Anxiety Flashcards
Define generalised anxiety disorder.
Excessive worry about every day issues that is disproportionate to any inherent risk
- chronic condition that may fluctuate in severity, with low rates of remission over the short- and medium-term
At least three of the following symptoms are present most of the time:
- Restlessness or nervousness
- Being easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
Symptoms are present for at least 6 months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
Most common in people aged 35-55
What are risk factors for GAD?
- Female sex.
- Comorbid anxiety disorders.
- Family history of anxiety disorders.
- Childhood adversity.
- History of sexual or emotional trauma.
- Sociodemographic factors
After how many weeks is anxiety classed as chronic?
4 weeks
If the anxiety symptoms are mild, a period of active monitoring should initially be undertaken. True or False?
True
If symptoms have not resolved following a period of active monitoring, offer non-pharmacological intervention
What is non-drug treatment for anxiety?
1st line: Low-intensity psychological
interventions such as education and self-help
2nd line: High-intensity psychological intervention such as CBT for 3-4 months (OR pharmacological therapy)
Management pathway for anxiety
1st line: Education and self-help
2nd line: CBT for 3-4 months OR drug treatment (equal effectiveness)
- Patient preference
3rd line: Specialist referral
- Complex treatment-refractory GAD and very
marked functional impairment, such as self-neglect or a high risk of self-harm
What is the drug treatment pathway for GAD/chronic anxiety?
1st line: SSRIs (usually sertraline, escitalopram, paroxetine)
- Sertraline most co-effective but off-label use (escitalopram and paroxetine licensed for GAD)
- No evidence that any one is more effective than the others
2nd line: SNRI (duloxetine, venlafaxine)
3rd line: Pregabalin
Review effectiveness every 2-4 weeks in first 3 months and then every 3 months
If no improvement after 4 weeks
- Ineffective
- Consider offering an alternative drug or high intensity psychological intervention
If partial effectiveness
- consider offering a high-intensity psychological intervention in addition to drug treatment
If effective, continue for at least 1 year
- Optimal efficacy may take up to 3 months
If SSRIs or SNRIs are started in someone under 30, they should be warned of what?
They should be warned that SSRIs/SNRIs are associated with an increased risk of suicidal ideation and self-harm in a minority of people under 30
Review them within 1 week of first prescribing and monitor the risk of suicidal ideation and self-harm weekly for the first month
Main side effects of SSRIs?
- Abnormal appetite
- Arrhythmias (QT prolongation)
- Impaired concentration
- Confusion
- Gastrointestinal discomfort
- Sleep disorders
Most common in first 2 weeks
What is serotonin syndrome?
What increases the risk?
Serotonin syndrome occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors
Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness
It is a serious side effect that can occur with the use of SSRIs and SNRIs
- Risk is higher if patients are taking other medicines that can increase serotonin levels (tramadol, metoclopramide, sumatriptan)
If a patient experiences symptoms of serotonin sydrome, they should contact their GP immediately. If this is unavailable, they should call NHS 111 for advice
How is GAD managed in pregnancy?
Offer a high-intensity psychological intervention first-line.
If pharmacological treatment needed be aware that:
- Data on the risk of congenital malformations with SSRIs or SNRIs in early pregnancy are conflicting so the teratogenic potential is unproven
- Treatment with an SSRI or SNRI after around 20 weeks of pregnancy may increase the risk of persistent pulmonary hypertension of the newborn (PPHN) and/or can lead to neonatal withdrawal
- Pregabalin use in pregnancy has not been shown to increase risk of malformations, or miscarriage, or adversely affects fetal growth.
If a woman becomes pregnant while on medication for GAD
- Discuss the option of stopping the medication and gradually switching to a psychological intervention
- In cases where drug treatment is continued in pregnancy, the lowest effective dose should be used
Can antipsychotics be used for treatment of GAD in primary care?
No
Can benzodiazepines be used for treatment of GAD in primary care?
No
Only for short term management of crisis (severe acute anxiety)
Management of acute anxiety involves the use of what drug classes?
Benzodiazepine or buspirone (contraindicated in epilepsy)
What benzodiazepines are used in crisis for GAD?
Diazepam
- Long half life (less dependence)
- Short term use only (2-4 weeks)
- Not indicated for mild anxiety
Is diazepam short or long acting?
Long acting
Good if insomnia is associated with anxiety
Is withdrawal is more common with the short or long acting benzodiazepines?
Short acting
What kind of effect can happen as a result of taking benzodiazepines?
