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Year 5: Conditions > Psychiatry- Anxiety Disorders > Flashcards

Psychiatry- Anxiety Disorders Flashcards

1
Q

What is generalised anxiety disorder

A

Characterised by excessive + persistent uncontrollable and disproportionate worry that significantly impairs social functioning for most days for at least 6 months

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2
Q

Risk factors for generalised anxiety disorder

A

• Age 35-54
• Divorced/separated
• Living alone
• Lone parent
• Co-morbid depression

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3
Q

DSM-V main criteria for generalised anxiety disorder

A

• >6 months of excessive, difficult to control worry (not due to substance abuse or underlying mental disorder)

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4
Q

Additional symptoms of generalised anxiety disorder

A

◦ Restlessness/nervousness
◦ Irritability
◦ Easily fatigued
◦ Poor concentration
◦ Sleep disturbance
◦ Muscle tension
◦ NOT triggered by a specific stimulus

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5
Q

Autonomic symptoms of generalised anxiety disorder

A

◦ Palpitations
◦ Sweating
◦ Flushing
◦ Dry mouth
◦ Shaking
◦ GI symptoms
◦ Nausea

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6
Q

Which questionnaire to use for generalised anxiety disorder

A

GAD-7

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7
Q

Cut offs of GAD-7

A

‣ 5=mild
‣ 10=moderate
‣ 15=severe

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8
Q

General investigations for generalised anxiety disorder

A

• TFTs: rule out hyperthyroidism
• ECG

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9
Q

What is first and second line for GAD management

A

1) Info booklet on GAD + active monitoring + lifestyle advice

2) Low-Intensity psychological interventions:
◦ 6 weeks individual, guided or group CBT
◦ Relaxation training, meditation, sleep hygiene

(Stepped approach)

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10
Q

3rd line: drug treatment for GAD

A

• 1st Line= SSRI- Sertraline
◦ Warn patients of increased suicidal thinking in first month when starting (arrange weekly follow-up)
• 2nd- different SSRI (after 8 weeks) e.g. Paroxetine
• 3rd SNRI (e.g. venlafaxine)
• 4th Pregabalin

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11
Q

What medication to never give in GAD

A

Benzodiazepines

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12
Q

Medication to manage adrenergic symptoms in GAD

A

• Adjunct Beta-Blocker (Propranolol): to manage adrenergic symptoms (never give BDZs)

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13
Q

Last line psychological management for GAD

A

3) High Intensity Psychological Interventions:
◦ 12-15 weeks CBT

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14
Q

Management of anxiety in pregnancy or if marked functional impairment

A

• Step 3- High intensity CBT + Drug treatment (SSRI)

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15
Q

What is acute stress reaction

A

Transient disorder that develops in a patient in response to a traumatic event that usually subsides within hours or days.

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16
Q

Onset and duration of acute stress reaction

A

• Onset:
◦ Within minutes
◦ Clear link between trauma and symptoms

• Must last for at least 3 days
• If lasts for >4 weeks, then consider PTSD

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17
Q

Common traumas causing acute stress reaction

A

• Road traffic accident
• Assault
• Burn
• Witnessing an accident

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18
Q

What can be initial symptom of acute stress reaction

A

• Initial state of ‘daze’:
◦ Can manifest as stupor
◦ Dissociation:
◦ Derealisation:
◦ Depersonalisation:
◦ Dissociative amnesia:
◦ Disorientated

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19
Q

What is derealisation

A

feeling of being in a dream state

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20
Q

What is depersonalisation

A

sensation of watching yourself from outside your body

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21
Q

What is dissociative amnesia

A

Unable to remember important aspects of event

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22
Q

What are other symptoms of acute stress reaction

A

• HARE:
◦ Hyperarousal: insomnia, always on guard, poor concentration, exaggerated startle

◦ Avoidance: avoid people/situations associated with trauma

◦ Intrusive Re-experiencing of event: flashbacks, nightmare, intrusive + distressing memories, children-repetitive play

◦ Emotionally numb: negative mood, flat affect
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23
Q

