Anxiety Disorders Flashcards
(75 cards)
1
Q
Define anxiety?
A
According to NICE:
‘Excessive worry about a number of different events associated with heightened tension’
2
Q
What are neuroses?
A
Disorders related to stress e.g. panic disorder, GAD, OCD.
Patient is not completely out of touch with reality
3
Q
Neuroses vs psychoses?
A
- Neuroses: Insight maintained; Psychoses: Insight not
- Neuroses: understandable and with which one can empathize with; Psychoses: delusions not understandable and cannot be empathized with
4
Q
What is the lifetime prevalence of GAD?
A
9% in the US
5
Q
What’s the prevalence of GAD?
What countries more common? Male or female ? When in life?
A
- More common in higher income countries than lower
- Affects females more than males
- Usually starts in adulthood and persists over time
6
Q
Presentation of GAD?
A
- Persistent nervousness
- Fear
- Worry
- Poor conc
- Insomnia
- Trembling
- Muscle tension/ jaw clenching
- Sweating
- Lightheadness
- Dizziness
- Palpitations/ chest pain
- Epigastric pain/ irritable bowels
- Tension headache
- Dry mouth
- Butterflies
- Nausea
7
Q
GAD risk factors?
A
- Family history
- Female
- Chronic physical health problem
- increased stress
- physical/ emotional trauma
- substance misuse
8
Q
ICD-10 criteria for GAD diagnosis?
A
- Marked symptoms of anxiety manifested by excessive worry that in not restricted to any paritcular environment or about negative events occuring in lots of aspects of everyday life
- Anxiety and general apprehensiveness or worry accompanied by additional symptoms, such as: muscle tension or motor restlessness; sympathetic autonomic overactivity (for example, frequent gastrointestinal symptoms, palpitations, sweating, trembling, shaking, and/or dry mouth); subjective experience of nervousness, restlessness, or being ‘on edge’; difficulty concentrating; irritability; sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep).
- Symptoms last for several months and have no other organic, neuro of drug cause
- Symptoms cause significant distress about experiencing anxiety symptoms and affect functioning in personal, family, social and occupational life. If pt is able to function, it is through significant effort.
9
Q
Drugs that can cause anxiety?
A
- salbutamol
- theophylline
- beta-blockers
- herbal medicines (including ma huang, St John’s wort, ginseng, guarana, belladonna)
- corticosteroids
- some antidepressants.
10
Q
Investigations for GAD?
A
- History and examination
FBC - as can can cause heart palpitations - TFTs- rule out hyperthryoidism
- can used GAD-7
- Assess risk of suicide/ risk assessment
- ECG- rule out orgnaic cause for palpitations
11
Q
What are some organic causes of anxiety that you must rule out?
A
- Hyperthyroidism
- Urine drug screen for any substance misuse
Less common: - 24 hour urine for vanillylmandelic and metanephrines-> PHAEOCHROMOCYTOMA
12
Q
DDx for GAD?
A
- Panic disorder
- Social anxiety disorder
- OCD
- PTSD
- Depression
- drug withdrawal
- Hyperthryoidism
- IBS
- Phaeochromocytoma
13
Q
GAD management?
A
1) Communicate the diagnosis, education + active monitoring
2) Low-intensity psych interventions (individual non-facilitated self help or individual guided self help or psychoeducational groups)
3) IF step 2 hasn’t helped or there is marked functional impairment: CBT or applied relaxation or drug treatment with SSRIs
4) Complex, treatment refractory GAD with very marked functional impairment or high risk of self harm: Offer specialist referral of needs and risks. For any intervention that has been refused in steps 1-3 offer the benefits and options to have that treatment
14
Q
What is the regime for individual non-facilitated self help in GAD?
A
Based on CBT principles
Written or electronic materials that the patient should work through systematically over a period of time.
Minimal therapist contact
15
Q
Regime for indivdual guided self help in GAD?
A
- Suitable electronic or written materials supported by trained practioner
- 5-7 weekly or fornightly telephone sessions each lasting 20-30 mins
16
Q
Regime for psychoeducational groups in GAD?
A
- Based on CBT principles
- Encourage observational learning through presentations and self-help manuals
- Conducted by trained practitioners
- Ratio of 1 therapist to 12 participants
- 6 weekly 2 hour sessions
17
Q
Regime for high intensity psycho-interventions?
A
12-15 weekly sessions lasting 1 hour
Pt must know that response to treatment is not immediate and that a prolonged course is needed
18
Q
What drug treaments are offered in GAD?
A
Sertraline (SSRI) first
If this is ineffective: offer an alternative e.g. escitalopram or an SNRI e.g. duloxetine
Review the effectiveness and adverse effects every 2-4 weeks during the first 3 months of treatment and then every 3 months after
Under 30 y/o pt needs to be seen within a week of starting the drug due to increased risk of suicide/self harm
19
Q
What is OCD?
A
Characterised by obsessions or compulsions- commonly both
These symptoms cause a significant functional impairment and/or distress.
20
Q
Prevalence of OCD?
A
Affects around 2% of the population
4th most common mental illness
Equal prevalence amongst males and females
Age of onset in late adolesence to early twenties, although males tend to develop it earlier
WHO has estimated than OCD is among the top 20 causes of illness-related disability for people between 15-44
21
Q
What is an obsession?
A
Unwanted intrusive thought, image or urge that repeatedly enters the persons mind
22
Q
What are compulsions?
A
Repetitive behaviours or mental acts that the person feels driven to perform
Can either be overt and observable by others e.g. checking that the door is locked or covert e.g. such as repeating a certain phrase in one’s mind
23
Q
Risk factors for OCD?
A
Family history
Age: peak onset is between 10-20 years
Pregnancy/ postnatal period
History of abuse, bullying and neglect
24
Q
How may a person present with OCD in primary care?
A
Derm symptoms from excessive washing
Genital or anal symptoms from excessive checking and washing
General stress ( from losing job for lateness etc.)
Fears about contracting HIV
25
Questions to ask someone with OCD to discover what type it is?
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you would like to get rid of, but cannot?
Do your daily activities take a long time to finish?
Are. you concerned about putting things in a special order or are you upset by mess?
Do these problems trouble you?
26
ICD-10 classification of OCD?
Presence of recurrent, obsessional thoughts or compulsive acts
Obsessions are:
* Ideas, images or impulses that enter the persons mind again and again
* Distressing and the person often tries, unsuccessfully to resist them
* Recognized as the persons own thoughts even if they are repugnant
Compulsive acts or rituals are:
* Stereotyped behaviours that are repeated again and again
* Not inherently enjoyable or useful
* Performed to prevent some objectively unlikely event (often involving harm caused to or from the person)
* Usually recognized by person as being pointless or ineffectual and repeated attempts are made to resist them
Anxiety is almost always present, if compulsions are resisted then anxiety gets worse
27
DDx for OCD?
* obsessive compulsive personality disorder
* Body dysmorphic disorder
* Somatic symptom disorder
* Delusional disorder
* Hypochondriasis
* ASD
* Trichotillomania
28
How to assess the functional impairment in OCD?
* Ask about effects on work or school, relationships, social life and quality of life
* If they are very distressed/ have severe functional impairment- must carry out a risk assessment for suicide and self harm + safeguarding.
29
What is the Yale-Brown Obsessive-compulsive scale?
Allows to identify the severity of OCD
Very long but below are some of the questions:
How much of your day is occupied by obsessive thoughts or spent performing compulsive acts (mild, less than 1 hour; moderate, 1–3 hours; severe, more than 3 hours)?
How much do your obsessive thoughts or compulsive behaviours interfere with your social or work/school functioning (including relationships)?
How much distress do your obsessive thoughts cause you?
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
How much of an effort do you make to resist the obsessive thoughts or compulsions?
How much control do you have over your obsessive thoughts? How strong is the drive to perform the compulsions?
30
When should you refer someone for specialist treatment for OCD?
* if the OCD and functional impairment is SEVERE
* Pt at risk of self harm, self neglect, significant co-morbitiy e.g. substance abuse, severe depression, anorexia
* Risk of suicide
31
Managment of a patient with mild functional impairment of OCD?
* Recommend psychological intervention- referral or self referral to IAPT
* Following IAPT. assessment a low-intensity CBT, incl exposure and response therapy may be offered
10 therapist hours per person of either
* individual CBT + ERP with structured self-help materials
* Brief individual CBT + ERP by phone
* Group CBT + ERP which may be for more than 10 hours
If pt hasn't been able to engage or response is inadequate treat as moderate functional impairment
32
How to manage pt with moderate functional impairment in OCD?
Confident in assessment of pt being moderately functionally impaired (apparently it is easy to underestimate this):
choice of intensive CBT incl ERP OR an SSRI
If NOT confident or inadequate response to treatment refer to secondary care mental health team.
33
Which SSRIs are used in OCD?
Escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline are all licensed for the treatment of OCD in adults.
