Anxiety disorders Flashcards
What are anxiety disorder?
Disorders where anxiety is the main symptom
Feelings of tension, worried thoughts, and physical changes
Recurring intrusive thoughts or concerns
What are the different types of anxiety disorders?
Generalised anxiety disorder - persistent anxiety
Mixed anxiety and depressive disorder - equal elements of anxiety and depression
Panic disorder - diagnosed when patient has repeated, sudden attacks of overwhelming anxiety, accompanied by severe physical symptoms
Phobic disorders - fear triggered by a stimulus that are predictable and are normally no concern to others
What are the risk factors for anxiety disorders?
Trauma Stress Personality type Other mental health disorders Having blood relative with anxiety Drugs or alcohol
What might the behaviour and appearance of a patient with anxiety be like?
Looking apprehensive or fearful, difficulty concentrating, restlessness
Unkempt
Lose fitting clothes if lost weight
What might the speech of someone with anxiety disorder be like?
Fast and anxious
What might the emotion of someone with anxiety disorder be like?
Mood - apprehension/fear or irritable
Affect - may vary
What might the perception of someone with anxiety disorder be like?
Derealisation
Depersonalisation
What might the thoughts of someone with anxiety disorder be like?
Worried
Apprehension
Fear
Fast thoughts
How common are anxiety disorders?
GAD - 4-6% of population, more common in women
Mixed - 7% prevalence
8% prevalence of phobias
What are the psychiatric differentials of anxiety disorder?
Depressive illness OCD Pre-senile dementia Alcohol dependence Drug dependence Benzodiazepine withdrawal
What are the organic differentials of anxiety disorder?
Hyperthyroidism
Hypoglycaemia
Phaeochromocytoma
Arrhythmias
What are the physical symptoms of anxiety?
GI Resp CVS GU Nervous system
What are the GI symptoms of anxiety?
Dry mouth Difficulty swallowing Epigastric discomfort Aeophagy Diarrhoea
What are the resp symptoms of anxiety?
Feeling of chest constriction
Difficulty inhaling
Over-breathing
Choking
What are the CVS symptoms of anxiety?
Palpitations
Awareness of missed beats
Chest pain
What are the GU symptoms of anxiety?
Increased frequency
Failure of erection
Lack of libido
What are the nervous symptoms of anxiety?
Fatigue Blurred vision Dizziness Sensitivity to noise and/or light Headache Sleep disturbance Trembling
What are the psychological symptoms of anxiety?
Apprehension and fear Irritability Difficulty concentrating Distractibility Restlessness Depersonalisation Derealisation
What investigations are done for someone with anxiety?
Physical examination History FBC, U&E, serum creatinine, eGFR ESR/CRP TSH Serum cortisol Kidney USS Afrenaline in blood and urine tests Glucose levels, HbA1c CXR ECG
What is the biological management of anxiety?
Benzodiazepines
SSRIs
Anti-psychotics
Beta-blockers
What is the psychological management of anxiety?
Relaxation techniques Anxiety management CBT Biofeedback Behavioural therapies - graded exposure
What is the social management of anxiety?
Financial - eligible benefits, debt counselling
Employment - acquiring or changing a job or career
Housing - adequate, secure tenancy, safe social neighbours
Young children - childcare support
What is OCD?
Frequent obsessive thoughts and compulsive behaviours
What are the different types of OCD?
Contamination - obsession over contracting illness/spreading germs, causes serious anxiety and distress, excessive washing/avoiding crowded spaces
Perfection - overwhelming fear of making mistakes, intense need for things to be perfect or done right, may or may not be accompanied by fear that harm will come to oneself or others if things aren’t done perfectly
Doubt/harm - aggressive, intrusive thoughts of violence to someone and the responses the person uses to cope with these thoughts
Forbidden thoughts - intrusive thoughts about the possibility of harming yourself or others, disturbing thoughts involving sex/religion
What questions is it important to ask in the history?
Are there thoughts that you have a need to act on?
Thought content?
Frequent unwanted thoughts that seem uncontrollable?
Do you try and get rid of these thoughts and if so what do you do?
Do you wash or clean a lot?
Do you keep checking things repeatedly?
Are you concerned with symmetry and putting things in order?
Do your daily activities take a long time to complete?
Do these problems trouble you?
Does this behaviour make sense to you?
Rituals/repetitive behaviour?
What are the risk factors for OCD?
Older teens/young adult Family history Presence of another mental illness Paediatric autoimmune neuropsychiatric disorders Stress Pregnancy and postpartum period
How common is OCD?
