Neurotic Disorders Flashcards
List different types of anxiety disorders
1) Phobic anxiety disorders
- Agoraphobia
- Social phobia
- Specific (isolated) phobias
2) Other anxiety disorders
- Panic disorders (episodic paroxysmal anxiety)
- Generalised anxiety disorder (GAD)
2) OCD
3) Reactions to severe stress and adjustment disorders
- Acute stress reaction
- PTSD
- Adjustment disorders
4) Dissociative (conversion) disorders
- Amnesia, stupor, motor, convulsions, trance and possession states, anaesthesia and sensory loss
5) Somatoform disorders
- Somatisation disorder
- Hypochrondriacial disorder
What is generalised anxiety disorder (GAD)?
A period of at least 6 months with prominent, tension, worry and feelings of apprehension about everyday events and problems
“Free floating” = not about ay particular situation (phobia) or episodic (panic disorder)
Causes significant distress / functional impairment
Is GAD more common in F or M? How common is it?
What age is affected?
F>M
3-4%
Early adulthood
Gradual onset
What is the pathophysiology of GAD?
Hyper-responsiveness of ANS, linked with:
- Loss of regulatory control of cortisol
- Prolonged corticotrophin releasing factor stimulation
- Neurotransmitter abnormalities (decreased GABA activity, 5HT dysregulation)
What is the aetiology of GAD?
Environment
- May be triggered by an environmental event or chronic stressors
- Drugs and alcohol misuse / withdrawal
Psychiatric disorders
- Mood disorders
- Psychotic disorders
- Eating disorders
Physical disorders
- Thyroid
- Cushing’s
Genetics (30% inheritability)
Psychological
- Unresolved childhood conflict and psychosexual development
- Displacement of subconscious fear, perpetuated by avoidance behaviour and negative reinforcement through fear reduction
What physical symptoms does GAD present with?
CV - palpitations, tachycardia, chest pain
GI - dry mouth, lump in throat, nausea, abdo pain, frequent / loose stool
Resp - hyperventilation, breathlessness, chest tightness
GI - urinary frequency, failure of erection, amenorrhoea
Others - hot / cold flushes, faint / light headed, dizziness, tremor, sweating, headache, muscle pains, numbness
What psychiatric symptoms does GAD present with?
Feeling of impending doom Restlessness Exaggerated startle response Concentration difficulties Irritability Insomnia Night terrors Derealisation / depersonalisation
(depression may coexist = mixed anxiety and depressive disorder)
How is diagnosis of GAD made?
At least 4 of physical / psychiatric symptoms
What are some medical conditions that may be differentials for GAD?
CV - arrhythmia, IHD
Resp - asthma, COPD, PE, hypoxia
Neuro - temporal lobe epilepsy
Endocrine - hyper/hypothyrodisim, hypoparathyroidism, pheochromocytoma
Other - hypoglyceamia, anaemia, SLE
What are some prescribed medications that may be differentials for GAD?
CV - anti HTN, anti arrhythmic
Resp - bronchodilators, alpha adrenergic agonists
Neuro - anticholinergic, anticonvulsants, antiparkinsonians
Psych - antidepressants, antipsychotics, disulfram, BDZ withdrawal
Other - thyroxine, NSAIDs, abx, chemo
Outline the stepwise approach to managing GAD
1) Education about GAD and active monitoring
2) Low intensity psychological interventions
- Self help
- Psychoeducational groups
- Sleep hygiene
3) High intensity psychological interventions
- CBT
- Applied relaxation
OR drug treatment
4) Highly specialist input
What drug treatment is recommenced for GAD?
1st line = SSRIs (low dose)
- Must warn about risk of suicidal thinking and self harm in those <30yr
- Weekly follow up for first month
Beta blockers for tremor and palpitations
BDZ short term
- 2-4wks as highly addictive
- Avoid if alcohol dependent as they are metabolised and cleared by liver
- Buspirone is an alternative anxiolytic medication
What is the prognosis of GAD?
Generally very poor with high remission rates
Comorbidities are frequent and often become more significant
- Other anxiety disorders
- Depression / dysthymia
- Alcohol and drug problems
- Other ‘physical’ symptoms eg IBS
30% never marry, often unemployed
What is a panic attack?
A period of intense fear with panic symptoms that develop rapidly, reach peak at about 10 mins, and subside after 20-30mins
May be spontaneous or situational, can occur during sleep
At least 4 specific symptoms of anxiety
What is a panic disorder?
Recurrent panic attacks not secondary to substance misuse, medical conditions or another psychiatric disorder
Variable frequency
Persistent worry about having an attack may lead to phobic avoidance or behavioural changes
How common are panic attacks and panic disorder?
Lifetime risk:
- 8% panic attack
- 4% panic disorder
Which gender and age group are panic disorders more common?
