Anxiety + Somatoform Disorders

Question 1

What types of psychotherapy can be effective for GAD?

Answer 1

1. Education + active monitoring
2. Low intensity psychotherapy e.g. Self help / gp psycho education
3. High intensity psychotherapy e.g. CBT
   Psychodynamic therapy
   Relaxation therapy

Question 2

What pharmacological treatment is effective in panic disorder and agoraphobia?

Answer 2

1st line: SSRIs

2nd line: TCA

Question 3

What pharmacological treatment is effective in GAD

Answer 3

1st line: sertraline -> paroxetine -> venlafaxine
2nd line: imipramine
Treatment resistant: consider diazepam, hydroxyzine, buspirone

Question 4

What psychotherapy is effective in panic disorder and agoraphobia?

Answer 4

CBT

Exposure therapy for agoraphobia

Question 5

What pharmacological treatment is effective for social phobia?

Answer 5

1st line: paroxetine/sertraline/fluvoxamine
2nd line: phenelzine
Treatment resistant: clonazepam, venlafaxine, nefadozone, gabapentin

Question 6

What psychotherapy is effective in social phobia?

Answer 6

CBT

Incl exposure therapy

Question 7

What treatment is effective for specific phobias?

Answer 7

No pharmacological usually
CBT
Desensitisation, flooding, modelling

Question 8

What pharmacological treatment is effective in OCD?

Answer 8

1st line: SSRIs
2nd line: clomipramine
Treatment resistant: anti psychotics, pindolol, clonazepam

Question 9

What pharmacological treatment is effective for PTSD?

Answer 9

1st line: paroxetine (sertraline, fluoxetine)
2nd line: mirtazapine (amitriptyline, imipramine)
Treatment resistant: phenelzine, lamotrigine

Question 10

What psychological treatment is effective in PTSD?

Answer 10

Systematic desensitisation
CBT
EMDR: eye movement desensitisation and processing therapy

Question 11

What would you diagnose the following patient with?
> 6 months anxiety
Disturbed sleep
Tremor
Autonomic overactivity: tachycardia, sweating

Answer 11

Generalised anxiety disorder

Question 12

What organic causes might you want to rule out in a patient seemingly presenting with GAD?

Answer 12

Excessive caffeine use
Thyrotoxicosis, parathyroid disease
Hypoglycaemia
Drug/alcohol withdrawal
Phaechromocytoma/ carcinoid syndrome
Cardiac dysrhythmias/ mitral valve disease

Question 13

What would you call episodes where a patient suddenly experiences: 
Chest pain, palpitations, SOB
Sweating, tremor
Nausea, dizziness
Paraesthesia, derealisation
Fear of dying, loss of control
Peak severity reached by 10 mins

Answer 13

Panic attack

Question 14

What would you diagnose in a patient who:
Experiences unpredictable panic attacks
Is scared of further attacks
Is scared abut losing control
Is avoiding all activities she worries may trigger attacks

Answer 14

Panic disorder

Question 15

What organic causes might you want to rule out in a patient seemingly presenting with panic disorder?

Answer 15

Acute intoxication/withdrawal from any drugs

Epilepsy

Question 16

What would you diagnose in a patient who presents with:
Extreme persistent fear of social situations
Fear of humiliation/embarrassment
Experiences extreme anxiety in social situations
Fear is excessive/unreasonable
Avoids social situations
Experiences anxiety thinking about social situations

Answer 16

Social phobia

Question 17

What might you diagnose is a patient who:
Has an extreme stress event - life threatening
Intrusive flashbacks
Emotional numbness
Distress if re exposure -> avoidance of similar circumstances
Hyervigilance + hyperarousal
Psychogenic amnesia, insomnia, irritability, pessimistic mood
Depression
Substance misuse
Anger

Answer 17

Post-traumatic stress disorder

Question 18

What might increase the severity of PTSD?

Answer 18

Premorbid mental/ psychological problems
Repeated similar stress
Human agency

Question 19

What screening questions might you ask for OCD?

