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anxiety disorders Flashcards

1
Q

What is anxiety?

A

normal reaction - consisting of psychological and physical reactions
o Evolutionary response to threatening situation - fight of flight response

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2
Q

When does anxiety become a problem?

A

symptoms of anxiety and worry that are so PERSISTANT and INAPPROPRIATE that they INTERFERE WITH FUNCTION

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3
Q

What are the psychological symptoms of Anxiety?

A

Feelings of fear and impending doom
Dizziness and light-headedness
Fear of passing out/losing control
Derealisation = feeling that surroundings/others are not real
Depersonalisation = feeling that self is not real
Globus hystericus = feeling of a lump in the throat associated with forced swallowing (cartoon)

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4
Q

What are the physical symptoms of anxiety?

A

Physical symptoms arise from autonomic arousal and hyperventilation

Palpitations/increased heart rate 
Chest pain
Difficulty breathing
Chest tightness 
Nausea 
Frequent loose motions 
Dry mouth 
Increased urinary frequency, ED, amenorrhoea 
Sweating 
Shaking
Hot flushes/cold chills 
Numbness/tingling
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5
Q

How can anxiety disorders be split up?

A

into continuous and episodic

Episodic can be split up further into Any situation (panic disorder), specific situations (phobias, and Mixed pattern

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6
Q

What is generalised anxiety disorder?

A

characterized by persistent free floating anxiety (not about particular environmental circumstances) not related to external stimulus. The anxiety may fluctuate but is neither situational as in phobic anxiety disorders nor episodic as in panic disorder

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7
Q

What are the diagnostic guidelines for GAD?

A

The patient must have symptoms of anxiety most days for at least several months (at least 6 months). These symptoms should usually involve elements of:
• Apprehension (about everyday events and problems – may have certain themes e.g. money, housing),
• Motor tension (restless, fidgety, tension headache),
• Autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnea, epigastric discomfort, dizziness, dry mouth)

Might present with somatic symptoms  headaches, back pain

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8
Q

What is the first step in management of GAD?

A

thorough assessment of symptom profile and effect on functioning

education about disorder - encourage good sleep hygeine

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9
Q

What is the second step in management of GAD?

A

low intensity psychological interventions
 Individual, non-facilitated self help
• E.g. CBT based written or electronic material
 Individual guided self-help
• E.g. written/electronic material supported by trained practitioner who facilitates self-help and does fortnightly reviews
 Psychoeducational support groups
• Groups based on CBT

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10
Q

How does CBT help in anxiety and why is it good?

A

CBT helps you make sense of overwhelming problems/feelings by breaking them down into situations, thoughts, emotions, physical feelings and actions
Pragmatic, highly structured, focused on current problems, collaborative

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11
Q

What is step three in GAD management?

A

high intensity psychological interventions
 CBT
 Applied relaxation

AND/OR

	Pharmacological treatment (should be adjunct to psychological treatment)
		Usually SSRIs (sertraline 1st as most cost effective)
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12
Q

What are the side effects of SSRIs

A 
o	Initial increase in anxiety
o	Bleeding risk (gastroprotection in older people or those taking NSAIDs)
o	GI upset
o	Increased suicidal thoughts <30
o	Withdrawal effects
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13
Q

If a patient cannot tolerate an SSRI what are your other options?

A

another SSRI, a SNRI or pregablin if not tolerated

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14
Q

Why can Beta blockers be helpful in GAD?

A

help with physical Sx of anxiety e.g. tremor

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15
Q

when are benzos appropriate in GAD and why arent they normally used?

A

acute short-term crisis

• Esp not in elderly
o Diazepam takes 2x long to metabolise in elderly
o Common SE = psychomotor retardation, memory impairment, disinhibitory reactions
• Also risk of dependence
• Relatively safe in OD (but toxic effects enhanced by alcohol and other drugs)

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16
Q

What is the antidote for benzo OD?

A

FLUMAZENIL

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17
Q

What is the prognosis for GAD?

A

poor if untreated (majority develop depression), better with treatment

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18
Q

What is a phobia?

A

defined as a persistent irrational fear that is usually recognised as such and that produces anticipatory anxiety for avoidance of the feared object, activity or situation.

Exposure to the feared object, activity or situation triggers intense anxiety that may take the form of a panic attack

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19
Q

what are the three types of phobic anxiety disorders?

