PTSD/Anxiety/OCD Flashcards
Acute stress disorder is defined as
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.
Acute stress disorder Features include:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
Acute stress disorder mx
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines - sometimes used for acute symptoms e.g. agitation, sleep disturbance
benzodiazepines should only be used with caution due to
addictive potential and concerns that they may be detrimental to adaptation
Post-traumatic stress disorder (PTSD) diagnostic criteria
symptoms have been present for more than one month.
PTSD features
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
PTSD features from other people
depression
drug or alcohol misuse
anger
unexplained physical symptoms
PTSD mx
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.
PTSD following a traumatic event single-session interventions (often referred to as debriefing) are recommended
false
Drugs in refractory PTSD
venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
Post-concussion syndrome is seen after even minor head trauma
Typical features include
headache
fatigue
anxiety/depression
dizziness
Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as
‘excessive worry about a number of different events associated with heightened tension.’
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include
hyperthyroidism, cardiac disease and medication-induced anxiety
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include (medications)
Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine
Management of generalised anxiety disorder (GAD)
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
Drug treatment generalised anxiety
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
Drug treatment generalised anxiety - patients under the age of 30 years
NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
Management of panic disorder
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
panic disorder treatment in primary care?
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
Obsessive-compulsive disorder (OCD) is characterised by
the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.
An obsession is defined as
an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Compulsions are
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.
It is thought that 1 to 2% of the population have OCD
true
OCD The aetiology is multifactorial but possible factors include:
genetic
psychological trauma
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)
OCD associations
depression (30%) schizophrenia (3%) Sydenham's chorea Tourette's syndrome anorexia nervosa
OCD mx If functional impairment is mild
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)
OCD mx If moderate functional impairment
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)
OCD mx If severe functional impairment
offer combined treatment with an SSRI and CBT (including ERP)
ERP is
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
SSRIs in OCD mx
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
examples of GABAA drugs and how they work?
benzodiazipines increase the frequency of chloride channels
barbiturates increase the duration of chloride channel opening
Frequently Bend - During Barbeque
Benzodiazepines used for:
sedation hypnotic anxiolytic anticonvulsant muscle relaxant
Patients commonly develop a tolerance and dependence to benzodiazepines
true
The Committee on Safety of Medicines advises that benzodiazepines are only prescribed for a short period of time - this is?
2-4 weeks
The BNF gives advice on how to withdraw a benzodiazepine:
The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight
The BNF gives advice on how to withdraw a benzodiazepine: if there is difficulty then ..
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
If patients withdraw too quickly from benzodiazepines they may experience
Benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome
Benzodiazepine withdrawal syndrome may occur up to ? after stopping a long-acting drug
may occur up to 3 weeks after stopping a long-acting drug
Benzodiazepine withdrawal syndrome sx
insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures
