Anxiety and obsessional disorders (neurotic, stress-related and somatoform disorders ICD-10)

Question 1

what are the features of neurosis?

Answer 1

this is generally synonymous with anxiety disorders
it refers to a functional illness in which the patient retains normal judgement of reality, so no psychotic symptoms, but patients are distressed.

Question 2

define normal anxiety

Answer 2

feelings of apprehension in response to threatening situations. Our flight or fight response is activated as a means of protection. This becomes abnormal if the apprehension and fear is out of proportion to the threat, and/or is prolonged, or occurs in the absence of a threat.

Question 3

what is the 1 difference in symptoms between normal anxiety and abnormal anxiety- a disorder?

Answer 3

when normal anxiety, the pt focuses their attention on the threat, but in abnormal anxiety, the focus is on the physiological response itself e.g. rapid HR, and is accompanied by concern about the cause of that symptom e.g. HD for a rapid HR, and may also worry that others are aware of the symptom and will think it strange. The concerns are themselves threatening, so increase anxiety, hence autonomic arousal to bring about further concern, and a vicious cycle of increasing anxiety.

Question 4

how are anxiety disorders classified?

Answer 4

based on frequency of symptoms, continuous=generalised anxiety disorder (GAD), episodic= phobic-occurring in part. situation, or panic=can occur in any situation.
phobic=simple phobia, social phobia and agoraphobia.
can be mixed- pts have both episodes of anxiety in part. situations, and random episodes=agoraphobia with panic.

Question 5

how is GAD diagnosed?

Answer 5

symptoms of anxiety have been present for several mnths, 6mnths in DSM-IV. if present for shorter time, diagnosis is stress or adjustment disorder.
diagnostic criteria DSM-IV: excessive anxiety and worry, occurring more days than not for at least 6mnths, about a number of ordinary events or activities.
person has difficulty controlling the worry
anxiety and worry assoc. with 3 or more of the following:
restlessness or feeling keyed up or on the edge
being easily fatigued
irritability
muscle tension
difficulty falling or staying asleep, or restless unsatisfying sleep
difficulty concentrating or mind going blank

symptoms can also include nausea, vomiting, chronic stomach aches.
the anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
disturbance not due to direct physiological effects of a substance or general med condition, and does not occur exclusively during a mood disorder, psychotic disorder, or a pervasive developmental disorder.

Question 6

how might an anxious patient appear?

Answer 6

concerned
restless
shaky
sweaty
fidgety, may twiddle fingers, scratch arms
tearfulness-reflects generally apprehensive state

Question 7

psychological symptoms of GAD?

Answer 7

fearful anticipation
irritability
sensitivity to noise
restlessness
poor concentration
depression
obsessions
depersonalization

Question 8

physical symptoms of GAD?

Answer 8

CVS: palpitations, chest discomfort, awareness of missed beats
GI: diarrhoea, epigastric discomfort, excessive wind- due to air swallowing
Resp: overbreathing, difficulty inhaling, chest constriction
GU: amenorrhoea, menstrual discomfort, frequent or urgent micturition, erection failure
NM: tremor, prickling sensations, tinnitus, dizziness-unsteady, bilateral headache, aching muscles-espec. back and shoulder
sleep:insomnia, night terrors.

Question 9

how can GAD be differentiated from depressive disorder with anxiety?

Answer 9

depressive disorder-symptoms of low mood, lack of energy and anhedonia which are more severe than the anxiety symptoms and appeared 1st, also other features if depressive disorder e.g. weight loss, appetite loss, early morning wakening, libido loss, feeling of guilt and shame, lack of self-esteem.

Question 10

how can GAD be differentiated from schizophrenia?

Answer 10

ask about psychotic symptoms, including paranoia

Question 11

how can GAD be differentiated from dementia?

Answer 11

screen for memory problems

Question 12

what does particularly severe anxiety on awakening in the morning suggest?

Answer 12

alcohol dependence or depressive disorder

Question 13

physical illnesses that may present similarly to GAD?

Answer 13

thyrotoxicosis
hypoparathyroidism
phaeochromocytoma
hypoglycaemia
arrhythmias
temporal lobe epilepsy
resp disease
carcinoid tumours

Question 14

predisposing factors to GAD?