What is used to treat it?
Paradoxical effects
A paradoxical increase in hostility, aggression, talkativeness, excitement, suicidal ideation
Treated with flumazenil (as often caused by overdose)
Why are benzodiazepines cautioned in liver impairment?
If they are needed, are short or long acting ones recommended?
Can lead to a hepatic coma
- especially long actingg
Short acting benzos preferred in liver impairment
(However, in alcohol withdrawal, a long acting e.g. chlordiazepoxide or diazepam is used via fixed dosed regimen)
What are the signs of benzodiazepine withdrawal?
- Insomnia
- Anxiety
- Loss of appetite/weight loss
- Tremor
- Perspiration
- Tinnitus
- Perceptual disturbances
Symptoms may be confused with original symptoms of anxiety/insomnia
Some symptoms may last for weeks/months
During benzodiazepine withdrawal, what 3 classes of drugs should be avoided if possible (in the case of additional therapy to help with withdrawal symptoms)?
Beta blockers
Antidepressants
Antipsychotics
Give examples of long acting benzodiazepines.
- Chlordiazepoxide (adjunct in acute alcohol withdrawal)
- Diazepam
- Clobazam (epilepsy)
- Alprazolam
Used as sedatives
Give examples of short acting benzodiazepines (M-CLOT)
- Midazolam (shortest acting - used for status epilepticus and febrile convulsions due to fast onset)
- Clonazepam
- Lorazepam
- Oxazepam
- Temazepam
M-CLOT
What is Buspirone?
A serotonin receptor agonist used for anxiety
Low potential for abuse or dependence however takes two weeks to work
Contraindicated in epilepsy
If on CYP3A4 inhib reduce dose to 2.5mg BD
How would you reduce someone’s diazepam dose if on SHORT term therapy (2-4 weeks) to prevent withdrawal?
Taper off within 2 - 4 weeks
How would you withdraw benzodiazepines if on long term therapy to prevent withdrawal?
If on high doses, how is this done?
1) Convert benzodiazepine to equivalent Diazepam dose
2) Reduce dose by 1–2 mg (up to 1/10th on larger doses) every 1-2 weeks as tolerated
3) Reduce by 0.5mg near the end
What groups of patients are short acting benzodiazepines more suitable for?
- Elderly
- Liver impairment (however in acute alcoholic withdrawal a longer benzodiazepine is used)
However, higher risk of withdrawal
What antihypertensive can be used to treat anxiety symptoms?
Propranolol
Reduces palpitations and tachycardia
Mechanism of action of benzodiazepines?
Act directly on CNS and bind to GABA-A receptors increasing the inhibitory effect of GABA
This reduces the communication between neurons and, therefore, has a calming effect on many of the functions of the brain
What is the main side effect of benzodiazepines?
How should patients be counselled?
Sedation
Avoid driving if drowsy (COLD FT benzos have legal driving limit)
Avoid:
- Alcohol, CNS depressants or CYP inhibitors
Which benzodiazepines have a legal driving limit? (COLD-FT)
(COLD-FT)
Clonazepam
Oxazepam
Lorazepam
Diazepam
Flunitrazepam
Temazepam
How should people with panic disorders be managed?
If present to A+E with chest pain
- Undertake physical tests to rule out cardiac causes
- Suspect panic disorder if tests negative, female or relatively young
- Refer to primary care for subsequent care, even if assessment has been undertaken in A&E
- Give written support materials
Management in primary care
If mild to moderate panic disorder
- Offer low-intensity psychological interventions (individual non-facilitated or facilitated self-help)
- Give information about support groups
- Benefit of exercise
If moderate to severe panic disorder (with or without agoraphobia)
- Consider referral for CBT or an antidepressant if the disorder is long-standing or the person has not
benefitted from or has declined psychological intervention
What pharmacological treatment is used in panic disorder?
If moderate - severe panic disorder which hasn’t benefited from/declined psychological intervention
- Antidepressant (SSRI licensed for panic disorder)
- Inform them about the delay in onset of effect, the potential for worsening symptoms in first week, time course of treatment, possible discontinuation withdrawal symptoms if not taken as prescribed
- Should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. - Alternative antidepressant from a different class if no improvement after 12 weeks
- Imipramine or clomipramine
- If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate
Benzodiazepines are associated with a good outcome in the long term and should be prescribed for the treatment of individuals with panic disorder.
True or False?
False
Benzodiazepines should not be prescribed in panic disorder
Also avoid antipsychotics and antihistamines
