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Anxiety disorders and reaction to stress and trauma | Flashcards

1
Q

Anxiety exists on a contiuum - What is the normal physiological response to stressful situations called?

A

Fight or flight - the normal adaptive response to the experience of threat or danger

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2
Q

What are characteristic features of normal behavioural responses to stress i.e. threat or danger?

A
  1. Escape or avoidance
  2. The search for safety or reassurance
  3. Preparatory vigilance
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3
Q

What distinguishes normal anxiety from pathological anxiety (4)?

A
  1. Autonomy: no or minimal environmental trigger
  2. Intensity: exceeds patient’s capacity to bear the discomfort
  3. Duration: symptoms are persistent
  4. Behaviour: anxiety impairs functioning and/or results in disabling behaviours – avoidance or safety behaviours
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4
Q

What are 2 broad categories of anxiety disorders?

A
  1. Constant

2. Episodic

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5
Q

What is a constant anxiety disorder?

A

Generalised anxiety disorder (GAD)

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6
Q

What types of episodic anxiety disorders are there (4)?

A
  1. Phobias
    - Agrophobia
    - Social
    - Specific
  2. Panic disorder
  3. PTSD
  4. OCD
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7
Q

What is the prevalence of the following anxiety disorders?

  1. Panic disorder
  2. OCD
  3. PTSD
  4. All phobias
  5. GAD
A
  1. Panic disorder 1.7%
  2. OCD 2.3%
  3. PTSD 3.6%
  4. All phobias 8.0%
  5. GAD 2.8%
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8
Q

What are 5 groups of symptoms of anxiety?

A
  1. Psychological arousal
  2. Sleep disturbance
  3. Muscle tension
  4. Autonomic arousal
  5. Consequences of hyperventilation
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9
Q

What are the 6 specific psychological arousal symptoms of anxiety?

A
  1. Worrying thoughts
  2. Irritability
  3. Sensitivity to noise
  4. Restlessness
  5. Fearful anticipation
  6. Poor concentration
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10
Q

What are the 2 specific sleep disturbance symptoms of anxiety?

A
  1. Insomnia

2. Night terrors

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11
Q

What are the 2 specific muscle tension symptoms of anxiety?

A
  1. Tremors

2. Aches

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12
Q

What are the 6 specific autonomic arousal symptoms of anxiety?

A
  1. Dry mouth
  2. Diarrhoea
  3. Difficulty breathing
  4. Palpitations
  5. Chest discomfort
  6. Frequent and urgent micturition
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13
Q

What are the 2 specific consequences of hyperventilation symptoms of anxiety?

A
  1. Dizziness

2. Tingling numbness

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14
Q

What are the 4 components of the anxiety cycle?

A
  1. Thoughts (cognitions)
  2. Behaviour
  3. Emotion
  4. Bodily responses
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15
Q

In the anxiety cycle, what are thoughts someone may experience?

A

“They will see how red I am”
“I will shake uncontrollably”
“I might freeze”

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16
Q

In the anxiety cycle, what are some behaviours someone may experience?

A

Avoid the situation
Hold paper up to face when speaking
Talk really fast
Look at the floor

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17
Q

In the anxiety cycle, what are some emotions someone may experience?

A

Anxiety
Panic
Embarrassed
Ashamed

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18
Q

In the anxiety cycle, what are some bodily responses someone may experience?

A 
racing heart
dry mouth
dizziness
stomach ache
headache
sweaty
feeling hot & cold
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19
Q

What are some physical consequences of anxiety (7)?

A
  1. racing heart
  2. dry mouth
  3. dizziness
  4. stomach ache
  5. headache
  6. sweaty
  7. feeling hot & cold
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20
Q

What is GAD?

A
  1. Characterised by free-floating anxiety that may fluctuate but neither situational nor episodic
  2. “worrisome” - fear the future to such an extent that they may behave overly
  3. Cautious or risk-averse
    patients can be “paralysed with fear”
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21
Q

What is the ICD-10 criteria for GAD?