Answer 19

Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you, that you’d like to get rid of but can’t?
Do your daily activities take a long time to finish?
Are you concerned about putting things in a special order or are you very upset by mess?

Question 20

What is the aetiology behind anxiety disorders?

Answer 20

Heritable vulnerability but no specific genetic links identified
Childhood adversity predisposes
Threatening life events predispose
? Dysregulation of serotonin, noradrenaline and GABA

Question 21

What are the behavioural and cognitive theories about anxiety disorders?

Answer 21

Classical conditioning: neutral stimulus paired with frightening stimulus
Negative reinforcement: anxiety relieving behaviours repeated preventing habituation, maintaining the fear response
Cognitive theories: worrying thoughts repeated in an automatic way that induces and maintains anxiety response
Attachment theory: insecurely attached children = anxious adults

Question 22

What is agoraphobia?

Answer 22

Fear of being unable to escape easily to a safe place
Onset in 20s-30s
Fear of open spaces and confined spaces e.g.
Travelling on planes, trains, buses
Queuing, supermarkets, large crowds, parks, cinemas
Depression common

Question 23

What are the consequences of hyperventilation?

Answer 23

CO2 blown off -> low PCO2, raised pH, hypocalcaemia

Nerve conduction affected: paraesthesia
In extreme cases = carpopedal spasm

Question 24

What investigations might you perform to rule out organic causes in apparent anxiety?

Answer 24

TFTs
LFTs
Urine drug screen
ECG
Glucose
24 hour urine for VMA

Question 25

What are the aims of CBT?

Answer 25

reduce patient’s expectation of threat and the behaviours that maintain threat-related beliefs
> education re physiology of anxiety and techniques for managing arousal
> likelihood and impact of anticipated catastrophe discussed
> behavioural experiments set up to test beliefs
> gradually increase confidence, more adaptive coping strategies

Question 26

What is exposure therapy?

Answer 26

Used when strong elements of avoidance and escape exist
In absence of actual harm body can only maintain anxiety response for a short period before habituation and drop in anxiety levels
Gradual desensitisation technique used in exposure therapy
Aim to stay in situation until anxiety has subsided

Question 27

What is the prognosis in anxiety disorders?

Answer 27

1/3 recover completely
1/3 partial improvement
1/3 suffer considerable disability and poor quality of life

Question 28

What is the aetiology of OCD?

Answer 28

Relatives at 3 x risk
Premorbid anankastic personality disorder
Basal ganglia:
Illnesses which affect them increase risk of OCD incl
Sydenham’s chorea, Tourette’s, encephalitis lethargica
Anti basal ganglia antibodies in those who have developed OCD following strep throat infection
Also linked to deficit in frontal -lobe inhibition

Question 29

What are the clinical features of OCD?

Answer 29

Obsessions:
Recurrent unwanted intrusive thoughts
Despite attempts to resist and recognition that they are irrational
Contamination, aggression, infection, morality
Tension/discomfort neutralised by compulsion
Compulsions= repeated stereotyped and seemingly purposeful rituals
Compelled to carry out, irrational, may lack link to obsession

Question 30

What is the clinical picture of PTSD?

Answer 30

Re-experiencing: flashback, nightmares, intrusive memories
Avoidance: of reminders of the event
Hyperarousal: inability to relax, hypervigilance, enhanced startle reflex, insomnia, poor concentration, irritability

Question 31

How would you manage a patient who has a panic attack?

Answer 31

Speak calmly, remove triggers
Explain that it is a panic attack and whilst frightening it will be over in a few minutes
Explain that they need to slow their breathing to stop the symptoms
Breathing through nose, counting, paper bag, cupped hands

Question 32

How would you manage panic disorder?

Answer 32

1. Recognise + diagnose
2. Primary care: CBT/SSRIs
3. If no response review at 12 wks: imipramine/clomipramine
4. Review + refer to specialists