Psychiatry SC070: Stress-related Disorders And Obsessive-Compulsive Disorder (Post-Traumatic Stress Disorder, Adjustment Disorder, Acute Stress Disorder)

Question 1

Anxiety

Answer 1

Normal anxiety:
- Adaptive to stress
- Inborn response to threat that can result in cognitive + somatic symptoms (physiological changes in preparation to threat)

Pathological anxiety:
- Maladaptive
- Excessive + Impair function

Neural response:
1. Amygdala: Processing of emotionally salient stimuli
2. Medial prefrontal cortex (Anterior cingulate cortex, Subcallosal cortex, Medial frontal gyrus): Modulation of affect
3. Hippocampus: Memory coding + Retrieval

Question 2

***Anxiety Diorders

Answer 2

1. Phobic anxiety disorders
   - Agoraphobia
   - Social phobias
   - Specific phobias
2. Other anxiety disorders
   - Panic disorder (Come and Go)
   - Generalised anxiety disorder (Persistent)
   - Mixed anxiety and depressive disorder

Epidemiology:
- 2-10%
- Early onset: teens / early 20s
- ***F:M = 2:1
- Wax and wane course over lifetime
- Functional impairment + decreased QoL ~major depression + chronic diseases e.g. DM

Question 3

Agoraphobia

Answer 3

Severity + Frequency + Duration (usually >=1 year) (differ from normal)

Marked + Consistently manifest fear in / avoidance of ***>=2 of following situations:
1. Crowds
2. Public places
3. Travelling alone
4. Travelling away from home

Symptoms of anxiety in the feared situation at some time since onset of disorder, with >=2 symptoms present together, on >=1 occasion, from the list below, one of which must have been from (記: **CABG):
1. **Autonomic arousal symptoms
- Palpitations or pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Dry mouth (not due to medication or dehydration)

2. ***Chest + Abdomen symptoms
   - Difficulty breathing
   - Feeling of choking
   - Chest pain or discomfort
   - Nausea or abdominal distress (e.g. churning in stomach)
3. ***Brain + Mind symptoms
   - Feeling dizzy, unsteady, faint or light‐headed
   - Feelings that objects are unreal (derealisation), or that one’s self is distant or “not really here” (depersonalisation)
   - Fear of losing control, going crazy, or passing out
   - Fear of dying
4. ***General symptoms
   - Hot flushes or cold chills
   - Numbness or tingling sensations (can be related to hyperventilation)

• ***Significant emotional distress due to the avoidance or the anxiety symptoms, and a recognition that these are excessive or unreasonable
• Symptoms are restricted to or predominate in the **feared situations or when **thinking about them

Question 4

Panic Disorder

Answer 4

• Recurrent panic attacks, that are **NOT consistently associated with a specific situation / object, and often occurring **spontaneously (i.e. episodes are ***unpredictable)
• Panic attacks are ***NOT associated with marked exertion / with exposure to dangerous / life-threatening situations (i.e. not PTSD)

A panic attack is characterised by all of following:
1. A discrete episode of **intense fear / discomfort (feeling of about to die)
2. Starts **abruptly
3. Reach a crescendo within **a few mins + last at least **some mins (then go away)
4. ***>=4 symptoms must be present from:
- Autonomic arousal symptoms
- Chest + Abdomen symptoms
- Brain + Mind symptoms
- General symptoms

DDx:
- Arrhythmia

Panic disorder can comorbid with Agoraphobia!

Question 5

Generalised Anxiety Disorder

Answer 5

• A period of **>=6 months with **prominent tension, worry + feelings of apprehension, about every-day events + problems (i.e. **Generalised, **More than usual, ***Persist)

***>=4 symptoms must be present from:
- Autonomic arousal symptoms
- Chest + Abdomen symptoms
- Brain + Mind symptoms
- General symptoms

Question 6

General treatment approaches of Anxiety Disorders

Answer 6

Rmb for any psychiatric illness: ***Biopsychosocial approach (Biological + Psychological + Social treatment)!!!

