Anxiety disorders

Overview of anxiety disorders

Anxiety forms part of our fear response, a normal emotional experience and crucial for survival. We all experience anxiety symptoms on a regular basis, such as worrying about passing MRCP Part II or having intrusive thoughts about having left the stove on. However, these symptoms form part of a “disorder” when they cause significant distress and/or are severe enough to interfere with daily functioning.

Panic disorder

A panic attack is an acute episode of intense fear which develops quickly and reaches its peak in approximately 10 minutes. It rarely lasts more than an hour. It may be out of the blue, triggered by specific situations, or occur during sleep. It is characterised by both physical and cognitive symptoms of anxiety.

Panic disorder describes when panic attacks occur repeatedly and are not due to psychiatric or medical conditions or substance misuse.

Epidemiology and aetiology of panic disorder

Panic attacks are common, with a lifetime prevalence of 5-10%. Fewer meet the criteria for panic disorder. There are two incidence peaks, at 15-24 and 45-54 years.

Risk factors include family history, female gender, Caucasian ethnicity, being widowed, divorced or separated, urban living, lower educational attainment, early loss of a parent, and being a victim of physical or sexual abuse.

Presentation and diagnosis of panic disorder

Common features of a panic attack are palpitations, tachycardia, dyspnoea, trembling, chest pain, gastrointestinal upset, presyncope, paraesthesia, fear of losing control, and fear of impending harm or death. Patients may repeatedly present to medical services. There is a risk of impulsive suicide or self harm as a coping mechanism.

For panic disorder to be diagnosed, attacks must recur over a period of at least 1 month. There may be avoidance behaviours to evade triggering situations.

Usually, the history is sufficient to make a diagnosis. Organic causes may need to be ruled out with ECG, blood glucose, thyroid function tests and drug testing.

Management of panic disorder

Cognitive behavioural therapy (CBT) is first line, with the potential addition of a selective serotonin reuptake inhibitors (SSRI) (e.g. sertraline) or serotonin noradrenaline reuptake inhibitors (SNRI) (e.g. venlafaxine) for longer-term management. Second line is an alternate antidepressant such as a tricyclic antidepressant (TCA), monoamine oxidase inhibitor (MAOI) or bupropion, although these are rarely used.

Benzodiazepines are not recommended by NICE but can be used as an acute treatment or as an interim measure whilst an antidepressant is taking effect.

Generalised anxiety disorder (GAD)

Generalised anxiety disorder is characterised by a global sense of worry and fear regarding everyday events, disproportionate to any inherent risk. It presents with both cognitive and somatic symptoms and causes significant distress and functional impairment.

Epidemiology and aetiology of GAD

GAD is also common, with a lifetime prevalence of roughly 5%. Incidence peaks in middle age.

Risk factors include female gender (especially for early onset), stressful events, being single, dysfunctional relationships and unemployment. It has a genetic component, sharing heritability with depression. Patients may have psychological vulnerabilities such as insecure attachment to primary caregivers, intolerance of uncertainty, or have received parenting which is overprotective or lacking warmth.

Presentation and diagnosis of GAD

In GAD, significant anxiety symptoms are present most days for at least 6 months. There may be either generalised apprehension (“free-floating” anxiety) or excessive worry related to daily events. This is accompanied by somatic symptoms such as muscle tension, restlessness, sympathetic overdrive (e.g. dry mouth, palpitations, sweating), or gastrointestinal upset. Sleep and concentration are often impaired.

Commonly used screening tools include the Hamilton Anxiety Rating Scale (HAM-A) and the Generalised Anxiety Disorder 7 (GAD-7) self-scoring tool.

Symptoms must not be caused by another condition, such as hyperthyroidism, phaeochromocytoma, lung disease, caffeine or cocaine use, or alcohol or benzodiazepine withdrawal. As such, thyroid function tests, urine drug screen, 24-hour urine metanephrines, pulmonary function tests and ECG may be needed. Medications can also cause anxiety symptoms such as commonly used salbutamol and thyroxine.

