Stress Disorders Flashcards
(35 cards)
What do stress reaction anxiety disorders have in common with their aetiology and signs/symptoms?
Includes GAD, phobias, panic disorder and OCD
Biological factors = genetics, neurochemical factors such as dysregulated serotonin/NA/GABA transmission
Psychosocial factors = early or life experiences (threatening events), behavioural/cognitive thinking (NATs, attachment theory, conditioning)
Common symptoms:
- > Autonomic arousal - dry mouth, palpitations, tremor, tight chest and dyspnoea
- > Worries and insomnia, night terrors
- > Urinary frequency
- > restlessness
How would you generally want to investigate anxiety/stress disorders?
Tip: ‘anxious people want to be SEDATED’
-> Hx and exam (and find out effect on social/occupational hx and QoL)
S - symptoms of anxiety (physical and psychological)
E - episodic or continuous
D - drink and drugs
A - avoidance and escape
T - timing and triggers
E - effect on life
D - depression screen (low mood, anergia, anhedonia)
- > Rating scales - HADS, GAD-7, Beck Anxiety inventory
- > Collateral history
- > Bloods if suspect organic cause (TFTs etc)
What is GAD and how is it defined?
What are some risk and protective factors for it?
GAD = at least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk and causes distress or impairment
Worry is not due to mental disorder, substance abuse or other condition
-> At least 6m Hx
-> At least 3 of the following Sx for most of the time:
- Restlessness/nervousness
- Irritability
- Easily fatigued
- Poor concentration
- Muscle tension
- Sleep disturbance
RFs = divorced, lone parent, living alone, 35-54yo Protective = 16-24, married, cohabiting
How may patients with GAD present?
Sx:
Autonomic = palpitations, sweating, trembling, dry mouth, tachypnoea
Chest/abdomen = dyspnoea, chest pain, nausea, choking sensation
- Neuro = Dizziness, light head, fear of losing control, fear of dying/illness
- General - numbness/tingling, muscle tension, restlessness, lump in throat, difficulty concentrating + sleeping, irritability, avoidance of triggers and using alcohol or drugs to help
How would you Ix a patient with suspected GAD?
Ix:
- Full Hx and exam (SEDATED qs)
- GAD-7 questionnaire where 5 = mild, 10 = moderate and 15 is severe GAD
- Becks anxiety inventory
- Hospital anxiety and depression scale (HADS)
How would you manage GAD?
Biopsychosocial approach and stepwise based on severity
- Written information on GAD + active monitoring + regular exercise
- Low intensity psychological interventions such as
- 6w individual, non-guided self help
- 6w individual, guided self help w weekly therapist appointment
- 6w psychoeducational groups with =12 people - High intensity psychological interventions such as
- CBT (12-15w, 16-20h/week) looking into errors of thinking and testing worry with behavioural experiments)
- Applied relaxation (12-15w)
OR
Medications in a stepwise approach
- > 1st = SSRI (sertraline, or paroxetine) - weekly follow up due to risk of suicide ideation initially
- > IF not working after 8w, switch SSRI or switch to SNRI such as venlafaxine - weekly follow up due to risk of suicide ideation initially
- > Then try Pregabalin (anti-epileptic)
- > Then, Quetiapine
- > ADJUNCT: Propanolol (if many phsyical symptoms)
note: never give BDZ to people with anxiety
What phobias are particularly important in psychiatry? What should you NOT use to treat them?
Seriousness of a phobia is related to the level of disability - therefore social and agoraphobia have the biggest impact on life
- > NEVER use BDZ as high risk of dependence but short term use is ok in specific phobias
- > Specific phobias don’t respond well to antidepressants but most don’t require treatment as avoidance is better
What is agoraphobia? Who is usually affected and how may they present?
ICD10 - cluster of phobias embracing the fears of leaving home, entering shops, crowds and public places or travelling alone
- > Classified with or without a panic disorder
- > 20-35yo onset, gradual or precipitated by a panic attack
- > F»_space; M
Sx:
- > Panic attacks
- > Avoidance of phobic situations +/- isolation behaviour
- > May be associated with depressive/obsessional symptoms, social phobias
How would you manage agoraphobia? How does ERP work?
Mx:
-> Education, reassurance and self-help
-> Exposure response prevention (ERP) therapy
= without actual harm, the body can only remain extremely anxious for <45m, after which habituation occurs, anxiety levels drop, and eventual fear dies out (extinction) –> therefore the therapy aims to desensititse and challenge existing thoughts
-> CBT - reduce patients expectation of threat and the behaviour that maintain threat related beliefs, improve self confidence, test feared situations
What is social phobia? Who does it affect and what are some associations?
ICD10: fear scrutiny by other people leading to avoidance of social situations
- associated with low self esteem and fear of criticism
- M = F (only anxiety disorder to affect equally)
How may social phobia present?
Sx:
- Complains of blushing, hard tremor, nausea or urinary urgency in social situations
- Self medicate with alcohol or drugs to desensitise
- Panic attacks
NB - will tolerate anonymous crowds but unlike agoraphobics, smaller groups may spike anxiety
How can you manage social phobia?