A
  1. Generalised and persistent somatic (physical) and psychological symptoms of anxiety on most days for at least several weeks at a time and usually several months
  2. Anxiety symptoms usually involve elements of:
    - Apprehension
    - Motor tension
    - Autonomic overactivity
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22
Q

What is panic disorder (episodic paroxysmal anxiety)?

A

Recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances, and which are therefore unpredictable

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23
Q

What are symptoms of panic disorder (3)?

A
  1. Sudden crescendo of severe anxiety
  2. Associated with intense awareness of threatening bodily sensations e.g. palpitations, choking, chest pain, dizziness.
  3. Feelings of loss of touch with reality are common and are associated with catastrophic cognitions e.g. thoughts one might be dying, losing control, going mad
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24
Q

What are characteristics of panic attacks with panic disorder (2)?

A
  1. Short-lived and most last less than 10 minutes
  2. They often result in a hurried exit from wherever the attack took place, and future avoidance of the same situation
  3. They can be recurrent
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25
Q

What can be a consequence of panic attacks?

A

Frequent and unpredictable panic attacks lead to fear of being alone or going out in public.

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26
Q

What is the ICD-10 criteria of panic disorder?

A
  1. Several attacks within one month
  2. In circumstances with no objective danger
  3. Not confined to known or predictable situations
  4. With comparative freedom from anxiety symptoms between attacks
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27
Q

What is agrophobia and its characteristics?

A
  1. Marked fear or avoidance of
    - Crowds, public places, travelling alone, travelling away from home etc.
    - A common key feature of agoraphobic situations is the lack of an immediate exit
  2. Symptoms restricted to fearful situations or contemplation of feared situation
  3. Avoidance is always present
  4. Can occur with or without panic disorder
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28
Q

What are the ICD-10 criteria of agrophobia?

A
  1. Psychological and autonomic symptoms primarily manifestations of anxiety and not secondary to other symptoms, such as depression or delusions.
  2. Anxiety must be restricted to at least two of the following: crowds, public places, travelling alone, travelling away from the home
  3. Avoidance of the phobic situation must be a prominent feature.
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29
Q

What is social phobia?

A

Marked fear of being the focus of attention, of embarrassment or humiliation.

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30
Q

What are symptoms of social phobia?

A
  1. Symptoms restricted to fearful situations or contemplation of feared situation
  2. Blushing or shaking
  3. Fear of vomiting
  4. Urgency or fear of micturition
  5. Avoidance present
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31
Q

What is the ICD-10 criteria of social phobia?

A
  1. Psychological, behavioural or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
  2. The anxiety must be restricted to or predominate in particular social situations
  3. The phobic situation is avoided whenever possible
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32
Q

What is specific (isolated) phobia?

A

Marked fear of a specific object or situation not included in agoraphobia or social phobia or marked avoidance of such objects or situations.

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33
Q

What are the most common objects or situations that trigger specific (isolated) phobia?

A

Animals, birds, insects, heights, thunder, flying, small enclosed spaces, sight of blood or injury, injections, dentists and hospitals.

34
Q

What are the symptoms of anxiety due to with specific (isolated) phobia?

A
  1. Due to the symptoms
  2. The avoidance
  3. Recognition that this is excessive or unreasonable.
35
Q

When do the symptoms of anxiety occur with specific (isolated) phobia?

A

Restricted to the feared situation or when thinking about it, ie no symptoms of generalised anxiety

36
Q

What is the ICD-10 criteria of specific (isolated) phobia?

A
  1. Psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
  2. The anxiety must be restricted to the presence of the particular phobic object or situation
  3. The phobic situation is avoided whenever possible
37
Q

What is OCD?

A

A disorder characterised by obsessive symptoms (thoughts, impulses, images) and/or compulsive acts or rituals, present on most days for at least two weeks, causing distress and interfering with activities.

38
Q

What is the incidence of OCD in M and F?

A

Equal

39
Q

What is the mean onset of symptoms to diagnosis for OCD?

A

9 years

40
Q

What 3 things do OCD often coexist with?

A
  1. Schizophrenia
  2. Tourette’s Syndrome
  3. Depression
41
Q

What are 6 criteria for obsessions?

