Anxiety Flashcards
Anxiety disorders
Severe, excessive, persistent anxiety and irrational fears that impairs functioning
_____, a temporal lobe structure, plays a critical role in assessment of fear stimuli and learned response to fear.
Amygdala
“Fear circuit” and symptoms are regulated by the _____.
Amygdala
“Worry circuit” and symptoms are regulated by ________.
Cortico-striatal-thalanic-cortical (CSTC) loop
Defence System originates in _____, responsible for _____ responses, responds to both ____________ threats.
Amygdala
Fear, fight or flight
Learned & unlearned
Behavourial Inhibition System is based in ________, responsible for _________.
Hippocampus & septum of limbic system
Avoidance behaviour
In response to threat or fearful situations, the ____ serves as an alarm centre, activating ____ release and stimulating the sympathetic and parasympathetic nervous system.
Locus ceruleus (LC)
NE
Which neurotransmitters are dysregulated in anxiety?
NE
5HT
GABA
GABA is a major _____ neurotransmitter, with strong regulatory or inhibitory effect on __, __, __ systems.
Inhibitory
5-HT, DA, NE
Medications that reduce anxiety and produce sedation target the _____ receptor.
GABAA
When GABA binds to the GABAA receptor, neuronal excitability is _______.
Reduced
How is 5HT involved in Neurochemical dysregulation?
Pathological fear/anxiety is related to over-activation of the amygdala. However, the amygdala receives input from serotonergic neurons which can inhibit its outputs.
Generalised Anxiety Disorder (GAD)
Excessive anxiety and worries >6 months
Panic Disorder (PD)
Anticipatory anxiety of recurrent panic attacks
Social Anxiety Disorder (SAD)
Fear of being scrutinized or humiliated by others in public
Medical conditions associated with anxiety (1)
CVD - Angina, arrhythmias, CHF**, ischemic heart disease, myocardial infarction
Medical conditions associated with anxiety (2)
Metabolic - Cushing’s disease, hyperparathyroidism, hyperthyroidism**, hypoglyceamia, hyponatraemia, hyperkalaemia, pheochromocytoma, vitamin B12 or folic acid deficiencies
Medical conditions associated with anxiety (3)
Neurologic - Dementia, delirium, migraine, PD, seizures, stroke, neoplasms, inadequate pain control
Medical conditions associated with anxiety (4)
Pulmonary - Asthma, COPD, PE, pneumonia
Medical conditions associated with anxiety (5)
Others - Anemias, systemic lupus erythematosus, vestibular dysfunction
Drug-induced anxiety (1)
Sympathomimetics** - Pseudoephedrine
Drug-induced anxiety (2)
Stimulants** - Amphetamines, Methylphenidate, Cocaine
Drug-induced anxiety (3)
Methylxanthines - Theophylline, caffeine
Drug-induced anxiety (4)
Thyroid hormone - Levothyroxine**
Drug-induced anxiety (5)
Corticosteriods** - Prednisolone
Drug-induced anxiety (5)
Antidepressants
Drug-induced anxiety (6)
Beta-adrenergic agonists** - Salbutamol (esp. systemic/oral)
Panic attack duration and frequency
A discrete period of intense fear/discomfort, in which ≥ 4 symptoms developed abruptly and reached a peak w/in 10mins (usually lasts no more than 20-30 min)
Panic attack symptoms
– Palpitations, pounding heart, ↑PR
– Sweating
– Trembling/ shaking
– Sensations of shortness of breath
– Feeling of choking
– Chest pain/ discomfort
– Nausea or abdominal distress
– Feeling dizzy, unsteady, lightheaded, faint
– Derealization (feelings of unreal) or depersonalization (being detached from oneself)
– Fear of losing control or going crazy
– Fear of dying
– Paresthesias (numbness or tingling sensations)
– Chills or hot flushes
GAD duration
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for ≥6 months, about a number of events or activities (e.g. work, school performance).
The person finds it difficult to control.