Management of GAD

NICE recommends patient education and low-intensity psychological interventions such as guided self help as first-line treatment. If response is inadequate or there is marked functional impairment, high-intensity psychological intervention such as CBT or drug treatment is indicated.

An SSRI would be the first-line medication, followed by an SNRI if ineffective, or pregabalin as a third-line option. Benzodiazepines are only to be used as a short-term measure in a crisis.

Beta blockers such as propranolol are commonly used for somatic symptoms.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder is a common, chronic condition characterised by obsessions and compulsions.

An obsession is an unwanted, unpleasant and intrusive thought, mental image or impulse which the patient recognises as abnormal. Obsessions lead to a compulsion, which is a stereotyped behaviour that neutralises the obsession and provides relief.

Epidemiology and aetiology of OCD

OCD affects up to 3% of the population. Men and women are equally affected. It affects younger people more commonly, with an average age of 20 years at diagnosis.

Risk factors include family history, comorbid depressive or anxiety disorders, alcohol or substance misuse, and certain personality traits, e.g. avoidant, dependent, or histrionic. OCD is also associated with schizophrenia, Sydenham’s chorea, and Tourette’s syndrome.

Presentation and diagnosis of OCD

Obsessions and compulsions must be time consuming (taking more than an hour per day) or result in significant distress or functional impairment.

Common obsessions include contamination, symmetry, safety and sexual or violent thoughts. Common compulsions include checking (e.g. doors), cleaning, counting, and hoarding.

Management of OCD

If functional impairment is mild, first-line treatment is low-intensity psychological treatments such as CBT. If not suitable or ineffective, an SSRI and/or intensive CBT should be offered. Clomipramine (a TCA) is an alternative to SSRIs, although not commonly used.

Other antidepressants such as TCAs (except clomipramine), SNRIs or MAOIs should not be used unless there is a comorbid anxiety or depressive disorder.

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. icd.who.int. World Health Organization; 2019 [cited 2022 Feb 23]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• Sawchuck C, Veitengruber J. Panic disorders – Symptoms, diagnosis and treatment [Internet]. BMJ Best Practice; 2021 [cited 2022 Feb 23]. Available from: https://bestpractice.bmj.com/topics/en-gb/121
• The National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults [Internet]. NICE, 2019. [cited 2022 Feb 23] Available from: https://www.nice.org.uk/guidance/cg113
• Gale C. Generalised anxiety disorder [Internet]. BMJ Best Practice; 2021. [cited 2022 Feb 23] Available from: https://bestpractice.bmj.com/topics/en-gb/120
• Seibell P. Obsessive-compulsive disorder [Internet]. BMJ Best Practice; 2021 [cited 2022 Feb 24]. Available from: https://bestpractice.bmj.com/topics/en-gb/362
• The National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder [Internet]. NICE; 2005. [cited 2022 Feb 23] Available from: https://www.nice.org.uk/guidance/cg31

Bipolar affective disorder

Overview of bipolar disorder

Bipolar disorder is a common but variable illness in which episodes of mania and depression typically alternate, with periods of remission. Depressive episodes usually predominate. However, it often does not present as described in textbooks; hypomania, mixed episodes, an absence of depressive episodes, and prolonged residual symptoms of mania or depression are also common.

Epidemiology and aetiology of bipolar disorder

Risk factors for bipolar disorder

It is more common in those with a family history of bipolar disorder or a personal history of depressive illness (especially in childhood or adolescence). As with many mental illnesses, adverse life events and concurrent alcohol or substance misuse increase the risk.

Medication-induced mania

Medications can cause or increase the risk of mania or hypomania, both in patients with established bipolar disorder and those who are yet to experience their first mood episode. Antidepressants are the most typical cause; TCAs and SNRIs, e.g. venlafaxine, are particularly culpable. SSRIs and bupropion are less likely to cause mania but it is still seen.

Other psychotropic medication causes include benzodiazepines (a paradoxical reaction), lithium, and stimulants, e.g. dexamfetamine (used in attention deficit hyperactivity disorder, ADHD).

Medications used in other health conditions can also induce mania, such as Parkinson’s treatment, steroids, propranolol, salbutamol and TB treatment.

