Anxiety disorders

Anxiety definition

Normal physiological response, can be helpful, often underestimated

ANXIETY DISORDER - erroneous cognitions, exaggerated perceptions, dysfunctional coping

Epidemiology/ Aetiology (anxiety)

Most common 12-month mental health disorder

Higher incidence in younger people, females Often develop in childhood and persist if untreated

Risk factors of anxiety

Genetic/biological

Personality

Ongoing stress/life events

Chronic/physical illness

Substance abuse

Other mental health problems

High co-morbidity with other MH disorders

Yerkes- Dodson law of anxiety

Increasing attention and interest as arousal increases -> optimal arousal (not too much) results in optimal performance - -> strong anxiety inpairs performance

Symptoms of anxiety

PHYSICAL

GI

Respiratory, Hyperventilation

Cardiovascular

Genitourinary

Muscle tension

Sleep disturbance

PSYCHOLOGICAL

Fearful anticipation

Irritability

Sensitivity to noise

Poor concentration

Worrying thoughts

DSM-V criteria for anxiety

Diagnostic and Statistical Manual of Mental Disorders

Typically ≥6 months

Fear or anxiety is excessive or out of proportion

Diagnosed only when symptoms not attributable to substance/medication or medical condition or another mental disorder

Treatment (anxiety)

Self-help and psychoeducation

Psychological treatments: CBT

Pharmacotherapy: Antidepressants, BDZ, Buspirone, Pregabalin

MILD: CBT

MOD: CBT or meds or both -> Review response to initial treatment and progress after 4-6 weeks. No response?

Check adherence and review therapeutic engagement and re-evaluate formulation, re-evaluate co-morbidities (depression, substance misuse, personality difficulties)

SEV: CBT and Meds -> Review response to initial treatment and progress after 4-6 weeks

how is treatment for anxiety modified?

if initially treated with dCBT -> change to face to face CBT or medication

if initially treated with face to face CBT -> add medication

if initially treated with medication -> add CBT or increase medication dose or both

Type of anxiety disorders

Generalised Anxiety Disorder (GAD)

Panic disorder

Social Anxiety Disorder (SAD) - Social phobia

Obsessive Compulsive Disorder (OCD)

Post Traumatic Stress Disorder (PTSD)

Generalised Anxiety Disorder (GAD)

Continuous, persistent, and excessive anxiety (can fluctuate)

Worry about everything, difficult to control worry --> significant distress of impairment

PHYSICAL SYMPTOMS: Restlessness, on edge, fatigued, difficulty concentrating, muscle tension, sleep disturbance

Panic disorder

Recurrent unexpected panic attacks - abrupt surge of intense fear/discomfort that peaks within minutes

Persistent fear/worry about attacks - frequency/severity varies widely

*Panic attack: individual episodes of panic. This is not panic disorder.

Social Anxiety Disorder (SAD) - Social phobia

intense fear, anxiety of being judged/ negatively evaluted by people

Social situations almost always provoke fear or anxiety, and often avoided

Obsessive Compulsive Disorder (OCD)

Separate category in DSM V

Presence of obsessions and/or compulsions

- Obsessions: recurrent, persistent, intrusive, unwanted thoughts/urges/images

- Compulsions: repetitive behaviours that individual feels driven to perform in response to an obsession

- Individuals may not be aware that they are repeatedly doing something

Post Traumatic Stress Disorder (PTSD)

Separate category in DSM V

Characteristic symptoms following exposure to ≥1 traumatic events (actual or threatened death, serious injury, sexual violence, war)

Varied presentation, impacts on mood (irritable, angry, sleep), avoidence of stimuli that might provoke symptoms

Cognitive Behavioural Therapy (CBT) (anxiety)

Involves education about:

- Condition

- Arousal management

- Graded exposure

- Safety response inhibition

- Surrender of safety signals and cognitive strategies

Antidepressants for anxiety

1st line for: GAD, SAD, panic disorder - less evidence for OCD, PTSD

SSRIs: most evidence

SNRIs: some have benefit - venlafaxine, duloxetine

-> ~50% have symptoms improvement

TCAs: may be used (GAD, Panic disorder), but S/E limit use

MAOIs (irreversible): efficacy in GAD & panic disorder, moclobemide effective in SAD

Duloxetine & Venlafaxine: may be less well tolerated

Mirtazapine or Agomelatine: very little data

Clinical points for use of antidepressants in anxiety disorders

- Lower starting dose: usually start with half normal starting dose. Titrate slowly and as tolerated

- Response usually by 4-6 weeks, up to 12 weeks for full benefit.

