Psychiatry- Anxiety Disorders Flashcards
What is generalised anxiety disorder
Characterised by excessive + persistent uncontrollable and disproportionate worry that significantly impairs social functioning for most days for at least 6 months
Risk factors for generalised anxiety disorder
• Age 35-54
• Divorced/separated
• Living alone
• Lone parent
• Co-morbid depression
DSM-V main criteria for generalised anxiety disorder
• >6 months of excessive, difficult to control worry (not due to substance abuse or underlying mental disorder)
Additional symptoms of generalised anxiety disorder
◦ Restlessness/nervousness
◦ Irritability
◦ Easily fatigued
◦ Poor concentration
◦ Sleep disturbance
◦ Muscle tension
◦ NOT triggered by a specific stimulus
Autonomic symptoms of generalised anxiety disorder
◦ Palpitations
◦ Sweating
◦ Flushing
◦ Dry mouth
◦ Shaking
◦ GI symptoms
◦ Nausea
Which questionnaire to use for generalised anxiety disorder
GAD-7
Cut offs of GAD-7
‣ 5=mild
‣ 10=moderate
‣ 15=severe
General investigations for generalised anxiety disorder
• TFTs: rule out hyperthyroidism
• ECG
What is first and second line for GAD management
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)
3rd line: drug treatment for GAD
• 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
What medication to never give in GAD
Benzodiazepines
Medication to manage adrenergic symptoms in GAD
• Adjunct Beta-Blocker (Propranolol): to manage adrenergic symptoms (never give BDZs)
Last line psychological management for GAD
3) High Intensity Psychological Interventions:
◦ 12-15 weeks CBT
Management of anxiety in pregnancy or if marked functional impairment
• Step 3- High intensity CBT + Drug treatment (SSRI)
What is acute stress reaction
Transient disorder that develops in a patient in response to a traumatic event that usually subsides within hours or days.
Onset and duration of acute stress reaction
• Onset:
◦ Within minutes
◦ Clear link between trauma and symptoms
• Must last for at least 3 days
• If lasts for >4 weeks, then consider PTSD
Common traumas causing acute stress reaction
• Road traffic accident
• Assault
• Burn
• Witnessing an accident
What can be initial symptom of acute stress reaction
• Initial state of ‘daze’:
◦ Can manifest as stupor
◦ Dissociation:
◦ Derealisation:
◦ Depersonalisation:
◦ Dissociative amnesia:
◦ Disorientated
What is derealisation
feeling of being in a dream state
What is depersonalisation
sensation of watching yourself from outside your body
What is dissociative amnesia
Unable to remember important aspects of event
What are other symptoms of acute stress reaction
• 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
What are autonomic symptoms of acute stress reaction
• Tachycardia
• Sweating
• Flushing
• Dry mouth
• Tachypnoea
Investigations for acute stress reaction
• Full personal + collateral history
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
Complications of acute stress reaction
Ptsd
What is PTSD
Severe psychological disturbance following a traumatic life event
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
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
Investigations for PTSD
• Trauma screening questionnaire
Mild PTSD management
◦ Symptoms <4 weeks
◦ Watchful waiting + lifestyle advice (sleep hygiene, exercise etc)
◦ Follow up within 1 month
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
Pharmacological management of PTSD
• If CBT or EMDR unsuccessful, not routinely recommended
• 1) SSRI (sertraline) or SNRI (venlafaxine)
Management if presentation within 1 month of traumatic event
• PTSD can be prevented with early cognitive processing therapy etc
What is adjustment disorder
• Development of emotional or behavioural symptoms in response to stress
• NOT TRAUMATIC, unlike acute stress disorder
Onset and duration of adjustment disorder
• Onset:
◦ Within weeks and lasts for less than 6 months
Causes of adjustment disorder
‣ Divorce/break-up
‣ Moving away from family
‣ Losing job
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
What is prolonged grief reaction
• Persistent grief response that exceeds norms, lasting longer than 6 months
Relationship between the event and symptoms in adjustment disorder
• Distress is out of proportion to the event and causes functional impairment
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
How are symptoms of prolonged grief reaction different from depression
As sadness + symptoms centred around dead person and not themselves
Investigations for adjustment disorder + prolonged grief reaction
• Full history + collateral
Management of adjustment reaction + prolonged grief reaction
• Support + Reassurance:
‣ Supportive counselling
‣ Usually all that is needed
Pharmacological:
• Short course of Antidepressants
What is agoraphobia
Fear of being unable to escape to a safe place (overwhelming desire to return home to safety)
Risk factors for agoraphobia
• Younger age
• Female
• Another phobia
• Concurrent depressive disorder
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
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
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
Triggering situations for social anxiety disorder
‣ Public speaking
‣ Small group events
‣ Going to school, work, shopping, being seen in public
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
Social anxiety disorder investigations
• 3-item Mini Social Phobia Inventory (Mini-SPIN):
◦ Do you find yourself avoiding social situations or activities?
Management of social anxiety disorder
• Education, reassurance and self-help
• Individual CBT + Exposure Response Prevention
• Pharmacological therapy:
‣ SSRI (sertraline) or SNRI (venlafaxine)
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
Management of specific phobia
• Psychoeducation, reassurance and self-help
• Individual CBT + Exposure Response Prevention
• Relaxation therapy + breathing techniques
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
What are obsessions
• Repetitive, involuntary and intrusive thoughts, images or impulses
What are compulsions
• Repetitive mental or physical acts that person is compelled to perform in response to obsessions or irrationally defined rules
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
Risk factors for OCD
• Family history
• Young (10-20 years old)
• Pregnancy/post-natal
• Childhood trauma
Obsessions presentation
• Fear of contamination
• Need for symmetry or exactness
• Fear of causing harm to someone
• Sexual obsessions
• Fear of behaving unacceptably
Compulsions presentation
• Counting
• Repeating words silently
• Ruminating
• Cleaning
• Tension/discomfort neutralised by performing compulsion (but not enjoyable)
• Anxiety can worsen if compulsion ignored
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?
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
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
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)
Severe functional impairment OCD management
• 1) Referral to secondary care mental health team for assessment + SSRI + CBT + ERP
What is panic disorder
Recurrent panic attacks (severe anxiety) which are NOT triggered by any particular situation- unpredictable
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
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
Panic disorder investigations
• ECG (palpitations)
• Respiratory alkalosis due to hyperventilation
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)
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