A

Thoughts, ideas or images which are:

  1. Acknowledged as excessive or unreasonable
  2. Repetitive
  3. Intrusive and resisted by the patient (although the resistance may diminish in chronic OCD)
  4. Unpleasant – i.e. the thought gives no pleasure
  5. Originate in the mind of the patient and are not imposed by outside persons or influences (i.e. not thought insertion)
  6. Cause distress and interfere with functioning
42
Q

What are 7 criteria for a compulsion?

A

A physical act which is:

  1. Acknowledged as excessive or unreasonable
  2. Repetitive
  3. Intrusive and resisted by the patient, causing mounting anxiety
  4. Unpleasant – i.e. the act itself gives no pleasure, but may relieve tension or anxiety.
  5. The desire to carry out the act originates in the mind of the patient and are not imposed by outside persons or influences ie not a made act arising from psychosis.
  6. Causes distress and interferes with functioning, usually due to wasting time.
  7. Magical thinking can occur – eg. “if I touch this door frame five times, no harm will come to my family”.
43
Q

What are common comorbidities of anxiety disorders?

  1. Endocrine
  2. Metabolic
  3. Hypoxia
  4. Neurological
  5. Cardiac
  6. Drug withdrawal
  7. Drug intoxication
A
  1. Endocrine
    - Thyroid dysfunction
    - Phaeochromocytoma
  2. Metabolic
    - Acidosis (e.g. diabetic ketoacidosis)
    - Hyperthermia or hypothermia
  3. Hypoxia
    - Congestive Heart Failure,
    - Angina
    - Chronic Obstructive Pulmonary Disease (COPD)
    - Anaemia
  4. Neurological
    - Seizures
    - Vestibular dysfunction
  5. Cardiac
    - Arrhythmias e.g. Supraventricular Tachycardia (SVT)
  6. Drug withdrawal
    - Alcohol
    - Opiates
  7. Drug intoxication
    - Caffeine
    - Amphetamine
    - Cocaine
    - New psychoactive substances (“legal high”)
44
Q

What are co-morbid psychiatric disorders that occur with anxiety disorders/.

A
  1. Depression - Are these causing the anxiety or resulting from it?
  2. Drug / alcohol misuse - significantly complicates treatment
  3. Personality disorders
  4. Anxiety symptoms secondary to organic pathology
45
Q

How do patients usually manage their own anxiety?

A

Through Avoidance and Safety behaviours

Unfortunately, these behaviours feed into the anxiety and worsen the illness

46
Q

What is the 4 step-care approach to management of anxiety?

A
  1. All known and suspected presentation of anxiety
    - Psychoeducation and active monitoring
  2. No improvement after education and monitoring
    - Guided self-help and low-intensity psychological interventions (primary care psychological services: IAPT)
  3. Inadequate response to step 2 interventions or marked functional impairment
    - High-intensity psychological intervention (CBT) or drug treatment (primary care)
  4. Complex treatment-refractory. Very marked functional impairment or risk
    - Referral to secondary care - complex drug or psychological treatment regimes; input from multi-agency teams
47
Q

What are the 7 possible components of psychoeducation?

A
  1. Definition and nature of illness
  2. Explaining cycle of anxiety for this diagnosis
  3. Precipitating and maintaining factors
  4. Treatment (medications and psychological)
  5. CBT approach
  6. Social interventions
  7. Prognosis
48
Q

What are the psychological management options of anxiety disorders?

A
  1. Psychoeducation
  2. Guided self-help
  3. CBT
    - Graded exposure/systematic desensitisation
    - Exposure and response prevention (ERP)
49
Q

What is psychotherapy?

A
  1. Process whereby patients (and carers) knowledge and awareness of the illness is improved
  2. Improves understanding and support patients have and receives.
  3. This is undertaken usually with support of trained professionals
50
Q

What is guided self-help?

A
  1. Done by the patient through access to variable resources e.g. books, computers etc.
  2. Usually, this will be guided or facilitated with a trained person to maximise efficacy
51
Q

What is graded exposure?

A

Patients expose themselves gradually to the stimulus e.g. fear of flying:

Visualise a plane

  1. Look at a plane in the sky
  2. Drive by an airport
  3. Go to a museum that has planes
  4. Same museum - visualise going inside planes
  5. Same museum - Go inside planes
  6. Go to an airport and watch planes take off and land
  7. Visualise yourself on a plane flying
  8. Flight simulator experience
  9. The real thing
52
Q

What is the first -line treatment of mild-moderate anxiety?

A

Psychological treatment

53
Q

What are 4 groups of medication that can be used for anxiety?

A
  1. Antidepressants - SSRI, TCA and SNRIs
  2. Beta blocker
  3. Benzodiazepines
  4. Antipsychotic
54
Q

Why are antidepressants given for anxiety?

A

All antidepressants are anxiolytics

55
Q

What should patients be warned about with regards to starting antidepressants for anxiety?

A

Possible brief increase in anxiety in the initial period

56
Q

Why are beta blockers used for anxiety?

A

Sometimes used to reduce the heart rate and autonomic arousal of anxiety

57
Q

What types of benzodiazepines are used?

A

Short half-life e.g. Lorazepam

Long half-life e.g. Diazepam

58
Q

What cautions should you take for benzodiazepines (2)?

A
  1. Can be addictive - so short-term use

2. Benzodiazepines can reduce the efficacy of psychological treatment

59
Q

When are antipsychotics prescribed for anxiety?

A

Not routinely used, but can be beneficial in severe cases

60
Q

What is the ICD-10 definition of an acute stress reaction?

A

A brief response (up to a month in ICD10 to severely stressful events

61
Q

What are symptoms of acute stress reaction?

A
  1. Include symptoms of anxiety and depression
  2. Possibly also numbness, detachment, poor concentration, derealisation, insomnia, restlessness, anger, autonomic symptoms​
  3. Patients may already be using coping strategies – avoidance of talking or thinking about the event, denial of events/not being able to remember
  4. Unhelpful strategies such as alcohol excess are also common
62
Q

In people who experience an acute stress reaction, what are risk factors for later development PTSD?

A
  1. Poor pre-existing support network
  2. Pre-existing mental health problems, making coping more difficult
  3. May have suffered a more serious trauma to provoke the acute stress reaction e.g. after surviving mass shooting etc
63
Q

What is the management of acute stress reaction?

A
  1. Reduce emotional response – talking to friends/family or professionals.
  2. Encouraging, but not forcing, recall (debriefing)
  3. Learning effective coping skills
  4. Anxiolytic only if severe anxiety (beware of addictive potential of benzodiazepines)
  5. Hypnotics if severe sleep disturbance
64
Q

What is the prognosis of acute stress reaction?

A

The vast majority go on to get better with no intervention or formal diagnosis

65
Q

What is adjustment disorder?

A

Psychological reaction to adapting to a new set of circumstances, e.g. new job/home, divorce, etc.
Starts within 3 months and must be understandably related to and in proportion to the stressful event.

66
Q

What events usually trigger adjustment disorder?

A

bereavement, the onset of terminal illness or sexual assault and medicalisation of these circumstances is avoided where possible

67
Q

What are symptoms of adjustment disorder?

A
  1. Symptoms of anxiety and worry
  2. Depression
  3. Irritability
  4. Physical symptoms caused by autonomic arousal, such as palpitations and tremor
  5. Occasional outbursts of dramatic or aggressive behaviour
  6. Sometimes abuse of alcohol or drugs: as with this case, the threshold is often reached for a comorbid alcohol dependence syndrome.
  7. Social functioning impaired
68
Q

How does the symptoms of adjustment disorder vary in time compared to acute stress reaction?

A

Onset more gradual than acute stress reaction, and it takes a more prolonged course

69
Q

What is the management of adjustment disorder?