Presentation and diagnosis of bipolar disorder

Bipolar disorder requires two mood episodes, at least one of which is manic, hypomanic or mixed (see below), with full recovery between them.

Mania

A manic episode is an elevated mood state lasting at least one week (unless treated). It presents with elation, irritability or expansive mood, with features such as increased energy, increased self-esteem and grandiose ideas, reduced sleep, and impulsivity. There may be pressured or rapid speech and flight of ideas.

As with any mental disorder, there is disruption of occupational, social and/or interpersonal functioning. This may lead to poor self-care, such as poor oral intake and maintenance of living conditions.

When more severe, mania can present with psychotic symptoms, which are usually consistent with the person’s mood. Grandiose ideas may become delusions, for example involving special powers or abilities. Similarly, paranoid ideas may develop into persecutory delusions.

Psychiatric differential diagnoses include anxiety disorders, ADHD, personality disorder and alcohol or substance misuse. Organic illness can also cause manic features, such as hyperthyroidism, Cushing’s, encephalopathies and epilepsy. These must be considered and investigated with blood tests, brain imaging and EEG as appropriate.

Hypomania

This is a milder version of mania, whereby symptoms are less severe and do not cause occupational and social dysfunction. The minimum length of an episode is four days. By definition, hypomania does not lead to hospital admission or involve psychotic features.

Depressive episodes

Depressive episodes in bipolar affective disorder present in a similar fashion to a unipolar depressive disorder. This often leads to misdiagnosis.

Mixed episodes

In mixed bipolar episodes there are both manic and depressive features for at least two weeks. Mixed episodes typically present as depression with overactivity, mania with reduced energy, dysphoria with manic symptoms, and rapid cycling between manic and depressive symptoms.

Management of bipolar disorder

Management of acute mania or hypomania

NICE recommends an antipsychotic as first-line treatment of acute mania or hypomania: haloperidol, olanzapine, quetiapine or risperidone. Another of these can be trialled if the first is not effective or tolerated.

Second and third-line options are lithium and valproate respectively. If the patient already takes lithium, plasma levels should be taken to ensure they are within range.

For severe, treatment-resistant mania, electroconvulsive therapy (ECT) may be considered.

Management of bipolar depressive episodes

In bipolar depression, psychological interventions such as CBT should be offered. If the depressive episode is moderate or severe and the patient is not taking any medications, NICE recommends fluoxetine with olanzapine (as a mood stabiliser) or quetiapine (has antidepressant and mood-stabilising qualities).

Antidepressants should not be given alone in bipolar; a mood stabiliser is needed to reduce the risk of manic relapse.

Maintenance therapy for bipolar disorder

NICE advises that drugs effective in the acute phases of bipolar should be considered for long-term treatment. Antidepressants must not be given without a mood stabiliser.

Lithium is the most effective long-term treatment, and switching to it should be considered for all patients if not contraindicated. Valproate and olanzapine are second-line long-term mood stabilisers.

Structured psychological treatment such as individual, group or family therapy is also recommended.

Lithium

Lithium is the gold standard for long-term management of bipolar disorder. However, it has a narrow therapeutic window and is associated with several significant adverse effects.

It can also be used to augment the effects of antidepressants in treatment-resistant depression.

Lithium monitoring and target levels

Prior to starting lithium, BMI, FBC, U&Es, calcium, and TFTs are required in all patients. An ECG is required for patients with cardiovascular disease or those at high risk. Whilst on treatment, BMI, U&Es, calcium, and TFTs need to be monitored every 6 months (more frequently if abnormal).

Lithium levels must be checked 5 days after starting or changing the dose (12 hours post-dose). Once established, levels should be checked every 3 months for the first year, and 6 monthly thereafter, or 3 monthly for patients over 65, those taking interacting medications, with impaired renal or thyroid function, or with poor adherence.

Adverse effects of lithium

Short-term adverse effects include polyuria and polydipsia (due to ADH antagonism leading to nephrogenic diabetes insipidus), weight gain, cognitive impairment, fine tremor, GI upset and benign leucocytosis. Benign ECG changes or exacerbation of existing arrhythmias may occur.

