Anxiety Flashcards
What is anxiety?
Feeling when we are worried, tense or afraid – particularly about things that are about to happen, or which we think could happen in the future.
Anxiety is a natural human response when we feel that we are under threat. It can be experienced through our thoughts, feelings and physical sensations
3 types of symptoms associated with anxiety
Psychological, physical, behavioural
3 Main physiological symptoms for anxiety
- Restlessness
- Difficulty concentrating
- Irritability
3 Main physical symptoms for anxiety
- Fatigue
- Muscle aches and tension
- Insomnia
What are the 6 types of anxiety disorder?
- Generalized Anxiety Disorder (GAD)
- Panic Disorder
- Specific Phobias
- Social Anxiety Disorder
- Post-Traumatic Stress Disorder (PTSD)
- Obsessive Compulsive Disorder (OCD)
Which two anxiety disorders have been moved to their own category?
PTSD and OCD
3 things for diagnosis of anxiety
Most days for 6+ months
Significant distress or impairment in social, occupational or other important areas
Not due to general medical condition or substance.
What is the classic stress response?
HPA axis (hypothalamic-pituitary-adrenal)
Mechanism of HPA axis
- Hypothalamus send stress signal to the pituitary gland (through CRH hormone)
- Pituitary gland sends the ACTH hormone to the adrenal gland.
- This leads to adrenalin (cortisol) into the blood stream.
What is CRH hormone?
Corticotropin-releasing hormone
What is ACTH hormone?
Adrenocorticotropic hormone
What does release of cortisol cause? (8)
- Mobilisation of energy
- Increased cardiovascular tone
- Suppression of digestion
- Suppression of growth
- Suppression of reproduction
- Enhancement of immune system
- Sharpening of cognition, alertness and pleasure
- Suppression of sexual energy
What is the amygdala in the brain responsible for?
One of the main centres for reactions to threats, fear, and anxiety.
What is cortisol?
A stress hormone
What 3 structures in the brain interact to generate a response to a threat?
Amygdala
Hippocampus
Prefrontal cortex
What is the prefrontal cortex made up of?
Medial prefrontal cortex, anterior cingulate cortex
Which structures project to the hypothalamus to trigger the HPA axis?
Amygdala (main)
Hippocampus
4 types of treatment for anxiety
- Lifestyle change
- Self-help
- Psychotherapy
- Pharmacotherapy
What do you do it treatment are ineffective for anxiety?
- Increase doses
- Combine (treatment types)
- Switch meds
SSRIs
Selective Serotonin Reuptake Inhibitors
SNRIs
Serotonin Norepinephrine Reuptake Inhibitors
TCAs
Tricyclic antidepressants
MAOIs
Monoaminoxidase inhibitors
How do SSRIs work?
They block the serotonin transporter in the presynaptic serotonin neurone.
Example of SSRIs?
- Escitalopram/citalopram
- Fluoxetine
- Paroxetine
Advantages of SSRIs? (5)
- Effective against various types of anxiety disorders
- Long lasting effects
- Less addictive than benzodiazepines
- Potent antidepressants
- Fewer side effects
Disadvantages of SSRIs? (2)
- Delay period
- Health issues if taken with other drugs (alcohol, NSAID)
What is the delay period?
When the SSRI is started it causes increased anxiety and depression before decreasing.
How long is the delay period?
2 weeks
Mechanism of delay period
You initially get more serotonin in the synapse which binds to the serotonin 1a receptors (auto receptors).
This reduced activity of serotonin.
Mechanism of end of delay period
By continue blocking receptors they downregulate so the neurones go back to normal firing so the is more serotonin in the synapse.de
Main side effects of SSRIs (5)
- Insomnia/somnolence
- Nausea
- Dizziness
- Sexual dysfunction
- Serotonin syndrome (high doses)
What re other drug targets for anxiety?
- Noradrenaline reuptake transporter
- MOA-A enzyme
Frist line drugs for anxiety
SSRIs and SNRIs
Second line drugs for anxiety
TCAs and MAOIs
Third line drug for anxiety
Benzodiazepines
How does SNRI work?
Increases serotonergic and noradrenergic transmission.
Main side effects of SNRIs
Similar to SSRIs, but tend to have more probably due to lower specificity.
Examples of SNRIs
Duloxetine
Venlafaxine
What are TCAs antagonists of? (4)
- various 5-HT receptors
- α1 adrenergic receptor
- histamine receptor
- muscarinic cholinergic receptor
Example of TCAs
Clomipramine
Imipramine
Main side effects TCAs (7)
- Dry mouth
- Sedation
- Weight gain
- Constipation
- Dizziness
- Heart rhythm problems
- May give higher risk of developing dementia (anticholinergic effect)
Why do we boost serotonin for anxiety?
- Thought to promote neuroplastic (brains ability to recognise in structure and function)
- More likely to resist anxiety
- Flexibility so brain is more capable of changing (also noradrenaline)
How does benzodiazepine work?
Targets GABA A receptor.
Increase chloride in the neurone so increase inhibition and depression of the nervous system.
Benzodiazepine binding site
It binds between the alpha and gamma subunit on GABA A receptor.
Benzodiazepines advantage
Quick onset
Benzodiazepines disadvantage (long term use)
- Highly addictive
- Withdrawal symptoms
- Impaired cognitive functions
6 things to consider for anti-anxiety drugs
- Particular symptoms
- Side effects (vary from person to person)
- Whether one drug worked for a close relative
- Interaction with other medications
- Pregnancy or breast-feeding
- Other health conditions
What are the 3 main pharmacological for anxiety?
serotonin, noradrenaline and GABA system
What tools may be used for the diagnosis of anxiety?
DSM-V
ICD-10
GAD-7
Anxiety diagnosis? (Step 1 of management)
- Assess severity (using GAD-7)
- Ask about comorbid factors and environmental stressors
- Consider mental health history
Step 1 of anxiety management?
Educate about GAD and treatment options
Active monitoring
Step 2
Low intensity psychological intervention: CBT
individual non-facilitated self-help
individual guided self-help
psychoeducational groups
Step 3
High intensity psychological intervention: CBT, applied relaxation or drug therapy
Drug therapy:
–1st line SSRI, e.g. sertraline, paroxetine, escitalopram, or SNRI, e.g. duloxetine, venlafaxine
–Discuss adverse effects and withdrawal
–Review every 2-4 weeks for first 3 months and then every 3 months
NB. < 30yrs old SSRIs increase risk of suicidal thinking and self-harm
Step 4
Refer for specialist treatment
In Primary care: self-care advice – sleep hygiene
