Anxiety Disorders

Question 1

What is anxiety?

Answer 1

Normal physiological stress response to danger that occurs when the danger does not exist. The response is exaggerated, lasts more than 3 weeks and interferes with daily life. Very simply fear results in arousal and avoidance.

Question 2

What causes anxiety?

Answer 2

Combination of genetic and environmental events. Risk factors include childhood abuse, family history and poverty.

Anxiety occurs when the estimate of danger outweighs the estimate of coping. Anxiety disorders occurs when the danger is psychological rumination and there appears to be little coping. Anxiety often causes or links in with depression.

Question 3

Describe some cognitive signs and symptoms of anxiety?

Answer 3

Agitation 
Feeling of impending doom 
Poor concentration and racing thoughts
Insomnia 
Excessive concern about self and bodily functions 
Repetitive thoughts 
Worry

Question 4

Describe some somatic signs and symptoms of anxiety

Answer 4

Somatization 
Tension
Fatigue
Trembling
Sense of collapse 
Butterflies in the stomach 
Headaches
Sweating
Palpitations 
Nausea 
Lump in the throat

Question 5

Describe some behavioural signs and symptoms of anxiety

Answer 5

Reassurance seeking 
Avoidance 
Dependence on person or object 
Substance and alcohol misuse
In children – thumb sucking, nail biting and bed wetting

Question 6

What systems should you consider investigating for organic causes of anxiety?

Answer 6

Check for Organic causes such as: endocrine, neurological, drug induced, infection and anaemia.

Question 7

What is Panic disorder

Answer 7

Panic Disorder (with or without agoraphobia) – fear of an immediate and catastrophic event fed by fear of your own physiological and psychological reactions. Bodily changes are viewed as signs of impending doom, insanity or death. Agoraphobia is a fear of situations where you feel unsafe and don’t have an easy escape.

Question 8

How is panic disorder managed?

Answer 8

Management of panic disorder
Recognition and diagnosis
1. Treatment in primary care – both facilitated and non-facilitated self-help groups, exercise, sleep hygiene and diet
2. Review and consideration of alternative treatments - CBT or Sertraline 1st them imipramine or clomipramine
3. Review and referral to specialist mental health services

Question 9

What is social anxiety disorder?

Answer 9

Social Anxiety Disorder (social phobia) – essentially a fear of negative evaluation by others. Involved avoidance and unhelpful post mortems following on from social interactions. Can progress to panic attacks and often present with a secondary symptoms of anxiety rather than specifically stating social phobia.

Question 10

How is social anxiety managed?

Answer 10

Management of Social Anxiety Disorder
• CBT is the most effective treatment
• SSRI if refusal for CBT or CBT did not help. Sertraline then paroxetine then venlafaxine (if under 30 warn of increased risk of suicidal thoughts and weekly follow up for first month).

Question 11

What are phobias?

Answer 11

Phobias – specific to a situation or object(s) with marked avoidance. Health Anxiety (Hypochondriasis). Most anxiety involve sympathetic drive but blood injury phobias are an exception where feinting occurs as a result of an overcompensating rebound parasympathetic activation.

Question 12

How are phobias managed?

Answer 12

Treatment – psychotherapy of exposure therapy.

For panic attacks try CBT + SSRIs, can also try TCAs, pregabalin or clonazepam.

Question 13

What is OCD?

Answer 13

Obsessions – stereotyped, distressing, intrusive thoughts, or images (obsessions) these are ego dystonic i.e. do not fit with a person’s normal moral/ethical values and the patient often tried to resist them.
Compulsions – stereotyped, neutralising behaviours (compulsions), these compulsions can be overt i.e. visible or covert such as praying, counting, and repeating words. They are not enjoyable, performed to prevent an event and usually recognised as pointless. Most commonly checking behaviours, but also hoarding, counting, cleaning, and rearranging.
Note can get OCD with predominantly obsessional thoughts or compulsive acts.

Question 14

What is Body dysmorphic disorder?

Answer 14

Body Dysmorphic Disorder – preoccupations with an imagined defect in appearance. This leads to time consuming behaviour such as: mirror gazing, excessive camouflage tactics, skin picking and reassurance seeking.

Question 15

How are OCD and BDD managed?