Long-term adverse effects include renal impairment, hyperparathyroidism (and thus hypercalcaemia) and hypothyroidism.

Lithium is teratogenic; it is classically associated with Ebstein’s anomaly of the tricuspid valve.

Drug interactions with lithium

Drug interactions can rapidly lead to toxicity or reduced efficacy (and relapse).

ACE inhibitors, angiotensin II receptor antagonists, NSAIDs, and diuretics are important and common causes of increased plasma concentration, due to lithium being excreted wholly renally in an unchanged form. Antacids and theophylline can decrease the plasma concentration.

When given with amiodarone, it increases the risk of hypothyroidism.

Lithium toxicity

Early clinical features include coarse tremor, anorexia, nausea and vomiting, diarrhoea and fatigue. As the level increases, severe complications develop such as myoclonus, hypertonia, drowsiness, confusion, cardiovascular collapse, seizures and coma. Neurological damage may be permanent.

Lithium toxicity requires urgent IV isotonic saline and possibly haemodialysis.

Lithium toxicity

Early clinical features include coarse tremor, anorexia, nausea and vomiting, diarrhoea and fatigue. As the level increases, severe complications develop such as myoclonus, hypertonia, drowsiness, confusion, cardiovascular collapse, seizures and coma. Neurological damage may be permanent.

Lithium toxicity requires urgent IV isotonic saline and possibly haemodialysis.

Sodium valproate

Valproate is licensed for acute mania and is also commonly used (unlicensed) for long-term prophylaxis.

It should not be offered to females of childbearing age unless other options are inappropriate, ineffective or not tolerated and a pregnancy prevention programme is in place.

Adverse effects of valproate

Dose-related adverse effects include GI upset, deranged LFTs, tremor and sedation. Leucopaenia, thrombocytopaenia, alopecia, weight gain, and pancreatitis are non dose-related adverse effects.

Like lithium, it has a narrow therapeutic window and thus toxicity can occur with high plasma levels; hypersomnolence, atrioventricular block, coma and death are seen.

Valproate monitoring

FBC, LFTs and BMI should be checked prior to starting then 6 monthly. An ECG should be done at initiation.

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. World Health Organization; 2019 [cited 2022 Mar 3]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• Selvaraj S. Bipolar disorder in adults [Internet]. BMJ Best Practice; 2020 [cited 2022 Mar 7]. Available from: https://bestpractice.bmj.com/topics/en-gb/488
• National Institute for Health and Care Excellence. Bipolar disorder [Internet]. NICE; 2020 [cited 2022 Mar 7]. Available from: https://www.nice.org.uk/guidance/cg185
• Joint Formulary Committee. British National Formulary. Lithium Carbonate [Internet]. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2020 [cited 2022 Mar 9]. Available from: https://bnf.nice.org.uk/drug/lithium-carbonate.html
• Joint Formulary Committee. British National Formulary. Sodium Valproate [Internet]. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2019 [cited 2022 Mar 10]. Available from: https://bnf.nice.org.uk/drug/sodium-valproate.html

Depressive disorders

Overview of depressive disorders

Depressive disorders are common, underdiagnosed, and an important cause of disability and time off work. They are a leading contributing factor for suicide and increase the morbidity and mortality associated with pre-existing organic illnesses such as myocardial infarction.

Epidemiology and aetiology of depressive disorders

Around 10-20% of the population will experience a depressive episode during their lifetime. Incidence is increasing in the younger population, and although prevalence is higher in females, it is believed that males are underdiagnosed.

Risk factors include family history of depressive or anxiety disorders, adverse childhood or adult experiences (in particular loss events), anxious personality, divorce, low socioeconomic status, and unemployment. Those with chronic, severe or painful organic illness are also more likely to develop a depressive disorder. Concurrent psychiatric illness is common, such as anxiety disorders, substance or alcohol misuse, or personality disorders.

Presentation and diagnosis of depressive disorders

Core and additional symptoms

The triad of core depressive symptoms is low mood, anergia and anhedonia (lack of enjoyment).