1. Pharmacotherapy
   - **Antidepressant (control serotonin which also helpful in anxiety symptoms)
   - **Anxiolytic (relief anxiety symptoms in a short duration / bridging for Antidepressant / preparation in facing specific situation)
   - Antipsychotic (uncommon)
   - Mood stabiliser (uncommon, used if refractory)
2. Psychotherapy
   - CBT (e.g. desensitisation approach for phobia)
   - Mindfulness-based therapy (get used to anxiety feeling, calm down oneself during anxiety attacks)

Question 7

***Trauma- + Stressor-related Disorders

Answer 7

1. Acute Stress Reaction
2. Post-traumatic Stress Disorder (PTSD)
3. Adjustment Disorders

Question 8

Post-traumatic Stress Disorder (PTSD)

Answer 8

• Objective (actual event) + Subjective (how the person feel towards the event, e.g. if the person don’t think the event is stress —> not develop PTSD)
• Duration of disturbance **>1 month (vs Acute stress disorder **<1 month)
• ***Significant impairment in function

Exposure to **actual / threatened death, serious / **sexual violence in >=1 of following ways:
1. Direct experiencing of traumatic event(s)
2. Witnessed in person the events as it occurred to others
3. Learning that the traumatic events occurred to person close to them
4. Experiencing repeated / extreme exposure to aversive details of trauma

***Intrusion
Presence of >=1 after the event:
1. Recurrent, involuntary + intrusive memories of event
2. Recurrent trauma-related nightmares
3. Dissociative reactions (e.g. memory loss)
4. Intense physiologic distress at cue exposure (e.g. travelling in same type of vehicle)
5. Marked physiological reactivity at cue exposure

**Avoidance
Persistent **avoidance by 1 or both:
1. Avoidance of distressing memories, thoughts / feelings of the event(s)
2. Avoidance of external reminders of that arouse memories of event(s) e.g. people, places, activities

**Negative mood
**Negative alterations in cognitions + mood associated with the traumatic event(s) as evidenced by ***>=2 of following:
1. Inability to remember an important aspect of the traumatic event(s)
2. Persistent distorted cognitions about cause / consequence of event that lead to blame of self / others
3. Persistent negative emotional state
4. Marked diminished interest
5. Feeling detached from others
6. Persistent inability to experience positive emotions

**Arousal
Marked alterations in **arousal + ***reactivity with >=2 of following:
1. Irritable behaviour + angry outbursts
2. Reckless / Self-destructive behaviour
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance

Specifiers:
1. With dissociative symptoms (derealisation / depersonalisation)
2. With delayed expression (don’t meet criteria until ***>6 months after event)

Epidemiology:
- 7-9% of population
- 60-80% of trauma victims
- 30% of combat veterans
- 50-80% of sexual assault victims
- Increased risk in women, young people
- Increased risk with “dose” of trauma, lack of social support, pre-existing psychiatric disorder

Co-morbidities of PTSD:
1. Depression
2. Other anxiety disorders
3. Substance use disorders (e.g. hypnotics)
4. Somatisation (expression of mental phenomena as physical (somatic) symptoms)
5. Dissociative disorders (experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity)

Etiology:
1. Conditioned fear
2. Genetic / Familial vulnerability
3. Stress-induced release
- Norepinephrine, CRF, Cortisol
4. Autonomic arousal immediately after trauma predicts PTSD

Neuroimaging:
- Increased amygdala activation
- Hypoactivation of medial prefrontal cortex (orbitofrontal cortex + anterior cingulate cortex) (area implicated in affect regulation)

Treatment:
1. **CBT
2. **Eye movement desensitisation + reprocessing (EMDR) (stimulate REM-like eye movement —> experience “dream-like” feeling —> allow person to tolerate anxiety feeling)
3. Medication
- **Antidepressant
- **Beta-blockers
- Mood stabiliser
- Clonidine
- Prazosin
- Gabapentin