Affects over 2% of population
50% of all cases are severe
Less than a quarter are mild cases
Gradual onset
What could be the differential diagnoses of OCD?
Depression
Anxiety
Hypochondriasis
How does OCD present?
Obsessions
Emotions
Compulsions
How do obsessions present in OCD?
Unwanted, intrusive and often distressing thoughts, images, or urges repeatedly entering your mind
- Fear of deliberately harming yourself or others
- Fear of harming yourself or others by mistake
- Fear of contamination by disease, infection, or unpleasant substance
How do emotions present in OCD?
Feeling of intense anxiety/distress
How do compulsions present in OCD?
Repetitive behaviours/mental acts a person with OCD feels driven to perform as a result of anxiety and distress
- Cleaning and hand washing
- Checking
- Counting
- Ordering and arranging
- Hoarding
- Asking for reassurance
- Repeating words in their head
- Thinking neutralising thoughts to counter obsessive thoughts
- Avoiding places and situations that could trigger obsessive thoughts
What is the pathology of OCD?
Dopamine-serotonin imbalance
Disturbed basal ganglia regulation
What are the NICE diagnostic questions for OCD?
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you’d like to get rid of but can’t?
Do your activities take a long time to finish?
Are you concerned about putting things in a special order or are you very upset by mess?
Do these problems trouble you?
What is the management of OCD?
Psychological therapy - CBT with exposure and response prevention
Antidepressants - SSRIs/clomipramine
Support groups
Psychoeducation
What is the prognosis of OCD?
15% show progressive worsening of symptoms or deterioration in functioning over time
5% have complete remission of symptoms between episodes of exacerbation
What is PTSD?
Type of anxiety disorder occurring in people who have experiences or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape of who have been threatened with death, sexual violence, or serious injury
What are the different types of PTSD?
Normal stress response Acute stress disorder Uncomplicated PTSD Complex PTSD Co-morbid PTSD
What are the risk factors for PTSD?
Living through dangerous events and traumas
Getting hurt
Seeing another person hurt, or seeing a dead body
Childhood trauma
Feeling horror, helplessness, or extreme fear
Having little or no social support after the event
Dealing with extra stress after the event such as a loss of a loved one, pain, injury, or loss of a job or home
Having a history or mental illness or substance abuse
How common is PTSD?
Can occur in all people of any ethnicity, nationality, or culture and at any age
Affects approximately 3.5% of adults every year
1 in 11 diagnosed with PTSD in lifetime
Women x2 likely to have it as men
Name 3 differential diagnoses of PTSD
Acute stress disorder Dissociation disorders Depression GAD Panic disorder Phobias Substance abuse Psychiatric manifestation of medical conditions
How does PTSD present?
Re-experiencing symptoms
Avoidance symptoms
Arousal or reactivity symptoms
Cognition and mood symptoms
Give an example of re-experiencing symptoms
Flashbacks
Reoccurring memories or nightmares related to the event
Distressing and intrusive thoughts or images
Physical sensations like sweating, trembling, pain, or feeling sick
Give examples of avoidance symptoms
Staying away from places, events, or objects that are reminders of experience
Feeling that you need to keep yourself busy all the time
Using alcohol or drugs to avoid memories
Feeling emotionally numb or cut off from your feelings
Feeling numb or emotionally detached from you body
Being unable to remember details of the trauma
Give examples of arousal and reactivity symptoms
Being jumpy and easily startled
Feeling tense, on guard, or on edge
Having difficulty concentrating on even simple and everyday tasks
Having difficulty falling asleep or staying asleep
Feeling irritable and having angry and aggressive outbursts
Self-destructive or reckless behaviour
Give examples of cognition and mood symptoms
Trouble remembering key features of the traumatic event
Feeling like you can’t trust anyone
Distorted thoughts about the trauma that causes feelings of blame and guilt
Overwhelming negative emotions, such as fear, sadness, anger, guilt, or shame
Loss of interest in previous acitivites
Feeling like no-where is safe
Difficulty feeling positive emotions such as happiness or satisfaction
What is the pathology of PTSD?
Hyperactivity of sympathetic branch of the autonomic nervous system as evidenced by changes in HR, BP, skin conductance level, and other psychophysiological measures
Elevated noradrenergic reactivity to pharmacological challenges
What investigations should you do with someone who has PTSD?
Bloods
What is the management of PTSD?
Trauma focussed CBT EMDR Psychoeducation Prolonged exposure therapy Medication - Venlafaxine or SSRIs - peroxitine or sertraline - Anti-psychotics - risperidone
