anxiety Flashcards
how does anxiety pose as a risk factor for other disorders
1) CVS: increased HR, HTN
2) cerebrovascular: persistent HTN -> stroke
3) GI: V, D
4) respiratory
classifications of anxiety
1) generalised anxiety disorder (GAD)
- excessive anxiety and worries > 6 months
2) panic disorder (PD)
- anticipatory anxiety about recurrent panic attacks
- causes agoraphobia (fear of going out)
3) Social anxiety disorder (SAD)
- fear of being scrutinised/humiliated by others in public
4) obsessive compulsive disorder (OCD)
- obsessive thoughts/impulses that cause anxiety
- followed by compulsive behaviours to relieve anixety
5) post traumatic stress disorder (PTSD)
- re-experiencing of trauma, persistent avoidance, increased arousal
6) phobias
- fear + avoidance of behaviours
pathophysiology of anxiety
neurochemical dysregulation of neurotransmitters, defence system and behavioural inhibition system resulting in over running of fear and worry circuit
anxiety pathophysiology - over running of fear and worry circuit
1) Fear circuit
- regulated by amygdala (Responsible for fear, fight/flight)
2) worry circuit
- regulated by cortical-striatal-thalamic-cortical (CSTC) loop
anxiety pathophysiology - neurochemical dysregulation
1) defence system
- originated in amygdala
2) behavioural inhibition system
- originate in hippocampus
3) neurotransmitters
- increased NE found between amygdala and CSTC loop
- decreased serotonin = decreased inhibition of amygdala by serotonin = overactivation of amygdala
drug induced anxiety
drug classes
1) sympathomimetics: pseudoepinephrine
2) stimulants: amphetamines, cocaine, methylphenidate
3) methylxanthines: theophylline, caffeine
4) corticosteroids
5) antidepressants
6) dopamine agonist
7) beta-adrenergic agonist
drug withdrawal
- caffeine, alcohol, sedative, benzodiazepine, antidepressants, nicotine
drug intoxication
- anticholinergic, antihistamines, digoxin
conditions associated with anxiety
1) CVS: atherosclerosis and conditions below
2) endocrine: hyperthyroidism
3) neurologic: dementia, delirium
4) pulmonary: asthma, COPD
clinical presentation of GAD
> /= 3 of the following for >/= 6 months
1) restlessness or feeling on the edge
2) being easily fatigued
3) difficulty concentrating or mind going blank
4) irritability
5) muscle tension
6) sleep disturbances: insomnia, restless unsatisfying sleep
clinical presentation of panic disorder w/wo agoraphobia
- recurrent unexpected panic attack
- > /= 1 of panic attacks that have been followed by >/= 1 month of >/= 1 of
1) persistent anticipatory anxiety of having additional panic attack
2) worry about implications of panic attack
3) significant change in behaviour related to panic attacks
- +/- agoraphobia
- panic attack not caused by medical disorder, substance use, other schizoaffective or mood disorders
clinical presentation of social anxiety disorder (SAD)
- marked and persistent fear of >/= 1 social/performance situations where person is exposed to unfamiliar people or possible scrutiny by others and patient fears that they will act/show anxiety symptoms that are humiliating/embarrassing
- last for >/= 6 months
- result in avoidance of situations -> significantly impair social functioning
- need differential diagnosis with avoidant personality disorder
clinical presentation of obsessive compulsive disorder (OCD)
- either obsession or compulsion
1) obsession
** recurrent and persistent thoughts/impulses/images that are intrusive and inappropriate, causing anxiety
** patient recognise that these are products of his own mind
2) compulsion
** repetitive behaviours or mental acts that are performed in response to an obsession to relieve anxiety
** behaviours or mental acts aimed at preventing/reducing distress but NOT connected in a realistic way or are clearly excessive
- recognise at some point that these are excessive/unreasonable
- obsessoin/compulsion maybe time consuming or significantly impair functioning
clinical presentation of PSTD
1) stressor
- direct exposure, witness in person, indirectly, repeated/extreme indirect exposure
2) intrusion symptoms
- re-experiencing traumatic event
3) avoidance of distressing trauma-related stimuli
4) negative alterations in cognition and mood
5) traumatic related alterations in arousal and reactivity
6) persistence of symptoms (2-4) for > 1 month
7) distress or functional impairment
diagnosis of anxiety
HAM-A scale (used in RCT)
treatment overview for each anxiety
1) GAD
- SSRI, venlafaxine XR, pregabalin
- CBT
2) panic disorder, SAD
- SSRI
- CBT
3) OCD
- SSRI, clomipramine
- CBT, exposure and response prevention (ERP)
4) PTSD
- SSRI
- CBT (1st line)
antidepressant dosing
- start low then titrate
- transient jitteriness in initial 1-2 wks initiation
benzodiazepine indication for anxiety
effective for physical symptoms (muscle tension)
types of benzodiazepine for anxiety
clonazepam, lorazepam, alprazolam XR (For PD)
treatment duration for benzodiazepine for anxiety
short term (3-4 month) PRN then taper dose
comparing benzodiazepine for anxiety
1) alprazolam
- more potent, lower dose required
- short duration, no active metabolite
- easier for addiction
2) clonazepam
- long duration of action
3) diazepam
- least potent so need higher dose
- long duration of action
4) lorazepam
- short duration, no active metabolites
- most common
tolerance to benzodiazepine for anxiety
- tolerance to hypnotic effect within days
- tolerance to anxiolytic action less common
dependence on benzodiazepine for anxiety
- avoid abrupt cessation after wks of continued use
- gradual taper required (2mg every 2-3 wks)
caution for benzodiazepine for anxiety
- paradoxical excitement (esp young, old)
- dependence and withdrawal symptoms if history of drug dependence
other adjunctives for anxiety
- antihistamines: hydroxyzine
- beta blockers: propranolol
- anticonvulsants: pregabalin (used for GAD if sexual dysfunction or GI SE intolerable
DDI for anxiety medications
1) alcohol and other CNS depressants
2) anticholinergic agents
3) MAOis and SSRIs/TCAs combination that cause serotonergic syndrome
4) antidepressant specific (CYP interactions)
5) benzodiazepine specific
- CNS depressant (alc 4-6hrs apart)
- benzodiazepine + opioid = increased mortality
- metabolised by CYP3A4 except lorazepam