Citalopram can also be used but is unlicensed
Clomipramine is used as an alternative to an SSRI
34
Management of pt with severe functional impairment for OCD?
* refer to secondary care mental health team
* Whislt waiting for assessment offer combined treatment: CBT (incl ERP) + SSRI
* Can prescribe clomipramine instead of an SSRI
35
How do you monitor a pt with OCD?
During each review:
* Be alert to suicidal ideation and assess suicide risk
* Monitor progress, taking into account factors incl severity and duration of symptoms as well as degree of distress
* Adherence to treatment
* Drug side effects
* If drug is effective adivse patient to continue taking it for at least a year
* Re-evaluate the required frequency of follow up based on pt preference, severity of symptoms, comorbid conditions, change since last review and response to interventions, symptoms during treatment changes
36
What is panic?
Excessice arousal with fear that the symptoms are evidence of catastrophe
37
What is panic disorder?
Characterised by recurring unexpected panic attacks over a 1 month period
Pts are persistently concerned about having another panic attack and/or the consequences of this
Pts may also change behaviour to avoid having more panic attacks e.g. avoid situations that may trigger it
38
What is a panic attack?
Involve the sudden onset of intense physical and cognitive symptoms of anxiety that may be triggered by specific cues or occur unexpectedly
39
What is the epidemiology of panic attacks and panic disorders?
8%-28% of people experience panic attacks at some time during their life
Agoraphobia can often be co-morbid with panic disorder
Panic attacks are more likely to develop in mid-20s with men presenting slightly earlier than women
2-3x more commen in women than in men
40
Risk factors for panic disorder?
* 20-30 years
* Female
* White
* Positive family hx
* Major life stressors
* Hx of recent trauma
41
Presentation of panic attack?
* Unexpected onset
* Apprehension/worry/sense of dread
* Shaky
* choking
* rapid heart beat
* palpitations
* chest pain
* dizziness
* depersonalization or derealization
Secondary fear"
* dying
* losing control
* going mad
42
Presentation of panic disorder (as oppose to panic attacks) according to ICD-10?
* Recurrent severe panic attacks
* Not restricted to any particular situation or set of circumstances
* unpredicatable
43
Presentation of panic disorder (as oppose to panic attacks) according to ICD-10?
* Recurrent severe panic attacks
* Not restricted to any particular situation or set of circumstances
* unpredicatable
44
What is the cognitive model of panic?
These individuals are more sensitive to changes in internal environment
1) Internal/external trigger e.g. feelings of unreality
2) percieved threat
3) Anxiety- what if i panic?
4) Anxiety leads to shaking, palpitations, high HR etc.
5) Misinterpretation of this as signs of disaster/catastrophe/heart attack
6) More anxiety--> and the loop (4-6) continues
7) This over time leads to avoidance behaviours
45
Investigations for panic disorder?
Usually clincal diagnosis
Exclude depression
ECG- rule out any cardiac cause
Blood glucose- rule out hypoglycaemia
TFTs- rule out hyperthyroidism
Toxicology screen- ensure no underlying substance misuse
46
Ddx for panic disorder?
* Agoraphobia
* Specific phobia
* Social anxiety disorder
* PTSD
* Substance-induced anxiety disorder
47
Managment of panic disorder?
Stepwise
1) recognition and diagnosis
2) Treatment in primary care- CBT or drug treatment
3) review and consider alternative treatments
4) review and refer to specialist mental health services
5) care in specialist mental health services
48
What drugs are used in panic disorder?
1st line: SSRIs
2nd line: TCAs e.g. imipamine or clomipramine
49
Managment of panic attack without panic disorder?
Reassurance
Encourage pts to monitor the intensity, frequency and duration of attacks and whether they are expected or unexpected
Provide written self help materials
Follow up within 2 weeks to reassess pts symptoms
50
What is PTSD?
Can develop in any age following a traumatic event
The symptoms must be present for at least 1 months
May be immediate or delayed response to trauma
51
Presentation of PTSD
* Episodes of repeated reliving of the trauma
* dreams or nightmares about the trauma
* numbness or emotional blunting
* detachment from other people
* unresponsiveness to surroudings
* anhedonia
* avoidance of activities and situations reminiscent of the trauma
* Usually a state of autonomic hyperarousal with hypervigilance
* May have co-existing anxiety or depression
* Suicidal ideation is not uncommon
52
Risk factors for PTSD?
* People with certain personality traits or previous hx of neurotic illness may lower the threshold for development of the syndrome
* Serious accident
* natural disaster
* torture
* sexual violence
* combat exposure
53
Epidemiology of PTSD?
