Anxiety, OCD, Stress, and Bodily Distress

Question 1

Define anxiety

Answer 1

Fear of perceived/anticipated future threat

Question 2

What rating scale will you use for anxiety?

Answer 2

HAM-A Hamilton rating scale for anxiety

Question 3

How long should Benzos be prescribed for on maximum? Should they ever be discharged with the patient

Answer 3

Should only be prescribed for 2-4 weeks, and preferably not discharged with that prescription

Question 4

What is the antidote for benzo overdose

Answer 4

Flumazenil

Question 5

Give the main side effects of benzos

Answer 5

Ataxia (coordination), amnesia, confusion, social disinhibition, aggression, Respiratory depression (esp if paired with alcohol), sedation ofcourse

Question 6

What are the withdrawal effects of benzos

Answer 6

Depersonalization/derealization, Tinnitus, visual hallucinations and sx of anxiety (Disphoresis, disorientation, PARAESTHESIA, nausea, tremor, insomnia, decreased appetite)

Question 7

What are the indications for pregabalin

Answer 7

GAD, Neuropathic pain, adjunctive for partial seizures

Question 8

What is the fear center of the brain that is involved with anxiety and stress disorders?

Answer 8

Amygdala. In charge of social disinhibition as well!! (sexual and aggressiveness)

Question 9

GAD - Generalized anxiety disorder
Define it on the basis of ICD-11.

Answer 9

Marked Symptoms: Either free-floating anxiety (no particular stimulus) OR excessive worry about negative events of everyday life including work, finances, and family
+ Characteristic symptoms of anxiety: Muscle tension/motor restlessness, sympathetic overactivity (GI nausea and vomiting, paraesthesia, palpitations, diaphoresis, tremor, dry mouth), Subjectively nervous/restless”on edge”, Difficulty concentrating, Irritability, sleep disturbances (particularly when trying to fall asleep)

Question 10

How long should anxiety symptoms be present for a diagnosis. Applied for all anxiety disorders but not stress.

Answer 10

Symptoms must not be transient and must persist for several months. Must be present more days than not.

Question 11

How is mild/moderate GAD or panic disorder treated? (only first and 2nd line) Hint: no biological

Answer 11

In these cases, we begin with monitoring and psychoeducation. In the case of moderate or if first line doesnt work, Individual guided self help and psychoeducational groups would be offered

Question 12

In severe GAD or Panic Disorders, or in the case where psychological management (monitoring, psychoeducation, guided help etc) what is the treatment plan?

Answer 12

High intensity CBT and/or SSRI/SNRI. If medications aren’t tolerated, pregabalin may help

Question 13

Define and state ICD 11 for Panic Disorder

Answer 13

1. Characteristic symptoms of anxiety - Muscle tension/motor restlessness, sympathetic overactivity (GI nausea and vomiting, paraesthesia, palpitations, diaphoresis, tremor, dry mouth), Subjectively nervous/restless/”on edge”, Difficulty concentrating, Irritability, sleep disturbances (particularly when trying to fall asleep)
2. Characteristics of Panic Attacks - SOB, choking, chills/hot flushes, fear of losing control/going mad/imminent death, depersonalization, derealization
3. At least some of the panic attacks are unexpected (out of the blue with no particular stimuli)
4. Attacks followed by persistent worry and avoidance behaviour in fear of the next panic attack in public OR belief they just had an MI or were going to die

Question 14

What are nocturnal panic attacks?

Answer 14

Panic attacks occurring when you sleep (dream?), waking you up from it.

Question 15

What medications may actually increase anxiety when withdrawn or started?

