Anxiety Disorders and OCD Flashcards
General Treatment Principles
- Decide on diagnosis / diagnoses (may co-exist with other mood/anxiety disorder)
- Decide on special investigations
- Do a risk assessment (harm to self / others / property)
- Decide on where to treat (in-pt, out-pt with/without supervision)
- Decide whom to involve (family, friend, work etc)
- Decide whom to refer to (psychiatrist, psychologist, social worker etc)
- Decide when to follow up and how frequently
Generalized Anxiety Disorder
Chronic excessive worrying
- accompanied by psychological and physiological Sx of anxiety
- functioning is impaired
- anxiety is significantly distressing
GAD Rx
(May only improve in 6-8w - longer than for depressive disorders)
Biological:
-SSRI: Citalopram 20-50mg/d OR Fluoxetine 20-60mg/d
OR
-Benzo: Lorazepam 0,5-2mg tds (response within days, but may be habit forming + other SE)
Psychosocial: CBT
Anxiety definition
An unpleasant feeling state in anticipation of future threat
Abnormal anxiety:
- excessive duration
- destructive
- effect on functioning
Stressor definition
An event/situation that requires adjustment
Panic attack
- A surge of intense fear or discomfort
- Peaks in minutes
- Accompanied by physical and psychological Sx of intense anxiety / intense autonomic arousal
Panic Disorder
Recurrent, UNEXPECTED panic attacks
-continuous worrying about attacks OR dysfunctional behavior due to attacks
Panic Disorder Rx
Biological
-SSRI: Citalopram 20-50mg/d OR Fluoxetine 20-60mg/d
(Continue for 12mo symptom free, then reduce)
OR
-Benzo if quick response needed - Lorazepam 0,5-2mg tds
2nd line
-TCA: only imipramine or clomipramine
Psychosocial
-CBT
Phobic Disorders
Excessive, persistent (6mo +) and unreasonable fear for a circumscribed stimulus, where stimulus is:
- avoided
- endured with much anxious distress
- functioning is impaired and there is clinically significant distress
Social anxiety disorder (social phobia)
Agoraphobia
Specific phobia
Social Anxiety Disorder (aka social phobia)
Fear/ anxiety about:
- social situations
- where exposed to possible scrutiny
- about showing anxiety symptoms that will be negatively evaluated
Agoraphobia
Fear/anxiety about 2+ of:
- using public transport
- being in open spaces
- being in enclosed spaces
- standing in line or being in a crowd
- being outside the house alone
Fears/avoids situations because of thoughts that:
- escape may be difficult
- help may not be available if panic like or embarrassing symptoms develop (falling/incontinence)
Specific Phobias
- Animal type: any animal or insect
- Natural environment type: heights, thunder etc
- Blood-injection-injury type: often ass.w. fainting
- Situational type: public transport, lifts etc
Other type
Substance induced anxiety disorder
-panic attacks or anxiety predominate
Specifiers:
- with onset during intoxication
- with onset during withdrawal
- with onset after medication exposure
(Caffeine, thyroxine)
Anxiety disorder due to another medical condition
- panic attacks / anxiety predominate
- evidence of direct effect from another medical condition where condition is a known culprit
(Hyperthyroidism)
Discontinuing medication in anxiety disorders
1yr of complete remission Full functioning restored Patient has sense of well-being Do it slowly over months Re-instate Rx lifelong if relapse
Anxiety Disorders in children
Separation anxiety disorder
Generalized anxiety disorder
Social anxiety disorder
Normal separation anxiety
- universal child awareness of separation from mother / primary caregiver
- peaks between 9-18mo, diminished by 2 and a half years
Separation anxiety disorder
-inappropriate & excessive anxiety when faced with separation from major attachment figure
Characteristic physiological traits: higher morning cortisol, higher average resting HR, low HR variability
Generalized anxiety disorder (paeds)
- significant distress in daily activities (fears incompetence in school performance, or in social settings (>4w)
- Sx of autonomic hyperarousal (sweating, nausea, tachycardia, SOB)
+ at least one:
- restlessness
- easily fatigued
- mind going blank
- irritability
- muscle tension
- sleep disturbance
Social anxiety disorder
-discomfort and distress in social situations - impaired by fear of scrutiny or humilitation
Distress expressed in form of crying, tantrums, avoidance, freezing, or becoming “mute”
- must experience anxiety in presence of peers, not only adults
- may exhibit performance type-like fear of public speaking.
Paeds anxiety Rx
CBT - first line
SSRI’s safe and effective (fluoxetine, citalopram)
Caution with tricyclic anti-depressants - increased risk of suicidal ideations
Use diphenhydramine for sleep disturbances
Obsession definition
Recurrent, persistent, intrusive, unwanted and distressing thoughts, urges or images.
Compulsion definition
Repetitive behaviors or mental acts that a person feels driven to do in response to an obsession or according to rigidly applied rules
- aimed at preventing/reducing anxiety or distress, or preventing something dreaded
- either unrealistic or excessive
Obsessive Compulsive Disorder
Related behaviors: avoidance, time consuming, injury or damage
Specifiers:
- with good/fair insight
- with poor insight
- with absent insight / delusional beliefs
OCD Mx
- Risk Assessment
- Psychoeducation
- Biological Rx
- SSRI (1st line)
- TAD: Clomipramine (later line) - Psychosocial Rx
- CBT and BT (behavioural therapy) - Decice whom to involve and whom to refer to
Body Dysmorphic Disorder
Preoccupied with exaggerated perceived flaws in physical appearance leading to repetitive behaviors or mental acts
- causes marked distress OR impairs functioning
- not better explained by an eating disorder
Specifiers:
- good/fair insight
- poor insight
- absent insight / delusional beliefs
About being too small or not muscular enough: with muscle dysmorphia
Body Dysmorphic Disorder Mx
- Risk assessment (comorbid disorders, unecessary surgery)
- Psychoeducation
- Biological Rx
- SSRI. Some evidence, but still a good start - fluoxetine - Psychosocial Rx
- CBT and BT - Whom to involve and whom to refer to
Hoarding Disorder
Persistent difficulty parting with possessions
-marked distress or impaired functioning
Hoarding Diff Dx
Can be a symptom of:
- a psychotic disorder
- OCD
- MDD
- neurocognitive disorder (alzheimers, brain trauma, post-encephalitis)
- intellectual disability
- autistic disorder
Hoarding Rx
Not very valuable: try SSRI, CBT and BT
Trichotillomania
Recurrent, irresistible urges to pull out body hair
Trichobezoar
A mass found in the digestive system (hairball)
Dermatotillomania
Aka excoriation disorder
-chronic skin picking, touching, scratching, digging
