Lecture 21 - Anxiety Flashcards by Callum Donoher

What is anxiety and is it normal?

Normal

Usually a trigger for it mediated by sympathetics (fight or flight response) proportional to the situation

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Which system mediates the stress/anxiety response?

Limbic system

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What are the neural parts to the stress response (limbic system)?

Hippocampus
Amygdala
Prefrontal cortex (not classically part of limbic system but definitely in emotion)

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How is the hippocampus involved in the stress response??

Receives input from parts of the cortex, this projects to the thalamus and so back to the cortex and also the hypothalamus
Hypothalamus sends signals to autonomic Preganglionics leading to sympathetic nervous system activation and adrenaline release

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What is the amygdalas role in the anxiety stress response?

Sits near tip of hippocampus
Receives inputs from sensory system and outputs to cortex and hypothalamus

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What is the role of the prefrontal cortex in anxiety?

Suppresses/modulates features of anxiety

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What axis is responsible for mediating the stress repsonse?

HPA (hypothalamic pituitary adrenal axis)

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What is the hormonal process occurring in the stress response?

Sympathetic activation leads to the Hypothalmus making CRH (Corticotropin-releasing hormone)
CRH leads to ACTH (Adrenocorticotropic hormone) being released which stimulates the adrenal cortex to releases Cortisol

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What part of the adrenal cortex releases cortisol??

Zona fasiculata

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When does anxiety become a problem?

When repsonse is to a perceived threat not actual threats
Symptoms and psychological response/arousal remains

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What are the stage so chronic stress?

Release of adrenaline and cortisol as well as sympathetic activation

Resistance (Andrenaline wears off) chronic stress response but Prolonged cortisols secretion

Exhaustion (chronic side effects of prolonged cortisol secretion)

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How can chronic stress causes sensitatsion of the HPA axis?

Dampens down negative feedback pathways of cortisol inhibiting CRH relase

Enhanced positive drive through amygdala increasing actiivty in paraventtrriucalr nucleus of hypothalamus
Inc activity in autonomic nervous system

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What is stress habituation?

When repeated mild stress exposure leads to reduced repsonse in the HPA axis so can reduce activity seen in ANS

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What are the symptoms of anxiety (pathological stress response)?

Sympathetic activation:
Palpitations
Sweating
Trembling or shaking
Dry mouth
Difficulty breathing
Nausea
Dizzy
Chest pain

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What is generalised anxiety disorder (GAD)?

Autonomic overactivity for most days for several weeks for several months

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What are thee symptoms of generalised anxiety disorder (GAD)?

Poor concentration
Irritability
Anxious thoughts
Fearful anticipation

Dry mouth, loose stool
Tight chest, difficulty inhaling
Urgency and frequency micturition, ED, menstrual discomfort
Tremor, tinnitus, headache
Insomnia, night terrors

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Why can anxiety develop?

Genetics?
Upbringing
Personality type
Maintained stressful life events

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How do you diagnose Generalised Anxiety Disroder?

Hx
Examination
Investigations

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What are some differentials when it’s actually depression?

Depression
Schizophrenia
Dementia
Substance withdrawal

Thryotoxicosis, Phaeochromocytoma
Ménière’s disease
Paroxysmal tachycardia

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How do you treat Generalsied anxiety?

Psychoeductation
Explain
Clear plan
Reduce stressors

SSRIs/SNRIs
Avoid benzodiazepines
Continue treatment after remission to ensure stays in remission

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Why are benzodiazepines not recommended for use in patients with anxiety disorders?

Drug needs to be prescribed long term and benzodiazepines lead to:
-tolerance
-dependance
-habituation

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What are some examples of SSRIs?

Fluoxetine (Prozac)
Sertraline

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What are the side effects of SSRIs?

Anxiety gets worse before it gets better

Nausea
Dry mouth
Heart burn
Insomnia

What are the different types of anxiety disorders?

Phobias
Social phobia
Panic disorder
Obsessional disorder (OCD)
PTSD
Generalsied anxiety disorder

Who are anxiety disorders most common in?

Women

What are specific phobias?

Fears of specific things so try to avoid them (spiders, heights) Are irrational

What are social phobias?

Anxiety about being in social situations

What is the pathophysiology of specific phobias?

Classical contioning, scary experience occurs so patient associates experience with an object

How do you diagnose phobia?

Hx Exam Investigations Then rule out physical disorder and substance use Then consider use of medication for concomitant conditions (may be cause)

How do you treat a phobia?

CBT Education Systematic desensitisation (heirachy) so start with picture of spider, plushy spider then actual spider

What is agoraphobia?

Fear of crowds, open spaces and travel

When are the peak onsets of agoraphobia?

Mid 20s and 30s when you’re starting to travel and explore

How is agoraphobia treated?

Psychoeduation CBT Desensitisation (heirachy)

What is social phobia?

Inappropriate anxiety in social situations (fear of judgment by others)

Who does social phobia most commonly present in?

Adolescents (panic once socially then fear it again) Mixed gender

How do you treat social phobia?

Relaxation training Densenstiasion CBT

What is panic?

A collection of anxiety symptoms for a short period of time with no trigger

What conditions is panic associated with?

General anxiety disorder Phobia Hyperventilation Depression Alcohol withdrawal

How are phobias and panic associated?

Phobias can be built on experiencing panic and associating it with a place or thing

How can episodic anxiety panic be explained to a patient?

Over sensitive alarm system with anxious thoughts and harmless physical symptoms

What are some treatments for epsiodic anxiety panic?

Tricyclic antidepressants (TCAs) SSRIs (causes short term increase in anxiety so needs review after 2 wks) CBT

What are some TCAs for episodic anxiety panic?

Imipramine Clomipramine

What is OCD (Obsessive compulsive disorder)?

Obsessions and compulsions

What are obsessions?

Unshakable thoughts: -recurrent ideas, images and impulse -distressing -try to resist them

What are compulsions?

Repeated actions or rituals Not enjoyable Short term relief of the obsession

What is the name of the mechanism of pathophysiology of Obsessive Compulsive Disorder?

Basal ganglia Re-entrant loop mechanism

What is the basal ganglia re entrant mechanism for OCD?

Cortex projects obsessive thoughts to basal ganglia Basal ganglia projects the obsessive thought via the thalamus back to the cortex for the obsessive thought to keep re entering into the cortex and basal ganglia

Why may the basal ganglia re entrant circuit mechanism take place in OCD? What does treatment for OCD target?

Overactivity in direct pathway Treatments inhibit thalamic activity reducing direct pathway Or stimulate indiscreet pathway

What increases the risk of OCD?

Genetics Early experiences Life events with avoidance or rituals

When do most cases of OCD start?

3/4 have started by 30 1/3 start between 10-15

How do you treat OCD?

Self help (resist rituals) Treat with SSRIs or clompiramine continue 6months after remission CBT

Why may you not always give clomipramine in OCD patients?

If they have risky life threatening behaviours since clomipramine is toxic so may overdose

What is Post Traumatic Stress Disorder?

Prolonged reaction to stress where flashbacks and nightmares can be experienced

How long after the initial event should you wait before diagnosing PTSD?

At least 6 months

What is thought to be the pathophysiology of PTSD?

Possible amygdala hyperactivity leading to exaggerated behavioural responses but its unclear

What are the treatments of PTSD?

SSRIs Short term benzodiazepines CBT Psychoeducation Eyemovemtn desensitisation therapy Charities