Chapter 7: Anxiety Flashcards
prevalence of anxiety
8-10 % in USA. One year prevalence is 19%.
Frequent comorbid organic or psychiatric disease. 30% have AUD, 17% have another SUD.
DSM-V criteria for general anxiety disorder (GAD)
Intense worrying a majority of the days for at least 6 continuous months.
In addition, three of the following signs and symptoms must be present:
1. easy fatigability
2. difficulty concentrating
3. irritability
4. muscle tension
5. restlessness,
6. sleep disturbance.
Most frequent signs are diaphoresis, headache, trembling. Can also have poor memory or difficulty concentrating.
Many organic disorders have a component of anxiety in their presentation (IE, myocardial infarct, hypoglycemia) and must be ruled out.
area of the brain invoked in anxiety disorder
Amygdala
Other potential contributors to anxiety are early stress exposures, low cortisol levels, too much NE & Epi, and genetics (functional serotonin polymorphisms)
Communicates with autonomic nervous system to relay danger to other parts of brain.
effect of eercise on anxiety
- reduced anxiety symptoms with increased exercise
- Aerobic > weight or flexibility regimens (though ALL are effective!)
- Length of session and duration of program are important. Max effect at 40 min.
- The movement prescription should reflect patient’s level of fitness, health concerns, and interests
Effects of Mind-body exercises on Anxiety
- Tai chi and Qigong are beneficial for anxiety and depression in a variety of populations (healthy adults, COPD, fibromyalgia, cancer)
- Similar benefits to usual care for Anxiety/ depression in people with SUD
- more rigorous trials needed for tai chi / qigong
- Yoga is beneficial compared to no treatment
- Likely beneficial in kids/ adolescents
- Likely optimal frequency is 2-3x/ week
effect of caffeine on anxiety
Some people get more anxious with 1-2 cups per day. Long-term use has been linked with anxiety and depression. Recommend discontinuation!
effect of alcohol on anxiety
Long-term use diminishes levels of serotonin and catecholamines. Discontinuation is warranted!
Omega-3 FA and anxiety
- omega-3 fatty acid deficiency or imbalance between the ratio of omega-6 and omega-3 fatty acids in the diet correlates with increased anxiety and depression.
- levels of polyunsaturated fats and cholesterol metabolism influence neuronal tissue synthesis, membrane fluidity, and serotonin metabolism
- increased supplementation with omega-3 fatty acids seems beneficial
- Recommend consumption of cold-water fish (sardines, mackerel, tuna, salmon, herring) at least two or three times a week or flaxseed oil (1000 to 2000 mg) or freshly ground flaxseed (2 tablespoons daily)
B vitamins and anxiety
- B vitamins, including B6 (pyridoxine) and B12, are linked with the synthesis of S-adenosylmethionine (SAMe)
- Vitamin B6 is essential for the production of serotonin
- B6 supplementation linked with improvement in anxiety
- large scale trials lacking but a course of B-complex is reasonable especially in older people or those taking meds that can deplete (OCPs, estrogen)
Folic acid and anxiety
(same info as depression chapter)
* supplementation helpful in people who are depressed
* people with folate deficiency esponde less well to SSRIs
* Check b12 level if giving folic acid (B12 deficiency can be masked by folic acid supplementation)
* CAUTIONS: high levels can cause sleep disturbance, seizure exacerbation, GI disturbance, bitter taste in mouth
5-Hydroxytryptophan and Anxiety
- shown to improve depression, but ONLY PRELIMINARY evidence suggesting it may improve anxiety
- the metabolism of 5-HTP by monoamine oxidase and aldehyde dehydrogenase forms 5-indoleacetic acid, which is excreted in the urine
- CAUTION: avoid with serotonergic agents to avoid serotonin syndrome. Some concern still exists about f-HTP (like L-tryptophan) and EMS - not certain that it is only from contaminated products - caution
- Can cause GI upset.
What are the main pharmaceuticals for Anxiety
- SSRI (paroxetine, sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine)
- Less cardiotoxicity compared to TCAs with the SSRIs
- SNRIs (venlafaxine, duloxetine)
- TCAs have anticholinergic, cardiovascular, and sedative effects
- 4-6 weeks trial before determining efficacy
- Anxiolytics (benzos) have been considered, but risk for abuse and habituation
- Buspirone 9nonbenzo anxiolytic) may avoid these issues
- Recent consideration of secong-gen antipsychotics
Kava and Anxiety
Piper methysticum
- pulverized lateral roots.
- Active constituents are the lactones (similar to myristicin in nutmeg)
- recognized as relatively safe in Europe
- Superior to placebo in treatment of GAD. Indicated for mild-mod GAD.
- mechanism: may be similar to benzos (except unclear effects on GABA site like benzos), or may affect limbic system (amygdala & hippocampus)
- Kava also beneficial as a muscle relaxant, anticonvulsant, anesthestic, antiinflamatory
- DOSE: 50-70mg TID or 2-4g of dried root boiled as a decoction TID. Stop after 4 months.
- CAUTIONS: excess sedation when combined with other sedatives. Extrapyramidal side effects - avoid in Parkinson’s. Kava dermopathy (yellow ichthyosiform skin, reverses with discontinuation). Avoid during pregnancy and lactation. Idiopathic hepatotoxicity - avoid in liver disease, AUD, or taking multiple meds metabolized by liver).
Valerian and anxiety
- Mixed efficacy for anxiety (most studies are for sleep)
- Combination with either passionflower (similar effect to thorazine) or St John’s wort (better than Valium) has been studied.
- Indicated for mild - moderate anxiety
- DOSAGE: 150-300 in AM and 300-600 at night (0.1% valerenic acid). consider combining with lemon balm and hops (empiricaal evidence, no trials for this). May take **several weeks **for effect!
- It is NOT suitable for acute treatment.
Mind-body therapies for Anxiety
- behavioral therapy = change the specific unwanted action by using several techniques
- behavioral therapy and CBT are effective
- relaxation training, stress reduction, and breath work are of proven benefit
- repeat exposure to induce anxiety (in a gradual way) is paired with relaxation training (using things like massage, sound, aroma, hypnosis, guided imagery) – something that induces a somatic relaxed state is helpful becuase many patients have somatic sensations that accompany their anxiety
