ic15 anxiety Flashcards
circuits involved in regulating anxiety disorders
fear circuit (fear flight or fight responses) = regulated by amygdala
worry circuit = regulated by cortico-striatal thalamic cortical loop (CSTC) loop.
pathophysiology (neurotransmitters) of anxiety disorders
NE (esp in locus coeruleus projecting from brain stem to amygdala and CSTC loop)
Serotonin (inhibits from amygdala, anxiety triggered by overactivation of the amygdala)
GABA (inhibitory neurotransmitter)
medical conditions associated with anxiety
pertinent conditions
cardiovascular: eg HF
endocrine: eg hyperthyroidism
neurologic: dementia, delirium
pulmonary: asthma, COPD
drugs associated with anxiety
similar to bipolar disorder, but with addition of resp agents like b2 agonists.
sympathomimetics: pseudoephrine
stimulants: eg amphetamine
caffeine, theophylline
thyroid meds eg levothyroixine
corticosteroid
antidepressants
dopamine agonsts
beta adrenergic agonists (eg salbutamol)
drug withdrawal or intoxication.
GAD presentation
1) excessive anxiety and worry ≥ 6 months about events/activity
2) difficult to control
3) ≥3 symptoms (of 6)
- restless, fatigue, concentration, irritation, muscle tension, sleep disturbance.
4) functional impairment
5) not due to another condition or drug
PD presentation
1) recurrent unexpected panic attacks
2) ≥1 panic attack followed by ≥1 month of ≥1 of following:
- persistent anticipatory anxiety for the next attack
- worry about the implications of attack
- a significant change in behaviour related to the attack
may or may not have agoraphobia
SAD (social anxiety disorder) presentation
marked and persistent fear of ≥1 social/performance situation in which the person is exposed to unfamiliar people or to possible scrutiny by others/peers
- fears acting humiliatingly or embarrassingly.
- exposure will provoke an anxiety response
- for > 6 months
avoidance/anxious participation/distress impairs functioning
OCD presentation
either obsession or compulsion that is recognised as excessive/unreasonable, is time-consuming (>1h) and functionally impairing (NOT THE SAME AS PSYCHOSIS)
1) obsession
- recurrent/persistent thoughts/impulses/images (intrusive and inappropriate) causing anxiety/distress.
- attempts to suppress.
2) compulsions
- repetitive behaviours or mental acts
aimed at preventing/reducing distress BUT NOT connected in a realistic way.
PTSD presentation
persistence of symptoms for >1 month
with functional impairment
1) stressor: exposed to death, threatened death, actual/threatened serious injury or sexual violence
2) intrusion symptoms: persistently re-experienced
3) avoidance: of event
4) negative alterations in cognition and mood (began or worsened after event)
5) alterations in arousal and reactivity
phx and non phx management of anxiety disorders (and plan)
aim for serotonergic antidepressants
1) SSRI
2) SNRI (venlafaxine XR)
3) TCA (Clomipramine)
except OCD where 2) and 3) swapped.
adjunct to CBT and psychotherapy
start low (transient jitteriness in initial 1-2 weeks)
- can consider BZP PRN 3-4 months as an adjunct for physical symptoms (eg muscle tension)
onset within 1-2 months, full response in 3 months
usually long term for atleast 1-2 years
maintenance dose may be at high end of range.
management of acute stress/agarophobia?
consider short course of PRN benzodiazepines
- hydroxyzine for acute stress?
- behavioural therapy for agoraphobia.
other phx considerations for GAD
pregabalin, beta blockers (e.g., propanolol), hydroxyzine…
considerations for benzodiazepines
aim for short term
risk of tolerance and dependence (avoid abrupt cessation; gradually taper)
prefer high potency agents: diazepam, clonazepam, lorazepam, alprazolam xr
caution for BZP DDI/special populations
PARADOXICAL excitement in children and elderly
dependence and withdrawal sx occur esp in patients w history of drug dependence
benzodiazepine + opioids = increased mortality
which meds to give for each condition (FDA approval)
paroxetine FDA licensed for all anxiety disorders
sertraline approved for all except GAD
fluvoxamine for SAD and OCD
fluoxetine for PD and OCD
escitalopram for GAD
no FDA approval for venlafaxine in PTSD or OCD.
duloxetine for GAD.
clomipramine only approved for OCD
alprazolam and clonazepam approved for PD
hydroxyzine and pregabalin approved for GAD.
