Anxiety

Question 1

Features of pathological anxiety

Answer 1

Autonomy: no or minimal environmental trigger
Intensity: exceeds patient’s capacity to bear the discomfort
Duration: symptoms are persistent
Behaviour: anxiety impairs functioning and/or results in disabling behaviours – avoidance or safety behaviours

Question 2

Constant vs episodic anxiety disorders

Answer 2

Constant: GAD

Episodic:
OCD
PTSD
Phobias
Panic disorder

Question 3

Psychological symptoms of anxiety

Answer 3

Worrying thoughts
Irritability
Sensitivity to noise
Restlessness
Fearful anticipation
Poor concentration

Question 4

Sleep symptoms of anxiety

Answer 4

Difficulty falling asleep
Night terrors (PTSD)

Question 5

Physical symptoms of anxiety

Answer 5

Muscle tension - tremors, aches
Autonomic arousal: 
Dry mouth
Diarrhoea
Difficulty breathing
Palpitations
Chest discomfort
Frequent and urgent micturition

Consequences of hyperventilation:
Dizziness
Tingling numbness

Question 6

ICD10 criteria of GAD

Answer 6

Generalised and persistent somatic (physical) and psychological symptoms of anxiety on most days for at LEAST SEVERAL WEEKS at a time and usually several months

Anxiety symptoms usually involve elements of
Apprehension
Motor tension
Autonomic overactivity

Question 7

ICD 10 criteria for panic disorder (episodic paroxysmal anxiety)

Answer 7

Several attacks within one month
In circumstances with no objective danger
Not confined to known or predictable situations
With comparative freedom from anxiety symptoms between attacks

Question 8

Agoraphobia (ICD 10?)

Answer 8

Psychological and autonomic symptoms primarily manifestations of anxiety and not secondary to other symptoms, such as depression or delusions.

Anxiety must be restricted to at least two of the following: crowds, public places, travelling alone, travelling away from the home

Avoidance of the phobic situation must be a prominent feature.

Question 9

ICD10 criteria of social phobia

Answer 9

Psychological, behavioural or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
The anxiety must be restricted to or predominate in particular social situations
The phobic situation is avoided whenever possible

Common anxiety symptoms are:
Blushing or shaking
Fear of vomiting
Urgency or fear of micturition

Question 10

ICD 10 of specific phobias

Answer 10

Psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
The anxiety must be restricted to the presence of the particular phobic object or situation
The phobic situation is avoided whenever possible

Question 11

What are obsessions

Answer 11

thoughts, ideas or images, which are:
acknowledged as excessive or unreasonable.
Repetitive
Intrusive and resisted by the patient (although the resistance may diminish in chronic OCD)
Unpleasant – i.e. the thought gives no pleasure
Originate in the mind of the patient and are not imposed by outside persons or influences (i.e. not thought insertion)
Cause distress
Interfere with functioning

Question 12

What are compulsions?

Answer 12

Physical act:
Acknowledged as excessive or unreasonable
Repetitive
Intrusive and resisted by the patient, causing mounting anxiety
Unpleasant – i.e. the act itself gives no pleasure, but may relieve tension or anxiety.
The desire to carry out the act originates in the mind of the patient and are not imposed by outside persons or influences ie not a made act arising from psychosis.
Causes distress and interferes with functioning, usually due to wasting time.
Magical thinking can occur – eg. “if I touch this door frame five times, no harm will come to my family”

Question 13

Which physical conditions can present with symptoms of anxiety?

Answer 13

Thyroid dysfunction
Phaeochromocytoma
Acidosis (eg. DKA)
Hyper or Hypothermia

Hypoxia (eg. CHF, angina, anaemia, COPD)
Seizures
Arrhythmias such as SVT
Alcohol/opiate withdrawal
Drug intoxication (caffeine, cocaine, amphetamines)

Question 14

Consider the comorbid psychiatric disorders in anxiety

Answer 14

Presence of depressive symptoms - Are these causing the anxiety or resulting from it?
Drug / alcohol misuse - significantly complicates treatment
Personality disorders
Anxiety symptoms secondary to organic pathology

Question 15

What is the effect of anxiety on the person’s life?

Answer 15

Avoidance and Safety behaviours to avoid triggers for anxiety.
Unfortunately, these behaviours feed into the anxiety and worsen the illness

Question 16

Step 1 of anxiety management (all suspected cases)

Answer 16

Psychoeducation and active monitoring

Question 17

Step 2 of anxiety management (no improvement after education and monitoring)

Answer 17

Guided self-help and low-intensity psychological interventions (primary care psychological services: IAPT)

Question 18

Step 3 of anxiety management (inadequate response to step 2 or marked functional impairment)

Answer 18

High intensity psych intervention (CBT)
Or 
DRUG treatment (primary care)

Question 19

Step 4 of anxiety management (complex/refractory, very marked functional impairment)

Answer 19

Referral to secondary care - complex drug or psychological treatment regimes; input from multi-agency team

Question 20

Educate a patient on his/her anxiety

Answer 20

Definition and nature of illness
Explaining cycle of anxiety for this diagnosis
Precipitating and maintaining factors
Treatment (medications and psychological)
CBT approach
Social interventions
Prognosis

Question 21

Implementation of psychoeducation and guided self-help

Answer 21

Psychoeducation usually with support of trained professionals (involves patient, family, carers)

Guided self-help: done by patient through access to resources (books, computers etc)
Usually guided by a trained person for efficacy

Question 22

What is eye movement desensitisation processing?

