Anxiety, Obsession and Reactions to Stress Flashcards
(18 cards)
Anxiety disorder general stepped management
Step 1: Low-intensity psychological support, often involving self-help interventions.
Step 2: If symptoms persist, offer low-intensity psychological therapies like cognitive behavioural therapy (CBT).
Step 3: For moderate to severe symptoms, offer higher-intensity psychological
interventions like individual CBT or applied relaxation.
Step 4: Consider pharmacotherapy, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors (SNRIs), if psychological interventions alone do not reduce symptoms.
Anxiety disorder pharmacological treatment
SSRIs, like sertraline, are typically the first-line pharmacological option for GAD and panic disorder. SNRIs may be considered if SSRIs are ineffective.
Benzodiazepines are generally avoided due to the risk of dependence, except for short-term use in acute cases.
GAD
When someone feels anxious or worried most of the time, about many different things,
even when there’s no clear reason
May find it difficult to relax, focus or enjoy daily life because worry feels constant
Can use GAD-7 questionnaire for screening
- 0–4: None to minimal anxiety
- 5–9: Mild anxiety
- 10–14: Moderate anxiety
- 15–21: Severe anxiety
Therapy involves testing predictions of worry with behavioural experiments and looking at errors in thinking
Panic disorder
Panic may be triggered by misinterpretation of physical anxiety symptoms as signs of
major catastrophe
Importantly is NOT related to specific triggers – panic attacks can occur at any time and are very random!
Safety behaviours may be adopted which reinforce beliefs (e.g. avoiding situations)
CBT educates the patient on the true meaning of the symptoms (i.e. panic not perish)
Be aware of possible comorbidities e.g. panic disorder with depression and panic disorder with substance misuse
If a person presents in A&E, or other settings, with a panic attack, they should:
- be asked if they are already receiving treatment for panic disorder
- undergo the minimum investigations necessary to exclude acute physical problems
- not usually be admitted to a medical or psychiatric bed
- be referred to primary care for subsequent care, even if assessment has been
undertaken in A&E
- be given appropriate written information about panic attacks and why they are being referred to primary care
- be offered appropriate written information about sources of support, including local and national voluntary and self-help groups.
Exposure therapy
Used as part of the CBT approach when there are strong elements of avoidance
and escape
In the absence of actual harm, the body can only remain extremely anxious for a short time (usually < 45 mins) before habituation occurs and anxiety levels drop
Habituation is characterised by a decrease in anxiety until fear dies out (extinction)
Exposure is usually through a gradual (or graded) approach called desensitisation
The patient identifies a goal (e.g. being able to hold a slug) and constructs a hierarchy of feared situations
The patient tackles it from least frightening to most frightening
The aim is to stay in the situation until the anxiety has subsided to induce learning
and challenge existing thoughts
Agoraphobia can be treated using this strategy
GAD management
CBT 12-15 weeks
Sertraline first line
SSRI or SNRI second line
Pregabalin third line
TCA (clomipramine, imipramine) if not responding or tolerating SSRI
Buspirone - serotonin partial agonist - delated action and dysphoric effect
Beta blocker (propanolol) - adrenergic symptoms (ASTHMA CONTRAINDICATION)
Panic disorder stepped management
Step 1: recognition and diagnosis
Step 2: treatment in primary care (self-help)
- 1st line: CBT (~7 to 14 sessions over 4 months) + SSRI
- If no response after 12 weeks: consider imipramine or clomipramine
Step 3: review and consideration of alternative treatments
Step 4: review and referral to specialist mental health services
Step 5: care in specialist mental health services
OCD
Characterised by persistent obsessions and/or compulsions
Obsessions = recurrent or persistent thoughts, urges or
images experienced as intrusive and unwanted
Compulsions = repetitive behaviours or mental acts that the person feels driven to perform in response to an
obsession or according to rules that must be applied