Additional symptoms include poor concentration, feelings of worthlessness or hopelessness, suicidal ideation, increased or decreased sleep, and decreased appetite. Depression can present with cognitive impairment (pseudodementia), which can cause diagnostic uncertainty in the older population.

Core and additional symptoms of depression can be quantified with the Hospital Anxiety and Depression Score (HADS).

Symptoms must be present for most of the day, on most days, for a period of at least 2 weeks to diagnose a depressive episode. If this occurs more than once, with resolution in between, it is a recurrent depressive disorder.

Psychotic symptoms

Depressive disorders can present with psychotic symptoms, usually only when severe. These tend to be congruent with mood. Delusions may be nihilistic, such as Cotard’s, where the individual believes that they are dead, non-existent, lacking in organs or blood, or rotting. There may be hallucinations, such as auditory hallucinations of criticising voices, olfactory hallucinations of unpleasant smells, or visual hallucinations of the devil.

Subtypes of depressive disorders

Depressive episodes are categorised according to severity (as determined by the number of core and additional symptoms), presence of somatic symptoms, and presence of psychotic symptoms. There may be accompanying symptoms of anxiety, leading to a diagnosis of depression with anxiety.

Depressive disorders also include the milder, subclinical syndromes of cyclothymia and dysthymia. Cyclothymia is a milder version of bipolar affective disorder in which high and low episodes occur but do not meet diagnostic criteria for mania or bipolar depression. Dysthymia is a milder version of recurrent depressive disorder in which low episodes occur without meeting diagnostic criteria for a depressive episode.

Differential diagnoses

Other psychiatric disorders can present similarly to depression such as adjustment disorder, post-traumatic stress disorder, anxiety disorders, eating disorders and personality disorders. The key in differentiating between them is the time course and predominance of certain features.

Organic illnesses are also important differential diagnoses. Common mimics include anaemia, dementia, Parkinson’s, stroke, Addison’s disease, hypothyroidism, menopause, hypercalcaemia, and sleep apnoea. As such, a thorough history and examination are essential, with consideration of investigations including FBC, U&Es, LFTs, TFTs, B12, folate, glucose, bone profile and morning cortisol.

Medications can also cause depressive symptoms, such as beta blockers, steroids, sedatives, interferon, oestrogen and antipsychotics. Recreational drugs such as alcohol, cannabis, cocaine and amphetamines can also be responsible.

Management of depressive disorders

Management of an acute depressive episode

First line for an acute mild-to-moderate depressive episode is a low-intensity psychological intervention, e.g. CBT.

If the response is inadequate, the symptoms have been mild but long lasting, or the episode is moderate to severe, NICE recommends high-intensity psychological interventions and antidepressant treatment.

Usually, an SSRI (e.g. sertraline) is first line. If ineffective, another SSRI (e.g. fluoxetine) may be trialled, then another class, such as an SNRI (e.g. venlafaxine). Switching antidepressants should be done cautiously and under specialist guidance due to the risk of serotonin syndrome.

In the initial period of antidepressant treatment suicide risk may increase due to improved energy and motivation.

For treatment-resistant depressive episodes, NICE recommends combination therapy with either two antidepressants (commonly mirtazapine and venlafaxine) or an antidepressant with lithium or an antipsychotic. The choice of agent is usually determined by the symptoms and what the patient has responded to in the past; for example, with psychotic symptoms, one might preferentially use an antipsychotic for augmentation.

For depressive disorders which are highly treatment-resistant and/or posing a threat to life (e.g. through poor oral intake), ECT is an important and effective management option.

Maintenance therapy for depressive disorders

NICE recommends at least 6 months of antidepressant treatment on recovery to reduce the risk of relapse or 2 years if there is a higher risk. Cessation of therapy should be gradual due to the risk of discontinuation syndromes. Lifelong treatment may be considered, especially if the episode was severe and/or this is the patient’s preference.

ECT is only recommended by NICE as treatment of acute depressive episodes, not as maintenance therapy.

Antidepressants

An oversimplified and commonly understood mechanism of action of all antidepressants is by increasing monoamine availability (serotonin, noradrenaline and dopamine).

