Anxiety Flashcards
what is anxiety?
“prolonged or exaggerated response to a real or imagined threat, which interferes with normal life and cannot be attributed to any known neurological or organic dysfunction”
what is the Pathophysiology of Anxiety
what are the mediators
If we consider the sensory and reaction pathways in the CNS responsible for processing threatening situations, we can see where the potential for dysfunction (and therapeutic interventions) lies (see Lecture 1 – CNS Intro, including limbic system).
Anxiety mediators: e.g. serotonin, noradrenaline, dopamine and GABA in CNS. Also PNS involvement
Symptoms can be e.g. behavioural, physiological, cognitive or affective
what are the clinical features - congnitive
Feelings of apprehension, tension, fear, panic or terror, being ‘on edge’
Labile mood, outbursts of hostility, irritability
Circling thoughts, inability to concentrate, easily distracted, lapses of memory
what are the clinical features somatic
Cardiovascular: palpitations, bradycardia or tachycardia; elevated blood pressure; flushing or pallor
Respiratory: rapid shallow breathing (hyperventilation) or breathlessness (dyspnoea)
Gastrointestinal: diarrhoea, dyspepsia, dysphagia, churning stomach
Musculoskeletal: agitation, restlessness, tremor, muscle tension
Metabolic: elevated blood glucose and glucocorticoids
Miscellaneous: excessive sweating, urge to defecate or urinate
Insomnia
what are the types of anxiety?
Generalised anxiety disorder (GAD)
Social phobia
Specific phobias
Obsessive compulsive disorder (OCD)
Panic disorder (PD)
Post traumatic stress disorder (PTSD)
what is the aetiology of anxiety?
Underlying cause of anxiety disorders not fully understood but likely risk factors may including genetic, environmental (including epigenetic), psychological and/or developmental factors
what is the Treatment aims and prognosis of anxiety?
Prognosis is generally good if the external stressor can be eliminated
Treatment aims to:
Discover cause and address/remove it
Assess the severity of the anxiety response
Relieve distress
Institute long-term measures to avoid same/related recurrence
Institute long-term measures in cases of chronic anxiety
what is the Psychological Treatments
Before looking at pharmacological interventions, we must consider psychotherapy as the principal means by which anxiety can be treated
Commonly used and effective approaches include:
Counselling
Cognitive behavioural therapy (CBT)
Exposure therapy
Mindfulness and relaxation training
what is the treatment for acute anxiety?
drug class
examples
moa
interactions
adverse effects
Benzodiazepines (e.g. lorazepam, alprazolam, diazepam)
Positive allosteric modulators of GABA binding to GABAA receptor
Fast-acting relief of severe anxiety (panic disorder, acute stress)
Sedative and hypnotic, reduce muscle tone and coordination
Amnesia
Drug interactions (pharmaco-dynamic & -kinetic)
Adverse effects
Toxicity in overdose (reverse by flumazenil, competitive antagonist)
Drowsiness, amnesia, confusion, impaired coordination, tolerance and dependence
Restrict use - only use if anxiety is severely disabling or leading to extreme distress, short-term (2-4 weeks)
Drugs to Treat Anxiety
SSRIs first line for many anxiety disorders
e.g. fluoxetine, escitalopram, paroxetine, sertraline, also SNRI (venlafaxine, duloxetine)
Useful/licensed in certain anxiety disorders but may need to adjust dose (compared to antidepressant). Recommended for long term therapy
Pregabalin (also for epilepsy, similar to gabapentin, MoA inhibition at auxillary a2d subunit of voltage-gated calcium channels, VGCC).