rigidly
Severity can be graded using Yale-Brown Obsessive-
Compulsive Scale (NOTE: not diagnostic tool but should be
used to track treatment progress e.g. every 6 months monitor score)
* 0-7 = subclinical/asymptomatic
* 8-15 = mild
* 16-23 = moderate
* 24-31 = severe
* 32-40 = extremely severe
OCD stepwise management
First line - Low-Intensity Psychological Therapies CBT including ERP, up to 10 hours
Second line - SSRI, fluoxetine, paroxetine for at least 12 months after remission
Third line - Clomipramine or other SSRI if first SSRI ineffective after 12 weeks
OCD prognosis
OCD has a chronic course with symptoms worsening at times of stress
Often disabling
Comorbid depression is common
Generally, need higher doses of SSRIs compared to other conditions
to treat effectively
Acute stress reaction
Lasts under 1 month since incident, develops shortly after traumatic event
Exclude injury
Support and reassurance
Benzodiazepines may alleviate short-term distress (does not prevent later PTSD)
Psychological debriefing is not routinely recommended (may increase risk of developing PTSD)
PTSD
Characterised by hyperarousal, flashbacks, avoidance, mood changes
Persists or starts >1 month since incident
Can screen for using Trauma Screening Questionnaire (TSQ), PTSD checklist for
DSM-5 (PCL-5)
PTSD management
Watchful Waiting may be considered if subthreshold symptoms of PTSD within 1 month of a traumatic event
- Arrange follow-up within 1 month
Trauma-Focused CBT (8-12 sessions) - offered to all patients with PTSD symptoms lasting > 1 month
Eye Movement Desensitisation and Reprocessing (EMDR)
- offer to adults with a diagnosis of PTSD or clinical important symptoms who have presented > 3 months after non-combat related trauma
Consider SSRI (e.g. paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD
- Consider antipsychotics (e.g. risperidone) in addition to psychological therapies if they have failed to respond to other drug treatment or have
disabling symptoms/behaviours (e.g. hyperarousal)
Debriefing not recommended
PTSD prognosis
Most patients recover
Some suffer for many years
Chronicity can lead to personality change
Adjustment disorder
An emotional or behavioral reaction to a stressful event or change in a person’s
life.
The reaction is considered an unhealthy or excessive response to the event or
change within three months of it happening.
Support, reassurance and problem-solving are often all that are needed
Many people with medically unexplained symptoms like tiredness, pain and heart palpitations also have comorbid depression or anxiety
Medically unexplained symptoms
Many people with medically unexplained symptoms like tiredness, pain and heart
palpitations also have comorbid depression or anxiety
Make sure to exclude other differentials like poorly understood syndromes e.g. chronic fatigue syndrome, IBS, fibromyalgia, functional neurological disorders
Chronic fatigue syndrome / Myalgic encephalomyelitis
Sudden or gradual onset of persistent disabling fatigue, post-exertional malaise
(PEM), unrefreshing sleep, cognitive and autonomic dysfunction, and pain,
with symptoms lasting at least 6 months
History of post-exertional malaise (PEM) aka post-exertional neuroimmune
exhaustion for minimum 6 months considered defining symptom
Observation of symptoms in adults should be 3 months before initiating therapy
MDT approach
Strong evidence for graded exercise (scheduled and gradually increasing activity)
Patients need realistic goals and should not do more activity than planned -
concept of an ‘energy envelope’ provides people with a strategy to manage their exertional tolerance
Pacing = individuals divide activities into smaller parts with interspersed rest
intervals to remain within limits of envelope
CBT improves fatigue and physical functioning
Conversion (Dissociative) Disorders / Functional Neurological Disorder
Typically involves loss of motor or sensory function - the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering) patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
Functional neurological disorder (previously termed conversion disorder) and
somatic symptom disorder are both characterised by somatic symptoms associated with significant distress or impairment.
Psychotherapy and CBT are mainstays of treatment
