Anxiety, Trauma, and Treatment

Question 1

Symptoms associated with cortico-striato-thalamo-cortical circuit

Answer 1

“Worry loop”
-anxious misery
-apprehensive expectation
-obsessions

Question 2

Symptoms associated with amygdala-centered circuit

Answer 2

Fear
-panic
-phobia

Question 3

Core symptoms of anxiety disorder?

Answer 3

anxiety and worry

Question 4

Generalized anxiety disorder (GAD)

Answer 4

Characterized by chronic, excessive worry, generalized anxiety/fear, increased arousal, fatigue, difficulty concentrating, sleep problems, irritability, and muscle tension

Question 5

Panic disorder

Answer 5

Involves sudden, unexpected episodes of intense fear. May have anticipatory fear/anxiety and worry about panic attacks.
Other symptoms: phobic avoidance/behavioral change, unexpected panic attacks
The role of the autonomic nervous system and hyperactivation of the fear circuits is highlighted.

Question 6

Benzodiazepine mechanism of action

Answer 6

Enhance phasic inhibition of GABA by positive allosteric modulation of postsynaptic GABA_A receptors, promoting a calming/anxiolytic effect by increasing chloride ion influx at GABA_A receptors. Theoretically reduces excessive amygdala activity.
Effective for short-term relief of severe anxiety

Question 7

Alpha-2-Delta (A2D) Ligands as anxiolytics

Answer 7

Bind to A2D subunit of presynaptic N and P/Q voltage-sensitive calcium channels (VSCCs), block the release of excitatory neurotransmitters such as glutamate that occurs when neurotransmission is excessive, as postulated in the amygdala to cause fear and in CSTC circuits to cause worry.
Anxiolytic actions in social anxiety disorder & panic disorder
Also effective treatment for epilepsy, neuropathic pain, and fibromyalgia
Gabapentin and pregabalin

Question 8

SSRIs first-line treatment for which disorders?

Answer 8

Depression, GAD, PTSD, and social anxiety

Question 9

SNRIs mechanism of action

Answer 9

Inhibit reuptake of both serotonin and norepinephrine, helping to alleviate anxiety symptoms by modulating both neurotransmitter systems.

Question 10

Beta-blockers mechanism of action

Answer 10

Block beta-adrenergic receptors to reduce physical symptoms of anxiety (e.g., heart palpitations, tremors). Commonly used in performance anxiety.

Question 11

Buspirone mechanism of action

Answer 11

A serotonin 5-HT1A receptor partial agonist, often used in the treatment of GAD, but not other anxiety/trauma subtypes

Question 12

GAD treatment

Answer 12

Tx: SSRIs, SNRIs, benzodiazepines, buspirone, and α2δ ligands such as pregabalin and gabapentin
Benzodiazepines can be useful in patients who are not substance abusers for short term when initiating an SSRI or SNRI, since these serotonergic agents are often activating, difficult to tolerate early in dosing, and have a delayed onset of action. Can also be used to “top-up” SSRI or SNRIs with patients not getting full relief. Benzos useful for symptom surges
α2δ ligands good alternative for benzos
Off-label tx: mirtazapine, trazodone, vilazodone, tricyclic antidepressants, or even sedating antihistamines such as hydroxyzine

Question 13

Panic Disorder tx

Answer 13

Tx: SSRIs and SNRIs, as well as benzodiazepines, and α2δ ligands
Off-label tx: mirtazapine, trazodone
MAOIs powerful efficacy for panic and should be considered second or third line treatment

Question 14

Social Anxiety Disorder tx

Answer 14

Tx: SSRIs and SNRIs and α2δ ligands
NOT benzos
Performance anxiety tx: beta blockers + benzodiazepines
Alcohol is effective and can be abused in these pts

Question 15

PTSD tx

Answer 15

Tx: SSRIs are approved but not very effective (side effects = sleep problems)
Exposure therapy most effective