Answer 15

Benzos - withdrawn
SSRI - Starting or withdrawing

Question 16

Define and state ICD-11 for Agoraphobia:
What is your management plan? (biological and psychological)

Answer 16

1. Marked and excessive fear of situations where escape might be difficult or help might not be available
2. Active avoidance of these situations and are entered only under specific circumstances (companion, equipment, time of day)
3. Consistently fearful of these situations due to specific negative outcomes/being embarrassed such as panic attacks, falling, incontinence

Biological: SSRI –> Sertraline
Psychological: Systematic desensitisation or modelling

Question 17

T or F: Life events such as childhood trauma or sexual violence is a very important part of the history in panic disorder, agoraphobia, specific phobia, and social anxiety

Answer 17

True

Question 18

What is your management plan for Specific phobia, agorabphobia, and social anxiety disorder? (biological and psychological)

Answer 18

Biological: SSRI –> Sertraline
Psychological: Systematic desensitisation or modelling

Question 19

What is stimulus fading and where is it used?

Answer 19

Selective mutism - Stimulus fading is where the child talks to a known person and is introduced to someone new where they continue talking while the original person slowly exits the conversation and eventually the room

Question 20

Define and state ICD-11 for Specific phobia

Answer 20

1. Marked and excessive fear of one or more specific objects or situations that is out of proportion to the actual danger
2. Phobic object/situation is actively avoided

Question 21

Define and State ICD-11 for specific phobia

Answer 21

1. Marked excessive fear in social situations (social interactions, feeling observed (restaurant/public toilet/writing in front of others), performing (presenting)
2. Concerned that they will show anxiety symptoms and be negatively evaluated
3. Situations are actively avoided

Question 22

Self-critical and perfectionistic personality that exacts standards. What are these characteristic of (in terms of anxiety disorders)

Answer 22

Social anxiety disorder

Question 23

Define and state ICD-11 for Separation Anxiety Disorder. Give examples
What is your management plan?
What type of parenting style is associated with this?

Answer 23

1. Marked excessive fear of separation to people they are attached to
2. Manifestations (dependent of developmental level of patient) examples include persistent thoughts that harm will occur to the person when away, refusal to go to work or school, recurrent distress (tantrums, social withdrawal) related to separation, recurrent nightmares about separation
3. Characteristic symptoms of anxiety - Muscle tension/motor restlessness, sympathetic overactivity (GI nausea and vomiting, paraesthesia, palpitations, diaphoresis, tremor, dry mouth), Subjectively nervous/restless/”on edge”, Difficulty concentrating, Irritability, sleep disturbances (particularly when trying to fall asleep)

Management: Psychological only which is CBT for separation anxiety

Parenting style: Authoritative that lacks the development of autonomy in the child.

Question 24

Define and State the ICD-11 for Selective mutism
What is your management plan? (biological and psychological)

Answer 24

1. Consistent selectivity in speaking such that the child demonstrates adequate language and competence in specific situations but not in others
2. Disturbance not due to lack of knowledge or comfort with the spoken language
3. Selectivity of speech is severe enough to affect educational achievement or specific areas of functioning (remember that this is something you say about any presentation just slightly modified from severe enough to affect quality of life and/or social functioning.

Biological: Only if persists into adolescence/adults –> SSRI (as the condition tends to remit spontaneously after 8 years on average)
Psychological: Positive reinforcement (can be applied to all CAMHS), Systematic desensitization, stimulus fading, Shaping (building rapport, playing games, making noises… complex skills learnt in a step-wise approach)

Question 25

Define Obsessions

Answer 25

Obsessions are repetitive and persistent thoughts or images or urges/impulses
that are experienced subjectively as intrusive and unwanted
Attempts to ignore or suppress them by performing compulsions

Question 26

Define Compulsions

Answer 26

Repetitive behaviours or rituals (including repetitive mental acts (such as counting or repeating specific phrases) that the individual feels driven to perform in response to an obsession, according to own rigid rules, or to achieve a sense of completeness
Compulsions are either not connected in a realistic way to the feared event (e.g. arranging items symmetrically to prevent harm to a loved one) OR clearly excessive (showering for hours to prevent illness)

Question 27

OCD ICD 11:

Management plan? Biopsychosocial

Answer 27

ICD11:
1. Presence of obsessions and/or compulsions
2. obsessions and compulsions are time consuming or result in significant distress/impairment in personal, family, occupational… functioning
3. Actively avoid situations or people that trigger their OCD

Management:
Biological: High dose SSRI (sertraline) but first give psycho
Psychological: CBT with exposure and response prevention, thought replacement, and thought stop (shouting stop till obsession ceases)
Social: Assigning a social worker to provide entitled benefits

Question 28

How would you differentiate psychosis with OCD?