F3:1M
Two common onset ages: early adulthood and middle ages
What are two theories behind the pathophysiology of panic disorder?
Hyper-responsive synaptic 5HT and NA receptors
Hypersensitive carbon dioxide brainstem receptors = false suffocation hypothesis
What is the inheritability of panic disorder?
30-40%
What is the ICD-10 of panic disorder?
1) Recurrent panic attacks
2) Not restricted to any particular situation or set of circumstances
3) Unpredictable
4) Dominant symptoms include:
- Sudden onset palpitations
- Tachycardia
- Chest pain
- HTN
- Tachypnoea
- Breathlessness
- Dizziness
- Tremor
- Sweating
- Nausea
- GI upset
- Feelings of unreality = depersonalisation or derealisation
These symptoms are commonly misinterpreted and people think they are going to die which adds to the anxiety
+/- agoraphobia
+/- hyperventilation syndrome (HVS)
(Diagnosis of panic disorder should not be given if someone has a depressive condition at the same time)
Ddx of panic disorder
Psych - another anxiety disorder, substance or alcohol misuse / withdrawal
Endocrine - Cushing’s, hyperthyroidism, hypoparathyroidism, hypoglycaemia, phaeochromocytoma
Haem - anaemia
CV- arrhythmia, mitral valve prolapse, MI
Resp - COPD/asthma, HVS
Neuro - temporal lobe epilepsy, vestibular dysfunction
What investigations should be done for panic disorder?
Exclude physical cause: FBC U&Es Glucose TFTs Calcium ECG Toxicology
What is the management of panic disorder?
Biological:
SSRI (sertraline) = first line
TCAs
BDZ if severe
Education and low/high intensity psychological interventions
- CBT = effective at treating avoidance, and teaches relaxation and control of hyperventilation
What comorbities are common with panic disorder?
Agoraphobia
Depression
Other anxiety disorders
Alcohol misuse (30%)
Is there a trigger in panic disorder?
No there is no specific stimuli
If the attacks of anxiety do have a specific stimulus consider it a phobic disorder rather than generalised panic
What is a phobia?
A persistent extreme irrational fear which causes anticipatory anxiety of the feared object or situation leading to avoidance
How common are phobias?
10% prevalence
What are some key characteristics of phobias? (4)
1) Avoidance
2) Panic attacks
3) Anticipatory anxiety
4) Fear cannot be explained or reasoned away
What is agoraphobia?
Cluster of phobias embracing: fears of leaving home, entering shops, crowds and public places travelling alone in trains, buses or planes
How may agoraphobia present?
Range from inability to go into crowded or busy spaces to not being able to leave the house
Close relationship with panic disorder - if people are in spaces where they can’t easily leave they may have a panic attack, and this can lead to a phobia of these sorts of places
Which gender / age group is most affected by agoraphobia?
F>M
Ages 20-45
What is social phobia?
Fear of scrutiny from others which might lead to humiliation or embarrassment
These can be specific isolated fears eg being seen eating by others, speaking to others or a fear of interacting with opposite sex, or can be extreme and involve all forms of social activities outside of the home
What gender / age is more commonly affected by social phobias?
F>M
Onset typically adolescence
What is the management of social phobias?
CBT
Exposure therapy
What are some common specific phobias?
Heights Germs Certain animals Driving Flying Dentists
How are specific phobias managed?
Same as others
Short term BDZ eg flying
Beta blockers may reduce ANS symptoms
What age / gender is most commonly affected by specific phobias?
F=M
Onset in childhood
What is the management of phobias?
CBT
Exposure therapy
- Eg for agoraphobia start by opening the front door, then taking a step outside, to the bottom of the drive etc
Self help
Applied relaxation
Medication rarely used
- SSRIs at low dose
- BDZ short term eg flying
- Beta blockers may reduce ANS symptoms
Outline CBT
1) Formulation:
- Understanding, defining and mapping out the problem in terms of thoughts, feelings, behaviours and physiology
- Identifying factors which make things better or worse/keep things going
- Explanation (what is anxiety/ how common is it?)
- What are the effects of arousal and over-breathing (draw a diagram)
2) Diary to gather information
- Frequency, when, where, thoughts and behaviours
3) Identify negative thinking patterns and problematic behaviours
4) Learn to behave differently through behavioural experiments, graded exposure or thought challenging
What are obsessions?
Recurrent and intrusive irrational thoughts that are experienced as being unpleasant and distressing
Enter the mind against conscious resistance (unable to resist thoughts)
Recognisable as being a product of their own mind - ie if they thought they were not of their own mind they might be demonstrating thought insertion (delusional disorder)
What are compulsions?
