
Treatment involves standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements.
EMDR therapy is as effective as cognitive behavioral therapy (CBT) in chronic PTSD