Answer 28

Patient is not psychotic as they are aware of these thoughts and recognize them as their own. These thoughts are also unwanted by the individual.

Question 29

How is insight in OCD
How is the onset?

Answer 29

Often very good insight as they recognize these thoughts and behaviours as unwanted
Onset is usually gradual and early in life. sudden or late presentation should prompt additional assessment due to similar presentations to basal ganglia stroke

Question 30

What is the rating scale used in OCD:

Answer 30

Y-BOCS - Yale-brown obsessive compulsive scale

Question 31

Body dysmorphic disorder:
ICD11 criteria
Management

Answer 31

1. Persistent preoccupation with one or more perceived defects in appearance (or ugliness in general) that is unnoticeable/slightly noticed by others
2. Excessive consciousness about perceived flaws as well as ideas of Self-reference (conviction that people are judging them)
   3.. Preoccupation/consciousness is accompanied by one of the following
   a) Repeated examination of their appearance/comparison w others (always carrying a mirror)
   b) Excessive attempts to camouflaged or alter perceived defect (e.g. saving up for cosmetic procedures)
   c) marked avoidance of social situations/stimuli that increase distress

Management: CBT that addressed key features of BDD. If more is needed, add SSRI

Question 32

Males with BBD often are worried about what? What is this called?

Answer 32

Muscle Dysmorphia: Males always think of their muscles and are conscious about them
They also care about their genitals

Question 33

Olfactory Reference Disorder:
ICD 11 criteria
Management?

Answer 33

ICD: Persistent preoccupation about emitting a foul body odour or breath that is unnoticed by others.
Excessive consciousness about perceived odour with Self-reference (judgement from others)
Pre-occupation accompanied by
a) repeated checking of clothes or breath smell, asking for reassurance
b) Excessive attempts to camouflage (mouthwash x10)
c) Marked avoidance of social situations and close proximity such as public transport (make sure to separate from agorabphobia)

Management: SSRI + CBT. Augmentation with Antipsychotics is indicated if inadequate response

Question 34

What is a TCA often used in OCD related stress disorders?

Answer 34

Clomipramine

Question 35

Hypochondriasis:
ICD 11:
Management: Biological and psychological

Answer 35

1. Persistent preoccupation or fear about possibility of having a progessive or life-threatening illness despite negative medical diagnostics accompanied by EITHER
   a) Repetitive and excessive health-related behaviours (checking body for evidence of illness, spending a lot of time looking for info about perceived illness, seeking reassurance and most importantly arranging multiple dr. appointments)
   b) complete opposite: maladaptive avoidance behaviour related to health (avoiding Dr. appointments incl. checkups)
2. Significant distress in daily functioning

Management: Biological: Dealt with likely comorbid conditions (depression and anxiety) with SSRIs
Psychological: Educate patient and inform of psychiatric interventions to improve quality of life. Centralize care to only 1 main doctor. Offer CBT and Family Therapy.

Question 36

Hoarding Disorder:
ICD 11
Management
How is insight in hoarding disorder

Answer 36

1. Accumulation of possessions that results in living spaces being cluttered. If uncluttered it is due to a 3rd party (family, cleaner). Individuals may find it hard to find important items such as bills or taxes, not circulate with ease inside home incase of an emergency
2. Accumulation occurs due to BOTH:
   a) Repetitive urges or behaviours related to amassing items passively (hoarding flyers and mail) or actively (hoarding free/purchased/stolen items)
   b) Difficulty discarding items due to perceived emotional, sentimental, or monetary value associated with distress with thought of discarding

Management: Difficult to treat, only CBT
Insight: Poor/limited

Question 37

Define:
Body-focused repetitive behaviour disorders
Trichotillomania
Excoriation Disorder

