ic14 anxiety Flashcards
what are the types of anxiety disorders (per DSM-5 classification) and differentiate between them
general anxiety disorder (GAD): excessive anxiety and worries >6m
panic disorder: anticipatory anxiety of recurrent panic attacks
social anxiety disorder (SAD): fear of being scrutinised or humiliated by others in public
obsessive compulsive disorder (OCD): obsessional thoughts or impulses that causes anxiety, f/b compulsive behaviours to relieve that anxiety
post traumatic stress disorder (PTSD): re-experiencing of trauma, persistent avoidance, incr arousal
what is stress and what is anxiety
stress refers to the overpowering pressure of an adverse force or influence exerted on the body
anxiety is the body’s response to that stress, results in psychological and physical sx that generally subsides after trigger subsides
what is the definition of “anxiety disorder”
anxiety disorders refers to severe, excessive and persistent anxiety and irrational fears that impairs daily living and functioning, and is out of proportion to the actual danger or threat of the situation
anxiety sx typically persists long after original trigger disappears (for more than 6m)
what is the prevalence of GAD and OCD in SG
GAD: 1.6%
OCD: 3.6%
what is the etiology and pathophysiology of anxiety disorders
two circuits that are overruning: fear circuit and worry circuit
fear circuit and sx are regulated by amygdala while the worry circuit and sx are regulated by the cortico-striatal-thalamic-cortical (CSTC) loop
the systems that are responsible for various actions are: defense system and behavioural inhibition system
defense system is responsible for fear, fight or flight responses and thus it originates in the amygdala of limbic system and it makes someone respond to both learned and unlearned threats vs behavioural inhibition system is responsible for avoidance behaviours and it originates in the hippocampus and septum of limbic system
ultimately anxiety disorders is resulting from neurochemical dysregulation of neurotransmitters: 5HT, GABA, NE
anxiety disorders may potentially be perinatal trauma or genetically caused
anxiety disorders can also be caused by medical conditions or is drug-induced
medical conditions assoc w anxiety disorder incl
i) CV (angina, arryhthmia, CHF, IHD, MI)
ii) endocrine/ metabolic (cushing’s disease, hyperparathyroidism, hyperthyroidism, hypoG, hypoNa, hyperK, vit B12/ folic acid deficiency)
iii) neurologic (dementia, delirium, migraine, PD, seizure, stroke, neoplasm, inadequate pain control)
iv) pulmonary (asthma, COPD, pulmonary embolism, pneumonia)
drugs that can induce anxiety disorders incl
i) sympathomimetics (pseudoephedrine)
ii) stimulants (amphetamines, cocaine)
iv) methylxanthines (theophylline, caffeine)
v) antidepressants
vi) corticosteroids (prednisolone)
vii) thyroid hormones (levothyroxine)
viii) dopamine agonist (levodopa)
ix) beta adrenergic agonist (salbutamol)
x) antihypertensives
xi) drug withdrawal (from alcohol, caffeine, sedatives, benzodiazepines, antidepressants, nicotine)
xii) drug intoxication (from anticholinergics, antihistamines, digoxin)
what are the NT involved in the etiology and pathophysiology of anxiety disorder
5HT, GABA, NE (among others like DA, CCK etc)
what constitutes as a “panic attack”
a panic attack is a discrete period of intense fear or discomfort in which at least 4 of the following sx that developed abruptly and reach a peak within 10mins and usually do not last more than 20-30min
sx incl
i) palpitations (incr HR)
ii) sweating
iii) trembling or shaking
iv) sensations of shortness of breath
v) feeling of choking
vi) nausea, abdominal distress
vii) feeling dizzy, unsteady, lightheadedness, faint
viii) derealisation or depersonalisation
ix) fear of losing control or going crazy
x) fear of dying
xi) parasthesia (numbing or tingling sensation)
xii) chills or hot flushes
it can be expected or unexpected
what is the clinical presentation of GAD (what is the criteria for the sx presented)
excessive anxiety and worry occurring more days than not for at least 6m
sx of anxiety and worry incl
i) restlessness or feeling on edge
ii) being easily fatigue
iii) difficulty concentrating or mind going blank
iv) irritability
v) muscle tension
vi) sleep disturbances (insomnia, restless unsatisfying sleep)
so should have at least 3 sx from above list on majority of the days in for at least 6m
sx should result in functional impairment and should not be due to another medical condition or drug/substance induced
sx are not better accounted for by another mental condition
what is the clinical presentation of PD (and what are the criterias of the sx)
panic disorder can present w/wo agoraphobia (fear of not being to escape when things go wrong)
