Management of Anxiety Disorders Flashcards
Before management of any anxiety disorder what first needs to be ruled out?
- medical condition
- medication
- toxin
- alcohol
When working to change beliefs in the management of anxiety disorder what are three levels of belief that exist?
- Automatic thoughts (thoughts pop into mind automatically e.g. sensations/feelings/images)
- assumptions
- early maladaptive schema (deeprooted unconditional basic beliefs that stem from childhood and are less accessable - they shape and colour assumptions/automatic thoughts, they are more resistant to change as are pervasive and stable)
describe how early maladaptive schemas develop into automatic thoughts
early life experiences > early maladaptive schema > dysfunctional assumptions > activating event ? automatic -ve thoughts > mood/behavior/physiology
what is the resonance phenomena?
Tend to tune into frequencies we’re familiar with which is directly influenced by our underlying beliefs
describe 5 psychological methods used to manage anxiety disorders
- thought record sheet
- considering alternatives
- developing a wise mind concept
- increasing the window of tolerance
- CBT
What is involved when creating a thought record sheet when managing anxiety disorders? what is the aim?
To help rationalise thoughts
- situation
- symptom
- beliefs (AT)
- evidence for
- evidence against
- balanced thought
What is involved in ‘considering alternatives’ when managing anxiety disorders?
- Disorder e.g. PTSD
- existing belief e.g. I am in danger
- alternative belief e.g. it is in the past, i am ok now
When managing anxiety disorders, what is ‘developing a wise mind concept’?
a wise mind is an overlap of the emotional mind and the rational mind
When managing anxiety disorders what does it mean to increase the window of tolerance? what is the window of tolerance?
In between the hyper-aroused state and the hypo-aroused state there is a window of tolerance - aim to stay in here.
-window of tolerance is e.g. comfort zone/ability to self soothe/ability to be emotionally regulated
Describe what a hyper aroused state is in anxiety disorders?
flight/fight response
e. g:
- anxiety
- overwhelmed
- chaotic responses
- outbursts
Describe what a hypo aroused state is in anxiety disorders?
Freeze response
e. g.
- memory loss
- shut down
- dissociation
- auto pilot
- no display of emotion
Describe some methods used to stay in or widen the window of tolerance
- mindfulness
- deep slow breathing
- recognise limiting beliefs and counter these with positive statements
- techniques for self soothing
When managing anxiety disorders what is the difference between top down processing and down up processing?
top down - working on cognitions/adaptive behavior
down up - working with physiological reactions/emotions
what are the 6 different types of anxiolytic drugs? (one type is not recommended)
1 - barbiturates (not recommended) 2 - Benzodiazepines 3 - antidepressant drugs 4 - Buspirone 5 - Pregabalin 6 - B-Blockers
Give examples of benzodiazepines and list their 6 pharmacological effects
Diazepam/Lorazepam/Nitrazepam…etc
- reduce anxiety
- reduce aggression
- hypnosis/sedation
- muscle relaxant
- anticonvulsant effect
- anteretrograde amnesia
How do benzodiazepines work?
bind to GABA receptors and allow more Cl- in than if just GABA binds
What is GABA? What is the effect of GABA?
Gamma Amino Butyric Acid
-main inhibitory neurotransmitter in brain (Glycine is another inhibitory neurotransmitter restricted to the brain and spinal cord)
-widespread distribution
Causes hyperpolarisation of target cells by allowing CL- in.
Describe the role of GABA in anxiety
- all receptor modulators GABA exhibit anxiolytic properties
- inverse BDZ agonists have anxiogenic properties
- GABA antagonist (Flumazenil - antedote for BZD’s) can increase anxiety
What is the antidote for benzodiazepines?
flumazenil
List the 8 uses of benzodiazepines?
- Acute treatment of extreme anxiety
- hypnosis
- Alcohol withdrawal
- Mania
- Delirium
- Rapid tranquilisation
- status epilepticus
- premedication before sugery or during minor procedures
Are benzodiazepines safe in overdose
- Fairly safe
- can cause respiratory depression (unlikely)
- can give flumazenil
What are the main adverse effects of benzodiazepines?
- anteretrograde amnesia and impaired co-ordination (rohypnol is a benzo)
- paradoxical depression
- Causes tolerance and dependence: rebound anxiet on withdrawal +/- physical symptoms
Describe what happens in benzodiazepine withdrawal, what can happen in rapid withdrawal?
Rapid withdrawal may = confusion/toxic psychosis and even convulsions
-insomnia/appetite loss/anxiety/wt loss/tremor/perspiration/tinnitus/perceptual disturbance
What can happen to the body’s response to GABA with chronic benzodiazepine use? how could this be explained?
- decrease in the body’s response to GABA
- withdrawal symptoms may be due to decrease in the number of GABA receptor receptors.
What are the 4 steps involved in withdrawal from benzodiazepines?
1 - transfer patient to daily dose of diazepam/chlordiazepam (preferably taken at night)
2 - decrease dose every 2-3 weeks in steps of 2 to 2.5 mg (if symptoms occur maintain dose until improvement)
3 - decrease dose further and in smaller steps if necessary (too slow is better than too quick)
4 - stop completely, this may take 4 weeks to a year or more.
Which antidepressants are used in anxiety? (4)
1 - SSRIs: panic disorder/OCD/PTSD/Phobias/GAD
(for GAD use escitalopram/fluoxetine)
2 - Tricyclic: 2nd line for panic disorder (unlicensed)/OCD
3 - Venlafaxine: GAD
4 - Moclobemide: social anxiety disorder (this is a new MAOI with no food/drug interactions)
What is the effect of MAOI on anxiety?
anxiogenic stimuli cause:
- an increase in noradrenaline release from neurons projecting to hippocampus and prefrontal cortex
- an increase in serotonin release from neurons projecting to dorsal raphe nucleus
- MAOI can block this increase (as can BDZ’s)
Describe the role of SSRI’s in anxiety management
Acutely they cause an increase in serotonin and have anxiogenic properties however chronically they have an anxiolytic effect (mechanism not understood)
=will cause and increase in anxiety first before working anxiolytically.
What is buspirone? What is it’s role in anxiety management?
5-HT1a agonist
-relatively weak anxiolytic in animals and humans and shows slow onset
What is pregabalins role in anxiety management?
‘new’ BZD licensed for chronic pain.
calcium channel blocker and GABA enhancer.
Only considered if unresponsive to other treatments
What are B-blockers role in anxiety?
-best for somatic symptoms e.g. palpitations
unlikely to work as primary treatment.
