Management of Anxiety Disorders

Question 1

Before management of any anxiety disorder what first needs to be ruled out?

Answer 1

• medical condition
• medication
• toxin
• alcohol

Question 2

When working to change beliefs in the management of anxiety disorder what are three levels of belief that exist?

Answer 2

• 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)

Question 3

describe how early maladaptive schemas develop into automatic thoughts

Answer 3

early life experiences > early maladaptive schema > dysfunctional assumptions > activating event ? automatic -ve thoughts > mood/behavior/physiology

Question 4

what is the resonance phenomena?

Answer 4

Tend to tune into frequencies we’re familiar with which is directly influenced by our underlying beliefs

Question 5

describe 5 psychological methods used to manage anxiety disorders

Answer 5

• thought record sheet
• considering alternatives
• developing a wise mind concept
• increasing the window of tolerance
• CBT

Question 6

What is involved when creating a thought record sheet when managing anxiety disorders? what is the aim?

Answer 6

To help rationalise thoughts

• situation
• symptom
• beliefs (AT)
• evidence for
• evidence against
• balanced thought

Question 7

What is involved in ‘considering alternatives’ when managing anxiety disorders?

Answer 7

• 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

Question 8

When managing anxiety disorders, what is ‘developing a wise mind concept’?

Answer 8

a wise mind is an overlap of the emotional mind and the rational mind

Question 9

When managing anxiety disorders what does it mean to increase the window of tolerance? what is the window of tolerance?

Answer 9

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

Question 10

Describe what a hyper aroused state is in anxiety disorders?

Answer 10

flight/fight response

e. g:
- anxiety
- overwhelmed
- chaotic responses
- outbursts

Question 11

Describe what a hypo aroused state is in anxiety disorders?

Answer 11

Freeze response

e. g.
- memory loss
- shut down
- dissociation
- auto pilot
- no display of emotion

Question 12

Describe some methods used to stay in or widen the window of tolerance

Answer 12

• mindfulness
• deep slow breathing
• recognise limiting beliefs and counter these with positive statements
• techniques for self soothing

Question 13

When managing anxiety disorders what is the difference between top down processing and down up processing?

Answer 13

top down - working on cognitions/adaptive behavior

down up - working with physiological reactions/emotions

Question 14

what are the 6 different types of anxiolytic drugs? (one type is not recommended)

Answer 14

1 - barbiturates (not recommended)
2 - Benzodiazepines
3 - antidepressant drugs
4 - Buspirone
5 - Pregabalin
6 - B-Blockers

Question 15

Give examples of benzodiazepines and list their 6 pharmacological effects

Answer 15

Diazepam/Lorazepam/Nitrazepam…etc

• reduce anxiety
• reduce aggression
• hypnosis/sedation
• muscle relaxant
• anticonvulsant effect
• anteretrograde amnesia

Question 16

How do benzodiazepines work?

Answer 16

bind to GABA receptors and allow more Cl- in than if just GABA binds

Question 17

What is GABA? What is the effect of GABA?

Answer 17

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.

Question 18

Describe the role of GABA in anxiety

Answer 18

• all receptor modulators GABA exhibit anxiolytic properties
• inverse BDZ agonists have anxiogenic properties
• GABA antagonist (Flumazenil - antedote for BZD’s) can increase anxiety

Question 19

What is the antidote for benzodiazepines?

Answer 19

flumazenil

Question 20

List the 8 uses of benzodiazepines?

Answer 20

• Acute treatment of extreme anxiety
• hypnosis
• Alcohol withdrawal
• Mania
• Delirium
• Rapid tranquilisation
• status epilepticus
• premedication before sugery or during minor procedures

Question 21

Are benzodiazepines safe in overdose

Answer 21

• Fairly safe
• can cause respiratory depression (unlikely)
• can give flumazenil

Question 22

What are the main adverse effects of benzodiazepines?

Answer 22

• anteretrograde amnesia and impaired co-ordination (rohypnol is a benzo)
• paradoxical depression
• Causes tolerance and dependence: rebound anxiet on withdrawal +/- physical symptoms

Question 23

Describe what happens in benzodiazepine withdrawal, what can happen in rapid withdrawal?

Answer 23

Rapid withdrawal may = confusion/toxic psychosis and even convulsions
-insomnia/appetite loss/anxiety/wt loss/tremor/perspiration/tinnitus/perceptual disturbance

Question 24

What can happen to the body’s response to GABA with chronic benzodiazepine use? how could this be explained?

Answer 24

• decrease in the body’s response to GABA

- withdrawal symptoms may be due to decrease in the number of GABA receptor receptors.

Question 25

What are the 4 steps involved in withdrawal from benzodiazepines?

Answer 25

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.

Question 26

Which antidepressants are used in anxiety? (4)

Answer 26

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)

Question 27

What is the effect of MAOI on anxiety?

Answer 27

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)

Question 28

Describe the role of SSRI's in anxiety management

Answer 28

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.

Question 29

What is buspirone? What is it's role in anxiety management?

Answer 29

5-HT1a agonist | -relatively weak anxiolytic in animals and humans and shows slow onset

Question 30

What is pregabalins role in anxiety management?

Answer 30

'new' BZD licensed for chronic pain. calcium channel blocker and GABA enhancer. Only considered if unresponsive to other treatments

Question 31

What are B-blockers role in anxiety?

Answer 31

-best for somatic symptoms e.g. palpitations | unlikely to work as primary treatment.