Can be used for GAD
Tricyclic antidepressants e.g. Clomipramine – obsessions, phobias
Common side effects (often muscarinic): dry mouth, dry nose, blurry vision, lowered gastrointestinal motility or constipation, urinary retention
Buspirone (hydrochloride) - 5-HT1A receptor partial agonist
Slow onset of action but no withdrawal effects
Generalised anxiety disorder short-term, acute anxiety
Side effects: nausea, dizziness, headache, restlessness
Beta blockers e.g. propranolol
Treats somatic symptoms. Useful for anxiety disorder with strong somatic symptoms e.g. social phobias, panic disorder
how can you diagnose general anxiety disorder (GAD)
As for depression, international diagnostic criteria can be used to aiddiagnosis, including both the DSM-V or ICD-11 criteria. Some overlap and some differences (see NICE CKS for GAD):
The DSM-V diagnostic criteria include:
Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events and activities
The individual finds it difficult to control the worry
Anxiety and worry are associated with 3 or more of the following symptomswith at least some symptoms having been present for more days than not for the past 6 months: restlessness/nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance
The anxiety, worry or physical symptoms cause significant distress or impairment in social, occupational or other areas of functioning
The disturbance is not attributable to physiological effects of a substance or another medical condition
The disturbance is not explained by another mental disorder
The ICD-11 diagnostic criteria include:
Marked symptoms of anxiety manifested by either general apprehensiveness that is not restricted to any particular environmental circumstance or excessive worry about negative events occurring in several different aspects of everyday life
Anxiety and general apprehensiveness or worry are accompanied by additional characteristic symptoms, such as: muscle tension or motor restlessness, sympathetic autonomic overactivity as evidenced by frequent gastrointestinal symptoms such as nausea and/or abdominal distress, heart palpitations, sweating, trembling, shaking, and/or dry mouth, subjective experience of nervousness, restlessness, or being ‘on edge’, difficulty concentrating, irritability, sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep).
The symptoms are not transient and persist for at least several months, for more days than not; are not better accounted for by another mental disorder (e.g., a Depressive Disorder); are not a manifestation of another medical condition (e.g., hyperthyroidism) and are not due to the effects of a substance or medication on the central nervous system
The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.
GAD-7 (questionare tool with 7 questions)
Scores of 5, 10, and 15 are taken as cut-off points for mild, moderate, and severe anxiety respectively.
what is the stepped care for GAD?
STEP 1: All known and suspected presentations of GAD
Identification and assessment; education about GAD and treatment options; active monitoring
STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care (for those without marked functional impairment – based on assessment of severity)
Low-intensity psychological interventions: individual non-facilitated self-help, individual guided self-help and psychoeducational groups
STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment
Choice of a high-intensity psychological intervention* (CBT/applied relaxation) or a drug treatment (typically SSRI sertraline) – see next slide
STEP 4: Complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm
Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from multi-agency teams, crisis services, day hospitals or inpatient care
what is the recommendation for pregnancy?
*in pregnancy, recommend psychological intervention as first line
what are the drug treatment for GAD?
Can be treated effectively with CBT or other psychological interventions
If drug therapy used, first line drug: SSRI e.g. sertraline*, escitalopram, paroxetine
*NICE recommends sertraline first-line (cost-effective, less interactions and risks than some other SSRIs, including discontinuation symptoms e.g., compared to paroxetine) but not licensed for this indication so needs consent. Escitalopram not for those with (or suspected) QT interval prolongation. Common side effects and interactions – see Lecture 2 and workshops
12 weeks then assess, possibly 6-12 months+
SNRIs also recommended alternatives e.g. duloxetine, venlafaxine
SSRIs and SNRIs – in a minority of those <30 yrs associated with increased risk suicidal ideation and self-harm
Pregabalin an option if SSRI/SNRIs not tolerated [Schedule 3 drug, also avoid in pregnancy unless benefit>risk]
Benzodiazepines only if necessary (typically not in primary care except in crisis)
Fast-acting, short-term relief, 2-4 weeks
e.g., Alprazolam, Lorazepam, Oxazepam, Diazepam
Buspirone hydrochloride, short-term use only (specialist)
what is STEP 3 Examples for Patient considerations: pharmacotherapy
Expected effects of drug prescribed (e.g. SSRI)
Gradual development of anxiolytic effect (1 week +)
Risk activation from SSRI/SNRIs (anxiety, agitation, insomnia)
Important to take as prescribed and continue after remission (1yr+) to avoid relapse
Potential side effectsof drug, interactions and withdrawal
Risk suicidal ideation
Monitoring
Follow-up: within 1 week, then every 2-4 weeks (3 months) then 3-monthly
Changes: Considered if no improvement, significant side effects, patient preference. If switching, many considerations (wash-out, interactions etc.) Refer to information Lecture 2/workshops such as tapering/switching from SSRIs
Note: If patient chose high-intensity psychological intervention but fails to improve, can offer drug therapy and vice versa. Can add non-pharmacological intervention if only partial improvement with drug therapy
