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Psychiatry > Anxiety disorders > Flashcards

Anxiety disorders Flashcards

1
Q

Main differentials for OCD

A
  1. Depressive disorder: Obsessions common
  2. Psychosis: Delusions are ‘believed’ and seen as reality
  3. Anankastic (aka obsessive) personality disorder
  4. Hypochondriasis, body dysmorphia
  5. Other anxiety disorder
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2
Q

M:F ratio of OCD

A

1:1

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3
Q

Aetiological factors for OCD

A

Bio: Genetic vulnerability (3-7% of first degree relatives affected), dysregulation of 5-HT system, ?autoimmune cause (e.g. in Sydenham’s chorea, encephalitis)

Psycho: Anankastic personality

Social: Stressful events precipitate OCD

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4
Q

Maintaining factors for OCD

A

Avoidance of situations triggering obsessions + performance of compulsions –> prevent habituation of anxiety

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5
Q

Core symptoms of OCD

A

Must cause distress/functional impairment (behaviours must take >1h per day)

Emotion: Anxiety around topic of obsessional thought

Cognition: Ego-dystonic (i.e. resisted) repetitive obsessional thoughts/images/ruminations/impulses

Behaviour: Compulsions/rituals (may be mental or physical, and may not be present).

Somatic symptoms: Tension, esp if stopped doing compulsions

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6
Q

Age demographics of OCD

A

Mean age: 20yrs

70% onset <25

15% >35

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7
Q

Prevalence of OCD in general population

A

0.5-3%

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8
Q

Frequent co-morbidities for OCD

A

Depression (obsessions follow depression in MDD, and vv for OCD)

Eating disorder

Other anxiety disorder

Tics, Tourette’s

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9
Q

Outcome for OCD

A

20-30% significant improvement within 1y

40-50% moderate improvement

20-40% chronic/worsening symptoms

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10
Q

Poor prognostic factors for OCD

A

Personal: Male, comorbid depression or PD

Illness: early onset, long duration, tics, acting on compulsions

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11
Q

Psychological treatment options for OCD

A

CBT + exposure-response prevention

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12
Q

Pharmacological treatment options for OCD

A
  1. First line: SSRI (fluoxetine, paroxetine, sertraline)
  2. Second line: Clomipramine

Continue for 12mo as maintenance

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13
Q

Important anxiety differentials to rule out in <18

A

ADHD

ASD

Substance misuse

Eating disorder

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14
Q

Important anxiety differentials to rule out in 18-35

A

Schizophrenia

Bipolar

Major depressive disorder

Substance misuse

Somatoform disorder

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15
Q

4 components of anxiety to assess

A

Cognition: What are you worried about? What is the nature? Any triggers?

Body sensations: Head to toe manifestation of symptoms

Behaviour: Anxious-avoidant behaviour that perpetuates anxiety disorder

Impairment: How has it affected your life? Can you put it out of your mind? –> become disorder

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16
Q

Typical duration of a panic attack

A

Peak at 10-15 min

Last 20-30 min

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17
Q

Definition of generalised anxiety disorder

A

Free-floating, excessive worry w/ psychic + physical tension causing functional impairment

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18
Q

ICD-10 symptoms criteria for generalised anxiety disorder

A

At least 4 of:

Autonomic arousal: E.g. palpitations, tachycardia, dry mouth

Physical symptoms: Difficulty breathing, chest pain, abdominal distress

Mental state: Dizziness, light-headedness, fear of dying/losing control/going mad, poor concentration, feeling on edge

Musculoskeletal: Tension, tingling/numbness, globus

Hypervigilance

Sleep disturbance: Nightmares, frequent waking, not EMW usually, that should alert to depression

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19
Q

Time criterion for generalised anxiety disorder

A

Most of the time for >=6mo, shorter –> likely adjustment

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20
Q

Prevalence of generalised anxiety disorder

A

lifetime: 5.4%

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21
Q

Demographic risk factors for anxiety disorder

A

Female

Unemployed

45-59yrs peak incidence

Marital/sexual disturbance or trauma

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22
Q

Biological aetiological factors for generalised anxiety disorder

A

Genetics: Shared heritability w/ depression, 5x more prevalent in first-degree relatives