(Debriefing immediately following trauma NOT necessarily effective (let person talk about how they feel after the trauma) —> may cause secondary trauma)

Question 9

Acute Stress Reaction

Answer 9

• Similar exposure to PTSD
• Duration of disturbance: **3 days - 1 month after trauma (vs PTSD **>1 month)
• Cause significant impairment
• Presence of >=9 of ***5 categories:
  1. Intrusion
  2. Negative mood
  3. Dissociation
  4. Avoidance
  5. Arousal related to trauma

Question 10

Obsessive-Compulsive and related Disorders

Answer 10

1. Obsessive-Compulsive Disorder
2. Body Dysmorphic Disorder
3. Hoarding Disorder (collect many things)
4. Trichotillomania
5. Excoriation Disorder (scratching)

Question 11

Obsessive-Compulsive Disorder

Answer 11

Obsessions (**想法):
- **Recurrent + **Persistent thoughts, impulses / images that are **intrusive + **unwanted that cause **marked anxiety + distress
- The person attempts to **ignore / **suppress / **neutralise such thoughts, urges / images with some other thought / action (i.e. **Compulsion)

Compulsions (**行為 (ritual)):
- **Repetitive behaviours / mental acts that the person feels **driven to perform in response to an obsession / according to **rigidly applied rules
- The behaviour / acts are aimed at **reducing distress / **preventing some dreaded situation however these acts / behaviours are not connected in a realistic way with what they are designed to neutralise / prevent (e.g. 洗手洗10秒only)

Obsessions / Compulsions cause marked distress, take **>1 hour / day or cause clinically **significant distress / impairment in function

Specify if:
- With good / fair insight: recognise beliefs are definitely / most likely not true
- With poor insight: thinks are probably true
- With absent insight: completely convinced the COCD beliefs are true
- Tic-related

Epidemiology:
- 2% of general population
- Mean onset 19.5 yo, 25% start by age 14
- Males have earlier onset
- F=M

Co-morbidities:
1. Anxiety disorder (>70%)
- PD, SAD, GAD, Phobia
2. Mood disorder (>60%)
- MDD
3. Tic disorder (30%)
4. Schizophrenic / Schizoaffective disorder (12%)

Etiology:
1. Genetics
2. Serotonergic dysfunction
3. Cortico-striato-thalamo-cortical loop
4. Autoimmune: PANDAS (Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection) (very rare)

Functional imaging studies:
- Increased activity in right caudate —> CBT reduces resting state glucose metabolism / blood flow in right caudate (similar results with drug treatment)

Treatment (40-60% response):
1. Serotonergic Antidepressant
2. Behavioural therapy
3. Adjunctive Antipsychotic
4. Psychosurgery (rarely)

(vs Obsessive-compulsive personality disorder (OCPD):
- OCD: has true obsessions + compulsions
- OCPD: pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, >=4:
—> preoccupied with details, rules, lists, order, organisation, schedules
—> perfectionism that interferes with task completion
—> excessively devoted to work + productivity
—> overconscientious, scrupulous, inflexible
—> unable to discard worn-out / worthless objects
—> reluctant to delegate tasks / work with others
—> adopts a miserly spending style (money viewed as sth to be hoarded for future catastrophes)
—> rigidity + stubbornness)

Question 12

Screening questions for Anxiety Disorders

Answer 12

1. When you are in a situation where people can observe you do you feel nervous / worry that they will judge you? (SAD)
2. Do you consider yourself a worrier? (GAD)
3. How ever experienced a panic attack? (Panic disorder)
4. Have you ever had anything happen that still haunts you? (PTSD)
5. Do you get thoughts stuck in your head that really bother you / need to do things over and over like washing your hands, checking things / count? (OCD)