Mx:
- > Education, reassurance and self help
- > Exposure response prevention (ERP)
- > CBT
- > SSRIs
What are specific phobias defined as? How may they present?
ICD10 - phobias restricted to highly specific situations such as proximity to slugs or snails
Sx:
- > Contact can evoke panic such as screaming/locking self away
- > May have a FH of phobia (-ve reinforcement)
- > Most phobias lead to tachycardia but blood/injury phobia may cause intial tachycardia followed by vasovagal bradycardia and hypotension –> nausea and fainting
How would you manage specific phobias?
Mx:
- Education, reassurance and self help
- ERP (flooding - exposing someone to maximal fear until it becomes extinct)
- Relaxation therapy and breathing techniques
- Short term BDZ for some certain phobias such as dental injections but never long term
What is panic disorder?
ICD10 - recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
- > Several within a month
- > Relatively fine with minimal anxiety in-between episodes
- > Panic disorder should not be a main diagnosis if a depressive disorder exists at the same time the attacks start
How may a person present with panic disorder?
Sx:
- Sudden onset, occurring out of the blue and last <30mins
- Alarming thoughts (‘going to die’) provoking panic until pt engages in safety behaviour such as calling an ambulance or taking aspirin
- Palpitations, chest tightness, shaking, sweating, choking sensation, dizziness, depersonalisation, pins+needles
How would you Mx a patient with panic disorder? What is the prognosis for it?
Biopsychosocial approach, stepwise
Education, reassurance and self help
- Low intensity psychological intervention
- Guided/Non-guided individual self help for 6w - High intensity psychological interventions AND/OR medications
- 1st line = CBT +/- SSRI (Citalopram)
- After 12w, change class to TCA (imipramine) or add BDZ (not exceeding 2-4w)
- Psychodynamic psychotherapy - Refer to psychiatry
65% achieve complete remission, 10-20% still have significant symptoms
What is OCD defined as? What are obsessions and compulsions?
ICD10 - recurrent obsessional thoughts OR compulsive acts (can have either or both)
- > must be present on most days for at least 2 or more consecutive weeks
- > must be a source of stress and interfere with ADLs
Obsessions = involuntary thoughts, images, impulses which are:
- > recognised as a product of OWN mind
- > thoughts of carrying out act are not pleasurable
- > thoughts are unpleasantly repetitive
- > > 1 thought/act unsuccessfully resisted
- > Themed commonly e.g. contamination, religion, sex, infection, aggression to self or others
- > Egodystonic = themes/ideas against that which the person associated with their ego
Compulsions = repetitive mental operations or physical acts
- > compelled to perform in response to own obsessions or irrationally defined rules
- > performed to reduce anxiety through irrational belief that they will prevent a dreaded event
What are some DDx for OCD?
DDx:
- > Obsessions and compulsions = body dysmorphic disorder, anakastic personality disorder
- > Mainly obsessions = depressive disorder (find out what developed first), other anxiety disorders, hypochondriac disorder, schizophrenia (delusions)
- > Mainly compulsions = habit and impulse control disorders
How does OCD present and what are some risk factors/causes?
Affecting 1%, M > F, 70% are less than 20y
Bio RFs = genetics (relatives inc 3x risk), neurological (BG affected by sydenhams chorea, encephalitis lethargic and Tourettes), infection (strep throat –> anti-BG Abs)
Psychosocial = personality (25%) have premorbid anakastic personality
Sx:
- > Obsessional thoughts
- > Compulsions (rituals repeated) - not inherently enjoyable but reduces tension (find out how often they do this, if daily)
- > Anxiety which gets worse the longer they ignore the compulsion
What Ix would you do in suspected OCD? What are some good screening questions?
Ix:
- Full Hx and collateral, plus physical examination + MSE
- Yale Brown OCD scale
- Bloods - TSH, FBC
note: OCD screening questions
- > any thoughts that keep bothering you/+ that you’d like to get rid of?
- > Daily activities take a long time for you?
- > Clean often/check time often?
- > Ritual behaviour
How would you manage OCD?
Biopsychosocial, stepwise approach
Mild functional impairment
= CBT with ERP
Moderate functional impairment
= Intensive CBT with ERP
OR
SSRI (continue for 12m after remission then taper off, higher dose in OCD of 60-80mg, use fluoxetine > sertraline)
-> IF after 12w of SSRI there is no response then try TCA (clomipramine) or alternative SSRI
-> Note: inform about side effects of SSRIs and how they shouldn’t suddenly stop it, and how initial anxiety can increase in starting, f/u soon after (1w)
Severe functional impairment = referral to psychiatrist\
Social: MIND, leaflets, help with school/job etc, manage comorbid depression
Whats the prognosis for OCD?
25% significantly improve, 50% have moderate improvement and 25% have chronic or worsening symptoms
NOTE: it is common (50%) to have co-morbid depression
What are 3 extreme stress reaction disorders? What are some key timeframe differences?
Acute stress disorder = onset from hours to days, doesn’t tend to persist past 1m
Adjustment disorder/Prolonged grief reaction = <1m of event, do not tend to persist past 6m
PTSD = Symptoms for >1m, within 6m of incident
