Anxiety disorders Flashcards
EPIDEMIOLOGY:
- 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,
Aetiology:
Environment, genetic and development
Symptoms of anxiety:
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
Different anxiety disorders exist, each with their own particular presentation
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]
Diagnosing anxiety:
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
Diagnostic Statistical Manual Fifth Edition (DSM-5) criteria:
Generalised anxiety disorder
- 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
Diagnostic Statistical Manual Fifth Edition (DSM-5) criteria:
Panic disorder
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
Diagnostic Statistical Manual Fifth Edition (DSM-5) criteria:
Social anxiety/phobia disorder
- Persistent and overwhelming fear of social situations that is out of proportion
- Excessive worrying before, during and after
- At least 6 months
Treating anxiety:
- 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
What should you do if anxiety co-exists with depression?
By treating depression you can reduce anxiety
NICE guidance
Treating generalised anxiety disorder (GAD)
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
NICE guidance
Treating panic disorder
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
NICE guidance
Treating social anxiety/phobia disorder
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
Considerations: antidepressants in anxiety disorders :
- 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)
Specific issues with antidepressants:
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
Benzodiazepines (BZDs) and anxiety disorders:
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
Benzodiazepines (BZDs): tolerance and dependence:
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
Withdrawal from BZDs:
- 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
Medicines optimisation in anxiety - summary
- 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
