ANXIETY Flashcards
What are the 3 types of Anxiety?
- Generalised anxiety disorder
- Panic disorder
- Social anxiety
WHAT ARE THE PSYCHOLOGICAL SYMPTOMS
- Irritability
- Restlessness
- Sense of dread
- Difficulty concentrating
WHAT ARE THE PHYSICAL SYMPTOMS
- Tiredness
- Fast/irregular heartbeat
- Muscle aches and tension
- Trembling
- Dry mouth
- Excessive sweating
- Feeling sick
- Pins and needles
How long should symptoms be present for to have GAD (and cause clinically significant distress, impairment in social, occupational or other important areas of functioning)
at least 6 months
What are the symptoms of GAD?
Symptoms for at least 6 months
* Excessive worry about a number of issues
* Preoccupation/seeking reassurance for somatic symptoms or chornic physical health problem
* Over-arousal and irritability
* Insomnia + poor conc
at least 3 of the following symptoms are present most of the time
restlessness or nervousness
easily fatigues
poor concentration
irritability
muscle tension
sleep disturbance
First line treatment
CBT
it is defined by, and its severity characterised, by one of two main classification systems
DSM5TR
ICD11
Pharmacological therapy for GAD
- SSRI - sertraline
- Alternative SSRI/SNRI
- Pregabalin
* Benzos for short term use only in severe anxiety state
* Do not use antipsychotics
WHAT ARE HYPNOTICS?
Most hypnotics will sedate when given during the day
What to do if pt has GAD + comorbid depressive or other anxiety disorder
treat primary disorder first i.e. the one that is more severe and in which is it more likely that treatment will improve overall functioning
NICE stepped approach in management of GAD (step 1)
- Communicate diagnosis, provide into about it,
- arrange active monitoring of pt symptoms and functioning at intervals based on clinical judgement
- if other comorbid anxiety or depression then treat the primary disorder
NICE stepped approach in management of GAD
step 2
- If symptoms not improved, offer low-intensity psychological interventions guided by pt pref
- e.g. individual non-facilitated self help, individual guided self help, psychoeducational groups
drug treatment of GAD (step 3 of NICE stepped approach)
include 1st line options + alternatives
1st line SSRI
if sertraline ineffective, offer alternative or SNRI (dulox, venla)
If above not tolerated then consider pregabalin
NICE stepped approach in management of GAD - step 3
- if GAD + marked functional impairment, of GAD that has not improved following step 2 (low intensity psychological intervention)
- offer individual high intensity psychological intervention e.g. CBT or applied relaxation
- or can offer drug treatment
If pt is being given SSRI or SNRI for GAD, what should you counsel them on?
- Adverse effects early in treatment with SSRI or SNRI may include increased anxiety, agitation, sleeping problems
- Will be gradual improvement in symptoms over 1 week or more before they experience full anxiolytic effect
Benefit for drug treatment is usually seen within
6 weeks and continues to increase over time
How often to review drug treatment
- review effectiveness and adverse effects every 2-4 weeks during first 3 months
- every 3 months thereafter
can you use BENZOS for treatment of GAD in primary care
Do not offer this except as short term measure during crises
Ideal treatment (step 3) for pregnant woman with GAD
- ideally offer high intensity psychological intervention
- decision on drug treatment should take into account benefit and harms of treatment in pregnancy incl risk of not treating condition and risks to woman and baby
advice about reviewing patients under 30 who are receiving SSRI or SNRI for GAD
review within 1 week of first prescribing and monitor risk of suicidal thinking and self harm weekly for the first month
How often to review people (over 30) who are recieving SSRI or SNRI
after 4-6 weeks of treatment
SHORT ACTING HYPNOTICS
- Sleep ONSET insomnia
- Less sedation, for elderly
- No hang over effect
- Loprazolam
- Lormetazepam
- temazepam
LONG ACTING HYPNOTICS
- For poor sleep MAINTENANCE
- When anxiolytic effect is needed during the day
- Nitrazepam
- Flurazepam
Z-DRUGS
Zolpidem, zopiclone
- Short duration of action, not for long-term use
USE IN THE ELDERLY
- AVOID benzodiazepines and Z-drugs
- greater risk of becoming ataxic and confused = falls and injury.
ANXIOLYTICS
Most anxiolytics (‘sedatives’) will induce sleep when given at night
BENZODIAZEPINES (Schedule 4 part 1 drugs)
Diazepam
Alprazolam
Chlordiazepoxide
Clobazam
Lorazepam
Midazolam
LONG ACTING BENZODIAZEPINES
Chlordiazepoxide Diazepam Alprazolam
Used as sedatives
SHORT ACTING BENZODIAZEPINES
Midazolam - Used for epileptic seizures (SE) and febrile convulsions due to its fast onset
INTERMEDIATE ACTING BENZODIAZEPINES
Clonazepam Lorazepam Oxazepam Temazepam
CLOT (Hence why some of these are used for agitation in our patients: As long-acting ones increase drowsiness)
BENZOS MOA
- Act on benzodiazepine receptors which are associated with (GABA) receptors.
- For short-term relief (2-4 weeks) of anxiety or insomnia that is severe, disabling or causing the patient distress and not for mild anxiety
DIAZEPAM
For insomnia associated with day-time anxiety - single dose at night
MHRA/CHM advice: BENZOS
- Reminder of risk of potentially fatal respiratory depression
- Patients should be informed of the signs and symptoms of respiratory depression and sedation
BENZODIAZEPINES CONTRAINDICATIONS
- Pulmonary insufficiency, respiratory weakness, not used alone for psychosis or depression
- Obsessional states, phobic states
- Sleep apnoea syndrome
WHAT ARE THE PARADOXICAL EFFECTS OF BENZODIAZEPINES?
A paradoxical increase in hostility, aggression, anxiety may be reported.
Adjust dose.
SIGNS OF OVERDOSE OF BENZODIAZEPINES
- drowsiness
- ataxia
- dysarthria
- nystagmus
- respiratory depression
- coma
BENZODIAZEPINES AND DRIVING
May cause drowsiness, impair judgement and increase reaction time
BENZODIAZEPINE WITHDRAWAL (DEPENDENCE SYMPTOMS)
- Anxiety
- Sweating
- Weight loss
- Tremors
- Loss of appetite
- Insomnia
WHEN WILL WITHDRAWAL SYMPTOMS DEVELOP?
- Any time up to 3 weeks after stopping long-acting nezodiazepine
- Within a day in short-acting
WITHDRAWAL PROTOCOL FOR LONG TERM BENZOS
- Convert all meds to a nightly dose of diazepam
- Reduce by 1-2 mg (1/10th on larger doses) every 2-4 weeks
* Only further withdraw if the patient has overcome any withdrawal symptoms - Reduce further (0.5mg near the end)
- Stop completely
OTHER TREATMENTS
Buspirone
Beta-blockers
Barbiturates
Clomethiazole
AntihistamineS
BUSPIRONE
serotonin 5HT1A receptor agonist
* Response to treatment takes up to 2 weeks
* Low dependence and abuse potential
BETA BLOCKERS
used for palpitations and tremor
BARBITURATES
avoided in elderly
CLOMETHIAZOLE
useful hypnotic for elderly because of its freedom from hangover
ANTIHISTAMINES
occasional insomnia- may cause headache, psychomotor impairment and anti-muscarinic effects
TREATMENT FOR CHRONIC ANXIETY
SSRI
o Sertraline
o Citalopram
o Escitalopram
o Fluoxetine
o Propranolol – alleviates physical symptoms only (e.g. tremors, rapid heart rate)
