4b. Anxiety PDF

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Anxiety...

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Zara Bashir

L4b Neurobiology

Anxiety LO • • • • •

What is anxiety? Types of anxiety disorders (symptoms and diagnostic criteria of anxiety) Brain abnormalities in anxiety (cause) Treatment Role of benzodiazepines in the treatment of anxiety-related disorders

What is anxiety? • • •

Normal component of everyday life – normal response to stressful/threatening situation Becomes a disorder when it is inappropriate or disrupts an individual’s social life Diagnosed using DSM 5

Types of anxiety disorders (AD) (symptoms and diagnostic criteria of anxiety) Generalised anxiety disorder (GAD) • • •

Excessive anxiety & worry >6months Difficulty in controlling the worry Anxiety/worry associated with 3+ sxs; - Restlessness/on edge - Easily fatigued - Difficulty concentrating or mind goes blank - Irritability - Muscle tension - Sleep disturbance

Panic disorder • • •

May occur within several types of AD Onset = sudden and peaks rapidly (~within 10mins) Intermittent, more severe than GAD Essential diagnostic criteria; a) Discrete period of intense fear/discomfort b) 4+ somatic or cognitive sxs - palpitations, pounding heart, or accelerated heart rate - sweating - trembling or shaking - sensations of sob or smothering - feeling of choking - chest pain or discomfort - nausea or abdominal distress - feeling dizzy, unsteady, lightheaded, or faint

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L4b Neurobiology

Zara Bashir -

derealisation (feelings of unreality) or depersonalisation (being detached from oneself) fear of losing control or going crazy fear of dying paraesthesia (numbness or tingling sensations) chills or hot flushes

OCD Obsessions • • •

Recurrent, persistent thoughts, impulses or images which can be inappropriate and intrusive – can cause anxiety/distress NOT simple worries about real-life problems Sufferer attempts to ignore/neutralise these feelings – they realise that these are products of their own imagination

Compulsions • • • •

Repetitive behaviours/mental acts which they feel driven to perform in response to obsession/rules which must be followed Acts are aimed at preventing/reducing distress or a dreaded situation – HOWEVER these are not related and it is clearly excessive Pt realises the acts are excessive Causes distress, time consuming & interferes with normal life

Social Phobia Marked & persistent fear of social/performance situations in which embarrassment may occur. Diagnostic criteria -

Persistent fear of social settings In children, symptoms must be age-appropriate Fear provokes anxiety and could predispose a panic attack In children may present as crying, freezing or shrinking from social situations with unfamiliar people Recognition that the fear is excessive or unreasonable In children this recognition may be absent

Agoraphobia Anxiety or avoidance of places or situations which may be difficult or embarrassing. e.g. being outside of the house alone, travelling in a bus/train. – these situations are then avoided.

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Zara Bashir

L4b Neurobiology

Brain abnormalities in anxiety Pt with AD can display brain abnormalities a) Size of structure b) Neural activity of structures Example – PTSD When combat veterans with PTSD listen to recordings which evoke bad memories – their amygdalae become more active – compared to control subjects. Example – panic attacks Amygdala also appears to trigger panic attacks – through its central nucleus. The amygdala maintains its connections with the brainstem – which control autonomic functions such as respiration & HR – which could explain the sxs – e.g. SOB/ increased HR

Treatment • •

Psychological interventions Pharmacological treatments

Psychological interventions • •

Low-intensity interventions (self-help approaches) High-intensity psychological therapies Stepped-care approach Stepped Care is a system of delivering and monitoring treatments, so that the most effective yet least resource intensive, treatment is delivered to patients first; only ‘stepping up’ to intensive/specialist services as clinically required. E.g. starting with self-help, then watchful waiting, then primary, secondary, tertiary care – as required. Who? ADULTS with GAD, panic disorder, PTSD, OCD, body dysmorphic disorder – stepped care approach CBT Who? Social anxiety disorder in adults, children & young people Psychological therapies Who? OCD, body dysmorphic disorder, PTSD – in children and young people

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L4b Neurobiology

Zara Bashir Pharmacological treatments Benzodiazepine (BZ) = associated with tolerance & dependence Antipsychotics = associated with AE

Therefore, the above should not be used routinely to treat AD. – They should be used as short-term treatment & anxiety disorder crises. Choice of drug • •

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1st line = SSRI (sertraline) If ineffective – alt SSRI or SNRI – taking in the following factors; a) Tendency to produce withdrawal syndrome b) SE & drug interactions c) Risk of suicide & likelihood of toxicity in overdose d) Patients’ prior experience or preference If SSRIs or SNRIs cannot be tolerate – pregabalin BZ should not be offered for GAD in primary or secondary care – ONLY for short term use of crises.

Role of benzodiazepines in the treatment of anxiety-related disorders Background Rapid success rate as lower risk-to-benefit ratio and lower risk of overdose compared to barbiturates

Classification Based on duration of action Class

Duration of action Long acting >24hrs Intermediate/short 5-24 hrs acting...