Anxiety and Depression Flashcards
What is the NHS definition of anxiety? When is a diagnosis made?
- “A feeling of unease; worry or fear, that can be mild or severe (chronic or acute”
- Diagnosis of anxiety made if:
> Anxiety occurs all the time.
What are the different types of anxiety?
- Panic disorder
- Obsessive compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Phobias; specific or social
- Generalised Anxiety Disorder (GAD)
What is Panic disorder? What symptoms is is characterised as?
- Intense and abrupt feeling of fear or discomfort
Symptoms:
1) Sudden temperature change
2) Chest pain/interruption to normal blood circulation; palpitations/tingling sensation
3) Nausea + dizziness
4) Overwhelming feelings
What is OCD? What are the characteristics of each part?
- A combination of obsessive thoughts and compulsive activity
Obsession:
- Unwanted/unpleasant thoughts that cause anxiety e.g. being burgled
Compulsive:
- Repetitive behaviour a person undertakes to relieve the unpleasant feeling
What is PTSD? What are its symptoms? Onset?
- Post-traumatic stress disorder; after experiencing a trauma e.g. serious accident, natural disaster, criminal assault, returning from war etc.
- Can develop immediately or years later
Symptoms:
- Insomnia
- Nightmares
- Flashbacks
- Isolation
What is Specific phobia?
Intense fear of something that in reality is of little or no actual danger.
What is Social phobia?
- Fear of social/performance situations, resulting from thoughts of negative judgement, embarrassment or humiliation
- Person ‘tolerates’ with dread, or avoids the situation
- Common with performers/actors etc
What is GAD?
> Generalised anxiety disorder Excessive, uncontrollable worry about everyday things such as: - Job - Finances - Health - Family - Chores - Car repairs - Late for appointments
- Intensity, duration and frequency of worry is disproportionate to the issue
- May occur w/other anxiety disorders, depressive disorders or substance abuse
- May also present w/physical symptoms e.g. difficulty sleeping, palpitations & tingling in hands
What are some potential causes of anxiety?
- Genetics? (no gene isolated, but familial history can predispose risk)
- Neurochemical/neurohormonal
- Environmental factors
- Substance abuse
What symptoms that can present as anxiety could be due to organic disease? Give examples.
SOB:
- Asthma
Palpitations, tachycardia:
- Heart disease
Palpitations, sweating, tremor:
- Hyperthyroidism
- Phaeochromocytoma (adrenal tumour)
Dizziness:
- Vestibular dysfunction (inner ear problem)
- Hypoglycaemia
Sweating:
- Menopause
What are the considerations that need to be made during assessment for anxiety?
- Mental health history
- Environmental stressors
- Medical and drug history
- Degree of distress and functional impairment (e.g. insomnia)
- Risk of suicide; doctor should outright ASK > refer
What is the aim of anxiety (e.g. GAD) management/treatment?
- Relieve symptoms
- Improve QoL
- Prevent relapse
What non-pharmacological treatments are there for anxiety (GAD)?
- CBT (NICE recommendation, evidence-based, whilst following are not:)
- Mediation and relaxation (complements pharmacological therapy)
- Mindfulness “stop and smell the roses”; appreciating what’s around you
- Exercise (complements pharmacological therapy)
How are autonomic symptoms (palpitations/tingling) managed in anxiety (GAD)?
β-adrenoceptor antagonists (propranolol)
- Reduces autonomic effect
- Used on PRN basis
- DO NOT withdraw abruptly; prevent rebound effects
What are the pharmacological options of treating anxiety (GAD)?
Selective serotonin reuptake inhibitor (SSRI):
- Serotonin (off-label treatment in GAD)
- Licensed; escitalopram and paroxetine
What are the options if there is no improvement of Patient A’s anxiety after 2 months treatment w/SSRI?
1) Increase dose if max. dose not yet achieved
2) Swap to another SSRI
3) Consider a serotonin-NA reuptake inhibitor (venlafaxine, duloxetine)
4) Consider anticonvulsant agent, pregabalin (last line due to large S/E profile; blocks Glu transmission)
What are the therapeutic properties of Benzodiazepines (BDZ)?
- Anxiolytic (appropriate for GAD)
- Sedative ‘minor tranquilisers’
- Muscle relaxant; central effects (e.g. used when intricate surgery required)
- Hypnotic (induces sleep)
- Anticonvulsant
- Amnesic
- Reduce aggression
- Treats alcohol withdrawal
What are the pharmacokinetic properties of BDZ?
- No enzyme induction; can monitor pharmacokinetic profile
- Metabolism through oxidation and conjugation (after getting to brain, like lorazepam)
- Oxidation reduced by agel effects may be prolonged in older patients (risk of toxicity if drug not metabolised; give lorazepam; metabolism through conjugation)
- Active metabolites
- Relatively safe in overdose
What are the disadvantages with BDZ use?
- Some tolerance (higher dose may be required)
- Dependence and withdrawal symptoms (2-3 weeks; use short-term)
What BDZs are suitable for GAD treatment? Are they first line?
Drugs with a short (1-10 hours) half-life: Hypnotics: - Temazepam - Nitrazepam - Zolpidem
Drugs with longer half-life (1-4 days): Anti-anxiety: - Diazepam - Chlordiazepoxide (alcohol withdrawal) - Lorazepam
> > > SSRIs first line; BDZs best avoided, but use restricted to 2-4 weeks.
What is the GABAa receptor complex? Why is it complex?
- Receptor complex for the inhibitory NT, GABA
- Pentameric structure w/Cl- pore in middle
- 5-sub-unts, each with a different binding site:
> Barbiturate (+ alcohol?)
> Picrotoxin (antagonist of GABA action)
> GABA site
> Steroid
> Benzodiazepines (and anaesthetics)
How do BDZs work?
- Occupy site on GABAa complex
- Increases affinity for GABA (conformational change of GABAa receptor complex)
- Thus greater flow of Cl- ions into neurone
- HYPERPOLARIZATION occurs; hence inhibitory action (and anxiolytic nature)
What are the risk factors for suicide?
- Own history of depression, suicide attempt
- Illness e.g. chronic pain syndrome (most common cause)
- Schizophrenia and dementia etc.
- Family history of depression
What is DSM-5, and what are the markers of depression?
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Core symptoms of depression (1+2):
1) Depressed mood; “Does not feel able to get back on track”
2) Loss of interest or pleasure “not attending rambling or yoga”
3) Fatigue; “Weary and lacking in energy during the day”
4) Feelings of worthlessness, guilt or inappropriate grief “husband’s death”
5) Recurrent thoughts of death or suicide/actual suicide attempts
6) Reduced ability to think or concentrate
7 Psychomotor agitation or retardation
8) Altered sleep “problems dropping off to sleep, early morning waking”
9) Significant weight change; “lost a lot of weight”
