GAD; OCD; PTSD

Question 1

How does NICE define anxiety? [1]

Answer 1

NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’

Question 2

Biological accounts of GAD:
- Greater [] response to emotional stimuli in GAD
- Atypical functional connectivity between the [] and the [] cortex –> emotional dysregulation model

Answer 2

Greater amygdala response to emotional stimuli in GAD

Atypical functional connectivity (hypoactivation) between the amygdala and the prefrontal cortex –> emotional dysregulation model

Question 3

Describe the psychological accounts of GAD [2]

Answer 3

Attention is biased towards threatening information

Tendency to interpret ambiguous information as negative or threatening

Question 4

How would you discuss with someone who thinks that worrying is normal [2]

Answer 4

Some individuals with GAD believe that worrying is necessary to:
* Anticipate and avoid problems
* Find a solution
* Be prepared if something bad happens
* Distract oneself from other negative emotions

However, worrying is perceived as distressing as it’s felt as:
* Uncontrollable
* Harmful

Question 5

What are the dispositional characteristics of GAD sufferers [3]

Answer 5

Intolerance to uncertainty (Dugas et al., 1998; Bottesi et al., 2016)

High on perfectionism (e.g. Handley et al., 2014)

Feelings of responsibility for negative outcomes (e.g. Avard & Garratt-Reed, 2021)

Question 6

What are medical causes of anxiety disorders? [3]

Answer 6

Hyperthyroidism
cardiac disease
medication-induced anxiety
- salbutamol
- theophylline
- corticosteroids
- antidepressants
- caffeine

Question 7

Describe the clinical features of GAD [3]

Answer 7

Constant apprehension and anxiety about future events that leads to chronic worrying: directed to major and minor issues of life, uncontrollable, catastrophising
Excessive worrying
Unable to control the worrying
Restlessness
Difficulty relaxing
Easily tired
Difficulty concentrating

Physical symptoms:
* Trembling
* Fatigue
* Body tension
* GI (naseua)
* Headaches

Question 8

Describe the DSM-5 diagnostic criteria for GAD [5+]

Answer 8

A Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities

B The individual finds it difficult to control the worry

C The anxiety and worry are associated with at least three of the following symptoms:
* Restlessness
* Being easily fatigued
* Difficulty concentrating or mind going blank
* Irritability
* Muscle tension
* Sleep disturbance

D The anxiety/worry or physical symptoms cause clinically significant distress or impairment in important areas of functioning

E The disturbance is not better explained by physiological effects of a substance, or by another medical condition

Question 9

NICE suggest a step-wise approach for treating GAD. What are the steps? [4]

Answer 9

step 1:
- education about GAD + active monitoring

step 2:
- low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

step 3:
- high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information

step 4:
- highly specialist input e.g. Multi agency teams

Lecture:
* 50% of people with GAD start their treatment with antidepressants such as SSRIs or SNRIs (comorbidity with depression)
* 35% are treated with benzodiazepines (anxiolytics)
* Stimulus control treatment: behavioural intervention to limit the contexts in which worrying occurs: limited amount of time; specific location

CBT: self-monitoring, relaxation training, cognitive restructuring, behavioural rehearsal

Question 10

What is the drug tx for GAD? [+]

Answer 10

NICE suggest sertraline should be considered the first-line SSRI
- if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
- examples of SNRIs include duloxetine and venlafaxine

If the person cannot tolerate SSRIs or SNRIs
- consider offering pregabalin
- interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
- Weekly follow-up is recommended for the first month

Question 12

The Generalised Anxiety Disorder Questionnaire (GAD-7) can help assess the severity. It involves seven questions, each scored depending on how often the symptoms are experienced. The total score indicates the severity:

[] indicates mild anxiety
[] indicates moderate anxiety
[] indicates severe anxiety

Answer 12

5-9 indicates mild anxiety
10-14 indicates moderate anxiety
15-21 indicates severe anxiety

Question 13

Describe what is meant by agoraphobia [+]

Answer 13

Marked / XS fear or anxiety that occurs / in anticipation of multiple situations / spaces where escape might be difficult (e.g. transport / shops)

Consistent feat of specific negative outcomes such as panic attacks / symptoms of panic or embarrassing physical symptoms

Persistent (over months) and result in situations being actively avoided or entered only under special circumstances (e.g/. with a companion)

Can become housebound

E.g someone with IBD might develop this because of incontinence

Question 14

Describe what is meant by social anxiety disorder [1]

Answer 14

Marked and XS fear or anxiety that occurs in more or more social situations - can be interactions, perfomance or feeling observed.
- Fear that will act in a way or show anxiety symptomns that be will negatively evaluated by others
- Significant distress or impairment
- Prolonged

Question 15

Describe what is meant by seperation anxiety disorder [+]

Answer 15

Fear or being apart from key attachment figure (parent / child / partner)
- can include fears that an event will cause sepeartion, refusal to be apart or XS distress on departing, physical sx on seperation
- Persistent
- Onset on childhood
- Often w co-morbid neurodevelopmental, mood or anxiety

Question 16

Describe what is meant by body dysmorphic disorder [1]

Answer 16

Persistent preoccupation with a percieved physical defect / flaw which might only be slightly noticeable to others
- XS self-conciousness
- Repetitive checking / comparing / XS attempts to camouflate
- Significant impairment
- High risk of suicide

Question 17

NICE recommend classifying impairment into mild, moderate or severe
they recommend the use of the [] scale

Describe what an example of severe OCD would look like

Answer 17

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

Question 18

Describe what is meant by hyprechondriasis [4]

Answer 18

Persistent preoccupying fear of serious illness
- repetitive checking and reassurance seeking
- Maladaptive avdoidance - e.g. of appointments
- catastrophic misinterpretations (e.g. headache = tumour)
- doctor shopping

Question 19

What are the differences between obsessions and compulsions? [2]

Answer 19

Obsessions
- are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore.
- Examples of this are an overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind.