* Military personnel, energency service workers, police and refugees have a higher exposure to PTEs (potentially traumatic events)
54
Ddx of PTSD?
Depression
GAD
Specific phobias
Panic disorder
Adjustment disorders
OCD
Psychosis
55
Investigations for PTSD?
Consider the ddx
Trauma Screening Questionnaire may be helpful
56
Outline the trauma screening questionnaire
* 10 questions
* designed for use 3 weeks or more following exposure to a traumatic event to identify people who are likely to be currently suffering from PTSD
* Ask pts which symptoms they have experienced at least 2x in the past week
* 6 or more positive responses- risk of having PTSD- referred for further assessment
57
ICD-10 criteria for PTSD
* exposed to traumatic event or situation of exceptionally threatening or catastrophic nature
* reliving the stressor in intrusive flashbacks, vivid memories, or recurring dreams, or experience distress when exposed to circumstances resembling or assoiated with the stressor
* Exhibit avoidance or preferred avoidance of circumstances resembling or associated with the stressor- not present before
Experience either of the following:
* inability to recall partially or completely some important aspects of the period of exposure to the stressor
* Persistent symptoms of increased psychological sensitivity and arousal: shown by any 2 of the following: difficulty in falling or staying asleep, irritability or outbursts of anger, difficulty in concentrating, hypervigilance, exaggerated startle response
* Symptoms should manifest within 6 months, although in some cases there may be a delayed onset
58
Mangement of PTSD?
* Watchful waiting may be used for mild symptoms lasting less than 4 weeks
* Military personnel have access to treatment provided by the armed forces
* trauma focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy may be used in mre severe cases
* Drug treatments should not be used as a routine first-line treatment for adults
* If drug treatment is used then venlafaxine or SSRIs (sertraline) should be tried
* Severe cases that risperidone may be used
59
What is adjustment disorder?
States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event.
Occurs within 3 months of the onset of this stressor
60
Presentation of adjustment disorder?
* Depressed mood
* anxiety or worry
* feeling of an inability to cope, plan ahead or continue in present situation
* Some degree of disability in the performance of daily routine
* Conduct disorders may be an associated feature, particularly in adolescents
61
Who gets adjustment disorder?
Adolescents, mid or late life- when life changes a good deal
Symptoms do not usually last more than 6 months
62
Management of adjustment disorder?
Conservative- usually healthy eating advice, exercise, reduction or total avoidance of alcohol and caffeine, breathing exercises
63
What is a phobia?
Anxiety in particular circumstances
Leads to avoidance
Anticipatory anxiety that cannot be reasoned away
Crowds, living things (e.g. spiders), natural phenomena
64
What is agoraphobia?
* Fear of crowds, open spaces, difficulty to get home/ public transport
* Pt has anticipatory anxiety, avoidance, anxious thoughts
* peaks of onset in mid-20s and mid-30s
* with or without panic disorders
65
Peak age of onset of agoraphobia?
Mid- 20s
Mid-30s
66
What is the prevalence of agoraphobia?
1 year prevalence of 2%
If present for a year, can persist for 5 years
67
Risk factors of phobia?
Somtisation disorders
anxiety disorders
mood disorders
family hx of a phobia
Female
68
How do you diagnose agoraphobia?
Clinical diagnosis
Explore and rule out differentials
69
DDx of agoraphobia
Panic disorder
Social phobia
PTSD
Seperation anxiety disorder
OCD
GAD
Schizophrenia (due to social withdrawl)
70
What is social phobia?
Fear of scrutiny by other people in comparatively small groups (as opposed to crowds), leading to avoidance of social situations
Often start adolesence
Affects both genders equally
71
Presentation of social phobia?
Physical symptoms: blushing, palpitations, trembling, sweating, fear of vomitting
avoidance of these social situations
anticipatory anxiety
use of safety behaviours e.g. always have to have water due to dry mouth
unhelpful post-mortems following social encounters
May abuse drugs or alcohol to deal with situations which then perpetuate the problem
72
Potential causes of social phobia?
Stressful or humiliating experiences
Death of a parents
Separation
Chronic stress
73
Ddx for social phobia?
Shyness
Agoraphobia
ASD
Benign essential tremor
74
Investigations of phobias?
History and Examination
Ratign scales of anxiety e.g. GAD-7, Beck Anxiety inventory and HADs score
Social and occupational assessments for effect on quality of life
Collateral history
75
Treatment of agoraphobia?
Exposure incl graded exposure
Antidepressants
CBT
Agoraphobia + panic disorder: CBT first line, SSRIs 2nd line