Answer 14

genetic factors-GAD 5X more prevalent in those with 1st degree relatives with disorder than in general pop.
neurobiological mechanisms-response to ANS stimulation prolonged, HPA axis -ve feedback via cortisol reduced.
childhood upbringing-inconsistent parenting, chaotic lifestyle, poor attachment-may cause apprehension and anxiety that may persist.
personality traits-anxious and worry-prone

Question 15

general measures in treatment of GAD?

Answer 15

agree a clear plan
psychoeducation-provide and discuss info. explain the cycle of anxiety that occurs with fear of symptoms being caused by a physical illness, give written info as often problems with concentrating, and involve relative/carer.
identify and reduce or avoid any stressors-problem-solving
advice about self help methods-e.g. taking time off to relax reducing caffeine intake. off info about local support groups.

Question 16

pharamacological tment of GAD?

Answer 16

antidepressants-SSRI 1st line drug choice, sertraline most cost effective, try another SSRI if no improvement in 3mnths, paroxetine may be best in GAD. venlafaxine can be used but must be started by a specialist-must monitor for hypo and hypertension.
usually continued for at least 1 yr following symptom improvement due to high risk of relapse.
if pt cannot tolerate SSRIs or SNRIs, consider pregabalin.
if relapse, may resume med. or refer for CBT.
must warn about ADRs or increased anxiety, agitation and problems sleeping with SSRIs and SNRIs
advise on gradual full anxiolytic effect achieved over 1 week or more
BZDs only indicated by NICE for ST tment during crises and should not be prescribed for more than 3wks due to dependency risk.
buspirone=non BZD anxiolytic, can be used for ST relief. less likely to cause dependence but takes up to 4wks to work.

if partial response to drug tment of GAD, consider offering a high intensity psychological intervention in addition to drug tment.

Question 17

3 distinguishing features of phobic anxiety disorder?

Answer 17

anxiety in part circumstance only
avoidance of circumstances that provoke anxiety
anticipatory anxiety when prospect of encountering the circumstance

Question 18

specific points in history to assess an anxiety disorder?

Answer 18

current symptoms an their effect upon life at home, work, school…
prev. diagnoses of anxiety disorders, mood disorders, eating disorders, OCD, or other psychiatric disorders-and are there current symptoms of these?
prev psych tments, were they effective?
current meds-prescribed, illicit, OTC, alcohol, caffeine, nicotine
premorbid personality traits
FH of anxiety disorder
poor upbringing
current social situation-accomodation, employment, finance
risk assessment-self-harm, self-neglect, driving

Question 19

lab tests in investigation of an anxiety disorder?

Answer 19

rule out other differentials:
TFTs-thyrotoxicosis, AF
24hr urine collec for catecholamines and metanephrines, plasma metanephrine testing-phaeochromocytoma
PTH-hypoparathyroidism
plasma glucose-hypoglycaemia
PFTs-resp disease

Question 20

psychological tments for GAD?

Answer 20

psychoeducation, support, problem solving
self-help books or computer courses-based on CBT principles
CBT-wkly sessions of 1hr to a total of 16-20hrs delivered within 4mnths. may be accessed more quickly as a group tment.

Question 21

2 components to an obsessional thought?

Answer 21

recognised by pt as their own thought they are being compelled to think
resistance of the pt to these thoughts

Question 22

what are obsessional ruminations?

Answer 22

internal debates in which continuous arguments reviewed endlessly

Question 23

what is obsessional phobia?

Answer 23

combination of fearful thoughts and avoidance that occurs when patient’s obsessional thoughts and compulsive rituals worsen in certain situations.

Question 24

what do obsessive-compulsive disorders need to be distinguished from?

Answer 24

anxiety disorders-obsessional symptoms less severe than those of anxiety, and develop later.
depressive disorder-obsessions in OCD precede the depression. important to distinguish as obsessional symptoms in depressive disorders usually respond well to ADs.
schizophrenia-rpt MSEs to look for other schizophrenia symptoms e.g. delusions and hallucinations.
organic cerebral disorders-obsessional sympts may occur in dementia but seldom prominent and other dementia features present.

