Anxiety Disorders: GAD, Acute Stress Disorder, PTSD, Phobias

Question 1

Presentation of anxiety disorders
- physical
- mental
- impacts

Answer 1

Physical symptoms - fight or flight
- head, back pain
- sleep problems

Mental symptoms
- inability to relax, stop worrying
- sense of dread
- low concentration
- needing constant reassurance
- depersonalisation, derealisation
- avoidance
- flashbacks, hypervigilance

Impacts
- poor self care
- affecting job, relationships, hobbies

Question 2

GAD
-core features
-diagnosis
-management

Answer 2

Core feature - excessive, persistent worry about activities, occurring more days than not, min 6months

Stepwise approach
1. GAD education + active monitoring
2. Low-intensity psych intervention (self/group-guided help)
3. High-intensity psych intervention (CBT) or meds
4. Specialist input

Meds
-1st line sertraline
-2nd line SSRI/SNRI
-U30, increased risk of suicidal thinking and self harm, so weekly f/u for the 1st month recommended
- BB - SNS response
- BZ in crisis AND NOT FOR GAD

Question 3

Non anxiety differentials
-physical
-medication
-mental

Answer 3

Physical
- hyperthyroid
- asthma, COPD
- dementia
- infections in older adults

Medication
-akithesia
-salbutamol, CS, antidepressants
-caffeine

Psychiatric
- depression
- substance use
- PTSD
- schizophrenia
- personality disorder

Question 4

Panic disorder
-core features
-diagnosis
-management

Answer 4

Recurrent panic attacks
-sudden, intense fear peaking in mins
-4+ symptoms
-don’t all have a trigger

Physical - fight or flight
-difficulty breathing, choking

Mental - fear of losing control, fainting, dying
-may lead to avoidance of going outside

Panic disorder
- moderate - 4+ panic attacks in 1 month
- severe - 4+ panic attacks in 1 week

Stepwise approach
1. Primary care - CBT/SSRIs
-if CI or no response after 3months => imipramine/clomipramine
-can use BZ for symptomatic relief
2. Escalate to CMHT

Question 5

Phobias
-core features
-management

Answer 5

Anxiety reaction triggered by situation or object
-fear and reaction is out of proportion to danger and impacts ADLs
-lasts for 6months+
May lead to avoidance of stressor

Social - acute fear of embarrassment when focus of attention/in small groups/social situations
Agoraphobia - fear of public places, crowds, travelling alone/away from home
Specific phobias - 1 specific trigger
Needle phobias - fainting episode from BP drop triggered by exposure to needles
-ONLY GENETIC PHOBIA!

Management
-in addition to anxiety management
-exposure therapy => gradual introduction to trigger to increase tolerance and familiarity

Question 6

Acute stress reaction vs PTSD
- onset, duration
- presentation
- management

Answer 6

Acute stress reaction
Onset within 1 month of trauma, lasting U1month
Management - trauma focused CBT

PTSD
Onset 1 month+ post trauma, lasting 1 month+

Presentation
- reexperiences - flashbacks, nightmares
- avoidance of similar situations
- hypervigilance
- emotional numbness
-drug/alcohol misuse

Management
1st line - trauma focused CBT, stress and relaxation techniques
-EMDR if severe

Drug- not routinely used
1st line - venlafaxine/sertraline
-risperidone if severe