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Psychiatry > Anxiety, Obsessions, Reactions to Stress > Flashcards

Anxiety, Obsessions, Reactions to Stress Flashcards

1
Q

Which personality trait is associated with higher risk of experiencing anxiety

A

Neuroticism

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2
Q

Give some psychological symptoms of anxiety

A

Fears
Poor concentration
Irritability
Feelings of unreality: depersonalisation & derealisation

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3
Q

Give some motor and neuromuscular symptoms of anxiety

A 
Restlessness
Feeling on 'edge'
Tremors
Headache (tension)
Dizziness, light-headedness, tinnitus
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4
Q

Give some GI and GU symptoms of anxiety

A 
GI:
Dry mouth 
Difficulty swallowing
Nausea
Flatulence

GU:
Urinary frequency
Erectile dysfunction
Amenorrhoea

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5
Q

Give some cardiovascular and respiratory symptoms of anxiety

A

CV:
Chest discomfort
Palpitations

Respiratory:
Difficulty INHALING

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6
Q

Explain the following behavioural theories for anxiety: classical conditioning & negative reinforcement

A

o Classical Conditioning: repeated pairing of a neutral stimulus with a frightening one results in a fear reaction to a neutral stimulus (similar to Pavlov’s dog)

o Negative Reinforcement: active behaviours that relieve anxiety (e.g. running away) are repeated. This prevents habituation (body gets used to the fear, so that anxiety decreases)

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7
Q

Explain the following cognitive theories for anxiety: cognitive theories, attachment theory

A

o Cognitive Theories: worrying thoughts are repeated in an automatic way which induces and maintains the anxiety response

o Attachment Theory: quality of attachment between children and their parents affects their confidence as adults

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8
Q

Define generalised anxiety disorder (GAD)

A

Anxiety that is not triggered by a specific stimulus, but instead is continuous and generalised

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9
Q

How long must symptoms of anxiety be present in order to diagnose GAD?

A

6 months

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10
Q

Give some differentials for GAD

A

o Hyperthyroidism
o Substance misuse
• Intoxication (e.g. amphetamines)
• Withdrawal (e.g. benzodiazepines, alcohol)
o Excess caffeine
o Depression
• Mixed anxiety and depressive disorder: low-level depressive and anxiety symptoms are present equally together
o Anxious (avoidant) personality disorder
o Dementia
o Schizophrenia

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11
Q

Give some examples of phobic anxiety disorders

A

Agoraphobia (fear of not being able to escape, fear of situations that are confined)

Social phobia

Specific phobias (e.g arachnophobia)

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12
Q

Give some features of agoraphobia

A

Fear of confinement and being unable to escape a situation (e.g large crowds, travelling on planes, trains, buses)

Severity can increase with distance from home

Presence of dependable companion can ease burden

Can become house bound in very severe cases

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13
Q

Give some differentials for agoraphobia

A
  • Depression (can cause social withdrawal)
  • Social phobia (the fear here is of scrutiny or humiliation)
  • OCD (time-consuming rituals can confine people to their homes)
  • Schizophrenia (patients may stay at home due to social withdrawal or as a way of avoiding perceived prosecutors)
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14
Q

Give some features of social phobia

A

Core fear is of being scrutinised or criticised by other people

Worry of embarrassing themselves

Symptoms of embarrassment: blushing, trembling, sweating

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15
Q

Give some differentials for social phobia

A
  • Shyness: some people are naturally shy
  • Agoraphobia: need to get somewhere safe is more important than fear of scrutiny
  • Anxious (avoidant) Personality Disorder: lifelong history of disabling shyness and anxiety
  • Poor social skills/autistic spectrum disorders
  • Benign essential tremor: this is a familial tremor that is worse in social situations. It responds to benzodiazepines and alcohol. There are no other features of anxiety.
  • Schizophrenia/Psychosis: patients may avoid social situations because of paranoia or because they have delusions of being watched. People with social phobia, on the other hand, know that their fears are exaggerated
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16
Q

What is panic disorder? (aka episodic paroxysmal anxiety or panic attack)

A

Anxiety which is intermittent and does NOT have an obvious trigger, a panic attack is a sudden attack of extreme anxiety with accompanying physical symptoms

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17
Q

Give some physical symptoms experienced during a panic attack

A
  • Breathing difficulties/choking feeling
  • Chest tightness
  • Palpitations
  • Tingling or numbness in the hands, feet or around the mouth (caused by hypocalcaemia due to increased respiratory rate)
  • Depersonalisation/derealisation
  • Shaking
  • Dizziness
  • Sweating
18
Q

What is the difference between a panic attack and panic disorder?