Question 25

predisposing factors to OCD?

Answer 25

genetic-arises more commonly in those with relatives with the condition, but may be result of family environment rather than genetics.
organic factors-pts have increased rate of minor, non-localising neurological signs but no specific lesion been found. functional changes have been reported in orbitofrontal cortex and caudate nucleus.
early experience-obsessional mothers transmit sympts via social learning to children.

Question 26

factors which worsen prognosis in OCD?

Answer 26

personality obsessional
severe symptoms
continuing stressful circumstances

Question 27

key aspects of OCD treatment?

Answer 27

general anxiety reducing measures, and address co-morbid depression
inform the pt-reassure about not acting on the impulses they resist and that they are not going mad.
reduce or avoid stressors-try and deal with situations in a different way e.g. stressors which make them feel angry.
self-help-resist rituals
drugs-5HT reuptake inhibitors e.g. clomipramine (TCA), fluoxetine (SSRI). up to 6 wks for full effect. must maintain tment for at least 6 mnths.
anxiolytics
CBT-exposure with response prevention-help to suppress rituals

Question 28

what is panic disorder?

Answer 28

diagnosed in those with rpt attacks of anxiety that occur unexpectedly-not in response to a known phobic stimulus. anxiety increases very quickly to a severe level and patients fear some kind of catastrophic outcome e.g. an MI.
attacks followed by at least 1 month of persistent worry about having another attack and concern about its consequences, or a significant change in behaviour related to panic attacks.

Question 29

key characteristics of PTSD?

Answer 29

flashbacks-form of intrusion where person acts or feels as if event recurring-may also be intrusive repetitive thoughts, nightmares or vivid memories=RE-EXPERIENCING SYMPTOMS.
avoidance behaviour and dissociative symptoms-detachment, emotional numbness, difficulty recalling events at will and diminished interest in activities. can also be depersonalization and derealization.
symptoms of hyperarousal e.g. severe anxiety, irritability, insomnia, poor concentration and hypervigilance for threat.
symptoms after a significantly traumatic event
depressive symptoms common, often feel guilt
maladaptive coping responses-persistent anger, excessive alcohol or drug use, deliberate self-harm and even suicide.

Question 30

psychological treatments for PTSD?

Answer 30

trauma-focused CBT

EMDR-eye movement desensitization and reprocessing

Question 31

ICD-10 description of what makes a stressful event traumatic?

Answer 31

a stressful event or situation of an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress in almost anyone.

Question 32

how is PTSD distinguished from acute stress disorder?

Answer 32

PTSD: symptoms have lasted for more than 4 weeks and dissociative symptoms e.g. difficulty recalling events at will, numbness, detachment and reduced interest in activities, must be present.

ICD-10 classification: symptoms must occur within 6 mnths of the traumatic event.

Question 33

how is PTSD distinguished from adjustment disorder?

Answer 33

in adjustment disorder, distress is considered out of proportion to the severity of the stressor, and may be caused by any stressful event.
symptoms of adjustment disorder are more generalised, and usually less severe.

Question 34

general considerations to PTSD treatment?

Answer 34

trauma-focused psychological therapy should only be started when the sufferer agrees that it is safe to proceed
if presenting with depression, treat PTSD 1st as the depression will then often improve. treat depression 1st if severe enough to make initial psychological tment of PTSD difficult.
assess for drug or alcohol problems, and treat these 1st
ensure risk assessment and if identified risk e.g. suicide, manage this 1st
extend tment duration if co-morbid PD
if pt lost close friend or relative to sudden death or unnatural death, treat PTSD 1st without avoiding discussion of grief.
watchful waiting where mild symptoms present for less than 4wks post trauma, and arrange F/U contact within 1 mnth.

Question 35

NICE tment of PTSD where symptoms present within 3 mnths of trauma?

