Anxiety Disorder Pathophysiology Flashcards
Anxiety as an emotion is…
Normal under circumstances of threat, and thought to be part of the evolutionary fight/flight reaction of survival
Normal reaction to a stressful situation
Anxiety becomes a disorder when it is…
Overwhelming, and affecting function + quality of life
Anxiety disorders share features of…
Excessive fear and anxiety, and related behavioural disturbances
Fear = emotional response to real/perceived imminent threat
Anxiety = anticipation of future threat
Core symptoms of anxiety can be split into two groups, of…
Psychological
Somatic (physical)
Psychologial anxiety symptoms can include…
Feelings of fear/anxiety
Worry + apprehension
Difficulty concentrating
Somatic symptoms of anxiety can include…
Increased HR
Tremor
Sweating
GI upset
Common anxiety disorders include…
Generalized anxiety
Panic
Social anxiety
Post-traumatic stress
Obessive-compulsive
Each anxiety disorder has a great deal of overlap with other anxiety disorders, but the 2 core symptoms remain the same…
Anxiety/fear and worry
…One could question if anxiety disorders are distinctly different, or just different aspects of the same illness
For majority of anxiety disorders, most 1st line medications…
Are effective, and are the same medications used for depression
Fear is associated with this brain region…
Amygdala-centered circuit
Worry is associated with this brain region…
Cortico-striato-thalamo-cortical (CSTC) circuit
The amygdala interprets sensory and cognitive information, and determines…
If there will be a fear response, both an affect response (feeling) and motor response (fight/flight/freeze)
The motor response of fear can include other physical symptoms involved with respiratory and CV symptoms, such as…
Respiratory sx’s - increased rate, SOB
Cardiovascular sx’s - increased BP, atherosclerosis, ischemia, HR issues
Activation of the amygdala-centered circuit and the CSTC-circuit involves some neurotransmitters, such as…
5HT
GABA
Glutamate
NE
Voltage-gated ion channels
GABA is a principle neurotransmitter that…
Is inhibitory - plays a role in decreasing activity of neurons, slowing down activity of amygdala and CSTC circuits
GABA is stored and released in…
Presynaptic vesicles, and released in synapse when needed
Then transported back to vesicles or metabolized + inactivated
These subtypes of voltage-sensitive calcium channels (VSCC) are relevant in psychopharmacology…
N and P/Q
Gabapentin and pregabalin MOA involves VSCC by…
Binding to subunit of presynaptic N and P/Q VSCC, blocking release of glutamate when neurotransmission is excessive to decrease fear + worry
The symptoms, circuits, and neurotransmitters for anxiety disorders overlap closely with…
Major depressive disorder
5-HT is a key NT that innervates…
The amygdala and CSTC - assisting with regulation of fear and worry
Hence SSRI/SNRI are effective, blocking reuptake
Buspirone is unique in that it is a…
5-HT partial agonist, effective only in GAD and to potentiate antidepressants
Norepinephrine is involved in anxiety via…
Regulator of amygdala + CSTC circuits, via attatching to alpha+beta receptors; autonomic activity triggers fear, panic, and anxiety
SNRI MOA may increase NE and interact with anxiety via…
Worsening symptoms at initial dosing, but improve fear/worry longterm as beta-receptors down-regulate
GAD stands for…
Generalized anxiety disorder
GAD often coincides with…
Other mental health disorders
Can also co-occur with physical leaht problems and exacerbate/interfere with management
Onset of GAD is usually…
In late adolescents/early adulthood
Cases have been seen in older adults as well
GAD etiology is unknown, but is likely to be…
The combined effect of biological (neurotransmitters) and psychological factors (thought processes, conflicts)
Cognitive behaviour theory describes the influences of…
Emotions, behaviours, and thoughts - and how they affect each other
Other suspected causes of GAD that we as pharmacists should be aware of include…
Medications/natural products
Medical conditions
Consider withdrawal of medications that may increase anxiety (alcohol, sedatives, BZD’s)
Common classes of drugs associated with anxiety symptoms include…
Corticosteroids
Stimulants
Sympathomimetics (pseudoephedrine, phenylephrine)
Psychological/cognitive symptoms of GAD include…
Excessive anxiety + worries that are difficult to control
Poor concentration
Restlessness + irritability
Sleep disturbances
