Anxiety Disorders Flashcards
Symptoms of Anxiety
- Cognitive e.g. poor concentration, difficulty in sleeping, pre-occupation with thoughts
- Somatic (physical manifestations of anxiety) e.g. trembling, hyperventilation, headaches, sweating, palpitations, loss of appetite, nausea, globus hystericus
- Emotional e.g. fear, low mood, terror, feeling of impending doom
What investigations should be done to rule out organic causes
- Urine toxscreen to rule out substance abuse or withdrawal
- TFTs to rule out hyperthyroidism, measurement of calcium levels and PTH to rule out hyperparathyroidism, and measurement of urinary catecholamines to rule out phaeochromocytoma
- BM to exclude hypoglycaemia, particularly in acute settings
- ECG to assess for the presence of arrhythmia and calculation of QTc
Giving patients with anxiety SSRIs
Initial increase in anxiety, agitation and jitteriness
Increased risk of suicidal thinking, particularly in under 30s. Patients should be reviewed within one week of prescribing and then weekly for the first month to assess for this
Side Effects: Nausea, loss of appetite, dizziness, blurred vision, dry mouth, headaches, sexual dysfunction
Acute settings-Use of BZDs can be beneficial, should not be prescribed for more than 4 weeks due to dependence and withdrawal
How is OCD diagnosed?
2+ weeks duration of obsessions and compulsions that cause distress/interfere with the person’s social or individual functioning
What are obsessions?
Unwanted intrusive thoughts, images or urges that repeatedly enter the person’s mind
What are compulsions?
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform
Managing OCD
The obsessions and compulsions are egodystonic and the patient finds them distressing
- Common content includes checking, washing, contamination, doubting, counting, and insistence on symmetry
Mild functional impairment from OCD is best managed with CBT and exposure response prevention (ERP). This involves exposing the patient to their obsession but preventing them from carrying out their compulsion in combination with relaxation techniques
In more severe cases there should be a combination of SSRIs (if not effective there should be clomipramine second line)
What is a panic disorder
syndrome in which there are recurrent panic attacks not secondary to another aetiology
- It can commonly co-exist with agoraphobia and social anxiety disorder
Diagnosis of panic attack
Diagnosis of panic disorder involves a >1 month’s duration of recurrent panic attacks and anxiety about the consequences of the attacks
- A panic attack is a period of intense fear characterised by rapidly developing symptoms lasting for around 10 – 30 minutes. These can be spontaneous or situational. It must have at least four of the following features
o Palpitations
o Sweating
o Trembling or shaking
o Dry mouth
o Shortness of breath, sensation of choking, or globus hystericus
o Nausea or abdominal distress
o Dizziness, light-headedness, and unsteadiness
Pharmacological Management of Panic Disorder
- Medications include
o SSRIs are first-line, starting with a low dose and titrating up. It may take up to 12 weeks before an effect is seen. These should be continued for 12 – 18 months before trial discontinuation
o SNRIs, TCAs, and MAOIs can also be used as second-line therapies particularly clomipramine and imipramine (TCAs)
o Benzodiazepines are not recommended by NICE due to the risks of tolerance and dependence. They may be effective for severe, frequent, incapacitating symptoms
Psychological Management of Panic Disorder
o CBT
o Psychodynamic psychotherapy, exploring fears
What are phobic disorders
Phobic disorders are recurring excessive and unreasonable psychological or autonomic symptoms of anxiety in the (anticipated) presence of a specific feared object or situation. This leads to avoidance.
Agoraphobia
panic symptoms occur in places where escape may be difficult or embarrassing
Social Anxiety Disorder
development of anxiety symptoms in relation to particular social situations leading to a desire for escape or avoidance. These patients fear being around people and having to interact with them
Managing Phobia
- Behavioural therapy with systematic desensitisation, this involves graded exposure to the phobic object. Flooding can also be used, but this is no better than graded exposure
- Education in anxiety management and coping strategies may also be useful
- Pharmacological therapies are not generally used except the use of benzodiazepines in severe cases, antidepressants may be effective (particularly SSRIs)
