ANXIETY DISORDERS

Question 1

EPIDEMIOLOGY:

a) Specific phobia
b) Panic disorder
c) Social phobia
d) PTSD
e) GAD
f) OCD

Answer 1

• Combined prevalence 12-17%
  a) 4.4%, Childhood-adolescence
  b) 3.9%, late adolescence-mid 30s, female 2-3:1
  c) 3.7%, Mid-teens
  d) 3.6%, any age, female 2:1
  e) 2.8%, childhood-late adulthood, 2-3:1
  f) 2.1%, Adolescence-early adulthood

Question 2

AETIOLOGY:

1. Genetic and biological factors
2. Psychosocial causes

Answer 2

1. • Overlaps with depression
     - Panic disorders and OCD most heritable, >1/3 have first degree relatives. OCD shares risk with Tourette’s syndrome
     - OCD associated with Sydenham’s chorea(damage to caudate nucleus)
2. a) Adverse life event
   - PTSD requires traumatic event, affects 10-30% who experience it.
   b) Misperception of normal stimulus by susceptible individual
   c) Conditioning

Question 3

MANAGEMENT OF ANXIETY:

a) GAD
b) Panic disorder
c) Social Phobia
d) OCD
e) PTSD
f) Specific Phobia

Answer 3

• Treat harmful and dependent substance use first.
• Treat depression first if anxiety secondary to depression and vice versa. If unlcear, ask for preference.

a) 1. Self-help
2. CBT, applied relaxation OR SSRI(sertraline) then 2nd line: alternative SSRI/venlafaxine/pregabalin
* when starting sertraline for <30y, warn of increased suicide risk, monitor weekly for 1 month.

b) 1. Self-help w bibliotherapy, info on groups and exercise.
2. CBT OR SSRI. 2nd line: Imipramine/clomipramine if SSRI not suitable/no improvement after 12w.

c) 1. Self-help/individual CBT
2. CBT OR SSRI(escitalopram/sertraline). If partial response after 10-12w, CBT+SSRI. If X response, alternative SSRI(Fluvoxamine/paroxetine)/venlafaxine. If still unresponsive, MAOI. If rejected, short-term psychodynamic psychotherapy

d) 1. Self-help/individual/group CBT w Exposure Response Prevention(ERP).
2. Individual CBT w ERP, consider involving family member/carer OR SSRI(fluvoxamine/paroxetine/sertraline/citalopram/fluoxetine). 2nd line: Alternative SSRI, Clomipramine

e) 1. Watchful waiting if ≤4w of trauma/ Trauma-focused CBT or EMDR if >4w since trauma
2. Trauma-focused CBT/EMDR. Trauma-focused CBT offered if severe PTSD ≤1/12 or if present ≤3/12 of event. Drugs not routine, paroxetine/mirtazapine 1st line. Amitriptyline/Phenelzine under specialist care. Short-term hypnotic meds for sleep disturbance. if long-term, consider antidep for ≥12w, if still unresponsive, increase dosage/switch to diff class of antidepressants w gradual withdrawal/adjunct olanzapine use

f) 1. Self-help
2. CBT/PRN benzodiazepine for rarely occurring situations

• Other therapies: psychodynamic and family therapies.
• Initial increase in anxiety Sx during first few days of initiating SSRI/TCA. Can tx by slow up-titration of dosage/benzodiazepines+antidepressants
• Propanolol reduces autonomic arousal to anxiety-inducing stimuli.

Question 4

REFERRAL TO SECONDARY CARE IF:

Answer 4

1. Risk of self-harm/suicide
2. Self-neglect
3. Unresponsive to ≥2 course of treatments
4. Significant co-morbidity(substance use/physical health problems)

Question 5

COURSE AND PROGNOSIS:

1. GAD
2. Panic disorder
3. Social phobia
4. Specific phobia
5. PTSD
6. OCD

Answer 5

1. likely becomes chronic-fluctuating, worsens during stress.
2. up to 50% symptom-free after 3y. 1/3 of remainder have chronic symptoms, sufficiently distressing. Agoraphobia can develop ≤1y of onset of panic attacks.
3. usually chronic course with long remission periods. life stressors worsen
4. uncertain long-term prognosis. those that persist from childhood relatively better response than those in adulthood
5. 50% recover fully ≤3/12. 1/3 left with moderate-severe Sx in long term.
6. Majority have chronic fluctuating course, worsening of Sx. drg times of stress. About 15% exp deterioration in functioning