Anxiety and Depression Flashcards
Anxiety disorder: assessment and management
Assessment= The GAD-7 anxiety questionnaire helps determine severity. Assess for co-morbidities and environmental triggers
Management
* Mild: watchful waiting and advice about self help strategies, diet, exercise and avoiding alcohol, caffeine and drugs
* Moderate to severe anxiety: referred to CAMHS to initiate: counselling, CBT, medication i.e. Sertraline
To meet the diagnostic criteria for anxiety symptoms must:
- Persist for several months, on more days than not
- Result in significant impairment (in personal, family, social, educational, occupational, or other important areas of functioning)
- Not be a manifestation of another health condition or the effects of a substance/medication
To meet the diagnostic criteria for anxiety symptoms must:
- Persist for several months, on more days than not
- Result in significant impairment (in personal, family, social, educational, occupational, or other important areas of functioning)
- Not be a manifestation of another health condition or the effects of a substance/medication
Anxiety Psychological therapies
- Childhood trauma
- Psychodynamic theories of intrapsychic conflict
- Pavlonian conditions- when you begin to associate an object with fear i.e. the hoover makes a loud noise so you fear it
- Operant conditioning theories- an association is made between a behaviour and a consequence (negative or positive) for that behaviour. By avoiding an anxiety provoking situation you are rewarded by a decrease in anxiety. So avoidance behaviour increases.
- Cognitive theories- patients with anxiety disorders tend to overestimate dangers which risks leading to avoidance.
In anxiety the stressor causes Sympathetic activation and cortisol is released from the adrenal glands
Types of anxiety disorders under ICD 10
Phobic anxiety disorders- Agoraphobia, social phobia, specific phobia
Other anxiety disorders- Panic disorders, generalised anxiety disorders, mixed anxiety and depressive disorders
Phobias
Have the same core symptoms of anxiety. The symptoms are brief and due to specific situations/objects/living things. It is out of proportion and normally results in avoidance. May get anticipatory anxiety, where you have anxiety before the event.
Specific and social phobias
Specific phobias= will be of an object or event like spider, has childhood onset. Leads to avoidance, to diagnose the symptoms should be present for more then 6 months.
Social phobias- emerges in teens, slightly higher percentage of females get it. Its fear of social situations or being the centre of attention (public speaking, parties, meetings). It is a fear of behaving in an embarrassing way and humiliating yourself. Leads to avoidance and blushing. Symptoms should be present for more then 6 months.
Agoraphobia and panic disorder
Agoraphobia- more common in females, onset is mid-twenties to mid-thirties. This is a fear of leaving the home, travelling alone and crowds and public places. Very debilitating, causes avoidance. Symptoms should be present for more than 6 months.
Panic disorders- they start abruptly and are discrete episodes of intense fear. They last some minutes and is a fear of catastrophic outcomes. It is random, not situational. Lasts for 20 minutes. They have the 4 symptoms of anxiety, the patient tends to think that they are going to die and lose control
Symptoms of anxiety disorder
- Cardiovascular (palpitations/rapid chest beat)
- Chest pain and sweating
- Trembling, shaking, feeling of choking
- Nausea/abdominal distress
- Fear of dying or loosing control ‘going mad’
- Depersonalisation/derealisation
- Chills/ heat sensations
- Paraesthesia- pins and needles
- Worry, rumination, inappropriate guilts
Generalised anxiety disorder
1) A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems. Difficulty controlling the worry.
2) It is diagnosed when they have four or more of: restlessness/feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension and sleep disturbances.
3) It is chronic but fluctuating, it is not situational. Fairly constant anxiety
4) Can’t be caused by substances/ medication/ another medical condition. It is not better explained by another medical disorder.
Features of obsessions and compulsions
Obsessions (thoughts, ideas or images) and compulsions (acts) share the following features all of which must be present:
* Originate in the mind of the patient
* They are repetitive and unpleasant
* The individual tries to resist them unsuccessfully
* Carrying out the obsessive thoughts or compulsive act is not pleasurable
Obsessive compulsive disorder
- Either obsessions or compulsions that present on most days for a period of at least two weeks
- The obsessions or compulsions cause distress and interfere with the subjects social or individual functioning, usually by wasting time. Might be they have to check the cooker nine times before they leave, because they are scared the house will burn down.
Obsessions vs compulsions
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
Risk factors for OCD
- family history
- age: peak onset is between 10-20 years
- pregnancy/postnatal period
- history of abuse, bullying, neglect
Classifying OCD
- NICE recommend classifying impairment into mild, moderate or severe
- they recommend the use of the Y-BOCS scale
- an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
OCD management: mild
- low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
- If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
OCD management: moderate functional impairment
- offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
- consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
OCD management: if severe functional impairement
- refer to the secondary care mental health team for assessment
- whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above
OCD- notes on treatment
- ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
- if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
- compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response
PTSD
Can develop at any age in people following a traumatic event, for example major disaster or childhood sexual abuse. One of the DSM-IV diagnostic criteria is that the symptoms have been present for more than one month.