Class	Examples	Clinical features
Selective serotonin reuptake inhibitor (SSRI)	Sertraline, fluoxetine, citalopram, paroxetine	Better tolerated and lower risk with overdose than TCAs. Common adverse effects: nausea, GI upset, headache, restlessness, insomnia and sexual dysfunction.
Serotonin noradrenaline reuptake inhibitor (SNRI)	Venlafaxine, duloxetine	Duloxetine is also used for chronic pain and urinary incontinence. Common adverse effects: nausea, GI upset, constipation, insomnia, sexual dysfunction and agitation.
Noradrenergic and specific serotonergic antidepressant (NaSSA)	Mirtazapine	Has sedating properties, so useful in patients with insomnia. Common adverse effects: increased appetite and weight gain.Less likely to cause GI upset or sexual dysfunction than SSRIs or SNRIs.
Tricyclic antidepressant (TCA)	Amitriptyline, clomipramine	No longer commonly used due to adverse effects (e.g. anticholinergic, postural hypotension, weight gain) and toxicity in overdose.
Monoamine oxidase inhibitor (MAOI)	Moclobemide	No longer commonly used due to adverse effects, e.g. hypertensive crisis after ingesting tyramine-rich foods and drug interactions.
Serotonin antagonist/reuptake inhibitor	Trazodone	Has sedating properties, so useful in patients with insomnia.
Melatonin agonist and specific serotonin antagonist (MaSSA)	Agomelatine (newer)	Liver function needs to be monitored before and during therapy.
Over the counter	St John’s wort	Not commonly used due to enzyme induction and the risk of serotonin syndrome.

Table 1 Common examples of antidepressants by class with key clinical features

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. WHO; 2019 [cited 2022 Mar 12]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• National Institute of Health and Care Excellence Depression in adults [Internet]. NICE; 2009 [cited 2022 Mar 12]. Available from: https://www.nice.org.uk/guidance/cg90
• MacKinnon D. Depression in adults [Internet]. BMJ Best Practice; 2021 [cited 2022 Mar 12]. Available from: https://bestpractice.bmj.com/topics/en-gb/55

Eating disorders

Anorexia nervosa

Presentation and diagnosis of anorexia nervosa

To make the diagnosis, a threshold of BMI <18.5 or rapid weight loss (>20% within 6 months) is used.

A typical pattern of behaviour prevents restoration of normal BMI: reduction of energy intake (restricted diet, purging with laxatives or vomiting, appetite suppressants) and increase in energy use (excessive physical activity). These features can be screened for using the SCOFF questionnaire.

Physical signs include sarcopaenia, dry skin, brittle hair and nails, Russell sign (thickened skin over the knuckles due to trauma from induced vomiting), hypothermia, pallor and swelling of the parotid and submandibular glands.

In order to investigate physical complications, the following investigations are recommended:

• FBC (anaemia, low platelets, leucopaenia)
• U&Es (raised urea, raised creatinine, low sodium and potassium)
• Bone profile (low phosphate and calcium)
• Magnesium (low)
• Bicarbonate (acidosis from laxative abuse or alkalosis from vomiting)
• LFTs (raised)
• Glucose (low)
• TFTs (low T3 and T4)
• ECG (sinus bradycardia, prolonged QTc, ischaemia, arrhythmia, complications of electrolyte derangement)

Physical illnesses such as brain tumours, Crohn’s and malabsorption disorders may mimic anorexia. Poor appetite may be caused by drugs, e.g. SSRIs. Depressive disorders or OCD can present similarly or may be concomitant.

Complications of anorexia nervosa

There is significant mortality; two thirds of cases due to physical complications, and one third suicide.

The physical health complications are widespread (Table 2). Cardiac complications are the most common cause of death, including bradycardia, hypotension, QT prolongation and cardiomyopathy. Amenorrhoea and infertility are seen in women due to hypothalamic dysfunction. Osteopaenia due to low progesterone and IGF-1 is common.