A

agoraphobia, social phobia and specific phobias.

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20
Q

What is agoraphobia?

A

• Does not describe a fear of open places but a fear of places that are difficult or embarrassing to escape from, which they don’t have control over, such as places that are confined, crowded or far from home.

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21
Q

What can happen in agoraphobia?

A

may have to rely on trusted companions to accompany them to feared places and in severe cases, may end up unable to leave their home.
o E.g. pets
• Patient may also have depressive and obsessional symptoms, as well as social phobia

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22
Q

What is the treatment for agoraphobia?

A
  • May respond to CBT such as graded exposure/systematic desensitisation and anxiety management (often complemented by cognitive therapy) and to antidepressant drugs.
  • Relapse is common.
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23
Q

Which group is agoraphobia most common in?

A

• F>M, onset = 20-25

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24
Q

What is social phobia?

A

• Fear of being judged by others and being embarrassed and humiliated, either in most social situations or in specific social situations such as dining or public speaking.
o Assoc with low self-esteem and fear of criticism/scrutiny
• Social phobia has many features in common with shyness - however it starts at a later age, is more severe and debilitating.

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25
Q

What is the treatment for social phobia?

A

• Social phobia may respond to CBT such as graded exposure/systematic desensitisation and anxiety management and to antidepressant drugs

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26
Q

What is common in social phobia?

A

• Alcohol and benzodiazepine misuse are more common than in other phobic anxiety disorders.

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27
Q

What group is social phobia most common in?

A

• F>M, onset = adolescence

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28
Q

What are specific phobias?

A
  • Specific phobia is by far the most common.
  • Specific phobia is a fear of a specific object or situation.
  • Unlike other anxiety disorders, specific phobias tend to begin in early childhood and there seems to be an innate predisposition to developing certain specific phobias of spiders or snakes.
  • Such innate predispositions are intended to protect us from the potential dangers commonly forced by our ancestors and so our chance of survival and reproducing.
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29
Q

What is the treatment for specific phobias?

A

may respond to CBT such as graded exposure/systematic desensitisation and anxiety management, flooding and modelling.
medication rarely used in any phobia

30
Q

what group are specific phobias most common in?

A

• F=M, onset = childhood

31
Q

What is systemic desensitisation?

A
  1. Teach patient deep muscle relaxation and breathing techniques
  2. Patient creates a fear hierarchy, starting with stimuli that provoke least anxiety
  3. Work way up fear hierarchy, using relaxation techniques as they go
32
Q

What is the ICD classification of panic attack?

A 
•	A discrete episode of intense fear. It starts abruptly, reaches a maximum within a few minutes and lasts at least some minutes
o	5-20 mins 
•	At least 4 specific symptoms of anxiety
o	(at least one from a-d)
Symptoms
•	A) Palpitations or pounding heart
•	B) Sweating
•	C) Trembling
•	D) Dry mouth
•	E) Difficulty breathing
•	F) Feeling of choking
•	G) Chest pain or discomfort
•	H) Nausea or abdominal distress
•	I) Dizziness, faintness, lightheaded
•	J) Derealization or depersonalization 
•	K) Fear of losing control, going crazy or passing out
•	L) Fear of dying
•	M) Hot flushes or cold chills
•	N) Numbness or tingling
33
Q

In what conditions can panic attacks occur?

A

• In isolation
• In other anxiety disorders e.g. phobic anxiety disorder, OCD, PTSD, separation anxiety etc
• In panic disorder
• In organic disorders (e.g. substance misuse, hyperthyroidism, hypoglycaemia, phaeochromocytoma)
• In depressive disorders
Panic disorder should not be given as main diagnosis if depression coexists as attacks are likely secondary to depression

34
Q

what is panic disorder?

A

The essential features of PANIC DISORDER are recurrent attacks of severe anxiety (panic attacks), which are not restricted to any particular situation or set of circumstances, and are therefore unpredictable

35
Q

describe a vicious cycle that can occur in panic disorder

A

fear of the implication and consequences of a panic attack (e.g. having a heart attack, losing control, ‘going crazy’) and this fears itself triggers further panic attacks.
 They fear the panic attack happening - A vicious circle takes hold, resulting in panic attacks becoming more frequent and more severe, and even occurring completely out of the blue.
 This can in some cases lead to the development of ‘secondary’ agoraphobia, in which the person AVOIDS leaving the home so as to minimise the risk and consequences of having a panic attack. – avoidance

36
Q

how do you define moderate and severe panic disorder?