What are autonomic symptoms of acute stress reaction

A

• Tachycardia
• Sweating
• Flushing
• Dry mouth
• Tachypnoea

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24
Q

Investigations for acute stress reaction

A

• Full personal + collateral history

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25
Management of acute stress reaction
1) Support + Reassure: ◦ Normalise stress response, and encourage expectancy to recover • Offer trauma-focused CBT: • Address beliefs about trauma • Exposure: help confront their fears • Benzodiazepines: ◦ Alleviates short-term agitation and sleep disturbances
26
Complications of acute stress reaction
Ptsd
27
What is PTSD
Severe psychological disturbance following a traumatic life event
28
Onset and duration of PTSD
• Occurs within 6 months of traumatic event ◦ Often within first month • Lasts at least 1 month: ‣ Less than month is acute stress disorder
29
Presentation of PTSD
• HARE: ‣ H: Hypervigilance/hyperarousal: • Constantly on guard for threat • Exaggerated startle response • Insomnia • Irritability • Poor concentration ‣ A: Avoidance: ‣ Avoiding people and situations resembling/associated with traumatic event ‣ R: (intrusive) Re-experiencing event: ◦ Distressing involuntary + intrusive memories ◦ Flashbacks ◦ Nightmares ‣ E: Emotional numbing: ◦ Anhedonia ◦ Feels detached ◦ Depression
30
Investigations for PTSD
• Trauma screening questionnaire
31
Mild PTSD management
◦ Symptoms <4 weeks ◦ Watchful waiting + lifestyle advice (sleep hygiene, exercise etc) ◦ Follow up within 1 month
32
Moderate-to-severe PTSD management
• 1) Trauma-Focused CBT: ‣ Offer to all patients with PTSD symptoms lasting >1 month ‣ Exposure therapy + trauma focused discussion ‣ 8-12 sessions • Eye Movement Desensitisation and Reprocessing (EMDR): ◦ Adults with PTSD who have presented >3 months after non-combat related trauma ◦ Patient recalls event in as much detail as possible whilst fixing their eyes on therapist’s finger as it quickly moves from side to side ◦ Aids memory processing
33
Pharmacological management of PTSD
• If CBT or EMDR unsuccessful, not routinely recommended • 1) SSRI (sertraline) or SNRI (venlafaxine)
34
Management if presentation within 1 month of traumatic event
• PTSD can be prevented with early cognitive processing therapy etc
35
What is adjustment disorder
• Development of emotional or behavioural symptoms in response to stress • NOT TRAUMATIC, unlike acute stress disorder
36
Onset and duration of adjustment disorder
• Onset: ◦ Within weeks and lasts for less than 6 months
37
Causes of adjustment disorder
‣ Divorce/break-up ‣ Moving away from family ‣ Losing job
38
Adjustment disorder presentation
• Low mood, tearfulness • Anxiety and worry • Feeling of inability to cope • Impacting daily life • NO BIOLOGICAL DEPRESSIVE SYMPTOMS: no impact on sleep, appetite, energy levels and suicidal ideation
39
What is prolonged grief reaction
• Persistent grief response that exceeds norms, lasting longer than 6 months
40
Relationship between the event and symptoms in adjustment disorder
• Distress is out of proportion to the event and causes functional impairment
41
Presentation of prolonged grief reaction
◦ Delayed onset ◦ Greater intensity of symptoms ◦ More likely if relationship with deceased was problematic or sudden death ◦ Negative thoughts, suicidal ideations, pseudohallucination experiences • Intense + persistent grief lasting 6-12 months • Yearning for + preoccupation with the deceased • Anhedonia • Diminished outlook of the future without the deceased • Disbelief, denial, frustration • Guilt • Dazed, lost, unfocused
42
How are symptoms of prolonged grief reaction different from depression
As sadness + symptoms centred around dead person and not themselves
43
Investigations for adjustment disorder + prolonged grief reaction
• Full history + collateral
44
Management of adjustment reaction + prolonged grief reaction
• Support + Reassurance: ‣ Supportive counselling ‣ Usually all that is needed Pharmacological: • Short course of Antidepressants
45
What is agoraphobia
Fear of being unable to escape to a safe place (overwhelming desire to return home to safety)
46
Risk factors for agoraphobia
• Younger age • Female • Another phobia • Concurrent depressive disorder
47
Agoraphobia presentation
• Avoidance of phobic situations ± isolation behaviour • Significant worry about at least 2 of the following situations: ◦ Using public transport ◦ Being in an open space ◦ Being in enclosed spaces ◦ Standing in line/being in a crowd ◦ Being outside of the home alone • Gradual anxiety or panic attacks
48
Management of agoraphobia
• 1) Psychoeducation, reassurance and guided self-help ◦ Individual non-facilitated self-help or facilitated • 2) Exposure Response Prevention (ERP): ◦ Gradual/hierarchical desensitisation approach (least to most frightening) ◦ Aim to stay in situation until anxiety subsides • 3) CBT
49
What is social anxiety disorder