Neurology	Cognitive impairment, difficulties concentrating, peripheral neuropathy
Endocrinology and reproduction	Amenorrhoea, low birthweight of child, infertility
Dermatology	Dry skin, alopecia, lanugo hair
Gastroenterology	Slowed gastrointestinal transit, constipation
Cardiology	Hypotension, cardiomyopathy, QTc prolongation, bradycardia, arrhythmias
Musculoskeletal	Osteoporosis/osteopaenia, myopathy
Haematology	Anaemia, thrombocytopaenia, leucopaenia, neutropaenia (with increased infection risk)
Nephrology	Kidney stones, chronic kidney disease, acute kidney injury
Metabolic	Hypothermia, low blood potassium, sodium, and glucose

Table 2 Physical health complications of anorexia nervosa

Management of anorexia nervosa

Most cases are treated in the community with simple measures, including psychoeducation, monitoring of weight, involvement of family members, dietary counselling and eating disorder-focused CBT. Medication may be used as an adjunct, as per the individual’s psychopathology (e.g. an antidepressant for depressive symptoms).

Electrolytes should be closely monitored whilst restoring BMI, as the risk of refeeding syndrome is significant.

Admission to hospital may be required if outpatient treatment is unsuccessful, physical health complications pose a threat to life, there is severe or rapid weight loss, psychotic features are present, or if there is a high suicide risk.

Bulimia nervosa

Presentation and diagnosis of bulimia nervosa

In contrast to anorexia, bulimia nervosa is associated with a personal or family history of obesity.

Its characteristic features are episodes of binge eating with compensatory behaviours to restrict weight gain, similar to those seen in anorexia nervosa. These are frequent and recurrent, at least once a week for more than a month. If the compensatory behaviours are not present, it is termed binge eating disorder.

The symptoms must not meet the diagnostic requirements for anorexia nervosa (BMI <18.5); in this case, it is termed anorexia nervosa binge-purge pattern.

The physical signs are similar to those of anorexia nervosa but usually less severe.

Management of bulimia nervosa

The management is similar to that of anorexia nervosa, with consideration of self-help programmes or eating disorder-focused CBT. As in anorexia nervosa, medication may be used as an adjunct, as per the individual’s psychopathology (e.g. an antidepressant for depressive symptoms).

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. WHO; 2019 [cited 2022 Mar 17]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• National Institute for Health and Care Excellence. Eating disorders [Internet] NICE; 2020 [cited 2022 Mar 17]. Available from: https://www.nice.org.uk/guidance/ng69/chapter/Recommendations
• Attia E, Walsh BT. Anorexia nervosa [Internet]. BMJ Best Practice; 2021 [cited 2022 Mar 17]. Available from: https://bestpractice.bmj.com/topics/en-gb/440
• Safer D. Bulimia nervosa [Internet]. BMJ Best Practice; 2021 [cited 2022 Mar 17]. Available from: https://bestpractice.bmj.com/topics/en-gb/441
• Oxford University Press. Physical Consequences of Anorexia Nervosa. Oxford Handbook of Psychiatry. 2019 

Phobias and stress disorders

Phobias

Overview of phobias

Phobias are recurrent, excessive (disproportionate) and irrational fears with anxiety symptoms regarding specific objects or situations. They often lead to avoidance behaviours.

For a phobia diagnosis, symptoms must last for at least several months and be severe enough to cause significant distress and impairment in interpersonal, social and/or occupational functioning.

In general, first-line treatment is with CBT and may include exposure therapy (graded desensitisation) and relaxation training. Pharmacological measures may also be needed, including SSRIs or SNRIs. Beta blockers can be used as required for somatic anxiety symptoms (particularly in social phobia). Benzodiazepines are used for short-term treatment only, such as to help engage with exposure therapy.

Specific phobias

In specific phobias, a simple object or situation, or anticipation of its exposure, is the subject of the phobia. This is in contrast to “complex” phobias such as agoraphobia or social phobia. 

The most common subjects are spiders (arachnophobia), snakes (ophidiophobia) and heights (acrophobia).

Agoraphobia

Agoraphobia is an anxiety disorder characterised by anxiety symptoms in places which are difficult to leave, such as crowded or public spaces, with active avoidance of these situations. There are fears regarding specific negative outcomes such as incapacitation, panic attacks, or embarrassing events.

There is an overlap of aetiological factors, clinical features, and effective treatments with panic disorder.

