Case 9- Treating anxiety and MUSD Flashcards
Physical symptoms of anxiety disorders
- Autonomic arousal symptoms- palpitations or pounding heart, accelerated heart rate. Sweating, trembling or shaking, dry mouth.
- Chest and abdomen- difficulty breathing, feeling of chocking, chest pain or discomfort, nausea or abdominal stress
- General symptoms- Numbness or tingling sensation, hot flushes or cold chills
Psychological symptoms of anxiety disorders
- The brain and mind- feeling light headed, feeling that objects are unreal (derealization) or that you are not there (depersonalization), fear of dying
- Symptoms of tension- muscle tension, aches and pains, restlessness, mental tension, feeling on the edge, difficulty swallowing, feeling a lump in your throat.
- Non-specific symptoms- exaggerated response to minor surprises, difficulty concentrating, persistent irritability, difficult to sleep because of worrying.
The effect of anxiety on the patient
- Distress
- Can negatively effect relationships.
- Premature mortality.
- Missing school/work
- Increased healthcare costs
- Reduced productivity
- Unemployment
Explain the under detection of anxiety disorders
Often patients do not present, patients and doctors may find it difficult to talk about emotional symptoms
Psychological treatment for anxiety disorders
First line intervention for most anxiety disorders. Cognitive-behavioural therapy (CBT) is the most widely used type. It is a talking therapy that aims to understand how your problems began and what keeps them going. CBT works by helping you to link the way that you think (thoughts and assumptions) with how you feel (emotions) and your behaviour. Can be used in primary or secondary care.
Drug treatment for anxiety disorder
SSRI’s such as sertraline, paroxetine and escitalopram. Often takes weeks to be effective. Benzodiazapines can be used in severe cases for a short amount of time. Drugs which reduce anxiety are anxiolytic
What to give for anxiety disorders when SSRI’s are not tolerates
Consider a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine. If both SSRI’s and SNRI’s are not tolerated/contraindicated consider using a pregabalin (anti-epilepsy drug). Benzodiazepines
Why are Benzodiazepines not prescribed often
Have associated problems with dependence and tolerance with chronic use and difficulty getting off them after only a few weeks of use. Use should therefore be reserved for short courses of treatment between 2-4 weeks
Examples of Benzodiazepines
Diazepam, alprazolam, chlordiazepoxide hydrochloride and chlobazam
What types of mental disorders are Benzodiazepines prescribed for
Should not be prescribed for stress-related symptoms or unhappiness but only for treating chronic stress. They are not appropriate for depression or chronic psychosis
The criteria for prescribing benzodiazepines
- You have severe, disabling, unacceptable distress
- Associated with insomnia which is severe, disabling and causing extreme distress
- Associated short-term psychosomatic, organ, or psychotic illness
Contraindications for Benzodiazepines and Z-drugs
Benzodiazepines and the Z–drugs (Zolpidem, zopiclone) contraindicated in the elderly due to risk of ataxia, confusion and falls
Beta blockers and anxiety
Beta blockers can reduce palpations and tremors but not anxiety associated muscle tension
Anxiolytic drugs- Buspirone (5-HT1A agonists)
Used to treat general anxiety disorders
Side effects of Buspirone
Dizziness, nausea and headache. There is no sedation or loss on coordination
Contraindications of Buspirone
Epilepsy
Treating insomnia
The cause of insomnia should be determined before prescribing drug treatment. Short acting hypnotics are an option for sleep onset insomnia and for elderly patients. Long-acting hypnotics may be considered for poor sleep maintenance with daytime effects. It is used when a daytime anxiolytic effect is required and when daytime sedation is acceptable.
Transient insomnia
Caused by extraneous factors such as noise, shift work and jet lag. Use a rapidly eliminated hypnotic drug with 1-2 doses. Only prescribe drugs when needed
Short term insomnia
Normally due to emotional problems or a serious medical illness. Hypnotics can be useful but shouldn’t be used for more than three weeks, a short acting drug is appropriate.
Chronic insomnia
Rarely benefitted by hypnotics. Sleep disturbance is very common in depression (early wakening) and the underlying psychiatric condition should be treated
Why is routine hypnotics undesirable
Tolerance can develop within 2 to 14 days. Subsequent withdrawal can cause rebound insomnia and withdrawal syndrome
Benzodiazepine hypnotics
Nitrazepam and Flurazepam have prolonged actions with effects lasting into the next day. Loprazolam, Lormetazepam and Temazepan have shorter actions with little or no hangover effect but withdrawal is more common. Diazepam is sometimes used for insomnia associated with daytime anxiety but effects may be long lasting.
