Anxiety Disorders Overview

PM3PY2: Anxiety Disorders

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• A trigger warning advises that the session contains content on mental health disorders and associated suicide risks.

Learning Outcomes

• Students will be able to understand and define anxiety as a disorder.
• Students will be able to describe individual symptoms of anxiety and specific types of anxiety.
• Students will be able to explain the treatment (pharmacological and behavioral), side effects, and limitations associated with treatments for anxiety.
• Students will be able to discuss considerations health professionals (HCPs) make in treating and advising patients with anxiety disorders.

What is Anxiety?

• Anxiety serves a useful function in daily life.
• Anxiety becomes problematic when the threat response is disproportionate to the actual or perceived threat, or when the threat is imagined.
• Anxiety is defined as a prolonged or exaggerated response to a real or imagined threat that interferes with normal life and cannot be attributed to neurological or organic dysfunction.
• Lifetime prevalence of anxiety is approximately 15%.
• Symptoms include anxiety, worry, despondency, sadness, somatic symptoms (e.g., pain), sleep disturbances, and difficulties in coping with life stressors.
• Anxiety is commonly seen by general practitioners (GPs).
• Long-term drug treatment is not typically recommended.

Pathophysiology of Anxiety

• An understanding of the sensory and reaction pathways in the central nervous system (CNS), including the limbic system, is important for understanding anxiety.
• Neurotransmitters such as serotonin, noradrenaline, dopamine, and GABA in the CNS play a role in anxiety.
• The peripheral nervous system (PNS) is also involved.
• Symptoms can be behavioral, physiological, cognitive, or affective.

Examples of Anxiety Clinical Features

• Cognitive/Psychological: Feelings of apprehension, tension, fear, panic, feeling on edge, labile mood, outbursts of hostility, irritability, circling thoughts, difficulty concentrating, and memory lapses.
• Somatic/Physiological: Cardiovascular issues (palpitations, bradycardia, tachycardia, high blood pressure, flushing), respiratory issues (rapid shallow breathing, breathlessness), gastrointestinal issues (diarrhea, dyspepsia, dysphagia, churning stomach), musculoskeletal issues (agitation, restlessness, muscle tension), metabolic issues (high blood glucose and glucocorticoids), other issues (excessive sweating, urge to urinate/defecate, insomnia).

Types and Aetiology of Anxiety Disorders

• Includes Generalized anxiety disorder (GAD), social phobia, specific phobias, obsessive-compulsive disorder (OCD), panic disorder (PD), and post-traumatic stress disorder (PTSD).
• The underlying causes of anxiety disorders are not fully understood, but risk factors include genetics, environmental factors (including epigenetic factors), psychological factors, and developmental factors.

Treatment Aims and Prognosis

• Prognosis is generally good if the external stressor can be eliminated.
• Treatment aims to discover the cause, address the cause, assess severity of the anxiety response, relieve distress, and institute long-term measures to prevent recurrence (especially important in cases of chronic anxiety).

Psychological Treatments

• Psychotherapy is a primary treatment approach for anxiety.
• Common approaches include counseling, cognitive behavioral therapy (CBT), exposure therapy, and mindfulness and relaxation training.

Treating Anxiety Disorders: Pharmacotherapy

• Treatment depends on the type of disorder.
• A stepped care model (e.g. NICE guidance) is often used.
• For acute anxiety, benzodiazepines (lorazepam, alprazolam, diazepam) can be used. They are positive allosteric modulators of GABA binding to GABA receptors, providing fast-acting relief, but are typically not recommended for long-term use due to potential side effects.
• Benzodiazepines can have adverse side effects in overdose.

Drugs to Treat Anxiety Disorders

• SSRI medications (fluoxetine, escitalopram, paroxetine, sertraline) are often a first-line treatment for many anxiety disorders.
• Pregabalin is another option (Class 3 controlled substance, Schedule 3 drug).
• Tricyclic antidepressants (e.g., clomipramine) and buspirone (a 5-HT1A receptor partial agonist) are also used to treat anxiety.
• Beta-blockers (e.g., propranolol) are helpful for anxiety with strong somatic symptoms.

Generalized Anxiety Disorder (GAD): Diagnosis

• International diagnostic criteria (DSM-V or ICD-11) can be used.
• GAD is characterized by excessive anxiety and worry occurring more days than not for at least six months, concerning a number of events and activities. Individuals find it difficult to control the worry.
• Associated with three or more symptoms (restlessness/nervousness, easily fatigued, poor concentration, irritability, muscle tension, sleep disturbance) occurring for more days than not for the past 6 months.
• Causes significant distress or impairment in social, occupational or other areas of functioning.
• Not attributed to substances, other medical conditions, or other mental disorders.
• The ICD-11 criteria also include marked symptoms of anxiety and worry, alongside additional characteristic symptoms (e.g. muscle tension, sympathetic autonomic overactivity).

GAD-7: Questionnaire Tool

• A self-scored 7-question questionnaire can be used to assess the severity of GAD.
• Scores of 5, 10, and 15 are cut-off points for mild, moderate, and severe anxiety, respectively.

Stepped Care for GAD

• A stepped-care model is often used for the treatment of GAD.
• Step 1: Identification and assessment, education about GAD and treatment options.
• Step 2: Non-facilitated self-help for those with low functional impairment.
• Step 3: Individualized high-intensity interventions (e.g., CBT, relaxation, medication) for those with marked functional impairment.
• Step 4: If Step 3 is not effective, treatment is focused on self neglect and highly specialist interventions.

Drug Treatment for GAD

• Sertraline is a first-line SSRI for GAD.
• SNRIs are also considered alternative treatments.
• Pregabalin is an option for those unable to tolerate SSRIs or SNRIs.
• Benzodiazepines are used only in severe cases, typically for short-term relief.
• Buspirone is a short-term medication option for specialists.

Mechanisms of Action

• Different classes of drugs have specific mechanisms of action in treating anxiety disorders.

Step 3 Examples for Patient Considerations: Pharmacotherapy

• Expected drug effects (time to onset, potential side effects, gradual development of anxiolytic effects).
• Risk activation and potential side effects during SSRI treatment.
• Importance of taking the drugs as prescribed to prevent relapse.
• Monitoring for risk of suicidal ideation.
• Follow-up and monitoring schedules.
• Considerations for switching medications.
• Important considerations for patients with high functional impairment.

Learning Outcome Recap

• The learning outcomes reiterate the key concepts covered in the session.

Reference Material

• Recommended textbooks (Neurological disorders and Mental Health)
• Relevant NICE guidance pages for GAD
• DSM-V diagnostic criteria
• The ICD-11 diagnostic criteria
• BNF information regarding antidepressants and anxiolytics and hypnotics

This quiz explores essential concepts related to anxiety disorders, including symptoms, treatment options, and prevalence rates. Test your knowledge on the critical aspects healthcare professionals must consider and the physiological and psychological factors involved in anxiety. Perfect for students or anyone interested in mental health.