sx should fulfil i) and ii)
i) recurrent unexpected panic attacks
ii) at least one of the panic attack is followed by 1m or longer of at least one of the following: persistent anticipatory worry about having additional panic attacks, worry about implications of the panic attack, significant change in behaviour relating to the panic attacks
sx should not be caused by a medical condition or drug/substance induced
sx are not better accounted for by another mental condition
what is “agoraphobia”
it refers to anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having unexpected situationally predisposed panic attack or panic-like sx
what is the clinical presentation of SAD (and what is the criteria for the sx)
marked and persistent fear of one or more social or performance situations in which they would be exposed to unfamiliar people or subjected to scrutiny by others or peers, and he or she is fearful of acting in a humiliating or embarrassing manner
duration >6m
these situations are either avoided or endured with intense anxiety or distress
the avoidance, anxious anticipation or distress in the feared situation significantly impairs functioning
sx should not be caused by another medical condition or drugs/ substances
what is the clinical presentation of OCD (and what is the criteria for the sx)
obsession and compulsions
obsession:
i) persistent and recurrent thoughts or images or impulses that are intrusive and inappropriate and are causing marked anxiety or distress
ii) not simply just excessive worries about real-life problems
iii) person tries to ignore or suppress these thoughts or images or impulses, or tries to neutralise them through another action or thought
iv) person recognises that these thoughts or images or impulses are a product of their own mind
compulsions:
i) repetitive behaviour or mental acts that are done in response to an obsession
ii) to prevent or reduce the distress but is not realistically connected to what it is designed to neutralise or prevent, or are just clearly excessive
*person also recognises that these obsessions or compulsions are excessive or unreasonable
*the obsession or compulsions cause marked distress and are time consuming (>1hr a day) or significantly impairs functioning
sx should not be due to another medical condition or drug or substance induced
what is the clinical presentation of PTSD (what are the categories to consider and what are the criterias)
categories for PTSD: stressor, intrusion sx, avoidance, neg alterations in cognition and mood, alterations in arousal and reactivity
(A) stressor (exposure to)
i) direct exposure
ii) witnessing in person
iii) indirectly, by learning that a close relative or close friend was exposed to it
iv) repeated or extreme indirect exposure to aversive details of the trauma (usually bc of profession duties)
(B) intrusive sx (persistently re-experience of trauma)
i) recurrent involuntary and intrusive memories
ii) traumatic nightmares
iii) dissociative reactions (flashbacks)
iv) intense or prolonged distress bc of reminders
v) marked physiologic reactivity after exposure to related stimuli
(C) avoidance (effortful avoidance of related stimuli)
i) trauma related thoughts or feelings
ii) trauma related external reminders
(D) negative alterations in cognition and mood (either began or worsened after the trauma)
i) inability to recall key features of the traumatic event
ii) persistent (and often distorted) negative beliefs and expectations about oneself and the world
iii) persistent distorted blame of self of others for causing the event or for its consequences
iv) persistent negative trauma related emotions
v) marked diminished interest in significant activities
vi) feeling alienated from others
vii) constricted affect: persistently unable to experience positive emotions
(E) alterations in arousal and reactivity (either began or worsened after event)
i) irritability or aggressive
ii) reckless or self-destructive
iii) hypervigilance
iv) problems in concentration
v) exaggerated startled response
vi) sleep disturbance
*for A-C, each only req at least 1 subpoint but for D and E, each req at least 2 subpoints
*sx in BCDE must be persistent
*diagnosis can only be made at least 6m after trauma even if onset of sx is immediate
*significant functional impairment or sx related distress
*sx not due to other medical conditions, drugs or substances
what is the ddx for SAD
avoidant personality disorder
what are some specifiers that can be included in diagnosis of PTSD
- w dissociative sx (derealisation, depersonalisation)
- w delayed expression
what are the scales used in order to assess the various clinical presentations of anxiety disorders (which is the gold standard)
for clinician rated:
1. hamilton anxiety scale (HAM-A) *gold standard
for self rated:
1. beck anxiety inventory (BAI)
2. zung self rated anxiety scale
what score for HAM-A indicates significant anxiety, response and recovery
significant anxiety if score 18-20
response if 40-50% reduction
recovery if score <7
outline the non pharmacotx for each type of anxiety disorder
GAD: CBT, psychotherapy, relaxation, anxiety management
PD: CBT
SAD: behavioural therapy
OCD: CBT, exposure and response prevention (ERP)
PTSD: CBT (impt first line), psychotherapy, counselling
agoraphobia: CBT, behavioural therapy, group therapy
specific phobias: behavioural therapy
what is “specific phobia”
marked and persistent fear that is excessive or unreasonable cued by presence or anticipation of a specific object or situation, typically immediate and often leads to avoidance
outline the pharmacotx for each type of anxiety disorder
GAD: SSRIs, venlafaxine XR (SNRI), pregabalin (anticonvulsant)
PD: SSRIs, TCAs
SAD: SSRIs
OCD: SSRIs, clomipramine (TCA)
PTSD: SSRIs
agoraphobia: short course PRN benzodiazepines
specific phobias: medication not helpful
rank the available pharmacotx for each type of anxiety disorders
SSRIs > SNRIs > clomipramine (TCAs last bc of the potential s/e)
except for OCD: SSRI > clomipramine > venlafaxine
what is the dosing considerations for pharmacotx for anxiety disorders
starting dose must be low (bc transient jitteriness in initial 1-2w when starting antidepressant; and people with anxiety alr abit of jitteriness)
can consider short term PRN benzodiazepine as adjunct when starting
maintenance dose usually on high end of range
what kind of sx is serotonergic antidepressants useful for and how long till onset of action and how long is the usual tx duration
serotonergic antidepressants useful for “excessive worrying” type of sx in anxiety
onset in 1-2m, full response generally 3m
tx duration at least 1-2yr usually long term
what are the possible adjunctive tx for tx of anxiety disorders (consider its effect, onset, duration of tx, s/e profile, type of agents, any cautions)
- adjunct short course PRN benzodiazepines
has therapeutic effect on physical sx of anxiety (eg. muscle tension)
fast onset (can be within 30mins)
aim for short term of 3-4m PRN then taper
may have tolerance and dependence s/e (tolerance to hypnotic actions common and develops within days while tolerance to anxiolytic action less common; for dependence, avoid abrupt cessation after weeks continued use if not result in withdrawal, instead gradual taper)
high potency agents preferred (clonazepam, lorazepam, alprazolam XR)
caution:
i) paradoxical excitement esp in children and elderly
ii) dependence and withdrawal sx can occur esp in pts w hx of drug dependence
- adjunct pregabalin for GAD (can incr enzymes that produce GABA but long onset of at least 1w, usually a few weeks)
what are the FDA indications for the SSRIs
paroxetine: ALL anxiety disorders
sertraline: ALL except GAD
fluoxetine: PD, OCD
fluvoxamine: SAD, OCD
escitalopram: GAD
citalopram: unknown
what are the FDA indications for the SNRIs
venlafaxine: GAD, PD, SAD (<clomipramine for OCD)
desvenlafaxine: unknown
duloxetine: GAD
what are the FDA indications for TCAs
clomipramine: OCD (>venlafaxine)
imipraine: unknown
what are the FDA indications for benzodiazepines
diazepam: GAD, PD
alprazolam: GAD
lorazepam: GAD
clonazepam: PD
what are the eg. of drugs based on each class for pharmacotx of anxiety disorders
SSRIs: paroxetine, sertraline, fluoxetine, fluvoxamine, escitalopram, citalopram
SNRIs: venlafaxine, duloxetine
TCAs: imipramine, clomipramine
NaSSA: mirtazapine
benzodiazepines: alprazolam, diazepam, lorazepam, clonazepam
antihistamines: hydroxyzine
beta blocker: propanolol
anticonsulvants: pregabalin (adjunct for GAD)
compare the equivalence dose, duration of action, primary hepatic metab mechanism, half life, adult daily dose range of alprazolam, diazepam, lorazepam and clonazepam
alprazolam: 0.5mg; short; oxidation; no active metab; 0.25mg TDS
diazepam: 10mg; long; oxidation; half life of both parent and active metab super long; 2-10mg BD-QDS
lorazepam: 1mg; short; glucoronidation; no active metab; 1-3mg/d
clonazepam: 1mg; long; oxidation; half life of both parent and active metab long; 0.5mg BD
what are the clinically significant ddi for tx of anxiety disorders
- general ddi: CNS depressants incl alcohol (space 6h apart), anticholinergic agents, sertonergic agents (MAOIs w TCAs/SSRIs) can cause serotonin syndrome
- antidepressants ddi: relate to cyp (1A2, 2B6, 2C8, 2C9, 2C19, 3A4)
- benzodiazepines ddi: CNS depressants incl alcohol (space 6h apart), opioids (benzo+opioids incr mortality), all benzodiazepines do not induce cyp but are metabolised by cyp EXCEPT lorazepam