Z-drugs (Z-hypnotics zolpidem and Zopiclone)
Non-benzodiazepine hypnotics which act on the benzodiazepine receptor alpha 1 subunit. It is not licensed for long term use. Both drugs have a short duration of action
Side effects of Z-drugs
May cause dependence, daytime sedation and ataxia so are not appropriate for elderly patients
Benzodiazepine mechanism of action
Benzodiazepine binds to GABA receptors -> increased GABA affinity towards its binding site -> increased frequency of Cl- channel opening -> increased Cl- influx -> Hyperpolarisation -> Increased CNS inhibition effect.
Benzodiazepine pharmacokinetics
They are orally well absorbed and reach peak plasma concentration after 1 hour. They bind highly to plasma proteins and are very lipid soluble so accumulate in fat causing a high VD. They can be given as IV in acute seizures or anaesthesia or through IM which results in slow absorption
Benzodiazepine excretion
Benzodiazepines undergo Hepatic P450 metabolism and are excreted as glucuronide conjugates in the urine (phase 2 metabolism). Metabolites may also be active causing cumulative effects and long hangovers. The duration of action can be divided into short, medium and long-acting drugs. This determines use of drug. The elderly may experience prolonged effects due to reduced metabolism
Short acting Benzodiazepine’s
Temazepam, Lorazepam. Used as hypnotics, there is a reduced hangover effect. Lasts 12-18 hours
Long acting Benzodiazepine’s
Chlordiazepoxide, Diazepam. 24-48 hours. Used as anticonvulsants, muscle relaxant and anxiolytics
Ultra short Benzodiazepine’s
Midazolam. Less then 6 hours. Surgical sedative/hypnotic
Acute toxic effects of Benzodiazepines
Overdose effects can be reversed by flumazenil which acts as an antagonist. Benzodiazepines are less dangerous then other drugs that cause prolonged sleep in overdose. If combined with a CNS depressant (i.e. alcohol) it may cause severe respiratory depression.
Tolerance and Dependence of Benzodiazepines
Tolerance of the drug causes an increase in the dose required to produce the desired effect as there is long term change in the number of receptors. Dependence may become apparent after 4-6 weeks with cessation causing increased anxiety, tremors, dizziness and insomnia. Withdrawal should be gradual and symptoms may take 3 weeks to appear.
Medically unexplained symptoms (MUS)
Physical symptoms persisting for more than several weeks and for which adequate medical examination has not revealed a condition that adequately explains the symptoms
How many people experience MUS?
10-20% of people will have multiple episodes in their lifetime. About 50% of outpatient clinics fulfil the criteria for MUS
Similarities between MUS and a functional disease
1) Lack of identifiable or visible pathology to cause symptoms
2) Persistence- lasts for weeks/months
3) Disorder of function
Functional disease
1) Disease which affects a function or performance
2) Condition marked by signs or symptoms of an organic disease but examination fails to reveal any evidence of structural or physical abnormalities
3) Symptoms are real
Impact of MUS
Annual NHS cost for MUS in adults is about £2.89 billion.
Sickness absence and decreased quality of life - cost the UK economy about £14 billion
Patients with MUS more likely to have more investigations:
- due to no answers or reassurance
- multiple tests, referrals, appointments
Quality of life with someone with MUS
People with moderate or severe MUS have significant impairment in quality of life to the same extent as someone with explained symptoms:
- similar rate of attendance and consultation
- similar rate of referral and investigation
Common MUS diagnosis
Gastroenterology - IBS Cardiology - non cardiac chest pain Rheumatology - fibromyalgia Neurology - chronic headache ENT - dizziness/vertigo Gynaecology - pelvic pain Medicine - chronic fatigue
Are MUS discrete conditions
No- there is a huge overlap between groups of symptoms and people vary with what they experience
Risk factors for MUS
Survivors of child abuse Current physical illness Severe illness or death of a close relative People with long term conditions Refugees People with low health literacy Women
Prognosis of someone with MUS
50-75% of people diagnosed with MUS by their GP - symptoms decrease over 12 month
Good doctor patient relationship is associated with more positive outcome
10-30% of symptoms will worsen
Number of symptoms, duration and severity are associated with worth outcome
Treatment for MUS
A good doctor patient relationship helps. Accepting suffering, managing symptoms and expectations and provide support for the patient.