Persistent and intense fear of being embarrassed, humiliated or negatively evaluated in social situations- leading to significant distress/impairment of function
50
Triggering situations for social anxiety disorder
‣ Public speaking ‣ Small group events ‣ Going to school, work, shopping, being seen in public
51
Social anxiety disorder symptoms
• Can TOLERATE anonymous crowds (unlike agoraphobia) • Present for at least 6 months • Minimal eye contact • Quiet tone of speech • Difficulty initiating conversations • Anticipatory: worrying for hours or days prior to event • Post-event processing: replay social encounters in a negative way • Panic attacks • Physical symptoms: ◦ Blushing, sweating, trembling, palpitations
52
Social anxiety disorder investigations
• 3-item Mini Social Phobia Inventory (Mini-SPIN): ◦ Do you find yourself avoiding social situations or activities?
53
Management of social anxiety disorder
• Education, reassurance and self-help • Individual CBT + Exposure Response Prevention • Pharmacological therapy: ‣ SSRI (sertraline) or SNRI (venlafaxine)
54
Presentation of specific phobia
• Contact can evoke panic: e.g. barricading room, screaming at people) • Family Hx of phobia • Autonomic symptoms • BUT blood or injury phobia: can cause Vasovagal bradycardia and hypotension
55
Management of specific phobia
• Psychoeducation, reassurance and self-help • Individual CBT + Exposure Response Prevention • Relaxation therapy + breathing techniques
56
What is OCD
Presence of obsessional thoughts AND/OR compulsive acts, that are present on most days for at least 2 consecutive weeks- impacting normal functioning
57
What are obsessions
• Repetitive, involuntary and intrusive thoughts, images or impulses
58
What are compulsions
• Repetitive mental or physical acts that person is compelled to perform in response to obsessions or irrationally defined rules
59
What is a key feature of OCD
◦ MAINTAINED INSIGHT: ‣ Obsessions and compulsions are self-recognised as a product of own mind ‣ NOT pleasurable or satisfying ‣ Effort to ignore or suppress obsessions or compulsions ‣ Differentiates OCD from obsessive-compulsive (anankastic) personality disorder
60
Risk factors for OCD
• Family history • Young (10-20 years old) • Pregnancy/post-natal • Childhood trauma
61
Obsessions presentation
• Fear of contamination • Need for symmetry or exactness • Fear of causing harm to someone • Sexual obsessions • Fear of behaving unacceptably
62
Compulsions presentation
• Counting • Repeating words silently • Ruminating • Cleaning • Tension/discomfort neutralised by performing compulsion (but not enjoyable) • Anxiety can worsen if compulsion ignored
63
OCD investigations
• Yale-Brown OCD scale: classifies severity of OCD • FBC, TFTs • Ask: ◦ Are there any thoughts that bother you that you would like to get rid of? ◦ Do you wash or clean a lot? ◦ Do daily activities take a long time to finish?
64
Mild functional impairment OCD management
1) Low-intensity psychological therapy: • CBT + Exposure Response Prevention (ERP): ◦ Gradual exposure of trigger (hierarchy) without permitting compulsion will help diminish urge and anxiety over time
65
Moderate functional impairment OCD management
• E.g. lost job, not functioning • 1) Intense CBT + ERP + SSRI: • Fluoxetine is first choice • Continue for at least 12 weeks and at least 12 months after symptom remission • 2) Clomipramine or alternative SSRI: ◦ Only if first SSRI not effective after 12 weeks
66
TCA side effects
◦ TCA SIDE EFFECTS (anti-muscarinic/cholinergic side-effects): ◦ Can’t see (blurred vision), cant pee (urinary retention), cant spit (dry mouth), cant shit (constipation)
67
Severe functional impairment OCD management
• 1) Referral to secondary care mental health team for assessment + SSRI + CBT + ERP
68
What is panic disorder
Recurrent panic attacks (severe anxiety) which are NOT triggered by any particular situation- unpredictable
69
Frequency of panic disorders
• At least 2 within a month • Relatively fine in-between episodes with minimal anxiety • Panic disorder should not be main diagnosis if a depressive disorder exists at the time attacks start • Unpredictable: no specific trigger
70
Panic disorder presentation
• Sudden onset • Extreme anxiety • Lasts <30min • Alarming thoughts: Impending doom, feels like you are going to die • Physical symptoms: ◦ Sweating ◦ Palpitations ◦ Chest tightness ◦ Tachypnoea ◦ Shaking ◦ Sensation of choking ◦ Nausea + GI distress ◦ Dizziness ◦ Derealisation or depersonalisation
71
Panic disorder investigations
• ECG (palpitations) • Respiratory alkalosis due to hyperventilation
72
First line management of panic disorders
1) Treat in primary care: ◦ Low-Intensity psychological therapy ◦ Individual non-guided self-help (6 weeks) ◦ Individual guided self-help (6 weeks- weekly therapist appointment)
73
2-4 line management of panic disorder
2) High intensity CBT + SSRI (e.g. sertraline) 3) TCA (e.g. Clomipramine): only if no response to SSRI after 12 weeks 4) Refer to psychiatry

Year 5: Conditions (17 decks)

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