Therapeutics - Anxiety Flashcards
What is the aetiology of anxiety?
Neurochem dysreg
- Defense sys ori from amygdala of limbic sys resp for “fear, fight or flight” resp
- Resp to both learned and unlearned threats
Behavioural inhib sys
- Based in hippocampus and septum of limbic sys
- Responsible for avoidance behaviour
Neurotransmitters
- NE: esp in locus coeruleus, that projects from brain stem to amygdala and CSTC loop (keep heart pumping, oxygenate muscles for fight. flight
- 5HT: pathological fear/anxiety is related to overaction of amygdala. However amygdala receives input from serotonergic neurons which can inhib its outputs
- Inhibitory neurotransm GABA: once activated, mind relax
- Others: CCK, DA, corticotrophin releasing factor (CRF), glutamate
Genetic
Medical conditions
- CVD: Angina, arrhythmias, CHF, IHD, MI
- Neuro: delirium, dementia, PD, seizures, stroke, neoplasms, inadequate pain control, migraine
- Pulmonary: asthma, COPD, PE, pneumonia
- Endocrine/meta: Cushing’s disease, hyper/hypoparathyroidism, hypoglycaemia, hyponatremia, hyperkalemia, pheochromocytoma, vit B12 or folic acid def
Describe the drug induced aetiology of anxiety.
Sympathomimetics
Stimulants
Methylxanthines
Thyroid hormone
GCs, NSAIDs
Antidepressants
Dopamine agonists
Beta adrenergic agonists e.g. salbutamol
Anti HTN
ASM, Abx (quinolones, isoniazid)
Anticholinergics, Antihistamines
Digoxin
What are the signs and symptoms of GAD?
- Xssive anxiety & worries, occurring more days than not for >6mo, abt a number of events or activities (e.g. work, sch performance)
- Pervasive range of things they worry abt
- Person finds it diffcult to control
- Anxiety and worry assoc w >3 of the following symptoms (w at least some symptoms present for more days than not for the past 6mo)
(1) Restlessness or feeling keyed up or on edge
(2) Being easily fatigued
(3) Difficulty concentrating or mind going blank
(4) Irritability
(5) Muscle tension
(6) Sleep disturbance (insomnia, restless unsatisfying sleep) - The focus of the anxiety/worry not confined to the features of another mental disorder
- Symptoms cause sig fnal impairment
- Symptoms are not due to another mental condition or direct physiological effects of a sub (e.g. drugs)
What are the signs and symptoms of panic disorder (w or without agoraphobia)?
- Both (1) and (2)
(1) Recurrent unexpected panic attacks and
(2) >1 of the panic attacks has been followed by >1mo of 1 of the following:
a. Persistent anticipatory anxiety of hvg additional panic attacks
b. worry abt implication of the panic attack
c. sig change in behaviour related to panic attacks - Indicate absence or presence of agoraphobia
- Panic attacks not due to physiological effects of a sub (e.g. drugs) or a general medical condition
- Panic attacks are not better accounted for by another mental disorder
What are the signs and symptoms of social anxiety disorder (SAD)?
Marked and persistent fear of >=1 social/performance situations in which the person is exposed to unfamiliar ppl or to possible scrutiny by others/peers
Fears that he/she will act in a way (or show anxiety symptoms) that will be humiliating or embarassing
- Exposure to phobic stimulus almost invariably provokes anziety resp (may be situationally bound/predisposed panic attack)
- Duration >6mo
Feared social/performance situations are avoided or endured w intense anxiety/distress
- Avoidance, anxious anticipation or distress in feared situation(s), sig impairs fning
Symptoms not due to another mental condition or direct physiological effects of a sub
Differential Dx: Avoidant personality disorder
What are the signs and symptoms of OCD?