MUS symptoms
- Gastrointestinal: abdominal pain, altered defecation, bloating/swelling, reflux, nausea and vomiting.
- Cardiovascular: palpitations, chest pain, shortness of breath
- Musculoskeletal: muscle or limb pain, joint pain, back pain, loss of strength, pain with movement.
- Neurological: headaches and dizziness
- ENT: dizziness, vertigo and tinnitus
- Gynaecological: pelvic pain, painful intercourse
- General: fatigue/tiredness, loss of memory, poor sleep
Psychological association with MUS
Depression and anxiety are more common in MUS. That may be due to the stress of the symptoms and lack of diagnosis. Is it cause or effect
Management of MUS
- May need psychological support ie CBT
- Exercise- discourage avoidant activity like not going out
- Occupational medicine support to get patients back to work
- Community activity groups
- Patient support groups
- Pain clinics
- Talk to colleagues about when to stop investigating.
MUS- Somatosensory amplification theory
Patients become hyper-aware of particular sensations and symptoms, the symptoms have an emotional quality like worry. The reception in the brain of the symptom becomes associated with the emotion. So by the time the person is aware of the symptom it is linked to the emotion. Example= ectopic heartbeats have been linked to fear.
MUS- endocrine dysregulation theory
There is evidence of hypothalamic-endocrine dysfunction affecting the feedback loop that regulates stress responses. May be linked to over production of cortisol. This can result in chronic fatigue and pain.
MUS- Immune system sensitisation theory
Chronic immune activation with production of cytokines that don’t switch off when the stressful stimulus is removed. Explains why illness is associated with symptoms like pain or fatigue.
MUS- Autonomic nervous system dysfunction theory
As a result of parasympathetic nerve system dysfunction, a patients pulse rate may not return to normal after a stressful event
MUS- Abnormal proprioception theory
Abnormal proprioception (feeling of where your body is and movement) can be a cause of physical symptoms in patients with MUS. Minimal changes in muscle tension could lead to an enhanced feeling of abnormality.
MUS- the theory of central sensation
Heightened perception of and distress from sensory inputs (enhanced somatic response). This is because there is no inhibition of the touch signal to the pain signal so they combine and the person feels pain
Hyperalgesia
Heightened perception of pain from painful stimuli (hurts more then it should)
Allodynia
Perception of pain from non-painful stimuli (light touch)
MUS- the signal filter model
This model uses the idea that we filter out signals from the body so that we don’t get over stimulation. When there are problems with the filter mechanism it increases our perception of pain.
MUS- Illness behaviour model
Patient beliefs lead to avoidance. Example= chronic fatigue makes the patient believe they will get tired after activity so they avoid it, they then become deconditioned.
MUS- sensitivity theory
Variant beliefs lead to avoidance. Example= chronic fatigue makes the patient believe they will get tired after activity so they avoid it, they then become deconditioned.
MUS- CBT model
Combines many different theories, it shows how the symptom, awareness and emotional and autonomic response are all linked. Eg experience of chest pain/tightness – increased heart rate, increased blood pressure, fear over symptoms, panic, anxiety
Diagnosing mood disorders
Diagnostics is largely based on history taking. Symptoms are subjective. Symptoms vary they can be situational (normal response to life event) or continual (continual unhelpful response to life events).
Biological factors which can effect mood disorders
Anaemia, menopause and hyperthyroidism can make you feel tired and depressed
Two core symptoms of depression?
During the last month have you felt depressed, down or helpless?
During the last month have you been bothered by little interest or pleasure in what you are doing?
PHQ-9
A questionaire used to assess depression. However, it is only one tool. Severity and duration do not tell the whole story
Characteristics of grief?
1) Biological symptoms of loss of sleep, appetite and concentration
2) Distress relates to a particular loss
3) The person retains their capacity for pleasure
4) Grief comes in waves
5) The person may express a passive wish for life to end
6) The person is able to look forward to the future
7) Most people cope without medical interventions
Characteristics of depression
1) Biological symptoms plus psychological symptoms of hopelessness, worthlessness and guilt
2) Distress is usually generalised to all facets of life
3) The person enjoys nothing
4) Depression is constant and unremitting
5) The person may express suicidal ideation
6) The person has no sense of a positive future
7) Medical or psychological interventions are usually necessary