What questionnaire can grade severity of OCD

When can medication be stopped

Answer 15

Management of OCD and BDD

1. Brief individualised CBT (can step this up) – exposure and response prevention (ERP) therapy can be useful
2. SSRI (avoid all other types of antidepressants other than clomipramine and avoid anxiolytics)
3. Combination of SSRI and CBT

Yale Brown questionnaire used to grade severity of OCD

After 12 months of treatment and 12 weeks remission can review whether medication is still necessary

Question 16

What is post traumatic stress disorder?

Answer 16

Post-traumatic Stress Disorder – following a traumatic event and consists of 3 main features: re-experiencing, avoidance, and hyperarousal. Must differentiate between this and an acute stress reaction which is transient lasting hours to days. PTSD can be delayed and not manifest until months to years after the event itself.

Question 17

How is PTSD managed?

Answer 17

Management of PTSD

1. CBT
2. Eye movement desensitisation and reprocessing (EMDR) only offered or considered in non-combat-related trauma
3. Hypnotherapy
4. Medication (always second line and usually in combination) e.g. SSRI paroxetine, other antidepressants, and second-generation antipsychotics.

Question 18

What is adjustment disorder?

Answer 18

Adjustment disorder occurs after a subjective distress and emotional disturbance that interferes with social functioning and performance where the acute stress response that is normal becomes chronic. Usually considered earlier on than PTSD and can be normal.

Question 19

What is generalised anxiety disorder?

Answer 19

Generalised Anxiety Disorder – a worry problems that is accompanied by low level physical symptoms such as insomnia, muscle tension, GI problems and headache. Usually occurs due to belief that worrying is useful. Includes type 1 worries i.e. about something or event and type 2 worries – worrying about worries.

Always rule out hyperthyroidism before a diagnosis of GAD

Question 20

How is GAD managed?

Answer 20

Management of generalised anxiety disorder (GAD)

1. Education about GAD + active monitoring
2. Low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
3. High intensity psychological interventions (cognitive behavioural therapy or applied relaxation) OR drug treatment – Sertraline first line (if under 30 warn of increased risk of suicidal thoughts and weekly follow up for first month) 2nd line try a different SSRI or SNRI, 3rdline try Pregabalin.
4. Highly specialist input e.g. complex drug and/or psychological interventions

Question 21

What general advice should be given in all anxiety disorders?

Answer 21

Regular non obsessive exercise
Meditation
Progressive relaxation training e.g. deep breathing
CBT attempts to reduce avoidance, cease safety-seeking behaviours, exposure and test (and consequently change) beliefs (by real life experiments)

Question 22

What are benzodiazepines, give some examples and what is used in overdose?

Answer 22

Benzodiazepines
Positive allosteric modulators of GABA receptors.

Diazepam (long half-life) Lorazepam (short half-life)

Flumazenil used in overdose

Question 23

What are the common side effects of benzos?

Answer 23

Tolerance and dependence do occur.

Drowsiness, psychomotor impairment, dizziness, respiratory depression, GI upset, reduced blood pressure, dry mouth, anterograde amnesia, and blurred vision.

Can occasionally cause paradoxical disinhibition at low doses.

Question 24

Can benzos be given during pregnancy?

Answer 24

Teratogenic causing cleft lip palate in early pregnancy and respiratory depression if used late in pregnancy.

Question 25

How long should benzos be prescribed for?

Answer 25

Should not be prescribed for longer than 4 weeks

Question 26

What is pregabalin?

Answer 26

Binds to voltage gated calcium channels and increases extra cellular amount of the enzymes responsible for synthesis of GABA.

Question 27

What are the side effects of pregabalin?

Answer 27

Less potential for misuse and dependence than benzos but still misused. Should only be for short term use but is actually used indefinitely

SE of sedation, and weight gain

Question 28

Other than anxiety what else is pregabalin used for?

Answer 28

Also used for neuropathic pain and epilepsy

Question 29

What are the symptoms of benzo withdrawel?

Answer 29

Symptoms – anxiety or psychotic symptoms 1-2 weeks after withdrawal. This is followed by months of rapidly decreasing symptoms such as insomnia, panic and depression. Irritability and feelings of unreality are common, but hallucinations are not.