A

 Moderate = 4 attacks in 4 weeks

 Severe = 4 attacks per week over 4 week period

37
Q

What should you do if someone with panic disorder presents to A+E?

A
  1. Ask if being treated for panic disorder
  2. Undergo minimum investigations to exclude acute physical problems
  3. Do not admit
  4. Refer to primary care
  5. Provide written info about panic attacks, support groups, local/national voluntary and self-help groups

Nice guidlines

38
Q

What is the chronic management of panic disorder?

A
  • Recognition and accurate diagnosis
  • Treatment in general practice
  • Review and consideration of alternative treatments
  • Review and refer to specialist mental health services (when 2 interventions tried)
  • Care in specialist mental health services
39
Q

What acute psychological therapies are there for panic disorder?

A

o 1st line = CBT
 very effective for panic disorder
 aims to help patient see symptoms as the result of anxiety and not as indicators of impending catastrophe (e.g. heart attack)
 1-2hr weekly sessions, 2-4 months

  • Self help
    o Books on CBT, support groups, psychoeducation, encourage exercise
40
Q

What acute pharmacological therapies are there for panic disorder?

A

o 1st line = SSRIs
 anti-depressants should be only long-term drug treatment for panic disorder
 start on a low dose and increase slowly until therapeutic response observed. Continue for at least 6 months after optimal dose reached, then to stop taper dose down
 inform about potential side effects
• Transient increase in anxiety at start of treatment
• risk of discontinuation/withdrawal symptoms if the treatment is stopped/missed doses.
• ?risk of suicide under 30
• Also, warn about delay in onset of effect (= >1 week)
o If SSRIs dont work, try TCAs
 Imipramine, clomipramine
o Do not prescribe benzos, sedating antihistamines or antipsychotics for panic disorder
 But benzos often used short-term/acutely
• ?to reduce initial increase in anxiety when starting SSRIs

41
Q

What is the prognosis in Panic disorder?

A

Prognosis = generally good, 65% remission in 6ish months, 10-20% continue to have significant symptoms

42
Q

what is obsession in OCD?

A

• Is a recurrent idea, image or impulse
• Almost invariably distressing
 Because violent or obscene, or simply because it is perceived as senseless
• Is recognised as being a product of one’s own mind
 Even though involuntary and repugnant
• Is unsuccessfully resisted.
• Results in marked anxiety and distress/impairment of functioning.
• Common obsessional thoughts involve:
 doubt, contamination, orderliness, symmetry, safety, physical symptoms, aggression and sex
 fear of harm coming to self or others
 “an indecisive, endless consideration of alternatives, associated with an inability to make trivial but necessary decisions in day-to- day living”

43
Q

what is compulsion in OCD?

A

• Is a recurrent stereotyped behaviour.
• Reduces anxiety but is neither useful nor enjoyable.
 Temporary relief from anxiety doesn’t count as enjoyable
• Is usually perceived as being senseless, but may be symbolic
o Individual often views them as preventing some objectively unlikely event, often involving harm to, or caused by, the individual
 Compulsive act/ritual cancels out obsessional thought
• Is unsuccessfully resisted.
• Results in marked distress/impairment of functioning.
• Common compulsive acts include:
 washing and cleaning, arranging and ordering, checking and other ritualistic behaviours, and mental rituals such as counting or repeating a phase.

44
Q

What are some screening questions for OCD?

A
  1. Do you wash or clean a lot?
  2. Do you check things a lot?
  3. Is there any thought that keeps bothering you that you’d like to get rid of, but can’t?
  4. Do your daily activities take a long time to finish?
  5. Are you concerned about putting things in a special order or are very upset by mess?
  6. Do these problems trouble you?
45
Q

What is the diagnostic criteria for OCD?

A

obsessional symptoms, or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of stress/interference with daily activities.
Must be:
• Recognised as patient’s own thoughts/impulses
• At least one thought/act that is still resisted unsuccessfully, even if individual no longer resists others
• Not pleasurable to think or carry out act
• Unpleasantly repetitive

Symptoms of comorbid depression may occur - if both occur acutely give precedence to the Sx that developed first - often depression

46
Q

What is the aetiology of OCD?