Answer 35

if tment within 1st month, brief psychological interventions e.g. 5 sessions, may be successful.
trauma-focused CBT if severe symptoms of severe PTSD within 1st month of trauma, or presenting with PTSD within 3 mnths of the event. therapy duration normally 8-12 sessions, with longer sessions if trauma to be be discussed. continuous and regular therapy, usually once a wk, and by the same person.
ST hypnotic medication may be considered acutely to help with sleep, but if LT med. required should consider early use of antidepressants to reduce later risk of dependence.

Question 36

NICE tment of PTSD where symptoms present for more than 3 months after trauma?

Answer 36

course of trauma focused psychological tment, either CBT or eye movement desensitisation and reprocessing (EMDR).
regular and continuous tment, delivered by same person usually 8-12 sessions. consider more than 12 sessions if after multiple traumas, traumatic bereavement or chronic disability from trauma or signif. co-morbid disorders or social problems.
several sessions may be needed to establish therapeutic relationship and emotional stabilisation if difficulty disclosing details of trauma.
if no improvement or only limited improvement, consider an alternative trauma-focused psychological treatment or augmentation of psychological tment with pharmacological intervention.

Question 37

only drug currently licensed for PTSD tment?

Answer 37

paroxetine (SSRI)

Question 38

recommendations on drug tment of PTSD?

Answer 38

offer paroxetine-ensure advice on discontinu symptoms or mirtazapine for general use, or amitriptyline or phenelzine for initiation only by MH specialists, if sufferer prefers not to engage in trauma-based psychological therapy (1st line), or cannot undergo psychological therapy due to serious ongoing threat of further trauma e.g. ongoing domestic violence, or pts who have gained little or no benefit from psychological tments.
offer hypnotic med if sleep major problem, and consider AD use early.
consider as adjunct to psychological tment if significant comorbid depression or severe hyperarousal significantly preventing sufferer from benefiting from pscyhological tment.
if not responding to drug, consider increasing dose before treating with a different class of AD or using adjunctive olanzapine.
if reponse to drug, continue for at least 1 yr before gradual WD.
if present inreased suicide risk or aged between 18 and 29, r/v after 1 wk of starting AD tment and frequently thereafter until risk no longer considered significant.

Question 39

% of people experiencing a traumatic event that can be expected to go on to develop PTSD?

Answer 39

around 25-30%

Question 40

NICE recommendations for GAD treatment when symptoms have not improved after education and active monitoring-monitoring of symptoms and functioning(step 1)?

Answer 40

low intensity psychological interventions:
1 or more of:
individual non-facilitated self-help-based on tment principals of CBT, minimal therapist contact
individual guided self-help-supported by a trained practitioner
psychoeducational groups-based on CBT design, interactive sessions with encouraged observational learning
can be offered.

Question 41

when is drug treatment or high intensity psychological intervention considered in GAD?

Answer 41

if marked functional impairment or symptoms have not responded adequately to step 2 interventions-individual non-facilitated self help, individual guided self-help and psychoeducational groups.
determine choice on person’s preference as neither have been shown to be more beneficial.

Question 42

step 3 high intensity psychological interventions in GAD?

Answer 42

offer CBT or applied relaxation

Question 43

treatment considered after unsuccessful stage 3 tment of GAD?

Answer 43

Consider offering combinations of psychological and drug treatments, combinations of antidepressants or augmentation of antidepressants with other drugs, but exercise caution and be aware that:
evidence for the effectiveness of combination treatments is lacking and
side effects and interactions are more likely when combining and augmenting antidepressants.

Question 44

common comorbidities with panic disorder?

Answer 44

depression
substance misuse
agoraphobia

Question 45

management of person presenting to A and E with a panic attack?

Answer 45

be asked if they are already receiving treatment for panic disorder

undergo the minimum investigations necessary to exclude acute physical problems

not usually be admitted to a medical or psychiatric bed

be referred to primary care for subsequent care, even if assessment has been undertaken in A&E

be given appropriate written information about panic attacks and why they are being referred to primary care

be offered appropriate written information about sources of support, including local and national voluntary and self-help groups

Question 46

treatment of panic disorder?