GAD symptoms criterion
Anxiety and worry are associated with ≥3 of the following symptoms (with at least some symptoms present for more days than not for the past 6 months)
GAD symptoms 1
Restlessness or feeling keyed up or on edge
GAD symptoms 2
Being easily fatigue
GAD symptoms 3
Difficulty concentrating or mind going blank
GAD symptoms 4
Irritability
GAD symptoms 5
Muscle tension
GAD symptoms 6
Sleep disturbance (insomnia, restless unsatisfying sleep)
Panic Disorder, with or without Agoraphobia (A)
(1) Recurrent unexpected panic attacks, and
(2) ≥1 of the panic attacks has been followed by ≥1month of ≥1 of the following:
(a) Persistent anticipatory anxiety of having additional panic attacks
(b) worry about implications of the panic attack
(c) significant change in behaviour related to the panic attacks
Panic Disorder, with or without Agoraphobia (B)
Indicate absence or presence of agoraphobia
Panic Disorder, with or without Agoraphobia (C)
Panic attacks are not due to direct physiological effects of a substance (e.g. drugs) or a general medical condition.
Panic Disorder, with or without Agoraphobia (D)
Panic attacks are not better accounted for by another mental disorder
Duration of marked & persistent fear of ≥ 1 social/performance situations in
which the person is exposed to unfamiliar people or to possible scrutiny by others/peers in SAD
> 6 months
SAD: Avoidance, anxious anticipation or distress in the feared situations significantly _____
impairs functioning
PTSD A
Stressor: exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence,
PTSD B
Intrusion symptoms: traumatic event is persistently re-experienced
PTSD C
Persistent effortful avoidance of distressing trauma-related stimuli after the event
PTSD D
Negative alterations in cognitions and mood that began or worsened after the traumatic event (2 required)
PTSD E
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event (2 required)
PTSD diagnosis
Persistence of symptoms for >1 month, diagnosis made at least 6 months after trauma(s)
Gold standard scale for anxiety disorders
(In RCTs) Hamilton Anxiety Scale (HAM-A)
HAM-A score in significant anxiety
18-20
HAM-A score for response to treatment
40-50% reduction
HAM-A score in recovery
<7
Pharmacotherapy for GAD
SSRIs
Venlafaxine XR
Pregabalin
TCAs, beta-blockers, hydroxyzine, buspirone, etc
Pharmacotherapy for panic disorder
SSRIs
TCAs
Pharmacotherapy for SAD
SSRIs
Pharmacotherapy for OCD
SSRIs
Clomipramine
Pharmacotherapy for PTSD
SSRIs
TCAs
1st line treatment for PTSD
CBT**
Psychotherapy
Counselling
What antidepressants are useful for long term management of anxiety disorders, ODC, PTSD?
ALL serotonergic antidepressants
Preference of antidepressants in anxiety disorder & PTSD
SSRIs
SNRIs
Clomipramine
What drug class is Clomipramine?
TCAs
Preference of antidepressants in OCD
SSRI > Clomipramine > Venlafaxine
What drug class is Venlafaxine?
SNRIs
Dosing approach for antidepressants
Low starting dose - transient jitter in initial 2 weeks, consider benzodiazepine as adjunct.
Maintenance dose - at high end of dosing range (for anxiety disorders)
Serotonergic antidepressant are effective for ____ type of symptoms in anxiety.
Excessive worrying
Onset of action of serotonergic antidepressant in anxiety
1-2 months, full response generally 3 months
What adjunctive drugs can be used for anxiety?
a. Benzodiazepines
b. Pregabalin (GAD)
Benzodiazepines are effective for ____ symptoms of anxiety.
Physical
Benzodiazepines have ____ onset of action
Fast, can be within 30 minutes (e.g. Lorazepam)
Duration of Benzodiazepines
Aim for short term (3-4 months), PRN dosing, then taper
Which benzodiazepines are preferred in anxiety?
High potency agents
- Clonazepam
- Lorazepam
- Alprazolam XR (panic disorder)
What is NOT recommended for anxiety disorder?
Kava (risks of hepatotoxicity)
Chamomile (avoid in pregnancy)
Valerian (increase GABA)
Alprazolam PO dose for anxiety disorders
0.25-0.5mg BD-TDS
Max 4-6mg/day
Lorazepam PO dose for anxiety disorders
1-3mg/day (in divided doses)
Max 6-8mg/day
Benzodiazepines DDI
a. CNS depressants/alcohol - space them 4-6 hours apart
