Anxiety Disorders

Question 1

What normal physiological responses are normal in anxiety?

Answer 1

Increased HR 
Increased BP
Sweating 
Shaking 
GI symptoms 
Muscle tingling 
Nausea

Question 2

Anxiety is normal, what makes it pathological?

Answer 2

When it interferes with functioning, when it is inappropriate in timing or magnitude
When it is persistent

Question 3

What are some examples of anxiety disorders?

Answer 3

Phobic anxiety (agoraphobia, social)
Panic disorder 
Generalised anxiety disorder 
OCD
Stress reactions and PTSD 
Somatoform disorders

Question 4

If anxiety is continuous what diagnosis would you be considering?

Answer 4

Generalised Anxiety Disorder (GAD)

Continuous persistent feelings of anxiety is its defining feature

Question 5

If feelings of anxiety were intermittent and can happen in any situations what diagnosis should you be thinking?

Answer 5

Panic disorder

Question 6

What is a panic attack?

Answer 6

Discrete episode of overwhelming anxiety usually accompanies by physical symptoms of:
- Racing heart, tachypnoea, sweating, sense of impending death,

They are usually sudden onset and only last a few minutes (they can last longer)

Question 7

If anxiety symptoms are intermittent and as a response to a specific situation what diagnosis should you be considering?

Answer 7

Phobic disorder

Question 8

How long does continuous anxiety have to last before before GAD is considered (in theory) and what are some common themes for anxiety?

Answer 8

6 months
Money, health, family and housing
Pattern of thought usually based around lots of ‘what ifs’ - trains of thought get carried away and people catastrophise

Question 9

What are the ICD-10 criteria for anxiety?

Answer 9

• Persistent, free-floating anxiety not related to external stimulus
• Accompanying symptoms such as

Psychological (worry, apprehension, fear)
Arousal (hyper vigilance, restlessness, increased startle response)
Motor (muscle tension, trembling, headaches)
Autonomic (CVS, palpitations, difficulty breathing, loose stools, dizziness)

Question 10

How do we manage anxiety disorders?

Answer 10

CBT - originally designed for anxiety and so is a really important part of treatment

Question 11

What medications can be used in anxiety?

Answer 11

First line recommendation is SSRI in low dose (SERTALINE)
Anxiolytics can be useful but should be avoided in the long term
BENZODIAZEPINES - should only be considered when anxiety is severe and disabling and use in the short term only (2-4 weeks before review)

HYPNOTICS (help with sleep)
Consider Zopiclone, Clomethiazole, Melatonin or low dose BZDs

Question 12

What are obsessions?

Answer 12

Recurrent and intrusive thoughts that are unpleasant and distressing
These thoughts enter the mind against conscious resistant and people recognise an obsession as being a thought from their own mind

Question 13

What is a compulsion?

Answer 13

An act that is done to ease an unpleasant, obsessive thought
They are usually recurrent mental or physical actions that ease obsessions
Patients often recognise them as pointless or symbolic

Question 14

How long must symptoms have been present for to make a diagnosis of OCD?

Answer 14

2 weeks

Question 15

What other psychiatric co-morbidity should you consider in OCD?

Answer 15

Depression
Over 2/3 of people with OCD will have depression and around 20% of patients with depression will exhibit obsessive compulsive traits at some point

Question 16

What are the ICD-10 guidelines for making a diagnosis of OCD?

Answer 16

Obsessions and Compulsions present for at least 2 weeks
Acknowledged as coming from the patients own mind
Unpleasantly repetitive
Resisted unsuccessfully
The compulsive act is not in itself pleasurable but anxiety is relieved from having performed it

Question 17

How is OCD managed?

Answer 17

CBT mostly
ERP exposure and response prevention
PHARMA: sometimes sertraline, fluoxetine and the TCA Clomipramine are used with success

Question 18

What is PTSD?

Answer 18

A stress disorder caused after a ‘traumatic life event’ that would cause ‘pervasive feelings of stress in anyone’e.g. war, rape, witnessing death, NDEs

Question 19

What is the cerebro-anatomical processing of PTSD?

Answer 19

Memories appear to get stuck in the midbrain and don’t become transferred to cortex

Question 20

What are some characteristic traits and behaviours of PTSD?

Answer 20

Flashbacks, intrusive thoughts and nightmares
Avoidance of activities known to stimulate
Hyper-arousal and vigilance
Numbness/emotional blunting
Depression and suicidal ideation

Question 21

What is the ICD-10 criteria for diagnosis of PTSD?

Answer 21

Delayed or protracted response to a stressful event that is likely to cause pervasive feelings of stress in almost anyone

• Usually there is a latency period after the trauma of around 1-6 months
• Symptoms should have lasted for 1 month
• Recovery can be expected
• Lifetime prevalence 1-10%

Question 22

What are some predisposing factors to PTSD?

Answer 22

Personality traits (compulsive)
Familial - over-sensitive amygdala 
Prev hx of neurotic illness 
Scale of trauma (large = more likely)
Patients support system
Previous experiences

Question 23

How should PTSD be managed?

Answer 23

Trauma focussed PTSD
EMDR - eye movement desensitisation and reprocessing
- hold traumatic image in front of patient and get them to follow your finger as you move it side to side
Antidepressants - paroxetine or mirtazapine
Prognosis os goof with 65% recovering with 18/12