Answer 46

psychological interventions-CBT, total of 7-14hrs, completed within a max. of 4 mnths
pharmacological therapy-SSRI or TCA. if SSRI not suitable or no improvement after 12 weeks, consider imipramine or clomipramine. if showing improvement, continue AD for at least 6 mnths after optimal dose reached.
advise of most common withdrawal/discontinuation symptoms when stopping AD or even when dose lowered-nausea and vomiting-most common GI disturbance, anxiety, sweating, sleep disturbance, dizziness, numbness and tingling, headache.
self-help-bibliotherapy based on CBT, info about support groups and advise on benefits of exercise.

refer to specialist mental health services if failure of 2 of the above interventions.

can monitor outcomes: Short, self-completed questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible.

Question 47

symptoms of a panic attack?

Answer 47

palpitations
tachycardia
sweating and flushing
trembling
dyspnoea
chest discomfort
nausea
dizziness or fainting
fears of an impending medical emergency
depersonalization- feeling that ones thoughts and feelings are do not belong to them or seem unreal.

Question 48

prevalence of panic disorder?

Answer 48

7-9% of the population
females more than males
peaks of onset between 15 and 24yrs, and 45 and 55yrs

Question 49

aetiology of panic disorder?

Answer 49

genetics: 40% heritability
biochemical hypothesis: NT imbalance in brain, involvement of 5HT and GABA systems
cognitive hypothesis: fears concerning physical symptoms of anxiety producing a vicious cycle. reducing fearful cognitions reduces panic.

Question 50

initial tment options for adults with OCD?

Answer 50

low intensity pyschological treatment (less than 10hrs of therapist input per patient), including brief individual CBT including ERP-exposure response prevention therapy- pt exposed to their fear but prevented from ritualising, and group CBT.
if mild functional impairment but cant engage or not effective, give SSRI or more intensive CBT.
SSRI e.g. fluoxetine, paroxetine, sertraline or citalopram plus CBT should be given for severe functional impairment.

for children and young people with mild impairment, offer guided self-help and support and info., offer CBT if moderate to severe.

in continuing tment, consider cognitive therapy adapted for OCD as an addition to ERP to enhance long‑term symptom reduction

r/v continued need for SSRI treatment after 12 months of therapy post remission

Question 51

when should clomipramine (TCA) be considered in tment of OCD?

Answer 51

in tment of adults after adequate trial of at least 1 SSRI has been ineffective or poorly tolerated, if the pt prefers it or has had a previous good response to it.

Question 52

options to consider in OCD treatment if no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone?

Answer 52

additional CBT or cognitive therapy
adding an AP to an SSRI or clomipramine
combined clomipramine and citalopram

Question 53

indications for IP treatment of OCD?

Answer 53

there is risk to life
there is severe self‑neglect
there is extreme distress or functional impairment
there has been no response to adequate trials of pharmacological/psychological/combined treatments over long periods of time in other settings
a person has additional diagnoses, such as severe depression, anorexia nervosa or schizophrenia, that make outpatient treatment more complex
a person has a reversal of normal night/day patterns that make attendance at any daytime therapy impossible
the compulsions and avoidance behaviour are so severe or habitual that they cannot undertake normal activities of daily living.

Question 54

ICD-10 definition of social phobias?

Answer 54

Fear of scrutiny by other people leading to avoidance of social situations. More pervasive social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem. Symptoms may progress to panic attacks.

Question 55

ICD-10 definition of adjustment disorders?

Answer 55

States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising period of adaptation to a significant life change or stressful life event-some sort of psychological stressor. The stressor may have affected the integrity of an individual’s social network (bereavement, separation experiences) or the wider system of social supports and values (migration, refugee status), or represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement). Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor. The manifestations vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine. Conduct disorders may be associated particularly in adolescents. The predominant feature may be a brief or prolonged depressive reaction, or a disturbance of other emotions and conduct.
grief reaction part of this.

Question 56

general measures in managing a pt with an adjustment disorder to a physical illness?

Answer 56

Facilitate the patient’s reactions and thoughts towards the illness
Encourage expression of both positive and negative feelings
Allow the patient to reflect on loss
Involve the patient in the decision making process
Involve the patient’s family/ support system where appropriate
Reduce the patient’s fear by providing clear explanations of the nature of the illness
Provide an optimistic but realistic prognosis of the illness