Anxiolytics CA2 Flashcards
Brief description of anxiety-related disorders
Generalised Anxiety Disorder: excessive anxiety and worries for >6 months
Panic disorder: anticipatory anxiety and recurrent panic attacks
Obsessive Compulsive Disorder (OCD): occasional thoughts/impulses that cause anxiety, followed by compulsive behaviours to relieve that anxiety.
Post-traumatic stress disorder (PTSD): re-experiencing of trauma, persistent avoidance and increased arousal.
Etiology and pathophysiology of anxiolytics
- Fear circuit is regulated by the amydala
- Worry circuit is regulated by the cortico-striatal-thalamic cortical (CSTC) loop.
- Neurotransmitters involved:
» Serotonin
»> Pathological fear/anxiety is related to the over-activation of the amygdala.
»> High serotonin output -> increased anxiety
» GABA
»> Inhibitory neurotransmitter
»> Low levels -> high anxiety
Medical conditions associated with anxiety
cardiovascular: heart failure
endocrine: hyperthyroidism
neurologic: dementia, delirium
pulmonary: asthma, COPD
Clinical presentation of GAD
- Excessive anxiety and worry ≥ 6 months
- 3 or more of the following symptoms:
1. Restlessness or feeling on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (insomnia, restless unsatisfying sleep) - Can cause significant functional impairment
Clinical presentation of panic disorder
- Recurrent unexpected panic attacks, and ≥1 of the panic attacks has been followed by ≥1 month of ≥1 of the following:
» Persistent anticipatory anxiety of having additional panic attacks
» Worry about the implications of the panic attack
» Significant change in behaviour related to the panic attacks.
Clinical presentation of social anxiety disorder
- Marked and persistent fear of ≥1 social/performance situations, where the person is exposed to unfamiliar people or possible scrutiny by other. He/she acts in a way that will be humiliating or embarrassing.
- Duration: >6 months
- Social situations are avoided, impairs functioning.
Clinical presentation of PTSD
- Person is exposed to a major stressor: e.g. death, threatened death, violence
- Traumatic experience is persistently re-experienced by the person
- Persistent, effortful avoidance of distressing, trauma-related stimuli post event
- Negative alterations in mood and cognitions
- Trauma-related alterations in arousal or reactivity
» Irritable and aggressive behavior
» Self-destructive etc. - Persistence of symptoms, could lead to functional impairment
Assessment of anxiety disorder
- Clinician-rated: Hamilton Anxiety Scale (HAM-A)
» Significant anxiety: Score 18-20
» Response= 40-50% reduction
» Recovery = score <7
» Pros: gold standard, Cons: takes a long time to be administered, and has to be by someone trained. - Self-rated :
» Beck Anxiety Inventory (BAI)
» Zung Self-rated Anxiety Scale - Identify target symptoms for each type of anxiety disorders
- Keep detailed diary to record fear levels, physical symptoms, cognitions and anxiety behaviors.
Treatment for GAD
Pharmacotherapy:
- SSRI
- Venlafaxine XR
- Pregabalin
Non-pharmacological:
- CBT
Treatment for Panic Disorder
Pharmacotherapy:
- SSRI
Non-pharmacological:
- CBT
Treatment for Social Anxiety Disorder
Pharmacotherapy:
- SSRI
Non-pharmacological:
- Behavioural therapy
OCD
Pharmacotherapy:
- SSRI, clomipramine
Non-pharmacotherapy:
- CBT
- Exposure and prevention therapy
PTSD
Pharmacotherapy:
- SSRI
Non-pharmacotherapy:
- CBT, psychotherapy, counselling
Treatment principles of antidepressants
- All serotonergic antidepressants can be used for long-term management of anxiety disorders, OCD, PTSD
- Approach to dosing: titrate upwards
- Serotonergic antidepressant: effective for excessive worrying types of disorders. Onset at least 1-2 months, to see the full impact must wait for 3 months.
Different types of antidepressants (SSRI)
escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
