Anxiety, Obsessions, and Reactions to Stress

Question 1

Anxiety disorders General conservative

Answer 1

Advice and reassurance my be sufficient for mild
Basic counselling to address worries
Self help eg CBT based book, reliance on supportive contacts
Relaxation techniques + breathing exercises

Question 2

CBT in Anxiety disorders

Answer 2

Aims to reduce pt expectation of threat and behaviours surrounding
Begin w/technique to manage arousal (relaxation)
Explore likelihood of anticipated tragedy
Use behaviour experiments to test feared situation
This increases pt confidence in capacity to deal

Question 3

CBT GAD

Answer 3

main feature is worry

Therapy involves testing predictions of worry w/behavioural experiments and looking at errors in thinking

Question 4

Panic disorder CBT

Answer 4

May be triggered by misinterpretation of physical anxiety sx as catastrophe
Safety behaviours may be adapted eg avoiding
CBT educates pt on meaning of sx ie panic not perish
Helps test whether their behaviours are true or misinterpretation

Question 5

Exposure therapy anxiety disorder

Answer 5

Used as part of CBT when strong elements of escape and avoidance
In absence of actual harm body can only remain extremely anxious for <45 mins before habituation (anxiety drops)
Continues until fear extinction
Through graded approach = desensitisation
Pt identifies goal and constructs hierarchy of feared situations
Stay in each situation until anxiety subsisdes
Agoraphobia treated like this

Question 6

Generalised anxiety disorder Mx

Answer 6

1. Education and active monitoring
2. Low intensity PI
   - individual non facil. self help (6+ weeks, minimal contact w/therapist)
   - indiv. guided self help (5-7 wkly sessions)
   - psychoeducation groups (6 wkly sessions)
3. High intensity PI
   - CBT 12-15wkly sessions
   - applied relaxation
   - Sertraline (2L other SS/NRI, 3L pregab. NOT BZ unless crisis short term)
4. Specialist assessment
   Other pharm:
   TCA
   Buspirone
   Beta-blocker

Question 7

Sertraline dose in anxiety?

Answer 7

higher than depression
200mg
OCD/eating dis. have the highest dose

Question 8

Panic disorder Mx

Answer 8

1. recognition and diagnosis
2. Rx in primary care (CBT + SSRI, if no response in 12w consider imi/clomipramine
   3, R/v and consider alternative Rx
3. R.v and referral to specialist mental health service
4. Care in specialist mental health service

Question 9

OCD Ix

Answer 9

Blood: FBC, TSH
Rating scale: Yale Brown OCD
Education and self help
Screening Qs:
Do you wash/clean a lot?
Any thought keep bothering you and want to get rid?
Daily activities take a long time to finish?
Concerned by special order or upset by mess?
Do these trouble you?

Question 10

OCD and Body dysmorphic disorder Mx

Answer 10

1. Low intensity PI
   -Brief CBT (inc. ERP)) using structured self help, or by phone
   - Group CBT inc. ERP
   (up to 10hr)
   2: SSRI (fluox., parox., sert., cital.) - cont. at least 12m after remission
2. Comipramine (or alt. SSRI)
   - use if SSRI uneffective after 12w

Question 11

Use of CBT in OCD

Answer 11

compulsions analogous to escape in phobia
Aim is to prevent compulsions allowing tolerated anxiety to habituate
e.g. compulsions for clean: touch something dirty and discuss anxiety w/therapist instead of cleaning
Hierarchy of fear used
Effective in well motivated

Question 12

Prognosis of OCD

Answer 12

chronic w/ sx worsening at times of stress
often disabling
comorbidity (depression common)

Question 13

PTSD Mx

Answer 13

1. Watchful waiting (if subthreshold PTSD sx within 1m of traumatic event, FU 1m)
2. Trauma focussed CBT (all w/Sx >1m)
3. Eye movement desensitisation and reprocessing (dx. PTSD or clinically important sx who present >3 after non-combat related trauma)
4. Group therapy
5. Pharm: SSRI (parox/sert. or venlaf.) consider antipsych if failure or disabling sx

Question 14

Trauma focused CBT?

Answer 14

Trauma can shatter previous belief system
These thoughts examined and tested
Exposure therapy important
Can be computerised
8-12 sessions
Key points:
- cognitive processing therapy
- Cognitive therapy for PTSD
- Narrative exposure therapy
- prolonged exposure therapy

Question 15

Eye movement desensitisation and reprocessing?

Answer 15

Original trauma is deliberately re-experienced in as as much detail as possible (patient narration)
Whilst talking they fix eyes on therapists finger as it quickly passes from side to side
Can be replicated by ant alternating L/R stimulus
Aids memory processing

Question 16

Prognosis of PTSD

Answer 16

most recover
some suffer for years
can lead to permanent personality change if chronic

Question 17

PACES PTSD

Answer 17

Occurs after trauma, characterised by flashbacks hyperarousal avoidance
Be wary of impact on ife
Offer trauma focused CBT (computer/face to face)
Consider pharm (sert./parox)
Consider group therapy
Offer FU

Question 18

Acute stress reaction Mx

Answer 18

Exclude injury
Support and reassure
BZ may alleviate short term stress

Question 19

Adjustment disorder Mx

Answer 19

Support, reassure and problem solving all thats needed

Question 20

Medically unexplained Sx Mx

Answer 20

Therapeutic assessment
Explain and reassure
Avoid over Ix
Emotional support
Encourage normal function
Antideps. may be useful even w/o depression (tension headache/IBS)
Treat comorb.
CBT
Graded exercise (CFS and fibromyalgia)

Question 21

Chronic fatigue Syn Mx

Answer 21

Strong evidence for graded exercise

Pts need realistic goal and should not do more than planned CBT can improve fatigue and functioning

Question 22

Conversion/dissociative disorders Mx

Answer 22

Encourage normal return to activities and avoid reinforcing sx of disability
Pts should be supported to address triggering stressors rather than focusing on physical manifestation
Better outcome than MUS