A
  1. If possible, help resolve the change of circumstances e.g. support to make changes at work or put in touch with support groups when dealing with personal difficulties/illness
  2. Help the natural process of adjustment, prevent avoidance and denial, encourage problem-solving to seek solutions and assess +/- of various courses of action.
  3. Relieve anxiety by encouraging to talk and express associated feelings
  4. Consider referring for talking therapy in primary care if the patient wishes for this
70
Q

What is the prognosis of adjustment disorder?

A
  1. Most last a few months
  2. A few last a few years
  3. Adults generally do well
  4. Adolescents with an adjustment disorder have an increased risk of developing psychiatric illness in adult life
71
Q

What is PTSD?

A

This is a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, likely to cause pervasive distress in almost anyone e.g. natural disasters, combat etc

72
Q

When do symptoms of PTSD start following trauma?

How long do symptoms of PTSD have to go on for to be classified as PTSD?

A

There is usually a latency period of a few weeks to a few months, but rarely exceeds 6 months.

Symptoms must persist beyond 6 months after the event, less than this would be classified as a normal response to severe trauma

73
Q

What are the core triad of symptoms of PTSD?

What are 2 other symptoms?

A
  1. Hyperarousal– persistent anxiety, irritability, insomnia, poor concentration
  2. Re-experiencing – ‘flashbacks’, recurrent distressing dreams, inability to recall stressful events at will
  3. Avoidance – of reminders of event, detachment, numbness, loss of interest in activities.

Others:

  • Depressive & guilt symptoms common
  • Substance use as a coping strategy common

(Symptoms may begin quickly after, rarely >6 months after)

74
Q

What is the management of PTSD according to the bio-psycho-social model?

A

Psycho

  1. Psychoeducation
  2. Trauma-focused CBT
  3. Eye Movement Desensitization and Reprocessing (EMDR)

Bio
1. Antidepressants (e.g. SSRI)

Social

  1. Educate family
  2. Support in reintegration to the environment
  3. Avoid alcohol
75
Q

What is the prognosis of PTSD?

A
  1. Around 50% recover within the first year.
  2. Poorer Prognosis if co-morbid mental illness, long duration, history of psychiatric illness, family history of mental illness, poor social support or pre-morbid functioning or outstanding compensation claims
76
Q

How would you explain the management of anxiety to a patient/carer?

A

First line is always psychological treatments:

  1. Psychoeducation - helps you and your family to better understand the nature of your condition
  2. CBT if more severe anxiety

If this is not enough, along with CBT, if it is moderate anxiety we may include pharmacological treatments:

  1. First line usually SSRI e.g. sertraline
  2. This is managed in primary care

In severe anxiety:

  1. We would consider admission to hospital
  2. Benzodiazepines can be given short term for a crises
  3. Anti-psychotics are possibly given in hospital for very severe anxiety

Social:
1. Self-care - sleep hygiene, encourage exercise, re-introduction to school/work etc

77
Q

How would you explain the aetiology of anxiety to a patient/carer?

A

Anxiety is a normal response caused by release of adrenaline in response to danger.
It becomes a problem when it occurs out of the patients control, when it is extremely intense, and severely affects their life.
We have the anxiety cycle which consists of 4 components: thoughts, behaviour, emotion and bodily response. So you might be giving a speech and think “everyone is going to see how red i am”, then you go red and feel embarrassed, and this makes you sweat etc.

78
Q

What are social effects of anxiety (8)?

A
  1. Fear of leaving the house, social withdrawal
  2. Extreme, unwarranted fear of particular situations or things
  3. Compulsive or repetitive behaviors
  4. Changes in personality
    trouble on the job or in school
  5. Family or relationship problems
  6. Alcohol or drug abuse
  7. Depression or suicidal thoughts
  8. Frequent emotional and physical health issues
79
Q

What are indications for benzodiazepines (2)?

A
  1. only for severe or disabling anxiety

2. insomnia

80
Q

What are side effects of benzodiazepines (9)?

A
  1. Dependence
  2. Tolerance so they need more
  3. Cognitive and psychomotor impairment
  4. Depression
  5. Irritability
  6. Loss of concentration
  7. Emotional blunting
  8. Risk of falls in elderly
  9. Risk of accidents while driving

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