Answer 22

For PTSD (NICE)
During the therapy, the original trauma is deliberately re-experienced in as much detail as possible, e.g. by the patient narrating or imagining every step that happened.  While doing this, they fix their eyes on the therapist's finger as it quickly passes from side to side in front of them.

Question 23

What are the pharmacological treatments of anxiety

Answer 23

All antidepressants (SSRIs, SNRIs, TCAs)
Warn about possible initial increase in anxiety

Sometimes beta blocker is used for heart rate and autonomic arousal

in severe cases - short term (<4 weeks) benzodiazepines (ADDICTIVE):
lorazepam (short half-life)
diazepam (longer half-life) - not used anymore

In very severe cases, antipsychotics

Question 24

Acute Stress Reaction

Answer 24

Brief (3 days - 1 month) after severely stressful event (eg. vehicle crash or violent crime)

Symptoms
Anxiety and depression
Numbness, detachment, poor concentration, derealisation, insomnia, restlessness, anger, autonomic symptoms​
Avoidance of talking or thinking about the event
Acohol excess is common

Question 25

Prognosis of acute stress reaction

Answer 25

Majority get better without formal diagnosis. Those who get formally diagnosed, 78% develops PTSD. The reasons are - no support network, thus more mental health problems. Also more serious trauma

Question 26

Management of acute stress reaction

Answer 26

``` Reduce emotional response - talk to family/therapist Encourage recall (debriefing) Learn effective coping skills Anxiolytics if very severe Hypnotics for sleep disturbance ```

Question 27

who is affected by adjustment disorder

Answer 27

Psychological reaction to adapting to a new set of circumstances, e.g. new job/home, divorce, etc. Starts within 3 months and must be proportionate to the stressful event in response to bereavement, the onset of terminal illness or sexual assault

Question 28

Symptoms of adjustment disorder

Answer 28

Anxiety, depression, irritability Palpitations and tremor Occasional outbursts of dramatic or aggressive behaviour Sometimes abuse of alcohol or drugs Social functioning impaired Onset more gradual than acute stress reaction, and it takes a more prolonged course

Question 29

Management of adjustment disorder

Answer 29

If possible, help resolve the change of circumstances e.g. support to make changes at work Prevent avoidance and denial Encourage problem-solving to seek solutions Relieve anxiety by encouraging to talk and express associated feelings Can refer to talking therapy in primary care - CBT

Question 30

Prognosis of adjustment disorder

Answer 30

Most last a few months A few last a few years Adults generally do well Adolescents with an adjustment disorder have an increased risk of developing psychiatric illness in adult life

Question 31

When is bereavement a medical issue?

Answer 31

If it lasts >6 months Affects the person's relationships or ability to function. Certain symptoms can indicate abnormal bereavement: Guilt about unrelated things Thoughts of death (except thinking that one would be better off dead etc) Preoccupation with worthlessness Significant psychomotor retardation Prolonged and serious functional impairment Hallucinatory experiences (other than the deceased person)

Question 32

What are the normal symptoms in someone going through bereavement

Answer 32

poor energy low mood Anhedonia disturbed sleep and appetite Even symptoms of anxiety Should gradually resolve within 3 months

Question 33

What is classified as PTSD?

Answer 33

Onset of symptoms following trauma, with a latency period of few weeks to months. Lasts longer than 6 months after trauma (otherwise it would be normal reaction)

Question 34

Which trauma has a very high prevalence for PTSD?

Answer 34

45% in domestic violence Otherwise usually 5-10% in different traumas

Question 35

Symptoms of PTSD

Answer 35

Core triad: Hyperarousal (anxiety, insomnia, irritable, poor concentration) Re-experiencing (flashbacks, dreams) Avoidance (or reminders, detachment, numbness, anhedonia) Depressive & guilt symptoms common Substance use as a coping strategy common Symptoms may begin quickly after, rarely >6 months after

Question 36

Management of PTSD

Answer 36

Psychological treatment: psychoeducation Trauma-focused CBT Eye Movement Desensitization and Reprocessing (EMDR) Social: educate family avoid alcohol support reintegration into environment Biological: antidepressants (eg. SSRIs)

Question 37

Prognosis of PTSD

Answer 37

50% recover in 1st year Poorer Prognosis if co-morbid mental illness, long duration, history of psychiatric illness, family history of mental illness, poor social support or pre-morbid functioning or outstanding compensation claims