Stress Disorders Flashcards
What do stress reaction anxiety disorders have in common with their aetiology and signs/symptoms?
Includes GAD, phobias, panic disorder and OCD
Biological factors = genetics, neurochemical factors such as dysregulated serotonin/NA/GABA transmission
Psychosocial factors = early or life experiences (threatening events), behavioural/cognitive thinking (NATs, attachment theory, conditioning)
Common symptoms:
- > Autonomic arousal - dry mouth, palpitations, tremor, tight chest and dyspnoea
- > Worries and insomnia, night terrors
- > Urinary frequency
- > restlessness
How would you generally want to investigate anxiety/stress disorders?
Tip: ‘anxious people want to be SEDATED’
-> Hx and exam (and find out effect on social/occupational hx and QoL)
S - symptoms of anxiety (physical and psychological)
E - episodic or continuous
D - drink and drugs
A - avoidance and escape
T - timing and triggers
E - effect on life
D - depression screen (low mood, anergia, anhedonia)
- > Rating scales - HADS, GAD-7, Beck Anxiety inventory
- > Collateral history
- > Bloods if suspect organic cause (TFTs etc)
What is GAD and how is it defined?
What are some risk and protective factors for it?
GAD = at least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk and causes distress or impairment
Worry is not due to mental disorder, substance abuse or other condition
-> At least 6m Hx
-> At least 3 of the following Sx for most of the time:
- Restlessness/nervousness
- Irritability
- Easily fatigued
- Poor concentration
- Muscle tension
- Sleep disturbance
RFs = divorced, lone parent, living alone, 35-54yo Protective = 16-24, married, cohabiting
How may patients with GAD present?
Sx:
Autonomic = palpitations, sweating, trembling, dry mouth, tachypnoea
Chest/abdomen = dyspnoea, chest pain, nausea, choking sensation
- Neuro = Dizziness, light head, fear of losing control, fear of dying/illness
- General - numbness/tingling, muscle tension, restlessness, lump in throat, difficulty concentrating + sleeping, irritability, avoidance of triggers and using alcohol or drugs to help
How would you Ix a patient with suspected GAD?
Ix:
- Full Hx and exam (SEDATED qs)
- GAD-7 questionnaire where 5 = mild, 10 = moderate and 15 is severe GAD
- Becks anxiety inventory
- Hospital anxiety and depression scale (HADS)
How would you manage GAD?
Biopsychosocial approach and stepwise based on severity
- Written information on GAD + active monitoring + regular exercise
- Low intensity psychological interventions such as
- 6w individual, non-guided self help
- 6w individual, guided self help w weekly therapist appointment
- 6w psychoeducational groups with =12 people - High intensity psychological interventions such as
- CBT (12-15w, 16-20h/week) looking into errors of thinking and testing worry with behavioural experiments)
- Applied relaxation (12-15w)
OR
Medications in a stepwise approach
- > 1st = SSRI (sertraline, or paroxetine) - weekly follow up due to risk of suicide ideation initially
- > IF not working after 8w, switch SSRI or switch to SNRI such as venlafaxine - weekly follow up due to risk of suicide ideation initially
- > Then try Pregabalin (anti-epileptic)
- > Then, Quetiapine
- > ADJUNCT: Propanolol (if many phsyical symptoms)
note: never give BDZ to people with anxiety
What phobias are particularly important in psychiatry? What should you NOT use to treat them?
Seriousness of a phobia is related to the level of disability - therefore social and agoraphobia have the biggest impact on life
- > NEVER use BDZ as high risk of dependence but short term use is ok in specific phobias
- > Specific phobias don’t respond well to antidepressants but most don’t require treatment as avoidance is better
What is agoraphobia? Who is usually affected and how may they present?
ICD10 - cluster of phobias embracing the fears of leaving home, entering shops, crowds and public places or travelling alone
- > Classified with or without a panic disorder
- > 20-35yo onset, gradual or precipitated by a panic attack
- > F»_space; M
Sx:
- > Panic attacks
- > Avoidance of phobic situations +/- isolation behaviour
- > May be associated with depressive/obsessional symptoms, social phobias
How would you manage agoraphobia? How does ERP work?
Mx:
-> Education, reassurance and self-help
-> Exposure response prevention (ERP) therapy
= without actual harm, the body can only remain extremely anxious for <45m, after which habituation occurs, anxiety levels drop, and eventual fear dies out (extinction) –> therefore the therapy aims to desensititse and challenge existing thoughts
-> CBT - reduce patients expectation of threat and the behaviour that maintain threat related beliefs, improve self confidence, test feared situations
What is social phobia? Who does it affect and what are some associations?
ICD10: fear scrutiny by other people leading to avoidance of social situations
- associated with low self esteem and fear of criticism
- M = F (only anxiety disorder to affect equally)
How may social phobia present?
Sx:
- Complains of blushing, hard tremor, nausea or urinary urgency in social situations
- Self medicate with alcohol or drugs to desensitise
- Panic attacks
NB - will tolerate anonymous crowds but unlike agoraphobics, smaller groups may spike anxiety
How can you manage social phobia?
Mx:
- > Education, reassurance and self help
- > Exposure response prevention (ERP)
- > CBT
- > SSRIs
What are specific phobias defined as? How may they present?
ICD10 - phobias restricted to highly specific situations such as proximity to slugs or snails
Sx:
- > Contact can evoke panic such as screaming/locking self away
- > May have a FH of phobia (-ve reinforcement)
- > Most phobias lead to tachycardia but blood/injury phobia may cause intial tachycardia followed by vasovagal bradycardia and hypotension –> nausea and fainting
How would you manage specific phobias?
Mx:
- Education, reassurance and self help
- ERP (flooding - exposing someone to maximal fear until it becomes extinct)
- Relaxation therapy and breathing techniques
- Short term BDZ for some certain phobias such as dental injections but never long term
What is panic disorder?
ICD10 - recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
- > Several within a month
- > Relatively fine with minimal anxiety in-between episodes
- > Panic disorder should not be a main diagnosis if a depressive disorder exists at the same time the attacks start
