Anxiety disorders Flashcards
What are the types of anxiety disorders?
Specific phobias
Social phobia
Generalized anxiety disorder
Agoraphobia
Panic disorder
OCD
What are some common symptoms of neuroses?
Psychological = anticipatory fear of impending doom, restlessness, poor concentration
Cardiovascular = palpitations, chest pains
Respiratory = hyperventilation, cough, chest tightness
GI = abdo pain, loose stools, nausea and vomiting
Genitourinary = increased frequency of micturition
Neuromuscular = tremor, myalgia, headache
What is generalized anxiety disorder?
- Present most of the time not associated with object / situations
- Excessive or inappropriate worry about normal life events
What medical conditions are associated with anxiety?
- Hyperthyroidism
- Hypoglycaemia
- Anaemia
- Phaeochromocytoma
- Cushing’s disease
- COPD
- Congestive cardiac failure
- Malignancy
What substance-related conditions are associated with anxiety?
- Intoxication e.g. cannabis, alcohol, caffeine
- Withdrawal e.g. alcohol, benzos, caffeine
- Side effects e.g. thyroxine, steroids, adrenaline
What psychiatric conditions are associated with anxiety?
- Eating disorders
- Depression
- Schizophrenia
- PTSD
- Adjustment disorder
What is generalized anxiety disorder?
Ongoing, uncontrollable, widespread worry about events / thoughts that the patient recognizes as excessive and inappropriate (present on most days for at least 6 months)
What are the risk factors for GAD?
- Family history
- Divorce
- Living alone / single parent
- Low socioeconomic status
- Domestic violence
- Unemployment
- Relationship problems
What are the features of GAD?
- Worry (excessive, uncontrollable)
- Autonomic hyperactivity (sweating, increased pupil size, increase HR)
- Tension in muscles
- Concentration difficulties
- Headaches / hyperventilation
- Energy loss
- Restlessness
- Startled easily
Name some symptoms of GAD?
- Difficulty breating
- Chest pain
- Nausea
- Abdo pain
- Loose motions
- Lightheadedness
- Fear of dying
- Hot flushes
- Numbness / tingling
- Headache
- Muscle tension
- Restlessness
- Being startled
- Concentration difficulties
What investigations for a patient presenting with anxiety?
- Blood tests (FBC for infection / anaemia)
- TFTs
- Glucose (hypoglycaemia)
- ECG for sinus tachycardia
- Questionnaires GAD-7, Beck’s anxiety inventory
What are some differentials for patients presenting with anxiety?
- GAD
- Other neurotic disorders: panic disorder, specific phobias, OCT, PTSD
- Depression
- Schizophrenia
- Personality disorder (e.g. dependent PD)
- Excessive caffeine or alcohol consumption
- Withdrawal from drugs
- Organic: anaemia, hyperthyroidism, phaeochromocytoma, hypoglycaemia
What to screen for in anxiety?
Depression and substance misuse
What is the bio-psycho-social management of anxiety?
Biological = SSRI e.g. sertraline, SNRI e.g. venlafaxine or duloxetine, or pregablin. Benzos ONLY for short-term measures
Psychological = psychoeducational groups (low intensity) CBT (high intensity)
Social = self help methods (e.g. writing down thoughts and analysing them objectively) and support groups. Exercise should be encouraged and may benefit.
What is NICEs stepwise management of anxiety?
- Identification and assessment. Psychoeducation and active monitoring
- Low intensity psychological interventions (individual guided self-help)
- High intentsity psychological intervention (CBT or applied relaxation) or drug treatment
What is a phobia?
Intense, irrational fear of an object, situation, place or person
What are the features of phobias?
- Tachycardia
- Vasovagal response (e.g. bradycardia)
- Psychological e.g. anticipatory event, inability to relax, urge to avoid the feared situation, at extremes a fear of dying
What are the features of agoraphobia?
What are some differentials for anxiety?
- GAD
- Panic disorder
- PTSD
- Anxious personality disorder
- Adjustment disorder
- Depression
- Schizophrenia
What forms the general management of anxiety disorders?
- Establish good rapport
- Advise avoidance of anxiety-inducing substances e.g. caffiene
- Screen for substance misuse, personality disorders
What is the specific treatment of agrophobia?
CBT involving gradual exposure and desensitization
SSRIs are first line
What is the specific treatment of social phobias?
CBT with graduated exposure
SSRIs e.g. sertraline or SNRIs e.g. venlafaxine or MAOI e.g. moclobemide
What is the treatment of specific phobias?
Exposures using either self-help or more formally through CBT
Benzos can be used short term (e.g. if patient is claustophobic and needs a CT)
What is a panic disorder?
Recurrent, episodic, severe panic attacks which are unpredictable and not restricted to any particular situation
What are the risk factors for panic disorders?
- Family history
- Recent trauma
- White ethnicity
- Major life events
- Female
- Asthma
- Age (20-30)
- Cigarette smoking
What are the features of panic disorder?
Peak within 10 mins and rarely persist beyond an hour
Recurrent panic attacks which are not associated with a specific situation
Discrete episode of intense fear or discomfort, starting abruptlu, reaching a crescendo within a few mins with autonomic arousal: palpitatioms, sweating, shaking / tremor, dry mouth
What are more of the features of panic disorder?
Palpitations
Abdo distress
Numbness
Intense fear of death
Choking
Chest pain
Sweating
Shaking
SoB
What are the management steps of anxiety?
- SSRIs are first-line (if no improvement after 12 weeks then TCA e.g. imipramine or clomipramine)
- CBT
- Self help e.g. support groups, encouraging exercise to promote health
What is PTSD?
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
What is adjustment disorder?
Significant distress (greater than expected) accompanied by an impairment in social functioning
Give examples of some traumatic events?
Severe assault
Major natural disaster (e.g. earthquakes, floods)
Serious RTA
Involvement in wars e.g. WWII
Freak occurences (e.g. near drowning)
What are the features of PTSD?
Symptoms must occur within 6 months of event:
- Reliving (flashbacks, nightmares)
- Avoidance (associated people or locations)
- Hyperarousal (irritability / outbursts)
- Emotional numbing
What are some differentials for PTSD?
- Adjustment disorder
- Acute stress reaction
- Bereavement
- Mood disorder
- Organic: head injury, alcohol / substance misuse
What is an acute stress reaction?
Exposure to an exceptional physical or mental stressor followed by immediate onset of symptoms (within 1 hour) with narrowing of attention, apparent disorientation, anger or verbal aggression. Must resolve within 48 hours
What is the treatment of PTSD where symptoms are present within 3 months of trauma?
- Watchful waiting
- Trauma-focussed CBT
- Zopiclone for sleep disturbance
- Risk assessment for suicide
What is the treatment for PTSD when symptoms have been present for more than 3 months after trauma?
- CBT / eye movement desensitization and reprocessing
- Drug treatment (if little benefit from therapy / patient refuses therapy)
- Paroxetine, mirtazapine, amitriptyline, phenelzine
What is OCD?
Recurrent obsessional thoughts or compulsive acts
What are obsessions?
Unwanted intrusive thoughts, images or urges which repeatedly enter the mind, they are distressing and recognised as absurd
What are compulsions?
Repetitive behaviours or mental acts that a person feels driven into performing - overt (observable) or covert (mental acts)
What are the theories for the aetiology of OCD?
Biological: related to decreased serotonin and abnormalities of the frontal cortex and basal ganglia. Childhood group A beta-haemolytic strep infection may have a role in causing OCD
Psychoanalytic: filling the mind with obsessional thoughts to prevent undesirable ideas from entering consciousness
Behavioural: Operant conditioning - anxiety created the obsession is reduced by performing the compulsion
How may OCD be diagnosed?
- Obsessions / compulsions present on most days for a period of 2 weeks
- Obsessions interfere with individual functioning
What is the most common obession and compulsion?
Obsession = being contaminated
Compulsion = checking and cleaning
What are some other obsessions and compulsions?
Obsession = fear of harm (e.g. locks not safe), excessive concern with symmetry
Compulsion = Checking gas taps, door locked, arranging objects
What are some differentials for OCD?
Eating disorder
Anxiety disorder
Depressive disorder
Schizophrenia
Organic = epilepsy, dementia, head injury
What is the management of OCD?
CBT (including exposure and response prevention)
Pharma (SSRIs e.g. fluoxetine, sertraline, paroxetine, citalopram, TCA e.g. clomipramine)
What is helpful for OCD patients in general?
Psychoeducation, self-help books
Assess potential suicide risk
Co-morbid depression should be identified
What is a somatoform disorder?
Group of disorders whose symptoms are suggestive of a physical disorder without physiological illness
What are dissociative disorders?
Symptoms which cannot be explained by a medical disorder where there are convincing associations in time between symptoms and stressful events
- Painful / stressful thoughts are subconsiously converted into more bearable physical symptoms by the patient
What is the cause of somatoform disorders?
Patients adopt sick role which provides relief from stressful interpersonal expectations (primary gain) or care from others (secondary gain)
What are some risk factors for somatoform and dissociative disorders?
Childhood abuse
Anxiety disorders
Mood disorders
Personality disorders
Social stressors
How can somatization disorder be diagnosed?
- 2 years duration of symptoms
- Preoccupation with symptoms causes physical distress leading to repeated consultations
- Refusal of reassurance from doctor
What is hypochondiral disorder?
Patient misinterprets normal bodily sensations, leading them to the non-delusional preoccupation that they have a serious condition e.g. cancer
What are the investigations for somatoform disorders?
- Diagnosis of exclusion
- Physical examination dependant on symptoms
- Bloods: FBC for anaemia, infection, U&Es for electrolyte disturbance, LFTs for liver or biliary pathology, CRP for infection or inflammation, TFTs for thyroid disorder
- GI symptoms: AXR, stool culture, OGD, colonoscopy, diagnostic laparoscopy
- Cardiac symptoms: ECG, 24 hr tape, ECHO, acngiogram
- GUM symptoms: urine dipstick, MSU, cytoscopy
What is Munchausen’s syndrome (malingering and factitious disorder)?
Physical and psychological symptoms are intentionally produced
Malingering = advantageous consequences
Munchausen’s = individual wants to adopt the ‘sick role’ in order to receive the care of a patient
Give examples of the difference between factitious, malingering, somatoform disorder and dissociative disorder?
What is the biopsychosocial management of somatoform and dissociative disorders?
Bio = SSRIs, physical exercise
Psychological = CBT, coping strategies
Social = meditation, long walks, or involve family where appropriate
How can somatisation be differentiated from hypochondria?
Somatisation = symptoms (2 years) - patient refuses negative test results
HypoChondria = cancer (belief in underlying disease)
How is conversion disorder unique?
- Loss of motor / sensory function
- Factitious disorder = patient consciously feigns symptoms
- Malingering = for material gain
- Dissociative = normally psychiatric symptoms e.g. amnesia, stupor