Recurrent mental operations
- Counting, praying, repeating a mantra
Recurrent physical acts
- Checking, seeking reassurance, hand-washing
Patient feels compelled to perform as a response to an obsession
Pt recognises as pointless or symbolic but performing them helps to reduce anxiety though belief they are preventing a dreaded event (eg hand-washing to stop friend dying)
Pt tries to unsuccessfully resist
What is the ICD-10 for OCD?
1) Obsession or compulsions must be present for at least 2 weeks and are a source of distress or interfere with the pt functioning
2) Acknowledged as coming from pt own mind
3) Obsessions are unpleasantly repetitive
4) At least one thought or act is resisted unsuccessfully
5) A compulsive act is not in itself pleasurable (excluding the relief of anxiety as ‘pleasure’)
What are the most common features of OCD?
Checking and washing
What is thought to be the pathophysiology of OCD?
Neurological - reduced size and hyper metabolism in caudate nucleus
Neurochemical - 5HT / DA interaction and dysregulation
Immunological - cell mediated AI factors against basal ganglia peptides
How common is OCD?
What is the mean age of onset of OCD? Which gender is most affected?
0.5-2% prevalence
M=F
Mean age onset = 20yrs
70% onset before 25yr
What are some ddx for OCD?
Normal recurrent thoughts / worries
Obsessive compulsive personality disorder
Schizophrenia - may present with OCD symptoms
Phobias
Depressive disorders
- 2/3 of pt with OCD experience depression and over 20% with depression with experience obsessions / compulsions at some point
Hypochondriasis
What is the difference between OCD and obsessive compulsive personality disorder?
OCD - pt typically depressed by nature of their behaviours / thoughts but are unable to control them
OCPD - believe their actions have an aim and a purpose
What is the psychosocial management of OCD?
CBT
Exposure response prevention (ERP)
- Preventing people from acting on compulsions and hsowing htem that nothing bad is going to happen
What is the pharmaological management of OCD?
1st line = SSRI: fluoxetine, sertaline
- High doses are usually needed and long term
- Combination of SSRI therapy more effective
2nd line: TCA = clomipramine
- Specific anti-obsessional action
3rd line: MAOIs
- If tried SSRIs or clomipramine, or associated panic attacks
Augmentation
- Buspirone if marked anxiety
- Antipsychotic if psychotic features
- Lithium if marked depression
What is the physical management of OCD?
ECT
- If suicidal or incapacitated
Psychosurgery
- For severe cases that are not responisve to any treatment
- Stereotactic cingultomy (65% success) disrupts neuronal loop between caudate nucleus and basal ganglia
What is the prognosis of OCD?
20-30% significantly improve
40-50% moderately improve
20-40% have chronic or worsening symptoms
Relapse rates high after stopping medication
Precipitating event is associated with good outcomes
Comorbidities common - depressive disorder, alcohol and drug misuse, phobias, and panic disorder.
What is PTSD?
Stress disorder that develops after experiencing a ‘catastrophic or life threatening event that would be likely to cause pervasive distress in almost anyone’
eg war, rape, near death experiences
What is the theory behind PTSD?
Memory of event doesn’t seem to be processed properly - gets stuck in midbrain and doesn’t get processed away in the cortex meaning the memory can be triggered by similar experiences
What are some characteristics of PTSD?
Flashbacks, nightmares or intrusive thoughts causing them to re-live the situation
avoidance of activities and situations associated with that trauma
Hyper-arousal / anxiety (‘jumpy’) around certain situations
Numbness, emotional blunting and detachment from others
Associated depression and suicidal ideation
What is the average latency period between trauma and experiencing PTSD symptoms?
1-6 months
How long must symptoms be present for before a diagnosis of PTSD can be made?
1 month
What is the lifetime prevalence of PTSD?
1-10%
What are some predisposing factors for developing PTSD?
Personality traits - compulsive personality, asthenic (abnormal physical weakness or lack of energy)
Previous hx of neurotic illness
Genetic - over-sensitive amygdala
Scale of trauma
Pt prev experience
Level of social support available
Whatis the management of PTSD?
Trauma focused CBT
Repeated graded exposure eg to loud noises / slightly threatening situations
Eye movement desensitisation and reprocessing (EMDR)
- Hold traumatic image or event in pts head and get them to move their eyes from side to side following your finger, eases the processing of trauma
Antidepressants - paroxetine or mirtazipine
What is the prognosis of PTSD?
65% recover in 18 months
When may zopiclone be used?
Short term to help with sleep and may aid anxiety (through sedative effects)
Should not be used for more than 4 weeks
What may zopiclone interact with?
Bnenzos = both cause CNS depression
What is a standard dose of zopiclone?
3.75mg in elderly or max 7.5mg in adult pt
Other than zopiclone, what drugs may be used for insomnia?
Melatonin
Chloral hydrate - commonly used in paeds
In what populations should zopiclone be used with caution?
Elderly - falls risk
Heavy drinkers
Hepatic impairment
