Anxiety disorders - BB Flashcards
Three system model - conceptualisation of panic disorder
- Thoughts
- Feelings
- Behaviour
PTSD diagnosis features
- Re-experiencing - flashbacks, nightmares, reptitive distressing images
- Avoidance - avoiding people or situations, or circumstances resembling event
- Hyperarousal - hypervigilence to threat, exaggerated startle response, sleep problems, irritability, difficulty concentrating
- Emotional numbing - lack ability to experience feelings, feeling detached
Secondary psychological disorders that are at increased risk of developing after PTSD
- Depression
- Drugs and alcohol misuse
- Panic disorder
- Somatisation
- Other anxiety disorder
Management of PTSD
- Watchful waiting if lasted less than 4 weeks
- Military personal have access to treatment via armed forces
Psychological:
* Trauma focused CBT
* Eye movement desensitisation and reprocessing
Pharmacological:
* Not routine
* Venlafaxine or SSRI
* Risperidone if necessary
Classic generic model of panic - Clark model
- Trigger stimulus (internal or external) causes perceived threat
- Cycles into apprehension
- Body sensations
- Interpretation of sensations as catastrphic
- And cycles round
Key thing that characterises panic disorder
- Catastrophic cognition - eg I am going to die, lose control and go crazy etc
Key features clinical depression
- Anhedonia
- Low mood
- Lack energy - one most days, for 2 weeks
Depression differentials
Differentials:
* Hypothyroidism - weight gain, dry hair/skin, nails breaking
* Bipolar affective disorder - any periods of euphoric mood? Feeling like can get lots done? Lots of energy?
* Depression with psychosis - ever see or hear things that other people can’t? delusions eg poverty, nihilism, guilt
* Anxiety - worry, preoccupation and checking
* Substance misuse disorder
* Organic disorder
Other symptoms of depression to cover
- Appetite - including weight changes
- Sleep
- Diurnal mood variation
- Libido change
- Focus and concentration
- Guilt
- Self harm
- Unusual or concerning ideas
- Unusual behaviour or experiences - delusions, hallucinations
What else to ensure cover in low mood history?
- Timescale
- Functional impairment
- RISK - self harm/suicide
- Collateral history
- Previous psychiatric history
- PMH
- DH
- FH - psychiatric disorders
- SH
- Personal history
- DONT FORGET ICE
Common side effects fluoxetine
- GI disturbance
- Headaches
- Dry mouth
- Dizziness
- Sexual dysfunction - diffiuclty achieveing orgasm and arousal
- Bleeding
- Suicidal ideation
Time required for fluoxetine benefit
2-3 weeks, often give it 4
Differentials for ?OCD
- Anxiety
- Normal reaction - any real life stressors that could cause this response?
- Psychotic dimension to depression
Core features OCD
- Obsessions - persistent ideas, images or impulses that enters mind that is distressing for patient. enters mind over and over again
- Compulsion - repetitive actions that ease the distress that the obsession cause by to prevent the unlikely event involved in obsession
Can people develop compulsions without obsessions and vice versa?
Yes - predominantly obsessional thoughts or ruminations
* Ideas, images or impulses which are nearly always distressing to subject
* Can cause inability to make trivial decisions in day to day
Predominatly compulsive acts (obessional rituals)
* Often cleaning related
* Underlying cause is fear - try to avert danger
Management options for OCD
Watchful waiting if not severe
Psychological:
* Referral for exposure and response prevention
* Allocation of CPN
* Psychoeducation - inc online resouces eg OCD-UK
Biological:
* SSRI - high dose
* Clomipramine
Class of Clomipramine
Tricyclic antidepressant
Side effects Clomipramine
- Similar to SSRI
- Can cause sedation - caution with driving and machinery use
Can you offer clomipramine if risk of suicide?
- No - much more toxic than SSRI in overdose (cardiotoxic)
- If indication for use is trong, consider offering short repeat prescriptions and ensure safety plans robust
Type of psychotherapy for OCD
- CBT
- Exposure and reponse prevention
NICE guidelines OCD
Low intensity treatments to begin with:
* Brief individual CBT + structured self help - including ERP
* Brief individual CBT via telephone - including ERP
* Group CBT - including ERP
If mild functional impairement unable to engage in low intensity CBT/inadequate response:
* SSRI or more intensive CBT (inc ERP)
Moderate functional impairemnt:
* SSRI or more instensive CBT
Severe functional impairement
* SSRI and CBT (inc ERP) combined
Ever need for patients with OCD to be hospitalised?
- Depends on nature and degree of illness, treatment available in hospital, degree of impairement and risk
- Sometimes need setting for focused OCD treatment
- Sometimes impairement of self care
- Risk to self high
- Risk to others - rare
What do patients typically do with repeitive thoughts in OCD?
- Try and resist them
- Then they give in and act to relieve tension and anxiety
- When resisted, anxiety gets worse
What forms can obsessions come as?
- Thoughts
- Images
What is somatisation?
- AKA Briquets syndrome
- Recurring, multiple frequently changing and current complaints about somatic symptoms
- At least 2 years duration - chronic and fluctuating
- Can be any part of body
- Negative investigations
What is hypochondriasis?
- Health anxiety disorder
- Persistent belief of the presence of minimum of 2 serious physical diseases (at least one specifically named by patient)
- At least 6 months
- Preoccupied with belief, refuse to accept medical advice that they is no physical cause (except sometimes for short periods after investigations)
Physical symptoms of GAD
- Not related to specific environmental circumstances - free floating
- Motor tension
- Trembling
- Light-headedness
- Palpitations
- Dizziness
- Epigastric discomfort
Most common symptoms of OCD
- Checking
- Cleaning
What can patients often do if they have severe social anxiety to cope?
- Use alcohol as dysfunctional coping strategy
- Self medicate - anxiolytic
Most significant underlying factor of anxiety disorders according to cognitive theory
- Catastrophisation
- Catastrophic misinterpretation of somatic symptoms is key component of panic disorder
- In other anxiety problems - patients have higher perception of threat and adverse outcomes
First line for combat trauma PTSD
- Trauma focused CBT
- EMDR offered to non-combat trauma
What causes fainting in phobia?
- Anxiety –> sympathetic drive
- However, blood injury phobia = classical exception
- It’s biphasic response includes vasovagal mediation sometimes which can cause syncope (reduced venous return and slowed heart rate, due to overcompensate rebound parasympathetic response after sympathetic arousal)
How can blood needle phobia syncope be avoided?
- Applied tension
- Tensing muscles to artificially raise BP
- Helps stay conscious even if you have extreme fear