A

• Premorbid anankastic or obsessional traits (or personality disorder) are common.
• They are characterised by feelings of doubt, perfectionism, excessive conscientiousness, checking and preoccupation with details, stubbornness, caution and rigidity.
• There may insistent and unwelcome thoughts or impulses that do not attain the severity of OCD.
• According to biological models, OCD results from pathology in the caudate nucleus, which fails to suppress signals from the orbitofrontal cortex.
o As a result, the thalamus becomes overexcited and sends strong signals back to orbitofrontal cortex and so on.

47
Q

What are the differentials for OCD?

A
  • Depressive disorders, anankasstic personality disorder, toruettes syndrome, other anxiety disorders, psychotic disorders and organic mental disorders
  • Co-morbid disorders, especially depressive disorders are common
48
Q

How do you manage OCD?

A
  1. RECOGNITION AND DIAGNOSIS
    a. Screen in those at high risk e.g. depression, anxiety, ED, alcohol/substance misuse
    b. Risk assessment (self-harm)
    i. Risk of compulsive acts on self and others
  2. LOW INTENSITY PSYCHOLOGICAL TREATMENT
    a. Brief, self-directed or group CBT
  3. HIGH INTENSITY PSYCHOLOGICAL TREATMENT
    a. CBT with exposure and response prevention (ERP)
    i. ERP = pt taught to delay responding to their urges and distract themselves for increasing long periods
    b. And/or drug treatment
    i. 1st line = SSRI
    ii. 2nd line = different SSRI or clomipramine (TCA)
49
Q

What is the prognosis of OCD?

A
  • OCD may run in a relapsing and remitting course, but untreated prognosis is poor.
  • In severe and refractory cases, neurosurgery, usually in the form of anterior cingulotomy (part of the limbic system) or capultomy can be considered.
50
Q

What is PTSD?

A

a protracted and sometimes delayed resonse to a highly threatening or catastrophic experience  most commonly combatant exposure in males and sexual abuse in females

51
Q

What are the classical triad and other symptoms of PTSD?

A
  1. Hyperrarousal (jumpy.hypervigilant)
  2. Involuntary and intensive flashbacks
  3. Avoidance (of activities and situations reminiscent of trauma
  • Numbing, emotional bluntness, detachment
  • Falshbacks, nightmares
  • Partial or incomplete amnesia of the event
  • Avoidance (and distress) of reminders of the event and prominent anxiety symptoms
52
Q

What are risk factors for PTSD?

A

• Personality traits (compulsive, asthenic)
• Prev Hx of neurotic illness
• Genetics (oversensitive amygdala & hippocampus, decreased hippocampal size on MRI
Scale of trauma
• Pt’s previous experience
• Level of support available

53
Q

What must be present to diagnose PTSD?

A

be evidence of severe trauma within 6 months of onset and REPITITVE, INTRUSIVE flashbakcs of event

54
Q

Which psych disorders are commonly found with PTSD?

A

• Depressive disorders, anxiety disorders, drugs/alcohol misuse

55
Q

What are the non-pharmalogical therapies for PTSD?

A

TRAUMA FOCUSED CBT
• With repeated graded exposure

EYE MOVEMENT DESENSITISATION REPROCESSING (EMDR)
• Move eyes back and forth while thinking about trauma
• Alters the way memories stored in brain
• As effective as CBT
• Useful for those who struggle to talk about trauma as only need to hold thoughts in mind

56
Q

When would you watch and wait in PTSD?

A

If symptoms mild and present <4 weeks, watchful waiting may be adequate
NB most patients presenting have had problems for many months/years

57
Q

What medication can you use in PTSD?

A

• Anti-depressants not routinely used
o But consider paroxetine or mirtazapine if no benefit from psychological treatment
 Or amitryptiline or phenelzine (but only by mental health specialists)
• Avoid benzos
o High risk of dependence in this group

58
Q

What is the prognosis of PTSD?

A

generally good but in some cases PTSD may persist chronically for many years.

59
Q

What is an acute stress reaction?

A

A transient disorder of significant severity which develops in an individual without any other apparent mental disorder in response to exceptional physical and/or mental stress

60
Q

What are the symptoms of an acute stress reaction?