Obsession:
Recurrent and persistent thots/impulses/images that are xp, at some time durg the disturbance, as intrusive and inappropriate and causing marked anxiety/distress
The thots, impulses or images not simply xs worries but real life problems
Person attempts to ignore or suppress such thots/impulses/images or to neu them w some other action/thot
Person recog that obsessional thots/images/impulses pdt of his/her own mind
Compulsions:
Repetitive behaviours or mental acts that person feels deiven to perform in resp to an obsession or according to rigid rules
Behaviours or mental acts aimed at preventing/reducing the distress but NOT connected in a realistic way w what they are designed to neut/prevent or are clearly xsive
Person recog that obsessions/compulsions are excessive or unreasonable
Obsessions/compulsions cause marked distress, are time consuming (>=1h a day) or sig impairs fning
If another mental condition is present, content of obsession/compulsion is not restricted to it
Symptoms not due to another mental condition or direct physiological effects of sub
Insight not impaired (know it is not realistic/practical/reasonable)
What are the 5 anxiety disorders?
Generalised Anxiety Disorder
Panic disorder
Social Anxiety Disorder
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
What are the signs and symptoms of PTSD?
A. Stressor - Person xposed to: death, threatened death, actual or threatened srs injury or actual or threatened sexual violence as follows (1 req)
* May be direct or indirect, happening to themselves or those ard them
B. Intrusion symptoms - Traumatic event persistently re-experienced in following ways (1req)
* Memorise, nightmares, dissociative rxns (e.g. flashbacks)
C. Avoidance - Persistent effortful avoidance of distressing trauma-related stimuli after the event (1req)
* Trauma related thots/feelings/xt reminders (e.g. ppl, places, convo, activities, objects, situations)
D. -ve alt in cognitions and mood that began or worsened after traumatic event (2req)
E. Alt in arousal and reactivity that began or worsened after traumatic event (2req)
* Irritable/aggressive. self destructive/reckless, hypervigilance, exaggerated startle resp, problems in concentration, sleep disturbance
* Persistence of symptoms in B-E for >1mo
- Full Dx not met until min 6mo after trauma(s), although onset of symptoms may occur immediately
* Sig symptom related distress or fnal impairment (e.g. social, occupational)
* Disturbance not due to meds, sub use or other illness
What are the differential Dx for PD?
Panic attack:
Discreete period of intense fear/disconfort
>4 of the following dev abruptly and reached a peak within 10min (usually lasts no more than 20-30min)
- Palpitation, punding heart, increased PR
- Sweating
- Trembling, shaking
- Nausea or abdo stress
- Dizziness, unsteady, lightheaded, faint
- Derealisation or depersonalisation
- Fear of losing control or going crazy
- Fear of dying
- Paresthesias (numbing or tingling sensations)
- Chills or hot flashes
What are the differential Dx for SAD?
Agoraphobia:
Fear of marketplace
Anxiety abt being in places/situations from which escape might be difficult or embarrasing or
Help may be unavail in event of havg unexpected situationally predisposed panic attack or panic like symptoms
Situations avoided or endured w marked distress or anxiety abt having panic attack or panic like symptoms or req presence of companion
Anxiety/phobic avoidance not better accounted for by another mental disorder
2 or more agoraphobia situations req for Dx
What are the recommendations for GAD?
Adjunct benzos»_space; BB, antihistamines, buspirone
Maintenance
1st line: SSRI (escitalopram, paroxetine), SNRI
2nd line: pregabalin > TCA
What are the recommendations for panic disorder?
Adjunct benzos
Maintenance
1st line: SSRI (fluoxetine, paroxetine, setraline)
2nd line: TCAs
3rd line: MAOIs, valproate
What are the reco for SAD?
Adjunct benzos
Maintenance
1st line: SSRI (fluvoxamine, paroxetine, setraline)
2nd line: MAOIs/RIMAs
What are the reco for OCD?
Adjuncts benzos»risperidone, aripiprazole, acetylcysteine
Maintenance
1st line: SSRI (fluvoxamine, fluoxetine, paroxetine, setraline)
2nd line: Clomipramine
3rd line: Venlafaxine XR
What are the reco for PTSD?
Adjunct benzos
Maintenance
1st line: SSRI (paroxetine, setraline)
2nd line: Clomipramine