Physical symptoms of GAD include…
Fatigue
Muscle tension
Trembling or shaking
Sweating
Feeling of fullness in throat/chest
GAD standardized rating scales include…
GAD-7
HAM-A
A panic attack is a distinct period of intense fear/discomfort when 4 or more symptoms develop suddenly. Some of these symptoms include…
Think of hyperactivity
Palpitations, increased HR
Sweating, trembling
Chest pain, nausea, abdominal distress
Feeling SOB, choking, dizziness, faint,
Feeling of unreality, or going crazy
Numbness, tingling sensation
Panic disorder is classified as…
Recurrent unexpected panic attacks, with at least 1 of the attacks followed by 1 of the following for month or longer:
Concern about having another attack
Anxiety over implications of attack/its consequences
Maladaptive change in behaviour to avoid panic attacks
Rates of panic disorder increase during… and peak during…
Increase during adolescence
Peak during adulthood
Identifiable stressors of panic disorder include…
Interpersonal stressors
Stressors related to physical well being
Unpredictable/uncontrolable life stressors
Psychological comorbidities with panic disorder include…
Other anxiety disorders
Depression
Bipolar
AUD
Some medical comorbidities that coincide with panic disorder may include…
Anything that may cause instability of catecholamines
Cardiac arrythmias
Hyperthyroidism
Asthma, COPD
IBS
Cushing’s
Most patients with panic disorder require ____ to achieve…
Long-term treatment, to achieve remission, prevent relapse, and reduce risks associated with co-morbidity
Predictors of chronic course of panic disorder include…
Long duration of illness
Comorbidity with personality, mood, or other anxiety disorders
Excessive sensitivity to physical symptoms of anxiety
Standardized rating scales for panic disorder include…
Can be referenced to help with monitoring
Panic disorder severity scale
Panic and agoraphobia scale
Social anxiety disorder is defined by intense anxiety/fear of…
Being judged, negatively evaluated, or rejected in a social/performance situation
Median age of onset of social anxiety disorder is…
13 years
Risk factors for SAD often include…
Temperamental - fear, behavioural inhibition
Environmental - life stressors, adverse experiences
Genetics - dopamine, serotonin
SAD often has comorbidities which are…
Concurrent anxiety
Depression
Substance use disorder
SAD fears include…
Scrutiny by others
Embarassment
Humiliation
Public speaking, eating/drinking with others, talking with strangers…
Physical symptoms of SAD may include…
Blushing
Diarrhea
Sweating
Tachycardia
Trembling
“Butterflies in stomach”
Generalized SAD refers to…
Fear and avoidance of a wide range of social situations
Standardized rating scales for SAD include…
All the ones used for GAD
Social phobia inventory
Liebowitz social anxiety scale
Help with monitoring
PTSD is when your body experiences anxiety, fear, and panic in response to…
A traumatic event that happened in the past
In PTSD, neuotransmitters that are overexpressed include ____, which causes…
Dopamine and Norepinephrine; cause persistent hyperarousal
These affect amygdala which activates SNS
In PTSD, fear memories often become ____, which leads to…
Reconsolidated; long-term fear memories
The 3 dimensions of PTSD involve…
1) Re-experiencing event with distressing recollections, dreams, flashbacks, psychological, and physical distress
2) Persistent avoidance of stimuli that might invite memories or experiences of trauma
3) Increased arousal
Co-morbid psychiatric conditions that often coincide with PTSD include…
MDD
SUD/AUD
Other anxiety disorders
Bipolar
Psychosis
PTSD patients often have higher rates of these medical co-morbidities…
CVD
Respiratory disorders
Autoimmune disorders
Pathophysiology of OCD is ____, and is possibly related to abnormalities in…
Serotonin neurotransmission
Dopamine transmission
Glutamate
OCD symptoms are usually ____ onset, occurring after…
Sudden onset, occurring after a stressful event
Treatment is usually delayed - waxing + waning symptoms
Co-morbidities with OCD include…
MDD
Bipolar
Other anxiety disorders
Tic disorder, ADHD
Indicators of poor OCD prognosis include…
Acting on compulsions
Childhood onset
Bizarre compulsions
Comorbid depression/personality disorder
Delusional beliefs/need for hospitalization
The two core symptoms of OCD are…
Obessessions
Compulsions
A good OCD standardized rating scale that could be used for monitoring response to treatment is…
Yale-brown obsessive compulsive scale
