Anxiety disorders Flashcards

1
Q

EPIDEMIOLOGY:

A
  • Up to 1 in 3 adults suffer with an anxiety disorder at some point in their lives
  • Up to 1 in 20 people suffer at any one time
  • Affects women > men
  • Onset generally young adulthood
  • Psychiatric comorbidity common
  • Multiple simultaneous anxiety disorders common
  • Anxiety associated with other physical illnesses e.g. IBS, pain,
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2
Q

Aetiology:

A

Environment, genetic and development

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3
Q

Symptoms of anxiety:

A

A spectrum of symptoms describe anxiety disorders

Psychological:
Worrying thoughts
Fearful anticipation
Poor memory
Insomnia
Poor concentration
Avoidance behaviours
Irritability 
Sensitivity to noise and light
Physical
Palpitations, SOB
Tremor
Sexual difficulties 
Problems with urinary/faecal excretion
Fatigue 
Dizziness, headache
Poor swallowing / dry mouth
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4
Q

Different anxiety disorders exist, each with their own particular presentation

A

Generalised anxiety disorder (GAD)
Panic disorder
Social phobia / social anxiety disorder most common
Obsessive compulsive disorder (OCD) [not examinable]
Post-traumatic stress disorder (PTSD) [not examinable]
Agoraphobia [not examinable]
Other phobias [not examinable]

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5
Q

Diagnosing anxiety:

A

Differential diagnosis important
If someone presents with the clinical features of anxiety, does this indicate an anxiety disorder? Not always, diabetes, thyroid problems, withdrawal from smoking, substance abuse

  • Most people become anxious over particular issues at some point in their lives, and episodes either spontaneously remit or are relieved following simple measures e.g. reassurance, relaxation methods
  • The difference with an anxiety disorder is the duration of symptoms and (at times) their severity
  • When someone presents with symptoms of anxiety, general screening can be performed with the generalised anxiety disorder scale (GAD-2) to determine whether further investigation is required
  • -> GAD-2 questions. How often have you experienced the following over the last 2 weeks?
  • -> Feeling nervous/anxious/on edge
  • -> Uncontrollable worrying
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6
Q

Diagnostic Statistical Manual Fifth Edition (DSM-5) criteria:
Generalised anxiety disorder

A
  • Excessive worry about a number of issues most of the time (not restricted to specific issue)
  • Preoccupation/seeking reassurance for somatic symptoms or chronic physical health problem
  • Over arousal and irritability
    Insomnia and poor concentration
  • Duration = at least 6 months
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7
Q

Diagnostic Statistical Manual Fifth Edition (DSM-5) criteria:
Panic disorder

A

Worrying thoughts and fearful anticipation
Unforeseen abrupt surge of intense fear (panic attack)
Poor memory

Panic attack followed by one month of persistent worry about recurrence

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8
Q

Diagnostic Statistical Manual Fifth Edition (DSM-5) criteria:
Social anxiety/phobia disorder

A
  • Persistent and overwhelming fear of social situations that is out of proportion
  • Excessive worrying before, during and after
  • At least 6 months
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9
Q

Treating anxiety:

A
  • Psychological treatments generally considered first line
  • Treatment should be tailored to individual needs and risks/benefits explained
  • Treatment choice is a shared decision with the patient

People may abuse substances as a coping mechanism and this should not normally preclude treatment

Drugs = anxiolytics

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10
Q

What should you do if anxiety co-exists with depression?

A

By treating depression you can reduce anxiety

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11
Q

NICE guidance

Treating generalised anxiety disorder (GAD)

A

Psychological therapy

  • Education and active monitoring important first step
  • Self-help (either non-facilitated or guided) and group education are considered as first line treatments for GAD if education ineffective
  • High intensity psychological intervention can be used if group education/self help not effective or marked functional impairment
  • -> CBT
  • -> Applied relaxation

Pharmacological therapy
- Offered to those who have marked functional impairment or education/self-help not effective
- Treatment choice:
Selective Serotonin Reuptake Inhibitor (SSRI) first line – sertraline (unlicensed)
Response increases over time
If effective treat for one year
Can take a while to see full effect
Alternative SSRI or SNRI second line
Offer pregabalin 3rd line (well tolerated, GI symptoms, euphoria and can be abused so is a CD)
Benzodiazepines for short term use only in severe anxiety state (crisis)
DO NOT use antipsychotics

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12
Q

NICE guidance

Treating panic disorder

A

Psychological therapy

  • Offer individualised cognitive behavioural therapy (CBT)
  • Over 1-2 hours for each weekly session
  • Max 4 months of treatment
  • Facilitated or non-facilitated self help materials – groups and exercise
  • If not effective, add in pharmacotherapy

Pharmacological therapy

  • Less evidence of longer duration of positive effects than CBT
  • Consider OD/harm risk, patient preference/history/co-morbidities/other meds

Treatment choice:

  • Selective Serotonin Reuptake Inhibitor (SSRI) first line – any licensed for panic disorder
  • Second line (tricyclin AD’s) – use imipramine or clomipramine
  • If treatment successfully used for 6 months dose can be tapered and stopped
  • DO NOT use benzodiazepines (BZDs) can worsen panic disorder, antipsychotics, sedating antihistamines
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13
Q

NICE guidance

Treating social anxiety/phobia disorder

A

Psychological therapy
- Offer individualised cognitive behavioural therapy (CBT)
–> Clark and Wells model
Heimberg model
- Those who decline CBT may be offered CBT-based self help
- Combine CBT with pharmacological approaches if partial/limited response
- Psychodynamic therapy last line

Pharmacological therapy:

Offered to those who:

  • Partially respond to CBT
  • Do not want psychological therapy

Treatment choice:

  • Selective Serotonin Reuptake Inhibitor (SSRI) first line – sertraline/escitalopram
  • Alternative SSRI or SNRI second line – venlafaxine/fluvoxamine (lots of interactions so rarely used)
  • Mono-amine oxidase inhibitor (MAOI) 3rd line – moclobemide/phenelzine – interacts with food and can cause a hypertensive crisis
  • DO NOT use benzodiazepines (BZDs), tri-cyclic antidepressants (TCAs), antipsychotics, St John’s Wort or anticonvulsants
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14
Q

Considerations: antidepressants in anxiety disorders :

A
  • Treatment may take 2 weeks or more to work – short term BZDs may be required
  • Important ADRs for antidepressants are anxiety, GI disturbances, anorexia, insomnia, agitation and suicidal thoughts/behaviours
    Careful monitoring for those aged under 30 / prior suicide risks
  • Careful with dosing SSRIs in GAD and/or panic disorder
  • Other pharmacological options for anxiety that are not in NICE guidelines
  • -> Propranolol for physical symptoms of anxiety, useful in situational stress (no effect on psychological / non-autonomic symptoms)
  • -> Buspirone for GAD (5HT1 partial agonist)
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15
Q

Specific issues with antidepressants:

A

Interactions and fluvoxamine - warfarin
TCAs are:
–> Associated with anti-muscarinic ADRs
–> Clomipramine more sedating than imipramine

  • Short half life with venlafaxine and paroxetine – swift withdrawal/relapse
  • Cardiotoxicity and risk in overdose – TCAs and venlafaxine
  • Hyponatraemia – caution in the elderly, maybe more common with SSRIs
  • QT prolongation a concern with TCAs, venlafaxine, moclobemide, citalopram/escitalopram

MAOI and dietary restrictions due to potentiating of pressor tyramine

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16
Q

Benzodiazepines (BZDs) and anxiety disorders:

A

BZDs have been used to treat anxiety for over 40 years

  • -> Short half life: lorazepam, oxazepam
  • -> Long half life: diazepam, clonazepam

NOT recommended for panic disorder or social anxiety disorder, but suitable for GAD crisis
However, some evidence for persistent/severe anxiety in short courses (max. 4 weeks) at lowest effective dose, with some benefiting from long term treatment

  • Diazepam a suitable choice in anxiety, avoid lorazepam and clonazepam
  • Become more harmful in overdose when taken with other CNS depressants/alcohol
  • Plasma levels of BZDs are affected by certain CYP3A3/4 enzyme inducers (e.g. Antifungals) and inhibitors (e.g. Macrolides)
  • ADRs sedation/drowsiness (driving), confusion, falls, amnesia, aggression, disinhibition, tolerance, dependence and abuse
17
Q

Benzodiazepines (BZDs): tolerance and dependence:

A

Long term treatment may result in:

  • Tolerance (even after 3-14 days!)
  • Psychological and physical dependence (more physical)
  • Withdrawal reactions upon treatment cessation

Withdrawal symptoms can even develop after 4-6 weeks of continuous use. Gradually stop.

Those with certain personality traits / history may be at higher risk

Symptoms of dependence mimic overdose: unsteadiness, drowsiness, speech disorder, nystagmus

18
Q

Withdrawal from BZDs:

A
  • Successful withdrawal from treatment may take months, especially for long term users
  • Switch patients on short/intermediate acting treatments to diazepam (useful liquid preparation)
  • Reduce dose gradually as abrupt withdrawal can be dangerous, e.g. 10% every 2 weeks
  • Slow withdrawal does not eliminate ADRs – psychological therapy may help
  • When withdrawal symptoms emerge, slow/halt titration, slight dose increase may be necessary
19
Q

Medicines optimisation in anxiety - summary

A
  • Rule out other (preventable) causes of anxiety symptoms.
  • Non-pharmacological methods usually first line treatment for anxiety
  • Tailor drug treatment for anxiety to individual patient wishes/history
  • -> SSRIs main first line drug treatment for anxiety disorders
  • -> Other options: SNRI, TCA, pregabalin, MAOI
  • -> Adjunctive treatments: propranolol, buspirone, others

Prescribing advice: selecting and initiating antidepressant treatment

Education: limited role of BZD in anxiety disorders, associated risks and withdrawal regime

Patient counselling: drug choice, initiation and important side effects