Anxiety Disorders Flashcards
What are the signs and symptoms of an anxiety disorder?
Mood and thought:
Tension Agitation Fear of loss of control. Dread Irritability ↓Concentration Depersonalisation and derealisation. Obsessions and compulsions. Physical symptoms:
Somatization Headache Insomnia, especially onset insomnia. GI: bowel and bladder changes, butterflies in stomach, nausea, ↓appetite, globus. Panic attacks:
Physical: palpitations, sweating, trembling.
Fear they are going mad, or fear they are dying (angor animi).
Last no more than a few minutes.
Hyperventilation. Can lead to tetany, tingling, parasthesia, chest pain, and respiratory alkalosis.
What are the risk factors for developing an anxiety disorder?
Risk factors for most anxiety disorders:
Family history (mild).
Women are at higher risk, except OCD and social anxiety disorder.
Onset is usually in teens and 20s. However, may rumble on untreated for years. Exception is GAD, which is commonest in 40s and 50s.
Life stressors. This can include physical illness.
What is the prognosis for an anxiety disorder?
In general, anxiety disorders run a chronic course if untreated, but respond very well to treatment.
GAD tends to have a slightly worse prognosis, with 70% having long-term residual symptoms.
What is generalised anxiety disorder?
Definition and epidemiology
Definition: generalised and persistent anxiety lasting >6 months which is not situational (i.e. not a phobia).
May occur in the context of a chronic health problem, and conversely, anxiety may present with somatic symptoms.
Depression may also be present, in which case treat whichever is most prominent first.
Epidemiology: commonest anxiety disorder. Commoner in women.
What are the psychological management options in GAD?
Psychological
The NICE stepped-care model, using the lowest effective step possible:
Psychoeducation for patient and family for all those with known or suspected GAD.
Low-intensity psychological intervention for 6 weeks, either self-help CBT or group psychoeducation.
High-intensity psychological intervention for 12 weeks, either weekly CBT or applied relaxation. Offer to those with marked functional impairment or failure to improve on lower steps. Drug treatment is an equally effective alternative.
Combine psychological and drug treatment, provide intensive MDT management, and consider inpatient admission.
What are the biological management options in GAD?
Biological
An alternative treatment for those needing high-intensity psychological intervention:
1st line: SSRI. Sertraline is most cost-effective.
2nd line: alternative SSRI or SNRI. 3rd line: pregabalin.
Warn that drugs will take 1 week to take effect, and may initially cause transient increases in anxiety or agitation. Discuss suicide risk if under 30, offer PPI if on NSAIDs or aspirin, and warn against sudden cessation due to withdrawal effects.
Continue for at least 12 months if effective.
Benzodiazepines should be avoided, except for short-term relief during crises.
What are the social management options in GAD?
Peer support groups.
Support with returning to work or training if needed.
What is panic disorder and agorophobia?
Signs and symptoms
Episodic and recurrent panic attacks which are not situational.
Often several attacks per month.
May interpret their symptoms as a physical health problem.
Can lead to situational fear e.g. agoraphobia. However, unlike social phobia, they don’t fear being with other people.
Depression may also be present.
Agoraphobia
Fear of public places, and fear that they will find it hard to escape from such places and/or have a panic attack.
Present in around 50% of those with panic disorder, and management is essentially the same.
How is panic disorder and agorophobia managed?
Initial psychological and biological treatment can be done in primary care. Secondary referral is only needed for those who have failed at least 2 treatments.
Psychological:
Psychoeducation for patient and family. This also applies to patients presenting with a panic attack in A&E, and may involve written information to take away with them.
Self-help or computerised CBT.
Individual CBT: 7-14 weekly sessions.
For agoraphobia, graded exposure therapy can be used. Home-based treatment may be necessary initially.
Biological treatments are an equally effective alternative to psychological therapy:
1st line: SSRI. Allow 12 weeks to see if effective. Counsel as always on side effects.
2nd line: TCA (imipramine or clomipramine).
Continue for at least 6 months if effective.
Other drugs: benzodiazepines should be avoided, except for short-term crises. There is little evidence for propranolol.
Social:
Peer support groups.
What are the signs and symptoms of social anxiety disorder?
Signs and symptoms
Fear and avoidance of meeting people and daily activities such as speaking by telephone, going to the shops, or eating and drinking in company.
Poor eye contact.
Low self-esteem and fear of criticism.
Panic attacks may occur.
In children, it may involve selective mutism.
How is social anxiety managed?
Management
Psychological therapy is usually 1st line:
Individual CBT. Usually involves psychoeducation, and graded exposure, either during sessions or as homework.
In adults, CBT may use the Clark and Wells model, which involves video feedback to correct negative self-imagery, and shifting from self-focused to externally-focused attention.
As an alternative to individual CBT, offer self-help CBT, group CBT, or psychodynamic therapy. Group CBT is particularly useful in children and young people.
Biological:
1st line: SSRI e.g. sertraline, escitalopram.
2nd line: a different SSRI or venlafaxine.
3rd line: MAOIs e.g. phenelzine, moclobemide.
May be needed long-term, depending on response.
Other drugs, including benzodiazepines, should not be routinely used.
Pharmacotherapy should not be routinely used in children and young people with anxiety disorders.
Social:
Difficult social situations may contribute to the condition and should be addressed e.g. for children, bullying in school or family problems.
What else should be considered in a patient with social anxiety disorder?
A validated scale such as the Social Phobia Inventory (SPIN) should be used for the initial assessment and to monitor treatment response.
Offer clinic appointments at less busy times, and private waiting areas if possible. Home-based appointments and treatment may be necessary.
If depression is the primary disorder, treat that first.
Children in particular may be at risk of self-harm.
What are the signs and symptoms of simple or speific phobia?
Signs and symptoms
Anxiety which is specific to objects or situations.
Anticipatory avoidance and anxiety.
Panic attacks may occur.
How is simple or specific phobia managed?
CBT involving graded exposure therapy and anxiety management.
Drugs have little role.
What are the signs and symptoms of OCD?
Obsessional thoughts e.g. around contamination, security.
Compulsive acts: repetitive behaviours which provide temporary relief but don’t give pleasure.
May be co-morbid with depression, substance misuse, or eating disorders.
There is a risk of self-harm and suicide.