A

Symptoms are mixed but could include being in a daze, disorientation, panic, amnesia. The symptoms usually appear within minutes of the impact of the stressful stimulus/event and then usually subsides within hours or days (2-3).

61
Q

What are the diagnostic criteria for an acute stress reaction?

A

There must be an immediate and clear temporal connection between the impact of an exceptional stressor and the onset of symptoms; onset is usually within a few minutes, if not immediate. In addition, the symptoms:
• show a mixed and usually changing picture; in addition to the initial state of “daze”, depression, anxiety, anger, despair, overactivity, and withdrawal may all be seen, but no one type of symptom predominates for long;
• resolve rapidly (within a few hours at the most) in those cases where removal from the stressful environment is possible; in cases where the stress continues or cannot by its nature be reversed, the symptoms usually begin to diminish after 24-48 hours and are usually minimal after about 3 days.

This diagnosis should not be used to cover sudden exacerbations of symptoms in individuals already showing symptoms that fulfil the criteria of any other psychiatric disorder, except for those in personality disorders. However, a history of previous psychiatric disorder does not invalidate the use of this diagnosis.

62
Q

What is bereavement?

A

grief that occurs after the loss of a loved one, but that can also happen after the loss of a pet or national figure, or the loss of an asset such as health or social status

63
Q

What is normal grief?

A
  • Grief: feelings, thoughts, and behaviour associated with bereavement.

typical symptoms experienced after bereavement include: disbelief, shock, numbness, and feelings of unreality; anger; feelings of guilt; sadness and tearfulness; preoccupation with the deceased; disturbed sleep and appetite and, occasionally, weight loss; seeing or hearing the voice of the deceased.

Usually these symptoms gradually reduce in intensity, with acceptance of the loss and readjustment.

A typical ‘grief reaction’ lasts up to 12mths (mean 6mths), but cultural differences exist. Intensity of grief is usually greatest for the loss of a child, then spouse or partner, then parent.

64
Q

What is abnormal grief?

A

grief reaction that is very intense, prolonged, delayed (or absent), or where symptoms outside normal range are seen, e.g. preoccupation with feelings of worthlessness, thoughts of death, excessive guilt, marked slowing of thoughts and movements, a prolonged period of not being able to function normally, hallucinatory experiences (other than the image or voice of the deceased)

65
Q

What tends to lead to more intense or longer grief?

A
  • Sudden and unexpected loss

loss of a person who was particularly close or with whom the patient had a dependent or ambivalent relationships.

66
Q

Is it common for grieving people to be depressed?

A
  • It is very common for those suffering bereavement to have depressive symptoms. However, it is less common for people to experience a clear depressive episode that requires treatment.
67
Q

How do you diagnose prolonged grief disorder?

A 
at least 5 out of 9 of:
	Feeling emotionally numb, stunned, or that life is meaningless;
	Experiencing mistrust;
	Bitterness over the loss;
	Difficulty accepting the loss;
	Identity confusion;
	Avoidance of the reality of the loss;
	Difficulty moving on with life.
	Symptoms must be present at sufficiently high levels at least 6mths from the death and be associated with functional impairment.
68
Q

How is bereavement managed?

A
  • Generally ‘normal’ grief does not require specific treatment (and shouldn’t be medicalised!!!) although benzodiazepines may be used to reduce severe autonomic arousal or treat problematic sleep disturbance in the short-term.
  • Where there are features of ‘abnormal’ grief, or where there are clinical symptoms of depression/anxiety, treatment with antidepressants ought to be considered, along with culturally appropriate supportive counselling (e.g. through organizations such as CRUSE).
69
Q

What is adjustment disorder?

A

arises in the period of adaptation to a significant life change or stressful life event (e.g. change of job, migration or divorce – not catastrophic like PTSD).
The stressor may have affected the integrity of an individual’s social network (through bereavement or separation experiences) or the wider system of social supports and values (migration, refugee status) The stressor may have represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement)

70
Q

What are the characteristics of adjustment disorder?

A

depressive symptoms and/or anxiety that are not severe enough to warrant a diagnosis of depressive disorder or anxiety disorder, but nonetheless impact on social functioning

The onset is usually within 1 month of the occurrence of the stressful event or life change, and the duration of symptoms does not usually exceed 6 months.

psychiatry (12 decks)

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