Anxiety Disorders: Diagnosis and Treatment

3.1 Introduction to Anxiety Disorders

• Medications used to treat anxiety disorders include: diazepam, nitrazepam, oxazepam, temazepam, amitriptyline, duloxetine, escitalopram, mirtazapine, sertraline, and venlafaxine.

Scenario: John's Case

• John, a 38-year-old, seeks alprazolam, having used it for 3 years for anxiety; it initially helped but is now less effective.
• He had stopped antidepressant medication due to worsened symptoms, drinks coffee excessively, and lacks sleep.

LO 1: Epidemiology of Anxiety Disorders

• Anxiety globally affects one-third of the population.
• In Malaysia, Generalized Anxiety Disorder (GAD) prevalence ranges from 0.4% to 5.6%.
• About 39.7% of adolescents aged 13-17 experience anxiety.
• Anxiety is a health issue that is often unrecognized and untreated.
• Anxiety disorders create significant economic burdens due to healthcare costs and lost productivity.

LO 2&3: Understanding Anxiety

• Anxiety levels follow a bell curve.
• Optimal anxiety enhances performance.
• Excessive anxiety impairs performance.
• Situational anxiety is a normal response to stress.
• Anxiety disorders involve persistent, excessive worry interfering with daily life.
• Examples of anxiety disorders: generalized anxiety disorder (GAD), social anxiety disorder, separation anxiety disorder, panic disorder, panic attack, agoraphobia, and specific phobias.
• Comorbid conditions with anxiety disorders: other mood disorders and substance misuse.
• Anxiety can be secondary to conditions like depression or hyperthyroidism.
• Anxiety disorders are defined under DSM-V.
• Increased anxiety is a common symptom across all anxiety disorders.
• Treatment approaches include addressing all anxiety symptoms and underlying causes with possible short-term psychological interventions.

LO 1 & 4: Pathophysiology of Anxiety

• Pathophysiology of anxiety includes: genetics, cognition/behavior, and neurochemistry interacting with environmental factors and medical conditions.
• Resilient factors can counteract anxiety triggers.
• Brain regions involved in anxiety include the amygdala, hippocampus, hypothalamus, and locus coeruleus.

Brain Regions and Anxiety

• The amygdala controls fear and emotional responses; stimulation can induce fear, anxiety, or euphoria.
• Larger amygdala volume and hyper-responsiveness of amygdaloid circuitry are linked to increased anxiety, while decreased prefrontal cortex suppression exacerbates anxiety symptoms.
• The Hippocampus is involved in emotional memory and the behavioral inhibition system; a larger volume is associated with increased anxiety.
• The hypothalamus regulates physical responses like breathing and flushing; managing its outputs may treat anxiety, but excessive CRF synthesis raises cortisol and anxiety.
• Locus Coeruleus: Overactivity can increase arousal, which may lead to anxiety symptoms, as it is a noradrenergic center involved in stress response.
• Amygdaloid-Hippocampal Circuit: Dysfunction in this circuit is related to persistent anxiety and enhances emotional memory and fear responses.
• Fight and Flight Response: The body activates the SNS, which is triggered by fear to protect against danger or pain.
• Leads to physical (cortisol release, heart rate increased, suppressed immune system), cognitive (evaluating and responding), and emotional responses.
• Specific brain alterations may explain symptom differences across anxiety disorders.

Neurotransmitters and Anxiety

• Neurotransmitters and their functions in anxiety: serotonin (mood regulation), GABA (inhibitory neurotransmitter), and noradrenaline (stress hormone).
• Serotonin: Mood regulation promotes well-being, and increased serotonin can reduce anxiety.
• Complex effects are possible.
• Altered serotonin signaling contributes to anxiety.
• GABA: Inhibitory neurotransmitter that calms brain activity.
• Insufficient GABAergic inhibition causes hyperexcitability and anxiety .
• Noradrenaline: Acts as a stress hormone, which increases arousal and alertness.
• Overactivity in the locus coeruleus heightens anxiety symptoms.
• The complex role is that increased NA, which may worsen or relieve anxiety depending on receptor downregulation.
• Dopamine: Dopamine modulates mood, reward, and attention.
• May influence anticipatory anxiety and hypervigilance.

Drugs Targeting Pathways

• SSRIs increase serotonin levels
• Buspirone decreases serotonin.
• Benzodiazepines increases GABA receptor affinity and enhances inhibitory effects.
• TCAs limit noradrenaline reducing anxiety.
• Propranolol targets β-receptors in the amygdala, which decreases anxiety symptoms and post traumatic stress disorder (PTSD) risk.
• NA based treatments may work through β-adrenoceptor downregulation
• Low dose antipsychotics may block dopamine receptors easing anxiety in some patients.

General Neurochemical Basis & Contributing Factors

• Anxiety lacks a clearly defined neurochemical cause but involves the interaction of multiple neurotransmitters.
• Pharmacological approaches aim to increase 5-HT or NA and uses anxiolytics to manage symptoms.
• Genetic: Moderate heritability for social phobia and specific phobias plus a stronger genetic component for Panic Disorder.
• COMT gene: linked to anxiety vulnerability.
• Environmental: Include negative life events, as well as lack of social interaction or exposure to negative coping models, along with learned behaviors and repeated stress responses.
• Cognitive Bias: Includes overestimation of danger and catastrophic thinking.
• There is a resilience vs. stress that determines anxiety disorder development.
• An interaction of genetic makeup, learned behaviors, and life stress impact vulnerability.
• Hyperthyroidism and cardiovascular issues, as well as stimulants, steroids and sedatives or alcohol withdrawal may contribute to anxiety.

Clinical Diagnosis of Anxiety Disorders

• Symptoms of emotional or physical feeling with worried facial expression, increased muscle tension, restlessness, impaired concentration, sleep disturbances, and irritability, are seen.
• Diagnosis depends on duration, onset, and type of symptoms, plus significant distress/impairment.
• Based on ICD - 10 are generalized anxiety disorder and panic disorder with or without agoraphobia
• Also social phobia, specific phobia, post-traumatic stress disorder, and obsessive-compulsive disorder
• Diagnostic categories: DSM lists 12 anxiety disorders (7 categories).

Clinical Features

• Generalized Anxiety Disorder: involves excessive, inappropriate, and persistent worry lasting months. (ICD-10)
• 6 months is the duration lasting in DSM-IV with physical and psychological symptoms and may coexist, and does not meet full criteria for this disorder
• Panic Disorder: Recurrent, unexpected panic attacks (≥4 symptoms) peaking within 10 minutes and lasting 30 -45 minutes causing anticipatory anxiety.
• Agoraphobia: A fear of future panic attacks and situations with difficult escapes and meets at least to in ICD -10.
• Social Phobia: involves marked, persistent, unreasonable fear of being observed or negatively evaluated.
• Physical and Psychological symptoms are seen in performance settings avoided or endured. Requires prominent avoidance in ICD - 10.
• Specific Phobia: causes excessive/unreasonable fear of specific objects, and stimulus requires to be avoided.
• Actual death exposure to threats to integrity. Symptoms of clusters are re-experiencing, avoidance, and hyper-arousal meeting and of ICD - 10.
• Obsessive - Compulsive Disorder: is characterized by the recurrent and unwanted thoughts and images or impulses, the recurring intrusive thoughts, the images, or impulses. The repetitive mental or physical rituals for anxiety must be present.

Diagnostic & Approach to Anxiety Disorders

• Diagnostics in explorations of suspected anxiety requires in all cases significant impairment and social occupational functioning.
• Identify type of anxiety disorder of the medical conditions and caffeine or stimulant the cause of the use or adverse prescribed drugs.
• Address contributing psychological and lifestyle considerations.
• In middle-aged or older patients, exclude depression or dementia as the primary cause.
• Other conditions that also need to be ruled out: caffeine intoxication, stimulant use, and alcohol/drug discontinuation.

Other Factors that Contribute to Anxiety Disorders

• Adjustment disorder: time-limited syndrome from stress.
• Comorbid conditions: Can often coexist with depression.
• There’s an overlap with “anxiety disorder”.
• There’s post-distress onset and it is harder to differentiate from related worries or physical conditions
• Diagnosis is harder if the patients are anxiety elderly
• The types of service require a direct and indirect approach to enable privacy and confidentiality skills through ethical and clinical knowledge in practice.

GABA: Role in Anxiety

• GABA, the primary inhibitory neurotransmitter in the mature brain reduces neuronal activity
• 50% of brain synapses contain GABA receptors
• GABA Types and MOA: binding of alpha and gamma that is used in Gaba-A &C with gated chloride to enter neuron causing hyperpolarization and action potentials.
• GABA in anxiety-controls neuron hyperactivity to fear convulsion
• Contains allosteric action to GABA and modulars for subunits that increase or decrease
• BDZ: frequency to y and causes anlyotic effects

Benzodiazepines Subtypes

• Alpah1 for all brain with Sedative-anticonvulsant and memory regulation, alpha2 for EEG acitivty anxiety alpha3 for antidepressant, Alpah5 for learning
• The sensitive types require classical, clinical benzodiazepines
• Positive modulators enhance enhance by alcohol bartz while enhancement by negative only
• Enhance GABA action by benzodiazepires barbituates which reduces over all anxiety
• Fear is reduced with sedation with relaxation anterograde amensia and action
• Agonists: ^ GABA
• Partial agonist: Lg GABA
• antagonists: lock benzodiazepines

Treatment of Children With Anxiety Disorders Pt.1

• The treatment of children that have any anxiety should be under the proper supervision of a child psychiatrist
• Its also recommended to consider in severe cases in terms of combination psychotherapy and or ineffective the medicine.
• Fluroxamine may also cause effective short issues that is recommended with the side effects
• There are non pharmaceutical treatment approachs that recommend counselling sleep with cognitive or behaviour therapties and address medical conditions

Treatment of Children With Anxiety Disorders Pt.2

Medication should happen in the patient if

• There as motivation or acceptance to receive counselling
• They are limited and are required to provide some preference such as past treatment to be reviewed and more factors for suicidal prevention to be prevented for health
• Severe symptoms in the planning if not Worsening with CBT
• Non response to the child with severe and effective and should be used more carefully.

BDZ's

• Short term use medication to suppress the limbic System
• Short side effects can arise from that such as rebound effects to alcohol
• Dependence side effects and not recommended for adults and for Chronic illness for older patients

Medication for anxiety

• Autonomic or acting side effects can cause hypertension or tachycardia such as heart
• On set is short acting the some last the whole way
• A lot of people have had those and they have been on it for multiple years.

Oral Dosages & Considerations

• Oral dosage is with the long half, it could've caused them to be for withdrawals to get them slowly off the drug as well or
• Abrupt could not be recommended when the person with drawl and could be anxious all day with what to treat them is the focus

Lower Dose

• Higher is often found with liver respiratory function Medication is used when high risk.

Antidepressants to Help

• Can show some types of side effects so the second line treatments are very effective
• Some people get it right the first day what else might do if those are not working to try to help

Generalised Anxiety Disorder (GAD) (eTG)

• Chronic condition marked by excessive, persistent, and unrealistic worry about everyday matters.
• Can be over things within or a person s long term, to be constantly on that edge.
• Most of the Australian population gets anxiety, about to develop with GAD is higher with females .
• Impaired inhibitory circuitry may lead to hyperactivity.
• Over active excitability and symptoms will increase from the pulses and are all
• the symptoms in the past 6 months is associated with a anxiety can then be caused in general of function

Things

• All medical conditions you must evaluate and then diagnose what psychological factors are affecting
• The GAD that has early intervention is highly recommended.

Cognitve Behavior (First Line GAD)

• Delivered by trained clinicians, it promotes understanding excessive worrying thoughts and addressing process
• The interventions should focus on trauma social support and understanding all the types of medication needed
• If medication used then it is from the expertise of clinicians in young children

Shorter Time

• It is highly recommended and usefullness depends on the anixiolyolitic effects
• May cause more side effects to young children for and if there not suitalble they may taper as long to to stop.

Panic Attack -Overview

• A panic attack is a sudden period of intense fear or discomfort and the symptoms peak within 10-20 minutes that causes high anxiety.
• panic disorders is twice as common for woman.
• NAergic has a high activity and low activity to help.

Recurrent (Panic Attack)

• In most episodes, must have some reaccuring, physical components need to also be included
• Not something due of use or other type of panic disorder and those interventions must be present.

PTSD

• May pose reoccuring , intense and flashbacks will increase.
• In the long term is a high impact, and does not need the high dose