Anxiety Disorders

Question 1

Classify 5 common anxiety disorders according to DSM-5

Answer 1

1. The anxiety disorders
   Generalized anxiety disorder
   Panic disorder
   Phobia
2. The Obsessive-compulsive disorders
   Obsessive Compulsive Dxso
3. The Traumatic and Stressor related dxso
   PTSD

Question 2

General anxiety disorder

Answer 2

Persistent, prominent and exaggerated worry/ tension apprehension about everyday events and problems
Feeling on edge most of the time
Muscle tension/aches
Restlessness/irritability
Difficulty concentrating/mind going blank

Question 3

CF Panic dxso

Answer 3

Acute onset of severe anxiety with no obvious trigger(out of the blue)
Reach a peak over the next few seconds/mins the subsides over few minutes.
Prominent autonomic symptoms
Fear of dying
Anticipatory anxiety

Question 4

Clinical features/Stages of phobias

Answer 4

Acute episodes of anxiety that are precipitated by exposure to specific triggered
Escape: pt escape from triggers to reduce the duration of anxiety
Avoidance: pt avoids exposing oneself to trigger
Symptoms similar to panic

Question 5

Types of phobias

Answer 5

Simple phobias
Agoraphobia
Social phobia

Question 6

Simple/specific/isolated phobias

Answer 6

Spiders/dogs
It
Enclosed spaces/lifts
Flying
Needles
Blood
Hospitals
Choking

Question 7

Agoraphobia

Answer 7

Crowds
Public places
Leaving home
Traveling alone

Question 8

Social anxiety disorder (Social Phobias)

Answer 8

Fear of being the focus of attention
Fear of behaving in an embarrassing way
Avoidance of social situations
Pt unhappy, acknowledges that fear is excessive and unnecessary

Question 9

CF of OCD

Answer 9

It’s xteris by obsession and compulsion

Question 10

What is obsession

Answer 10

Obsession
Recurrent intrusive unignorable distressing thought impulse or image arising from the subject mind and recognized as such.

Contamination, safety, illness, sex, violence, religion, doubt

Question 11

What is compulsion

Answer 11

Compulsion
A receptive, irresistibly, time-consuming behavioral ritual that is performed as an attempt to neutralize the anxiety induced by the obsession despite the pt being aware that the ritual is unnecessary

Question 12

Social signs of OCD

Answer 12

Inability to break routine
Need to check the same thing over and over again
The constant need for reassurance
Intense anxiety when things are not orderly or symmetrical
Fear of shaking hands or touching things in public
Raw hands from too much hand washing
Having trouble getting to work on time of keeping to a schedule due to rituals
At least an hour daily on unwanted thoughts or rituals
Counting for no reason, repeating same words phrase or action
Avoidance of certain situations that trigger the obsessive thoughts

Question 13

CF of PTSD

Answer 13

After an exceptionally threatening catastrophic event
Pt relieves that trauma in the form of flashbacks while awake and nightmares while asleep
Avoids places conversations people asso with the trauma
Hypervigilant
Easily startled
Others: Emotional numbing, insomnia, irritability, poor concentration, misuse of alcohol/drug, despensation/derealization

Question 14

Diagnostic criteria and duration

Answer 14

GAD: ICD10 - At least 6 months
DSM-5 At least 6 month
Panic dxs: ICD-10 At least 4 attacks within a 4 week period
DSM-5 at least 1 month of impairment
Phobias: DSM 5: at least 6 months
OCD: At least 2 weeks
PTSD: Not specified but within 6 months of trauma

Question 15

Atielogy of anxiety dxso

Answer 15

Neurotransmitters: COMT, 5-HTT, CRF
Amygdala - the insula, anterior cingulate cortex
Hormonal factors

Question 16

Assessment of Anxiety Dxso

Answer 16

1. Hxs, rule out hyperthyroidism
2. Psychiatric assessment; Rule out schizophrenia, BPSD, Delirium tremens of alcohol withdrawal, unipolar, bipolar
3. Routine blood test (CBC, LFT, U&E, IFT, Glucose) ECG
4. Neuroimaging, EEG, Psychometric testing

Question 17

Differential

Answer 17

1. Substance Abuse cocaine amphetamine
2. Cardiac causes: atypical MI, supra ventricular tachycardia,
3. Hypoglycemia
4. Phaecochromocytoma
5. Neurological: Atypical seizures,

Question 18

Rating scales for anxiety disorders

Answer 18

GAD- HAM-A
Panic Disorder - PDSS, PAS
Phobias - Liebowitz social anxiety scale, SPIN
OCD- Y-Bocs, MOCI
PTSD - IES-R, CAPS

Question 19

CBT for GAD

Answer 19

Cognitive behavior therapy is the tx of choice
Education
Self Monitoring
Relaxation, training: progressive muscular relaxation, relaxation, breathing exercises, meditation.
Cognitive restructuring: help pt make more realistic estimations of likelihood of danger and ones ability to cope

Question 20

CBT for Panic Disorders and Phobias

Answer 20

Help pt.
1. Make more realistic appraisal of the anxiety
2. Educating the pt that anxiety will not last forever and will not kill
3. Avoiding the anxiety -short term, long term avoidance perpetuates the problem.
4. Facing the anxiety may worsedn short term but in die course will help overcome

Question 21

Behavioral strategies for panic disorder

Answer 21

Familiarize pt with symptoms to help pt realize it’s not ominous sign

Question 22

CBT for phobias

Answer 22

Graded exposure
Response prevention
Systematic desensitization
Extinction

Question 23

CBT for OCD

Answer 23

Exposure and response prevention: I.e Facing the anxiety without performing their habitual compulsive rituals.
Done gradually

Question 24

CBT FOR PTSD

Answer 24

Education about nature and impact of trauma
Relaxation training
Identifying and correcting cognitive distortion
Discussion of the trauma
Exposure to trauma reminders where necessary and appropriate

Question 25

Other options for anxiety disorders

Answer 25

Self-help books : bibliography gives simple practical steps
Online CBT
Support Group
Exercise therapy
Yoga
Meditation

Question 26

Pharmacological tx of anxiety dxso

Answer 26

SSRI for long-term and maintenance
Benzodiazepines for immediate, short-term symptomatic Rx.

For all except simple phobias an SSRI Fluoxetine escitalopram is the first line

For GAD consider venlafaxine, duloxetine, mirtazapine, buspirone, and pregabalin

For OCD consider: Clomipramine(sereotgenic TCA)

Not >2 weeks

B-blockers d sympathetic symptoms of anxiety - tachycardia and tremors

Tx resistant OCD: SSRI + low dose antipsychotic(haloperidol, risperidone)

Question 27

General Prognosis of anxiety disorders

Answer 27

Unlikely to remit spontaneously without Tx
Best prognosis - simple phobias
Remission of 50% within 3 years
1:3 likely to relapse

Question 28

Factors associated with poor prognosis

Answer 28

Earlier onset
Long delay before seeking treatment/chronicity
Severity
Co-morbidity (alcohol/substance misuse, depression, personality disorder)
Previous unsuccessful treatment
Noncompliance with medication/lack of motivation in CBT
Ongoing social issues (isolation/unemployment), relationship
Overall, there is an increase in suicidal ideation and attempts in patients with Anxiety Disorders