- Continue for 12 months if responsive with gradual discontinuation

- Take d, not prn for anxiety symptoms

- Variances between anxiety disorders: clomipramine has evidence in OCD

- Treat in conjunction with graded exposure to feared situations

- Many may require long term AD treatment

- Discontinuation - can be worse with anxiety disorders

AE of antidepressant use in anxiety

(may be more pronounced in anxiety)

Akathisia (restlessness)

Suicidal ideation

Initial exacerbation of anxiety symptoms

Nausea

Headache

Sleep disturbances

BENZOs in anxiety (use, therapeutic actions)

ONLY USE IN SEVERE DISABLING ANXIETY causing extreme distress

- Rapid symptomatic relief from acute crises and immediate short term relief

- Well tolerated, strong evidence for efficacy in most prominent symptoms

- Use lowest effective dose for shortest time (Max 4 wks)

- Short t½ (<6h) not recommended: most addictive

Therapeutic actions:

- Anxiolytic: anxiety relief

- Hypnotic: promotes sleep

- Myorelaxant: muscle relaxant

- Anticonvulsant: stops fits, convulsions

- Amnesia: impairment of short-term memory

BENZOs in anxiety (risks and considerations)

Risks:

- Cognitive impairment (affects judgement), falls, sedation

- >1 mth use: Physical dependence, tolerance, misuse, withdrawal symptoms

- CAUTION: older adults, history of problem substance use

- C/I + Precautions: respiratory depression, hepatic impairment, myasthenia gravis due to muscle relaxant properties

Considerations:

- Age, frailty, co-morbidities, potential harm

- Assess risk of misuse: history of misuse?

- Discuss potential for addiction

- Small quantities at a time

- Patient factors in dosing: age, body size, comorbidities, other meds

- Advise on AE: ability to drive/ operate machinery etc

- Discuss expected duration of treatment

BENZOs in anxiety (AE and withdrawal)

drowsiness

over sedation

light headedness

memory loss

ataxia

slurred speech

Withdrawal (>1 mth use risks dependence, tolerance & misuse)

Withdrawal symptoms: anxiety, insomnia, tremor, nausea, depression, sensory disturbance, seizures

- TREATMENT: Stabilise on diazepam equivalent then gradual tapering dose reduction (minimises withdrawal symptoms)

Buspirone (Alternative to BDZ)

- Special Access Scheme.

Use in anxiety:

- Partial agonist at serotonin 5HT1A receptors

- Preferable to BDZ if history of drug dependence

- Inhibition of CYP3A4 = BDZ potentiation

- Optimal benefits: 2 weeks

In comparison to BDZ:

- Slower onset

- Doesn't prevent BDZ withdrawal symptoms: withdraw gradually if changing to buspirone

- Less potential for: sedation, psychomotor impairment, abuse, dependence

BDZ Options + half-life

LONG ACTING (half-life >24h): clobazam, clonazepam, diazepam, flunitrazepam, nitrazepam

MEDIUM ACTING (half-life 12-24h): bromazepam, lorazepam

SHORT ACTING (half-life 6-12h): alprazolam, oxazepam, temazepam

VERY SHORT ACTING (half-life <6h): triazolam

OTHER PHARMACOTHERAPY OPTIONS for anxiety

• Pregabalin - Evidence of benefit in GAD, Not licensed in Aust for anxiety

• Atypical Antipsychotics (quetiapine) - Limited evidence, risk vs benefit

• Beta-Blockers - Tachycardia, performance anxiety

• Antiepileptics (lamotrigine)