1- Mental health conditions (Anxiety disorders 1/2)

Question 1

define neuroses

Answer 1

Is a collective term for psychiatric disorders characterized by distress, that are non-organic, have a discrete onset and where delusions and hallucinations are absent.
- Functional and not an organic illness
- Not psychotic
o Patients are distressed, but no delusions
- Synonymous with anxiety disorders

Question 2

classification of neuroses

Answer 2

• Paroxysmal or episodic anxiety
• Continuous or generalised anxiety

Question 3

Common symptoms of neuroses

Answer 3

Question 4

clinical features of neuroses

Answer 4

Clinical features
- Common symptoms (see above)
- Associated cognitions inc worries or fears that are inappropriate or excessive
- Associated behaviour inc avoidance or escape from the situation that causes anxiety
- Depressive symptoms

Question 5

Conditions associated with anxiety

Answer 5

Question 6

anxiety

Answer 6

• Anxiety is an unpleasant emotional state involving subjective fear and somatic symptoms.
• Every human experiences anxiety, but if these anxieties become excessive or inappropriate they are described as an illness.

Question 7

The Yerkes–Dodson law

Answer 7

states that anxiety
can actually be beneficial up to a plateau of
optimal functioning. Beyond this level of
anxiety however, performance deteriorates

Question 8

The most common anxiety disorders, in order of prevalence are:

Answer 8

o Specific phobia
o Social phobia
o Generalized anxiety disorder
o Agoraphobia
o Panic disorder
o OCD

Question 9

Anxiety disorders can be split into

Answer 9

• Specific phobias
• GAD and panic disorders

Question 10

aetiology of anxiety

Answer 10

• Positive / re-entry feedback loops
• Trait anxiety: a stable characteristic arising from a multitude of genetic and environmental factors, particularly adaptive responses to experiences of potential threat during development
• State anxiety simply the state of feeling anxious. This is not rocket science (we’re all familiar with the experience of anxiety), but like any illness, the disorder is identified when these symptoms become severe and persistent enough to cause significant distress and functional impairment.

Question 11

langs three system model

Answer 11

basis of many CBD models

Question 12

Padeskys anxiety equation

Answer 12

Question 13

Neurotic and stress-related disorders (ICD-10 classification) are split into:

Answer 13

Split into:
Phobic anxiety disorders
o Specific phobia
o Agoraphobia
o Social phobia

Other anxiety disorders:
o Panic disorder,
o Generalised anxiety disorders
o Mixed anxiety
o Depressive disorder

Obsessive-compulsive disorder: predominantly obsessional thoughts, predominantly compulsive thoughts, mixed

Reaction to severe stress and adjustment disorders
o Acute stress reaction
o Post-traumatic stress disorder
o Adjustment disorder

Question 14

define GAD

Answer 14

Generalized anxiety disorder (GAD) is a syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the patient recognizes as excessive and inappropriate. Symptoms must be present on most days for at least 6 months duration

Question 15

Type 1 vs Type 2 GAD

Answer 15

• Type 1- specific content of worries change/ varies
• Type 2- worries about worries

Often maintained by the belief that worry is useful e.g. it motivates

Question 16

prevalence of GAD

Answer 16

o GAD has a prevalence of 2–4% in the general population.
o It is more common in F at a ratio of 2:1.

Question 17

risk factors for GAD

Answer 17

Question 18

Causes of GAD

Answer 18

biospychosocial

Question 19

Difference between GAD and stress

Answer 19

Stress is typically caused by an external trigger
- Trigger can be short term, such as a work deadline or a fight with love one
- Can experience mental and physical symptoms
 Irritability
 Anger
 Fatigue
 Muscle pain
 Difficulty sleeping

Anxiety is defined as persistent, excessive worries that don’t go away even in the absence of a stressor
- Can lead to identical set of symptoms as stress

Question 20

Differential diagnosis for GAD

Answer 20

• Other neurotic disorders: panic disorders, specific phobias, OCD, PTSD
• Depression
• Schizophrenia
• personality disorder
• Excess caffeine or alcohol
• Withdrawal from drugs

Organic
o Anaemia
o Hyperthyroid
o Phaeochromocytoma
o Hypoglycaemia

Question 21

presentation of GAD

Answer 21

Symptoms concerning chest and abdomen
 Difficulty breathing
 Feeling of choking
 Chest pain or discomfort
 Nausea
 Abdominal distress or pain
 Loose motions.