Answer 37

Body-focused repetitive behaviour disorders: Recurrent and habitial actions that target the Integument or protective layers with attempts to decrease or stop behaviour and possible dermatological sequalae (hair loss, skin lesions, lip abrasion)
Trichotillomania: Recurrent pulling of hair
Excoriation Disorder: Recurrent picking of ones skin

Question 38

What are the 3 core elements of PTSD

Answer 38

a) Re-experiencing (not remembering) the traumatic event. This typically occurs in the form of Flashbacks during the day and Nightmares during the night related to the event.
b) Deliberate avoidance of reminders likely to produce re-experiencing the event
c) Hyper-vigilance - constant perception of heightened threat and may adapt behaviours to ensure safety

Question 39

PTSD: ICD 11
Complex PTSD: ICD 11
Management of (complex) PTSD including biological and psychological

Answer 39

PTSD: 1) Exposure to an event or situation of an extremely threatening or horrific nature
2) Satisfies all 3 core elements of PTSD: Re-experiencing, avoidance, and hyper-vigilance
3) Significant impact on daily functioning

Complex PTSD:
1) Exposure to a series of horrific events. Most commonly prolonged or repetitive from which escape is difficult (torture, slavery etc..)
2) Satisfies all 3 core elements of PTSD: Re-experiencing, avoidance, and hyper-vigilance
3) Severe problems in Affect Regulation. Heightened emotional reactivity, violent outbursts etc
4) Persistent belief in oneself as diminished “dirty and worthless”. May have guilt or delusions of guild
5) Persistent difficulties in sustaining relationships and feeling close to others. They may have little interest in relationships

Management:
Biological: Venlafaxine or SSRI. Offer antipsychotics if patient has psychotic symptoms or if they haven’t responded well (after checking compliance)
Psychological: EMDR (eye movement desensitisation and reprocessing) which is CBT + Bilateral eye movements. OR CBT with graded exposure to traumatic imagery

Question 40

When do Symptoms of PTSD normally appear after the traumatic event?

Answer 40

Within 3 months

Question 41

What is the psychological treatment of choice for PTSD/Complex PTSD

Answer 41

EMDR - Eye movement desensitisation and reprocessing

Question 42

Prolonged Grief Reaction:
ICD 11
Management (bio + psych)

Answer 42

1) History of bereavement following the death of a person close to the bereaved
2) Persistent pre-occupation with deceased accompanied by intense emotional pain manifested as guilt, denial, blame, sadness etc
3) Persists for an atypically long time (>6 months) with cultural norms in mind

Note: Patient might alternate between periods of excessive preoccupation and avoidance

Management:
Bio: SSRI/SNRI
Psych: CBT for grief/complicated grief therapy.

Question 43

Adjustment Disorder:
ICD + management (bio + psych)

Answer 43

1) Maladaptive reaction to an identifiable psychosocial stressor that usually emerges within a month of a stressor
2) Preoccupation with stressor or its consequences with excessive worry and recurrent thoughts about the stressor
3) Once the stressor and its consequences have ended, symptoms resolve within 6 months
4) actually important here. Symptoms are not due to another mental disorder or diagnosis and failure to adapt causes significant impact on life

Management:
Bio: SSRI
Psycho: Supportive therapy

Question 44

In adjustment disorder, when do the symptoms emerge after the psychosocial stressor. After that stressor and its consequences have been resolved, by when do the symptoms subside?

Answer 44

Emerge within 1 month. Subside within 6 months

Question 45

What is Dissociative Neurological Symptom Disorder?

Answer 45

Motor, sensory, or cognitive symptoms that imply disruption of normal integration that are not consistent with a recognised disease of the nervous system, mental health, or behavioural disorder

Question 46

What is Dissociative Amnesia?

Answer 46

Inability to recall important autobiographical memories, typically of traumatic events, that is inconsistent with ordinary and not consistent with any other medical disease…

Question 47

What is Trance Disorder? State ICD11
Compare with Possession Trance Disorder.

Answer 47

1) Marked alteration in consciousness with LOSS of the individual’s personal identity with unusually selective and narrow focusing on immediate environmental stimuli with restriction of movements, postures, and speech to a repetition of a small repertoire and is experiences as being outside of one’s control
2) No experience of being replaced by an alternate identity
3) Trance episodes are recurrent or last several days
4) Trance state is unwanted

Compared to Possession Trance:
1) Replacement of personal identity by external “possessing” identity in which their movements and behaviours are experienced as being controlled by possessing agent
2) involuntary and unwanted trance
3) Recurrent or episode lasting several days

Question 48

Define Dissociative Identities and Dissociative Intrusions and where they occur.

Answer 48

Dissociative identities are the disruptive identities that occur in dissociative and partial dissociative identity disorder in which there is discontinuity in sense of self and self agency

Dissociative intrusions are the non-dominant personality traits when they intrude on the dominant one and are typically aversive. These occur mostly in Partial Dissociative Identity Disorder

Question 49

Dissociative Identity Disorder:
Compare ICD 11 between full (A) and partial versions (B) of the disorder

Answer 49

1) Disruption of Identity in which 2 or more distinct personality (Dissociative Identities) with discontinuity in sense of self and self agency
2) Each personality state has its own pattern of experiencing, perceiving, conceiving, and relating so self, body, and environment. (obv dont memorize)
3A) At least 2 distinct personalities recurrently take executive control of the person’s consciousness, functioning, and interactions with others
3B) One personality state is dominant but is intruded upon by non-dominant personality states (Dissociative Intrusions) and are typically aversive (disliked by dominant). There may be transient episodes that non-dominant state takes full control (rare)

4A) Changes in personality are accompanied by related alterations in memory (episodes of amnesia may be severe), senses, perception, affect, cognition…

Question 50

Define Depersonalisation
Define Derealisation

Answer 50

Depersonalisation is the experience of feeling strange/unreal or they are an observer of one’s actions, thoughts, and emotions

Derealisation is the feeling that the world is strange/unreal where the person feels etached from one’s surroundings

Question 51

In Depersonalisation and derealisation disorder, what perceptual abnormalities would you suspect being present?

Answer 51

No perceptual abnormalities. this disorder is a disorder of thought content and not perception.

Question 52

When would you prescribe medication in patients with Bodily Distress disorder? How and why would their treatment be different from others?

Answer 52

Only if they are comorbid with something else. In those cases, very low doses as these patients are very sensitive to side effects of most meds.

Question 53

Bodily Distress Disorder:
ICD 11
How would you classify based on severity?
Most common complaints?
Management (Biopsychosocial)

Answer 53

ICD:
1) Bodily sx (usually multiple) that are distressing to the individual
2) Excessive attention directed towards symptoms manifested as persistent preoccupation/repeated contact with medical services clearly in excess
3) Excessive preoccupation persists despite appropriate investigations/examinations (usually unsatisfied with them)
4) Bodily symptoms are persistent for most days for more than 3 months

Mild: less than 2 hours/day with mild impairment in functioning
Moderate: >2hrs/day with moderate impairment + frequent medical visits
Severe: Nearly exclusive focus and full impairment

Most common: Pain (MSK, back, headache), fatigue, GI, Resp (SOB)

Biological: Only if Comorbid. In those cases, very low doses as these patients are very sensitive to side effects of most meds.

Psychological:
1) Psychoeducation about pathophysiology of illness
2) Activity Pacing and Graded physical exercise
3) Biofeedback therapy training
4) CBT or Interpersonal therapy

Social: Family therapy and include family member/friend when explaining disorder and treatment plan.

Question 54

Patient describes feelings of being overcomplete and is attracted to disabled people. What disorder is this? What gender is more commonly associated with this disorder?

Answer 54

Body integrity disorder
Males

Question 55

Body integrity Disorder:
ICD 11

Answer 55

1) Intense and persistent desire to become physically disabled in a significant way (major limb amputation, blindness) with persistent discomfort/intense negative feelings about one’s current body
2) Desire to be disabled results in harmful attempts to actually become disabled putting their lives at significant risk and/or preoccupation results in significant impairment socially
3) Onset of desire occurs by early adolescence

Note: No management for this other than CBT and SSRIs for comorbid cases