Lecture 9 - anxiety

Question 1

what is anxiety ?

Answer 1

’ the fight or flight survival program’
Feelings of anxiety are uncomfortable, but anxiety is a normal part of being a human being

Question 2

what is the heroes-dodson curve?

Answer 2

describes the relationship between stress and performance

Question 3

what are the pathological symptoms of anxiety? x12

Answer 3

Adrenaline acts on organs to produce the following effects:
Shortness of breath, choking

Palpitations, chest pains, flushes

Trembling, sweating

Dry mouth, butterflies, nausea, belching

Feel dizzy and light-headed

Damaging cognition and fear

Question 4

what is the difference between ‘healthy’ and ‘pathological’ anxiety

Answer 4

Healthy anxiety: anxiety experienced by most people under unaccustomed stress. Normal response to an unusual situation e.g. exams, sport etc. This is usually facilitating!

Pathological anxiety: an unadaptive response - no useful purpose. Anxiety is experienced both in the presence of, or the absence of, what can be seen to be obvious stimuli. The patients know that their fears are irrational and groundless, but this is of no help to them in allaying their anxiety e.g. fear of heights, spiders etc.

Question 5

what are key clinical points for diagnosing generalised anxiety disorder?

Answer 5

Generalized anxiety disorder is characterized by persistent anxiety and uncontrollable worry that occurs consistently for at least 6 months.

This disorder is commonly associated with depression, alcohol and substance abuse, physical health problems, or all these factors.

In primary care, patients with this disorder often present with physical symptoms such as headaches, muscle tension, gastrointestinal symptoms, back pain, and insomnia.

Brief validated screening tools such as the Generalized Anxiety Disorder 7 (GAD-7) scale should be used to assess the severity of symptoms and response to treatment.

Question 6

what are social signs of anxiety disorder? x9

Answer 6

fear of leaving the house, social withdrawal,

compulsive or repetitive behaviours

trouble on the job or in school

alcohol or drug abuse

frequent emotional and physical health issues

extreme, un warranted fear of. aprtiualr situation or things

changes in personality

family or relationship problems

depression or suicidal thoughts

“Patients with generalized anxiety disorder often describe a sense of helplessness, whereas patients with major depression may feel hopeless.”

Question 7

what is DSM-5 classification?

Answer 7

Social Anxiety Disorder (Social Phobia)

Specific Phobia
Panic Disorder
Agoraphobia

Generalized Anxiety Disorder
Anxiety Disorder Due To Another Medical Condition
Substance/Medication-Induced Anxiety Disorder
Selective Mutism
Separation Anxiety Disorder
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder

Question 8

what is in the ICD-10 classification?

Answer 8

F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive-compulsive disorder
F43 Reaction to severe stress, and adjustment disorders
F44 Dissociative and conversion disorders
F45 Somatoform disorders
F48 Other nonpsychotic mental disorders

Question 9

what can be the triggers for symptoms of specific phobia?

Answer 9

Animal
Natural environment
Blood-injection-injury
- Fear of blood
- Fear of injections and transfusions
- Fear of other medical care
Fear of injury
Situational
Other

Question 10

what is the pathophysiology of anxiety in the brain?

Answer 10

Brain regions: The limbic system is thought to play central role in anxiety disorders (evidence form animal and human models).

Neurotransmitter systems: Altered sensitivity of the GABA system is implicated.

In addition, some evidence exists for the serotoninergic (5-HT) system to be involved.

Question 11

what is the amygdala?

Answer 11

The amygdala is located Deep within the temporal lobe of the brain. the thalamus plays a role in sensory association and processing. of emotions and sends to the amygdala which sends the the brainstem.

Question 12

what is used for the treatment for anxiety?

Answer 12

anxiolytics:
benzodiazepines
SSRIs
TCAs
5-HT agonists

Question 13

descried the use of benzodiazepines

Answer 13

One of the most heavily prescribed psychoactive drugs, with alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan) amongst the top 100 most commonly prescribed medicines.
Used in other CNS disorders as well as in anxiety.
Generally produce almost immediate effects, and thus may be prescribed for short-term, intermittent, ”as-needed” use.
Used historically but not recommended under current guidelines.

Question 14

what is the effect of benzodiazepines on GABAergic neurotransmission?

Answer 14

benzodiazepines are positive modualtors of GABAa channels.
benzodiazepines icnrease the freqeucny of openign gaba channels

Question 15

What is the metabolism and elimination BZDs?

Answer 15

Rapid (t 1/2 < 5 hrs): midazolam
Short (t1/2 = 5-20 hrs): lorazepam, temazepam
Intermediate (t 1/2 = 20-40 hrs): nitrazepam.
Slow (t1/2 > 40 hrs): diazepam, chlordiazepoxide
Long half-lives usually means the generation of active metabolites.
Side effects: overdose, drug interaction, tolerance & dependence

Question 16

what are benefits and disadvantages of SSRIs?

Answer 16

Benefits: Can be helpful for depression, panic disorder and social phobia.
Safe in overdose. No tolerance and no withdrawal unless patient stops abruptly. No weight gain.

Disadvantages: 4-6 weeks to see effects, full benefit develops in up to 12 weeks.
Patients often experience a temporary worsening of symptoms.
Side effects such as nausea, insomnia, headaches, sexual dysfunction, initial agitation.
Prescribed drugs include: fluoxetine (prozac), sertraline, paroxetine, citalopram.

Question 17

describe 5-HT1A agonsit: buspirone

Answer 17

A 5-HT1A partial agonist regarded as a mild tranquliser.
Used to treat generalised anxiety and social phobias
Benefits:
No sedation or impairment of performance
No cross-tolerance with BZs
No tolerance or withdrawal
No abuse potential
Disadvantages:
Nausea, headache, insomnia, nervousness, restlessness. dizziness, light headedness. Might requires extended treatment to see beneficial effects.

Question 18

what are the NICE guidelines for SSRIs?

Answer 18

if a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor. consider offering sertraline first because it is the most cost-effective drug.

Question 19

what is anxiety associated with?

Answer 19

as with depression, evidence suggests anxiety is associated with deficiency in 5-HT/ serotonin. this neurotransmitter is also implicated in panic disorders.

5-HT1A -Anxiety, alcoholism, sexual function
5-HT1C -Anxiety, migraine pain
5-HT1D -Migraine pain
5-HT2 -Anxiety, depression, schizophrenia negative symptoms, sexual function
5-HT3 -Migraine pain, emesis, schizophrenia (e.g., ondansetron)
5-HT4 -Anxiety, schizophrenia?

note the dosage for treating anxiety is usually higher than for depression

Question 20

what should a person with GAD be advised for a treatment plan?

Answer 20

assessment of symptom using GAD-7. ie suicide risk, co existing liabilities etc. lifestyle advice
threat such as CBT
avoid benzodiazepines if heavy alcohol intake/ patterns
may use SSRI instead