Symptoms concerning the brain and mind
 Feeling dizzy or light headed
 Fear of dying
 Fear of losing control
 Derealization and depersonalization.

General symptoms
 Hot flushes or cold chills
􏰀 Numbness or tingling
 Headache.

Symptoms of tension
 Muscle tension, aches or pains
􏰀 Restlessness
 Feeling on edge
 Difficulty swallowing
 Sensation of lump in throat.

Non-specific symptoms
 Being startled
 Concentration difficulty and mind blanks
 Persistent irritability
 Sleep problems.

Question 22

Diagnosis/investigations for GAD

Answer 22

1) Screening tool e.g. GAD 2/7
2) Full history / ICD-10
3) MSE
4) Physical exam
5) Investigations

Question 23

GAD-2/7

Answer 23

Question 24

MSE for GAD

Answer 24

Question 25

ICD-10 for GAD

Answer 25

Question 26

general management of GAD

Answer 26

**Psychological therapies** address the problem (for instance by helping the patient to break some of the positive feedback loops described above), and medications reduce the intensity of state anxiety to better enable the person to engage with psychology. **Psychological treatment** most important - Often both approaches are essential. - Treatment is effective but takes time and significant effort because the patient is required to go against their innate self-protective impulses (such as avoidance). **General management** - Self help methods - Exercise - Support groups

Question 27

stepwise approach to anxiety

Answer 27

The stepwise treatment algorithm, depending on severity, is as follows:18 1. **Psychoeducation, sleep hygiene, and self-guided cognitive-based therapy (CBT) relaxation techniques:** it may be helpful to acknowledge that these can appear basic/low intensity, but emphasise their evidenced effectiveness for mild/moderate anxiety if done regularly. **2. CBT:** identifying then gradually unlearning the maladaptive patterns of thought/behaviour which are perpetuating symptoms. A CBT practitioner may employ techniques such as exposure therapy (allows extinction of erroneously learned fears) and applied relaxation. **3. Pharmacological**(equal 1st line with CBT). SSRI (e.g. escitalopram or sertraline), SNRI (e.g. duloxetine or venlafaxine) or atypical antidepressant (e.g. Mirtazapine) with the choice depending on side-effect profile. o Pre-gabalin (addictive) o Buspirone (seratonergic) o Benzodiazepines (tranquilisers) o B blockers for symptoms

Question 28

DO NOT GIVE BENZODIAZEPINES FOR MORE THAN

Answer 28

4 WEEKS

Question 29

Anxiety (GAD) history taking

Answer 29

Question 30

define phobia

Answer 30

is an intense, irrational fear of an object, situation, place or person that is recognized as excessive (out of proportion to the threat) or unreasonable.

Question 31

types of phobia

Answer 31

1) Agoraphobia 2) Social phobia 3) Specific phobia

Question 32

prevalence of phobias

Answer 32

specific phobias most common

Question 33

phobia pathophysiology and risk factors

Answer 33

* **Biological**: Tachycardia is the usual autonomic response, however in phobias of blood, injection and injury, a vasovagal response (bradycardia) is produced, commonly leading to fainting (syncope). For a complete list of biological symptoms see GAD, Section 5.2. * **Psychological**: Include unpleasant anticipatory anxiety, inability to relax, urge to avoid the feared situation and, at extremes, a fear of dying. * **Agoraphobia** is strongly linked to panic disorder. Indeed the ICD-10 divides agoraphobia into: agoraphobia with panic disorder and agoraphobia without panic disorder.

Question 34

define agoraphobia

Answer 34

Agoraphobia literally means a ‘fear of the marketplace’. It is a fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack.

Question 35

Pathophysiology of agoraphobia

Answer 35

Maintained by avoidance which prevents deconditioning and sets up a vicious cycle of anxiety.

Question 36

management of agoraphobia

Answer 36

- CBT with graduated exposure - SSRIs

Question 37

graduated exposure therapy

Answer 37

Graduated exposure is the process of exposing the patient slowly and methodically to more and more raw aspects of those experiences.

Question 38

social phobia def

Answer 38

A fear of social situations which may lead to humiliation, criticism or embarrassment- lies a fear of negative evaluation by others

Question 39

pathophysiology of social phobia (social anxiety disorder)

Answer 39

Uncertain aetiology. Usually begins in late adolescence, an age at which people are concerned about the impression they make on others.

Question 40

presentation of social phobia

Answer 40

- Can lead to avoidance of feared situation (counter-productive, use of safety behaviours, anticipatory anxiety, and unhelpful ‘post mortems’ following social encounters

Question 41

management of social phobia

Answer 41

- CBT with graduated exposure to feared situations e.g. to feared situations - Pharmacological intervention e.g. SSRIs (escitalopram or sertraline), SNRIs (venlafaxine) or if no response to these, a MAOI (moclobemide)

Question 42

specific phobia def

Answer 42

A fear restricted to a specific object or situation (excluding agoraphobia and social phobia).

Question 43

speciifc phobias pathophysiology

Answer 43

Conditioning event in early life, i.e. a frightening experience. Possibly a role for learned behaviour, e.g. from parents

Question 44

management of specific phobias

Answer 44

- Exposure therapy either using self-help methods or through CBT - Benzodiazepines for short erm e.g. if a patient needs a CT scan and they are claustrophobic

Question 45

diagnosis/investigations of phobias

Answer 45

1) history 2) ICD-10 criteria 3) MSE 4) Risk assessment 5) Investigations

Question 46

history taking for phobia

Answer 46

* ‘What situations cause you anxiety or embarrassment?’ (specific phobia) * ‘Do you get symptoms in situations from which escape would be difficult?’, ‘Do you get symptoms in places or situations where help may not be available?’, ‘Do you get symptoms while being in a crowd or travelling on public transport?’ (agoraphobia) * ‘Do you ever worry about what people think of you? Does this worry ever lead to you avoiding certain situations?’ (social phobia) * ‘Do you avoid any situation because you know you will feel panicky?’ (anticipatory anxiety)

Question 47

ICD criteria for phobias

Answer 47

Question 48

MSE for phobias

Answer 48

Question 49

risk assessment for phobias

Answer 49

suicie and self harm

Question 50

investigations for phobias

Answer 50

- Questionnaires e.g. social phobia inventory and Liebowitz social anxiety scale

Question 51

Panic disorders characterised by

Answer 51

recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.

Question 52

panic disorders prevalence

Answer 52

- 1% - More common in women - Onset most common in late adolescence

Question 53

pathophysiology and risk factors of panic disorders

Answer 53

**Biological** o Genetics – very heritable o Neurochemical- post synaptic hypersensitivity to serotonin and adrenaline o Sympathetic nervous system- fear or worry stimulates the NS -> increased cardiac output which can lead to further anxiety **Cognitive** o Misinterpretation of somatic symptoms (e.g.. feat that palpitations will lead to a heart attack) **Environmental** o Presence of life stressors can lead to panic disorder

Question 54

panic disorder presentation

Answer 54

Presentation Panic symptoms usually peak within 10 minutes and rarely persist beyond an hour. * Shortness of breath * Chest pain * Excessive sweating * Palpitations or tachycardia * Dizziness or feeling faint * Trembling or shaking * Intense feeling of terror * Nausea * Tingling or numbness in fingers or toes * Derealisation/depersonalisation * Dry mouth * Chills or hot flashes * Visual disturbances * Fear of dying * Fear of losing control or impending doom

Question 55

diagnosis/investigations for panic disroders

Answer 55

1) History 2) ICD-10 3) MSE 4) investigations

Question 56

history for panic disorders

Answer 56

o ‘Are you generally anxious or are there periods where you are anxiety-free?’ (episodic) o ‘Can you predict when these attacks will come on?’ (unpredictable) o ‘Have you ever been so frightened that you felt your heart was pounding and that you might die?’ (intense fear and anxiety) o ‘Are you worried about your health or any other specific things?’ (major life stressors)

Question 57

ICD-10 panic disoders

Answer 57

Question 58

MSE for panic disorders

Answer 58

- MSE- same as GAD, may be more intense e.g. hyperventilation and restlessness | - MSE- same as GAD, may be more intense e.g. hyperventilation and restle

Question 59

investigations for panic disorders

Answer 59

o Bloods: FBC (infection, anaemia), FTFs (hyperthyroidism), glucose (hypoglycaemia) o ECG: may show sinus tachycardia o Questionnaires: GAD-2, GAD-7, Becks anxiety inventory, hospital anxiety and depression scale