PTSD/Anxiety/OCD

Question 1

Acute stress disorder is defined as

Answer 1

an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc).

This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.

Question 2

Acute stress disorder Features include:

Answer 2

intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance

Question 3

Acute stress disorder mx

Answer 3

trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line

benzodiazepines - sometimes used for acute symptoms e.g. agitation, sleep disturbance

Question 4

benzodiazepines should only be used with caution due to

Answer 4

addictive potential and concerns that they may be detrimental to adaptation

Question 5

Post-traumatic stress disorder (PTSD) diagnostic criteria

Answer 5

symptoms have been present for more than one month.

Question 6

PTSD features

Answer 6

re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating

emotional numbing - lack of ability to experience feelings, feeling detached

Question 7

PTSD features from other people

Answer 7

depression
drug or alcohol misuse
anger
unexplained physical symptoms

Question 8

PTSD mx

Answer 8

watchful waiting may be used for mild symptoms lasting less than 4 weeks

trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases

drug treatments for PTSD should not be used as a routine first-line treatment for adults.

Question 9

PTSD following a traumatic event single-session interventions (often referred to as debriefing) are recommended

Answer 9

false

Question 10

Drugs in refractory PTSD

Answer 10

venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

Question 11

Post-concussion syndrome is seen after even minor head trauma

Typical features include

Answer 11

headache
fatigue
anxiety/depression
dizziness

Question 12

Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as

Answer 12

‘excessive worry about a number of different events associated with heightened tension.’

Question 13

Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include

Answer 13

hyperthyroidism, cardiac disease and medication-induced anxiety

Question 14

Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include (medications)

Answer 14

Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Question 15

Management of generalised anxiety disorder (GAD)

Answer 15

NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring

step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.

step 4: highly specialist input e.g. Multi agency teams

Question 16

Drug treatment generalised anxiety

Answer 16

NICE suggest sertraline should be considered the first-line SSRI

if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)

If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Question 17

Drug treatment generalised anxiety - patients under the age of 30 years

Answer 17

NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Question 18

Management of panic disorder

Answer 18

step 1: recognition and diagnosis
step 2: treatment in primary care
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services

Question 19

panic disorder treatment in primary care?

Answer 19

NICE recommend either cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 20

Obsessive-compulsive disorder (OCD) is characterised by

Answer 20

the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

Question 21

An obsession is defined as

Answer 21

an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.

Question 22

Compulsions are

Answer 22

repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

Question 23

It is thought that 1 to 2% of the population have OCD

Answer 23

true

Question 24

OCD The aetiology is multifactorial but possible factors include:

Answer 24

genetic
psychological trauma
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)

Question 25

OCD associations

Answer 25

depression (30%)
schizophrenia (3%)
Sydenham's chorea
Tourette's syndrome
anorexia nervosa

Question 26

OCD mx If functional impairment is mild

Answer 26

low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)

If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)

Question 27

OCD mx If moderate functional impairment

Answer 27

offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)

Question 28

OCD mx If severe functional impairment

Answer 28

offer combined treatment with an SSRI and CBT (including ERP)

Question 29

ERP is

Answer 29

psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Question 30

SSRIs in OCD mx

Answer 30

if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement

If SSRI ineffective or not tolerated try either another SSRI

Question 31

examples of GABAA drugs and how they work?

Answer 31

benzodiazipines increase the frequency of chloride channels

barbiturates increase the duration of chloride channel opening

Frequently Bend - During Barbeque

Question 32

Benzodiazepines used for:

Answer 32

sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant

Question 33

Patients commonly develop a tolerance and dependence to benzodiazepines

Answer 33

true

Question 34

The Committee on Safety of Medicines advises that benzodiazepines are only prescribed for a short period of time - this is?

Answer 34

2-4 weeks

Question 35

The BNF gives advice on how to withdraw a benzodiazepine:

Answer 35

The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight

Question 36

The BNF gives advice on how to withdraw a benzodiazepine: if there is difficulty then ..

Answer 36

A suggested protocol for patients experiencing difficulty is given:

switch patients to the equivalent dose of diazepam
reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg

time needed for withdrawal can vary from 4 weeks to a year or more

Question 37

If patients withdraw too quickly from benzodiazepines they may experience

Answer 37

Benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome

Question 38

Benzodiazepine withdrawal syndrome may occur up to ? after stopping a long-acting drug

Answer 38

may occur up to 3 weeks after stopping a long-acting drug

Question 39

Benzodiazepine withdrawal syndrome sx

Answer 39

insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures