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Year 3 Psychiatry > Anxiety Disorders > Flashcards

Anxiety Disorders Flashcards

1
Q
A
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2
Q

Which scale rates stressful events in life?

A

Holmes & Rahe scale

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3
Q

What types of response exist in relation to stressors?

A

Body responses = somatic responses

Emotional responses

Psychological responses

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4
Q

What are the typical somatic responses to stress?

A

Fight or flight responses

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5
Q

What is the difference between fear and anxiety?

A

Fear is experienced when real danger is present. Anxiety is a response to the threat of danger.

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6
Q

What are potential emotional responses to stress?

A

Fear
Anxiety
Depression

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7
Q

What are some psychological responses to stress?

A

Avoidance / denial
Problem solving
Acceptance

Alcohol / drug misuse
Aggression / exaggerated behaviour
Self-harm

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8
Q

What is an acute stress reaction?

A
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9
Q

What are the Sx of a typical acute stress reaction?

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10
Q

What are dissociative Sx?

A

Emotionally numb
Difficulty recounting event
Depersonalistion
Derealisation

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11
Q

What is the difference between depersonalisation and derealisation?

A

Depersonalisation = feeling unreal and detached, separated from people as thought by a pane of glass

Derealisation = similar to depersonalisation but separated from the environment

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12
Q

What is an adjustment disorder?

A
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13
Q

When is PTSD diagnosed?

A

If an acute stress reaction goes on longer than 1m - becomes a pathological disorder of PTSD.

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14
Q

What are the Sx of PTSD?

A
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15
Q

What is the usual course of PTSD?

A

30% recover within 3m
most within a year
30% - chronic course

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16
Q

What is an anxiety disorder known as if:
- Anxiety is continuous
- Anxiety is episodic and in specific situations
- Anxiety is episodic and in any situation

A

Generalised Anxiety Disorder

Phobia

Panic Disorder

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17
Q

What are the general Sx of anxiety disorders?

A

Psychological arousal
Autonomic arousal
Muscle tension
Hyperventilation
Sleep disturbance

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18
Q

How can psychological arousal of anxiety present?

A
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19
Q

What are autonomic Sx of anxiety?

A
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20
Q

How does muscle tension present in an anxious patient?

A

Tremor
Headaches
Aching muscles

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21
Q

How can hyperventilation present in a P?

A

Dizziness
Tingling hands and feet
Breathlessness

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22
Q

How is generalised anxiety disorder defined?

A

Symptoms of anxiety are persistent = there all the time and not restricted to specific circumstances. Sx are present >6m.

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23
Q

What are the clinical features of GAD?

A
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24
Q

What are the comorbidities common with GAD?

A

Depression
Phobia
Panic

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25
Q

What are the differentials for GAD?

A

Anxiety disorders
Depression
Schizophrenia
Dementia
Substance misuse
Physical illness

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26
Q

Who is more likely to develop GAD?

A

F (X2 than M)

Can happen at any age in adulthood

Can be ass with poverty, unemployment, divorce and separation

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27
Q

What is panic disorder?

A

Recurrent panic attacks - that are not in response to a phobic stimulus.

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28
Q

What are the Sx of a panic attack?

A

Sudden onset severe anxiety Sx
Usually lasts a few mins

Usually display hyperventilation -> reduced CO2 in blood = dizziness, tingling tinnitus, faintness, breathlessness

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29
Q

What is the aetiology of panic disorder?

A

Some heritability
Traumatic early life events
+ Precipitating new events

30
Q

What are the causes of specific phobias?

A

Genetics

Classical conditioning

Also - biological preparedness hypothesis

31
Q

What is social anxiety disorder?

A
32
Q

What are the symptoms of social anxiety disorder?

A
33
Q

What is agoraphobia?

A
34
Q

What is OCD?

A

Obsessional thinking -> compulsive behaviours

35
Q

What other psychiatric Sx can be seen in Ps with OCD?

A

Anxiety
Depression
Depersonalisation

36
Q

What are obsessions?

A

Intrusive, unwanted, usually unpleasant thoughts

37
Q

What are compulsions?

A

Repetitive, purposeful behaviours carried out in a stereotyped way in response to an obsession.

38
Q

Is there evidence that OCD has an inheritability factor?

A

Yes - some evidence that there could be a genetic susceptibility.

Also other theories

38
Q

Which part of the brain is responsible for the fear response?

A

The amygdala

39
Q

What are the key inputs to the amydala?

A

Hippocampus = relates fearful memories to present contexts

Sensory thalamus
Somato-sensory cortex
Anterior cingulate gyrus
- all input sensory information

40
Q

How does the amydala excite a stress response?

A

Activates SNS, flight or fight response and HPAA

41
Q

The amygdala activates the hypothalamus which leads to a cascade of hormones in the HPAA. Which hormone is released as a final product of this?

A

Cortisol

42
Q

What happens when the locus coeruleus is activated?

A

Noradrenaline is released = fight or flight response

43
Q

What do GABA receptors do?

A

They have an inhibitory effect in the brain when activated - reduce anxiety

44
Q

In stress and anxiety disorders - the locus coerelus is activated causing increased amounts of noradrenaline in the prefrontal cortex. What can this cause?

A

Impaired cognitive function

45
Q

Where do serotonergic neurons arise from?

A

The raphe nuclei

46
Q

How do serotonin and noradrenaline interact in the brain?

A

Oppose each other.

Therefore in anxiety disorders more NOR is associated - by increasing the amount of serotonin you can push the balance back.

47
Q

Do drugs that increase or decrease GABA activity decrease anxiety?

A

Drugs that increase GABA = decreased anxiety
- inc alcohol which partially increases GABA activity

48
Q

How have panic disorders been linked to GABA receptors?

A
49
Q

How does chronic stress affect the hippocampus?

A

Chronic activation by cortisol = increased Ca into neurons = inc cell death in the hipopcampus

Damaged hippocampus can’t feed back to inhibit cortisol production

50
Q

What is the general management for anxiety disorders for
- Mild
- Moderate
- Severe
anxiety?

A
51
Q

What does CBT focus on?

A

The maladaptive thinking and feelings that lead to unwanted behaviour.

52
Q

What is first line pharmacological Rx for anxiety disorder

A

SSRIs

53
Q

Why are outcomes for GAD treatment relatively poor?

A

Not diagnosed until at least 6m = therefore quite chronic Sx by time od diagnosis

Often comorbid with other anxiety disorders and depression

Tends to have chronic and fluctuating course

54
Q

How is panic disorder managed?

A

General principles of anxiety disorder Rx with specific psychoeducation and CBT regarding hyperventilation and panic attacks

55
Q

How are specific phobias managed?

A

CBT is tailored to the phobia - can use graded exposure

Little role for medications

56
Q

How is social anxiety disorder managed?

A

Ideally CBT tailored for social anxiety
Psychodynamic psychotherapy may help too
SSRIs may help

57
Q

How is OCD managed?

A

CBT - focussing on obsessions and compulsions

Meds = SSRIs
Poss also Clomipramine (TCA)

If no response - may consider adding antipsychotic

58
Q

How is PTSD managed?

A

General support <4w

Then CBT - specialist psychological therapy
Can think about using eye movement desensitisation therapy (EMDT)

Second line = antidepressants

Specialist - adding in antipsychotics

59
Q

A 25 year old man has been experiencing episodes where he feels extremely anxious and fearful for a few minutes, which then passes. During these episodes, he often experiences a feeling that his heart is racing and feels dizzy and faint. He sometimes feels so overwhelmed by this that he worries that he might actually die. He has had these episodes on and off for a long time, and they happen more at times when he feels that his life is stressful. Early on, medical causes were ruled out. In people experiencing this disorder, it has been demonstrated that there are fewer binding sites for one particular type of drug.

Which type of drug is this?

a) Antipsychotic
b) Benzodiazepine
c) Lithium
d) SSRI
e) SNRI

A

Correct answer: b) benzodiazepine

PET studies have demonstrated that there are fewer benzodiazepine binding sites in people with panic disorder than in healthy controls. One possible explanation is that people with panic disorder have a lack of GABA inhibitory control, which means that cortical and limbic regions do not adequately supress inappropriate fear responses. (NB: Benzodiazepines are indirect agonists of GABA).

60
Q

2) In situations of chronic stress, the hypothalamo-pituitary-adrenal axis is chronically activated, leading to elevated levels of cortisol. One particular area of the brain has a high density of glucocorticoid receptors and which are chronically activated by this as part of the feedback loop. This results in an influx of calcium and death of cells, with resulting atrophy.

Which area of the brain is this?

a) Amygdala
b) Basal ganglia
c) Hippocampus
d) Pituitary gland
e) Prefrontal corte

A

Correct answer: c) Hippocampus

61
Q

A 42 year old man was a driver in a motor vehicle accident 5 days ago that resulted in a fatality. He is struggling to sleep and feels anxious all of the time. He jumps when his partner opens the door and has been snapping at her. He does not want to go out and can’t enjoy spending time with his friends. He describes feeling numb and dazed.

Which condition is it most likely that he is experiencing?
a) Acute stress reaction
b) Adjustment disorder
c) Complex post traumatic stress disorder
d) Generalised anxiety disorder
e) Post traumatic stress disorder

A

Correct answer: a) Acute stress reaction. Events that may trigger and acute stress response include, but are not limited to, directly experiencing natural or human-made disasters, combat, serious accidents, torture, sexual violence, terrorism; assault, acute life-threatening illness (e.g., a heart attack); witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner; and learning about the sudden, unexpected or violent death of a loved one. It is associated with a range of symptoms including autonomic arousal, dissociative symptoms, restlessness, insomnia, poor concentration, anger, anxiety, low mood, social withdrawal.

This description is slightly different from the one in the McKnight textbook, which describes Acute Stress Disorder, as it appears in DSMV. ICD-11 does not classify Acute Stress Reaction as a disorder, but rather a response to a major stressor. At this point don’t worry about different ways of classifying/describing acute stress reactions, but recognise the general concept of a time-limited severe response to stress.

An acute stress reaction usually starts to subside a few days after exposure to the stressful event (or a month if it is ongoing, e.g. in conflict zone). If it continues for several weeks, PTSD will be considered, but this case would be too early for a diagnosis of PTSD to be considered.

Adjustment disorder is a response to a stressor that is not normally life-threatening (e.g. relationship or work problems) and is associated with a wide range of behavioural symptoms. It is out of proportion to the stressor and is a more gradual and prolonged response to stressful changes.

62
Q

There is evidence for the use of trauma focused cognitive behavioural therapy for people who are experiencing post traumatic stress disorder.

Which other type of psychological therapy for this condition has a strong enough evidence base to be recommended by NICE

A

Eye movement desensitisation and reprocessing (EMDR) therapy

Eye movement desensitisation and reprocessing therapy is an evidence-based psychological intervention for PTSD. The patient tracks the therapist’s finger back and forth with their eyes, which induces saccadic eye movements. During this process, the patient is asked to recall the traumatic event. The theory behind this (in short) is that the brain handles traumatic memories differently to other memories and does not process them – the memories become “stuck” and remain vivid; EMDR enables processing of these memories.

63
Q

A 25 year old former soldier is living with mental illness. He relives the experiences of the loss of his friends in combat as though he were there. His sleep is poor and he avoids any interactions with or reminders of those experiences. He never sits with his back to the door and often startles at minor noises. He has had medication and psychological therapy as treatment but continues to experience difficulties. He finds it very difficult to make new friends or to interact with people at all; his relationship with his partner has broken down. He often flies off the handle at work over quite minor things, and lost his gardening job after shouting at a customer who asked if he minded that they didn’t have sugar for his tea. He ruminates over how he could have done things differently and how he let his friends down, referring to himself as “pointless” and “worthless”. He has been drinking heavily and taking risks when driving, including driving when he has been drinking and driving at over 100mph on the motorway.

Which features described are suggestive of complex PTSD rather than PTSD? (select all that apply)

a) Difficulties in sustaining relationships
b) Marked avoidance behaviours
c) Reliving the stressful event
d) Persistent thoughts of being worthless and having let others down
e) Severe problems with affect regulation

A

Correct answers: a, d, e

b and c describe symptoms of PTSD. a, d and e refer to additional symptoms seen in complex PTSD

PTSD is characterised by 1) A response to an extremely threatening or horrific event or series of events; 2) Re-experiencing of the event (flashbacks, vivid intrusive memories, nightmares); 3) Dissociative symptoms; 4) Avoidance of anything that triggers a memory of the traumatic event; 5) Persistent perception of a heightened level of threat – e.g. hypervigilance to threat (e.g. always checking rear-view mirror, never sitting with back to door), enhanced startle reaction (jumping at minor noise).

ICD-11 has added the diagnostic category of complex PTSD. Complex PTSD is characterised by the clinical features of PTSD as well as three other key features
i. Severe and pervasive problems with affect regulation – violent outbursts, marked over-reactions to minor stressors, inability to experience pleasure or positive emotions. In this case – shouting about not having sugar, reckless behaviour in the form of driving
ii. Persistent beliefs about the self as diminished, defeated or worthless
iii. Persistent difficulties in sustaining relationships and feeling close to others

64
Q

A 28 year old PhD student is struggling to keep up with their studies and research because they are very anxious about presenting their work to others, including to their own lab team or at conferences. They often feel shaky and sweaty whenever faced with this situation, and worry that their colleagues will see this and think badly of them. They avoid having lunch with their team because they feel uncomfortable eating in front of other people – it makes them feel like they are being scrutinised. They also worry about saying the wrong thing, and play conversations with other people over and over in their minds afterwards. They have always had a bit of an “anxious personality” but these symptoms are relatively new and have been worsening for about 6 months.

Which other physical symptom is most often associated with this disorder?
a) Blurred vision
b) Blushing
c) Motor tics
d) Paraesthesia
e) Parasympathetic response leading to syncope

A

Correct answer: b) blushing

The symptoms described are those of social anxiety disorder, and blushing is commonly associated with this. People experiencing social anxiety disorder may express concern about the physical symptoms that they experience (sweating, trembling, blushing) rather than acknowledging their fears of being thought of in a negative way than others.

65
Q

A man sitting in a lecture feels a frequent and unwanted impulse to shout at the lecturer and call them a “***** idiot”. He finds this really uncomfortable and tries to push it out of his mind – he really respects this lecturer. He does not think anyone or anything else is making him think this, but feels like it is intruding into his mind. It has happened many times before but he has never said a word to a lecturer.

Which specific type of symptom has been described?
a) Compulsion
b) Delusion
c) Hallucination
d) Obsession
e) Formal thought disorder

A

Correct answer: d) Obsession

Obsessions are repetitive and persistent thoughts (e.g., of contamination), images (e.g., of violent scenes), or impulses/urges (e.g., to stab someone) that are experienced as intrusive and unwanted, and are commonly associated with anxiety. In OCD, the individual typically attempts to ignore or suppress obsessions or to neutralize them by performing compulsions. (ICD-11)

Compulsions are repetitive behaviours or rituals, including repetitive mental acts, that the individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of ‘completeness’. Examples of overt behaviours include repetitive washing, checking, and ordering of objects. Examples of analogous mental acts include mentally repeating specific phrases in order to prevent negative outcomes, reviewing a memory to make sure that one has caused no harm, and mentally counting objects. Compulsions are either not connected in a realistic way to the feared event (e.g., arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (e.g., showering daily for hours to prevent illness). (ICD-11)

The symptoms described are not a delusion – a delusion is belief that is very strongly held despite clear evidence that it is incorrect. A hallucination is a perception in the absence of a stimulus – e.g. hearing a voice or seeing a person that is not there. Formal thought disorder refers to abnormalities in the form of thought, e.g. flight of ideas, knight’s move thinking.

66
Q

A man has a phobia of flying which is preventing him from travelling for his job. He decides to seek help for this.

What is the most appropriate treatment plan?

a) Behavioural therapy based on graded exposure
b) CBT based on cognitive reframing of negative automatic thoughts
c) CBT based on exposure and response prevention
d) Prescription of an SSRI for at least 6 months
e) Prescription of a supply of diazepam 5mg to use for each flight

A

Correct answer: a) behavioural therapy based on graded exposure.

Graded exposure (a type of behavioural therapy) involves the person being gradually exposed to increasingly close encounters with the thing that they are phobic of (the phobic stimulus). This could start with visualising it in their mind, then seeing a picture, looking at a real plane, getting on a plane on the ground etc.

There is little role for medication in the management of specific phobia and no evidence for use of SSRIs. Benzodiazepines may be prescribed in the short term to allow the person in this scenario to travel but this is not generally helpful in the long term, and it’s preferable to try psychological therapy.

67
Q

A 38 year old woman is has been experiencing anxiety for several years now, and it has been getting worse over time. She feels on edge and tense pretty much all of the time, and often gets headaches and non-specific abdominal symptoms. She worries about all aspects of her life, and the worry moves from her partner’s job to the health of her children to their financial circumstances. She struggles with sleep and gave up work because it was hard to concentrate and she was anxious about making mistakes. She has had 1:1 psychological therapy and trials of several antidepressant medications.

Which anticonvulsant medication might be prescribed in these circumstances?

a) Carbamazepine
b) Gabapentin
c) Lamotrigine
d) Pregabalin
e) Sodium valproate

A

Correct answer: d) pregabalin

The symptoms described are those of generalised anxiety disorders. As always in anxiety disorders there is a step-wise approach to management that starts with psychosocial approaches and self-help and escalates through more intense types of psychological therapy and use of medications. Pregabalin is sometimes used in generalised anxiety disorder where other medications have not been effective (this is covered in a bit more detail in the tutorial).

68
Q

You are a year 5 medical student on your final year GP placement. You go with the GP to visit a patient who does not come to the surgery because of long-standing agoraphobia.

What is/are the key feature(s) of situations that are avoided by people living with this condition?

a) Crowds are present, indoors or outdoors
b) Small/confined spaces
c) Large and open spaces which are overwhelming
d) Escape or help may not be available
e) Far from home

A

Correct answer: d) escape or access to help may not be possible

The other options are also often avoided by people with agoraphobia, but the unifying feature is difficulty in escaping or the possibility that help might not be available. This may lead to people not wanting to go far from home, or only going out with a trusted supporter. Agoraphobia is a complex disorder and often co-exists with other disorders, notably panic and depression.

ICD-11 description of key diagnostic criteria for agoraphobia:
- Marked and excessive fear or anxiety that occurs in, or in anticipation of, multiple situations where escape might be difficult or help might not be available, such as using public transportation, being in crowds, being outside the home alone, in shops, theatres, or standing in line.
- The individual is consistently fearful or anxious about these situations due to a fear of specific negative outcomes such as panic attacks, symptoms of panic, or other incapacitating (e.g., falling) or embarrassing physical symptoms (e.g., incontinence).
- The situations are actively avoided, are entered only under specific circumstances (e.g., in the presence of a companion), or else are endured with intense fear or anxiety.

69
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A

Year 3 Psychiatry (11 decks)

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