HPA axis: Reduced cortisol responsiveness to DMST

NA/5-HT/BDZ axis: Dysregulation

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23
Q

Psychological aetiological factors for generalised anxiety disorder

A

Diminished sense of control: Trauma or insecure attachment to primary caregivers –> intolerance of uncertainty

Parenting: Overprotective or lacking warmth

Personality: Esp anxious-avoidant

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24
Q

Social aetiological factors for GAD (aka specific psychological vulnerability)

A

Trauma: war/parental loss/abuse

Dysfunctional family/marital relationships

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25
Q

Medical conditions associated w/ anxiety-like symptoms

A

Cardio: Arrhythmia, ischaemic heart disease, mitral valve disease, heart failure

Resp: COPD/asthma, PE

CNS: vestibular nerve disease, temporal lobe epilepsy

Endocrine: Hyperthyroidism, hypoparathyroidism, hypercalcaemia, phaeochromocytoma, carcinoid, hypoglycaemia

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26
Q

Prognosis for generalised anxiety disorder

A

Generally poor

30% remission at 3 years

68% residual symptoms at 6 years

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27
Q

Management for generalised anxiety disorder

A

Step 1: Psychoeducation - breaking cycle of anxiety + treat any co-morbidity

Step 2: Facilitated/independent self-help - computerised CBT, problem-solving techniques, relaxation techniques

Step 3a: CBT

Step 3b: Pharmacology: sertraline, other SSRI (e.g. paroxetine, escitalopram for social), pregabalin (take longer to be more effective)

28
Q

Demographic risk factors for panic disorder

A

Female

Widowed, divorced, separated

Physical/sexual abuse

Early parental loss

15-24yo or 45-54yo

29
Q

Symptoms of panic attacks

A

Palpitations, tachycardia, chest pain

Sweating

Trembling/shaking

Hyperventilation, shortness of breath, fealing of choking

Psych: Fear of dying, dissociative symptoms

Paroxysmal: No trigger, or triggered in site of earlier attacks

30
Q

Common comorbidity for panic disorder

A

Agoraphobia (esp if untreated)

Substance misuse

Major depressive disorder (should not Dx panic if depressive disorder present at start of panic attacks)

Bipolar disorder

31
Q

Emergency management of panic attack

A

Reassurance

Exclude medical cause if first presentation

BDZs if severe

Psychiatric referral if recurrent (i.e. panic disorder)

32
Q

Prognosis of panic disorder

A

Functional recovery in 25-75% at 1 yr

10-30% at 3 years (chronic course)

If attacks present for >6mo –> will run a prolonged, fluctuating course

33
Q

Management of panic disorder

A

1st line: Self-help

2nd line: CBT and/or SSRI (e.g. sertraline, paroxetine, citalopram)

3rd line: TCA (e.g. imipramine, clomipramine)

34
Q

Aetiological models for panic disorder

A

NAergic/5-HTergic: Hypersensitivity

Lactate/CO2: brainstem hypersensitivity

GABA: Reduced activity

Cognitive: Hypersensitivity to autonomic cues

35
Q

Clinical features of agoraphobia

A

Emotional: Situational anxiety, in open spaces where escape may be difficult or embarrassing

Cognitive: Thoughts of collapsing/having panic attack in public, inability to escape (c.f. fear of scrutiny in SA)

Behaviour: leading to avoidance –> risk of self-neglect

Somatic: +/- panic attacks (i.e. agoraphobia with(out) panic disorder)

36
Q

Aetiological factors for agoraphobia

A

Bio: Genetic (first degree relatives have higher incidence of alcohol dependence, MDD, other anxiety disorder)

Psycho: Fear/loss of confidence due to previous panic attack/trauma/physical frailty –> learned response

37
Q

Differential for agoraphobia

A

Presence of panic disorder, other anxiety disorder (esp GAD, social)

Presence of delusions in psychotic disorder

Major depressive disorder

38
Q

Management of agoraphobia

A

Psychological: CBT, esp exposure therapies

Pharma: SSRIs for panic disorder (e.g. paroxetine, citalopram)

Prognosis: Present for >1year, likely to persist for at least 5y

39
Q

Definition of simple phobia

A

Recurring, excessive, unreasonable fear in presnce (or anticipation of) specific stimulus/situation

Cannot be reasoned away, beyond voluntary control

Causes impairment

40
Q

Mean age of onset for simple phobias

A

15yo, 7-8 for animal/needle and 20 for situational

41
Q

Comorbidities in simple phobias

A

Mood or other anxiety

>80% lifetime comorbidity

42
Q

Management of simple phobias

A

Exposure therapy (rarely use BDZs to allow engagement in exposure therapy)

43
Q

Aetiology of simple phobias

A

Genetic vulnerability (esp in non-situational)

Learned response (perpetuated by avoidance)

44
Q

Clinical features of social anxiety

A

Cognition: Fear of being judged (not harmed) by others, anticipatory anxiety

Bodily sensations: Embarrassment, blushing, hand tremor, nausea, sweating

Behaviour: Avoidance

Associations: Substance misuse, suicidality, low self-esteem, perfectionism, 80% co-morbidity w/ other condition

45
Q

Aetiology of social phobia

A

Bio: Minor genetic component (MZ:DZ 24:15)

Psycho: Learned responses e.g. from previous social trauma, learned from parents, overprotective parenting

46
Q

Management of social phobia

A

Assessment: Mini Social Phobia Inventory (Mini-SPIN)

First line: CBT or CBT-based self-help book with telephone guidance. >90% response + reduces relapse. Includes behavioural/exposure therapy. May be combined with medication (see below)

Second line: SSRI (sertraline, citalopram are licensed)

Third line: Alternative SSRI, venlafaxine

47
Q

Neuroses not more prevalent in women (i.e. equal prevalence)

A

Social phobia

OCD

Panic disorder (equivocal)

48
Q

Comparison of panic disorder, phobic anxiety, and generalised anxiety, onset

A

Panic: Paroxysmal

Phobic: Situational

Generalised: Persistent

49
Q

Comparison of panic disorder, phobic anxiety, and generalised anxiety, behaviour

A

Panic: Escape (e.g. agoraphobia)

Phobic: Avoidance

Generalised: Agitation

50
Q

Comparison of panic disorder, phobic anxiety, and generalised anxiety, cognition

A

Panic: Fear of symptoms/dying

Phobic: Fear of situation/stimulus

Generalised: Worry

51
Q

Mechanism of action of buspirone

A

5-HT agonist –> overall decrease in synaptic 5-HT levels + increase in DA/NA

52
Q

Short-term management of acute anxiety

A

Benzodiazepines

Buspirone

Review after 2-4w max!

53
Q

Mechanism of action of benzodiazepines

A

Allosteric modulators of GABA receptors

54
Q

Timecourse for withdrawal symptoms from benzodiazepines

A

Up to 3 weeks after stopping if long-acting, within a day if short-acting

More likely with short-acting

55
Q

Symptoms of benzodiazepine withdrawal

A

Tremor, perspiration, seozures

Tinnitus, perceptual disturbances

Low appetite +/- weight loss

Insomnia, anxiety

56
Q

Common classes of hypnotics

A

Benzodiazepines

Z-drugs (zopiclone, zolpidem)

Antihistamines (esp promethazine)

57
Q

Common side effects of benzodiazepines

A

Mental state: Depression, confusion, drowsiness, ‘hangover effect’, suicidal ideation

Neuro: Ataxia, dizziness, headache, tremor, muscle weakness, vision disorders

Other: Dysarthria, fatigue, GI disturbance, respiratory depression

58
Q

Timecourse to tolerance of hypnotics

A

3-14d, should not be used long-term!

59
Q

Indications for buspirone

A

Non-sedating anxiolytic, for use in generalised anxiety

60
Q

Age distribution for GAD

A

15-30 and 40-60 (bimodal)

61
Q

Age distribution for agoraphobia

A

15-30 and 70-80 (bimodal)

62
Q

Age distribution for social phobia

A

Childhood - 30years

63
Q

Age distribution for panic disorder

A

15-25 and 40-60

64
Q

Age distribution for OCD

A

Generally onset in teenage years

65
Q

Differentials for GAD

A

Withdrawal from drugs/alcohol

Drugs: e.g. bronchodilators, antiarrhytmics, thyroxine, psychotropics

Dementia

Depression

SCZ

Physical illness

66
Q

Poor prognostic factors for GAD

A

Severe symptoms, agitation

Derealisation

Conversion symptoms

Suicidal ideation

Concurrent depressive illness

Psychiatry (20 decks)

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