Compulsions
- are repetitive actions the person feels they must do, generating anxiety if they are not done.
- Often these compulsions are a way for the person to handle the obsessions.
- For example, checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down. This is a normal behaviour, but in OCD the person may check every plug in the house 10 times before being able to go to sleep or leave.

Question 21

Describe the clinical features of OCD [+]

Answer 21

Obsessive Themes:
* Contamination fears: Fear of becoming contaminated by germs, dirt, or harmful substances.
* Harm-related obsessions: Fear of causing harm to oneself or others due to negligence or unintentional actions.
* Unwanted sexual thoughts: Intrusive and distressing sexual thoughts or images involving inappropriate behaviours.
* Religious/moral obsessions: Excessive concern with religious or moral issues, also known as scrupulosity.
* Perfectionism/symmetry: Intense need for orderliness, symmetry, or exactness.

Compulsive Behaviors:
* Cleaning/washing: Excessive handwashing, showering, cleaning of objects, etc., in response to contamination fears.
* Checking rituals: Repeatedly checking doors, appliances, etc., to ensure safety and prevent harm.
* Counting/repeating rituals: Performing mental acts (e.g., counting) or repeating actions a specific number of times to reduce anxiety.
* Ordering/arranging behaviours: Arranging objects in a particular manner or following strict routines to achieve a sense of orderliness and control.
* Mental neutralizing strategies: Attempting to counteract intrusive thoughts with other thoughts (e.g., prayer) in an effort to alleviate distress.

Question 22

Which assessment tools can be used to dx OCD? [2]

Answer 22

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS): A widely used clinician-administered scale that measures the severity of obsessions and compulsions.

Obsessive-Compulsive Inventory-Revised (OCI-R): A self-report questionnaire assessing the severity of various OCD symptoms.

Question 23

OCD is strongly related to which other mental health issues? [5]

Answer 23

Anxiety
Depression
Eating disorders
Autistic spectrum disorder
Phobias

Question 24

Describe the management of mild, moderate and severe OCD [+]

Answer 24

PM:
If functional impairment is 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 choice of either a course of an SSRI or more intensive CBT (including ERP)

If 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)

If severe functional impairment
* offer combined treatment with an SSRI and CBT (including ERP)

ZtF:
- Mild OCD may be managed with education and self-help resources.

More significant OCD may require:
* Cognitive behavioural therapy (CBT) with exposure and response prevention (ERP)
* SSRIs
* Clomipramine (a tricyclic antidepressant)

Question 25

Describe ERP [1] How do you manage alongisde SSRI tx? [2]

Answer 25

**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** - **If SSRI ineffective or not tolerated try either another SSRI**

Question 26

How long is the tx for OCD for if effective? [1]

Answer 26

if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement - If SSRI ineffective or not tolerated try either another SSRI

Question 27

If the symptoms of post-traumatic stress disorder (PTSD) persist for less than a month, it's typically classified as **[1]**

Answer 27

If the symptoms of post-traumatic stress disorder (PTSD) persist for less than a month, it's typically classified as **Acute Stress Disorder (ASD).**

Question 29

Describe the features of PTSD [+]

Answer 29

**HARD** - features of PTSD * **H**yperarousal/hypervigiliance: poor sleep, irritability, difficulty concentrating * **A**voidance: avoiding people * **R**e-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images * **D**ull/ emotional numbing - lack of ability to experience feelings, feeling detached **Features** * **re-experiencing:** flashbacks, nightmares, repetitive and distressing intrusive images * **avoidance**: avoiding people, situations or circumstances resembling or associated with the event * **hyperarousal**: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating * **emotional numbing** - lack of ability to experience feelings, feeling detached ZtF: Key symptoms include: **Intrusive thoughts** relating to the event **Re-experiencing** (experiencing flashbacks, images, sensations and nightmares of the event) **Hyperarousal** (feeling on edge, irritable and easily startled) **Avoidance of triggers** that remind them of the event (e.g., people, places or talking about the event) **Negative emotions** (e.g., fear, anger, guilt or worthlessness) **Negative beliefs** (e.g., the world is dangerous) **Difficulty with sleep** **Depersonalisation** (feeling separated or detached) **Derealisation** (feeling the world around them is not real) **Emotional numbing** (unable to experience feelings) ## Footnote **NB**: One of the DSM-IV diagnostic criteria is that symptoms have been present for **more than one month.**

Question 30

Describe the managment of PTSD [+]

Answer 30

following a traumatic event **single-session interventions** (often referred to as debriefing) are **not recommended** **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 cognitive behavioural therapy (CBT)** or **eye movement desensitisation and reprocessing (EMDR) therap**y may be used in **more severe cases** - **1st line** for those presenting **within 1-3 months = Trauma focused CBT** - **1st line for those presenting after 3 months = EMDR** **drug treatments for PTSD should NOT be used as a routine first-line treatment for adults.** - If **drug treatment** is used then **venlafaxine** or a **selective serotonin reuptake inhibitor (SSRI), such as sertraline** should be tried. - In **severe cases**, NICE recommends that **risperidone** may be used