A

Panic disorder: must be recurrent panic attacks in order to diagnose, in between episodes the person should be relatively free from anxiety

19
Q

Give some differentials for panic disorder/attacks

A
  • Other anxiety disorder (e.g. GAD, agoraphobia)
  • Depression
  • Alcohol or drug withdrawal (can cause severe anxiety which mimics panic attacks)
  • Organic causes (e.g. cardiovascular/respiratory disease, phaeochromocytoma)
20
Q

What initial investigations would you do for anxiety disorders?

A

• Thorough history and physical examination

• Rating scales of anxiety (provide a baseline score to measure treatment response):
o GAD7 questionnaire
o Beck anxiety inventory
o HADS: Hospital anxiety and depression scale

  • Social and occupational assessments for effect on quality of life
  • Collateral history
21
Q

What are the types of management offered for anxiety disorders?

A
  • Advice and reassurance (may be enough for mild problems)
  • Basic counselling (to address worries)
  • Problem-solving (help deal with stressors)
  • Relaxation techniques and breathing exercises
  • CBT
  • Exposure therapy
  • Pharmacological
22
Q

Outline the main aims of CBT for anxiety disorders

A

Formulation of thought processes

These allow identification of NATs or thoughts of imminent danger

Thoughts discussed (e.g “I will embarrass myself”) and behavioural experiments are set up to test them

Education of true meaning of symptoms to ultimately allow adaptive coping mechanisms to replace unhelpful behaviours

23
Q

Outline the main aims of exposure therapy for anxiety disorders

A

Can be used as part of CBT approach

Gradual approach of exposure to ultimately aim to desensitise

Hierarchy of feared situations outlined: mark each step with a level of fear and target a particular step as a realistic goal

Main objective is for patient to stay in a certain situation until the anxiety subsides (habituation)

Induces new learning and challenges existing thoughts: courageous involvement in a step wise approach can result in a complete cure

24
Q

Outline the main pharmacological therapies for anxiety disorders

A

SSRIs
o Treat many anxiety disorders
o May be combined with CBT
o Therapeutic doses for anxiety disorder are generally higher than for depression and responses take longer (6-8 weeks)
o Be wary of suddenly stopping antidepressants: can worsen anxiety symptoms

TCAs
o E.g. clomipramine, imipramine

Buspirone
o Serotonin partial agonist

Benzodiazepines
o Useful for short-term anxiety treatments (e.g. whilst waiting for SSRIs to work)
o Tolerance builds rapidly and dependence is an issue
o Must NOT be used for > 2-4 weeks
o Side-Effects: amnesia, ataxia, respiratory depression

Beta-Blockers
o E.g. propranolol
o Sometimes used to treat adrenergic symptoms (e.g. tremor, palpitations)
o IMPORTANT: consider contraindications

25
Give the stages of management approach for GAD
Step 1: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) Step 2: drug treatment (sertraline) Step 3: highly specialist input (e.g. multi-agency teams) Drug Treatment - 1st line: Sertraline - Weekly follow-up is recommended in patients < 30 years (because of increased risk of suicidal thinking and self-harm)
26
Give the stages of management approach for panic disorders
• Step 1: recognition and diagnosis • Step 2: treatment in primary care (self-help) • Step 3: review and consideration of alternative treatments • Step 4: review and referral to specialist mental health services • Step 5: care in specialist mental health services • Treatment in Primary Care o 1st line: CBT + SSRI o If no response after 12 weeks: consider imipramine or clomipramine
27
What is the rule of thirds when it comes to prognosis for anxiety disorders?
o 1/3 recover completely o 1/3 improve partially o 1/3 fare poorly and suffer considerable disability
28
Outline some risk factors for obsessive compulsive disorder (OCD)
* Genetic component (relatives of pts with OCD are at threefold increased risk) * Anankastic personality traits (rigidity, orderliness) * Stress * Diseases associated with OCD: Sydenham's chorea, encephalitis lethargica and Tourette's syndrome
29
Outline the clinical presentation of OCD (defining obsessions and compulsions)
Obsessions: recurrent unwanted intrusive thoughts, images or impulses that enter the patient's mind despite attempts to resist them Patient recognises thoughts as irrational and their own (unlike delusions and thought insertion) Common themes of obsessions; Contamination, Aggression (thoughts of harming self or others), Infection, Morality (sex and religion) Obsession --> anxiety --> compulsions to neutralise the discomfort/anxiety Compulsions: repeated, stereotyped and seemingly purposeful rituals that the patient feels compelled to carry out, even though they are irrational and may lack any obvious link to the obsession (e.g cleaning, counting, checking and ordering objects) Compulsions can be very time-consuming and decrease quality of life
30
Give some differentials for OCD
o Anxiety disorders o Depression o Anankastic personality disorder o Schizophrenia: Beliefs are delusions not obsessional o Organic causes (e.g. Sydenham's chorea)
31
Give the stages of management approach for OCD
1st line: CBT with ERP (Exposure & Response Prevention) - similar approach to exposure therapy for phobias, but for compulsions instead 2nd line: SSRI (continue for 12 months after remission) 3rd line (after 12 weeks): clomipramine or alternative SSRI
32
What is acute stress reaction?
Transient state starting within minutes of trauma and resolving spontaneously within hours (1-3 days maximum) Person is usually anxious but my appear dazed, disorientated, agitated and panicked
33
What is the management for acute stress reaction?
* Exclude injury * Support and reassurance * Benzodiazepines may alleviate short-term distress (does not prevent later PTSD)
34
Outline risk factors for developing PTSD
* Nature of trauma: increased risk with degree of exposure, proximity and human design (e.g torture) * Some genetic component * Risk factors: neurotic traits, personal or family history of psychiatric problems, childhood abuse, poor early attachment
35
What is the window period following the traumatic event that PTSD symptoms usually begin?
Within 6 months
36
Give the 4 main domains of clinical symptoms of PTSD
Re-Experiencing • Flashbacks, Nightmares, Intrusive memories Avoidance • Avoiding reminders of the event (as it often triggers flashbacks and increased anxiety) ``` Hyperarousal • Persistent inability to relax • Hypervigilance (patient always feels on red alert) • Enhanced startle reflex • Insomnia • Poor concentration • Irritability ``` Other changes: mainly emotion • Emotional detachment (numbness) • Decreased interest in activities • Powerful emotion including anger, loss of control, shame and uncontrollable crying
37
Give some differentials for PTSD
o Depression or anxiety disorder | o Adjustment disorder
38
Outline the management approach for PTSD
Same as OCD but with trauma focussed CBT NOTE: talking about the experience can make the patient feel re-traumatised: be sensitive 1st line: CBT with ERP (Exposure & Response Prevention). - - Usually 8-12 regular session - Can be computerised if the patients would prefer not to do it face-to-face 2nd line: Drugs: Consider SSRI (e.g. paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD o Consider antipsychotics (e.g. risperidone) in addition to psychological therapies if they have failed to respond to other drug treatment or have disabling symptoms/behaviours (e.g. hyperarousal) Others: Eye Movement Desensitisation and Reprocessing (EMDR) o Offer to adults with a diagnosis of PTSD or clinical important symptoms who have presented > 3 months after non-combat related trauma Trauma deliberately re-experienced in as much detail as possible Group Therapy o Involves meeting and speaking with other people who have had similar experiences
39
What is adjustment disorder?
Person's reaction to life changes that require adaptation to cope (e.g. moving to university) is greater than usually expected It is NOT severe enough to diagnose anxiety or depressive disorder
40
What is the management for adjustment disorder?
* Symptoms start within 1 month of the stressor and resolve within 6 months * Support, reassurance and problem-solving are often all that are needed

Psychiatry (14 decks)

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