Social phobia

Social phobia is also known as social anxiety disorder.

The patient has severe anxiety symptoms in specific social situations, such as meeting strangers, public speaking or eating in front of others. There are preoccupations that the individual will be negatively perceived by others due to how they come across. These social situations are either avoided or endured with intense anxiety symptoms.

There is a high rate of concomitant anxiety disorders, depressive disorders and substance misuse.

Stress disorders

Acute stress reaction

This is a temporary experience with a quick onset and resolution. It occurs as a result of severe stress, which typically threatens the security or safety of the individual or someone close to them, such as natural disasters, war, sexual or physical violence, and witnessing death or injuries of others.

It is a syndrome of transient emotional, physical, cognitive and/or behavioural symptoms, including autonomic anxiety symptoms (e.g. tachycardia), confusion, low mood, anxiety, social withdrawal, dissociation, and stupor. The response to the stressor occurs within an hour and subsides within a few days of removal from exposure. If removal is not possible, symptoms reduce in intensity within a month.

Due to the short natural history of acute stress reaction, management is typically supportive until resolution.

Acute stress disorder

Acute stress disorder is a continuation of the acute stress reaction, with a larger role of dissociative symptoms. It is more common with particular stressors, such as witnessing mass shootings, assault, and involvement in a road traffic accident, and in those with concomitant psychiatric disorders, substance misuse and a history of trauma.

Onset of symptoms is within 4 weeks of the stressor and persists for up to another 4 weeks. After this, the diagnosis changes to post-traumatic stress disorder.

Brief psychological interventions such as CBT may reduce the risk of developing post-traumatic stress disorder or other chronic problems. 

Post-traumatic stress disorder (PTSD)

PTSD is a significant psychological disturbance following a traumatic incident or incidents which may have occurred recently or many years before (although usually within 6 months). The incident must be severe in its intensity, such as exposure to actual or threatened death, serious injury or sexual violence. The individual may have experienced, witnessed, or learned about the incident.

Archetypal symptoms of post-traumatic stress disorder are:

• Involuntary reliving the traumatic event(s) via intrusive thoughts, flashbacks, or nightmares
• Avoidance of thoughts, activities or situations which are associated with the event(s)
• Persistent “hypervigilance” with increased perception of threat and exaggerated startle reaction

In addition to these core symptoms, low self-esteem, hopelessness, emotional dysregulation, and emotional numbness are commonly seen. Medically unexplained symptoms may be present.

Symptoms must last for at least a few weeks and impede social, occupational and/or interpersonal functioning.

NICE recommends trauma-focused psychological treatments, including trauma-focused CBT and eye movement desensitisation and reprocessing (EMDR). Antidepressants (SSRI, SNRI) may be considered along with patient preference or if psychological treatments are awaited or ineffective. Sleep is often disrupted, so short courses of hypnotic medications such as zopiclone may be required.

Adjustment disorder

Adjustment disorder is a variant of PTSD where the reaction is similar but milder in intensity, with functional impairment. The precipitating stressor is usually less severe in nature, such as divorce, loss of a job, or diagnosis of an illness. Another distinction is that the symptoms resolve within 6 months. Adjustment disorder carries a significant risk of suicide and deliberate self-harm, especially in younger patients.

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. WHO; 2019 [cited 2022 Mar 17]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• Huberman A. Phobias [Internet]. BMJ Best Practice; 2022 [cited 2022 Mar 21]. Available from: https://bestpractice.bmj.com/topics/en-gb/693
• NHS. Phobias [Internet]. NHS UK. NHS; 2021. Available from: https://www.nhs.uk/mental-health/conditions/phobias/
• Hoskins M, Lewis C. Post-traumatic stress disorder [Internet]. BMJ Best Practice; 2022 [cited 2022 Mar 28]. Available from: https://bestpractice.bmj.com/topics/en-gb/430
• National Institute for Health and Care Excellence. Post-traumatic Stress Disorder [Internet]. NICE; 2020 [cited 2022 Mar 28]. Available from: https://cks.nice.org.uk/topics/post-traumatic-stress-disorder/