Anxiety Disorders PDF

ANXIETY DISORDERS Dr. Mohsina Hyder Lecturer JSS College of Pharmacy Ooty  ANXIETY DISORDERS ❖ Anxiety is a normal emotion. It’s the brain’s way of reacting to stress as well as alerting about the potential danger ahead. Occasional anxiety...

ANXIETY DISORDERS Dr. Mohsina Hyder Lecturer JSS College of Pharmacy Ooty  ANXIETY DISORDERS ❖ Anxiety is a normal emotion. It’s the brain’s way of reacting to stress as well as alerting about the potential danger ahead. Occasional anxiety is ok. But anxiety disorders are different. ❖ Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational and personal functions are significantly impaired. 2  TYPES OF ANXIETY DISORDERS Generalized Anxiety Disorder includes persistent and excessive anxiety and worry about activities or events — even ordinary, routine issues. The worry is out of proportion to the actual circumstance, is difficult to control and affects how the person feel physically. It often occurs along with depression. Panic Disorder involves repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (Panic attacks). They experience shortness of breath, chest pain as well as heart palpitations. These panic attacks may lead to worrying about them happening again or avoiding situations in which they have occurred. 3  TYPES OF ANXIETY DISORDERS Agoraphobia is an anxiety disorder that causes an intense fear of being in places where escape may be difficult or help may not be available like being in an elevator or bridge, air travel or crowded areas. Anxiety disorder due to a medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem like diabetes, asthma, tumours etc. Selective mutism is a consistent failure of children to speak in certain situations, such as school, even when they can speak in other situations, such as at home with close family members. This can interfere with school, work and social functioning. 4  TYPES OF ANXIETY DISORDERS Separation Anxiety Disorder is a childhood disorder characterized by anxiety that's excessive for the child's developmental level and related to separation from parents or others who have parental roles. Social Anxiety Disorder (Social phobia) A chronic mental health condition in which social interactions cause irrational anxiety and concern about being judged or viewed negatively by others. Intense fear of interacting or talking with strangers. Post-traumatic stress disorder (PTSD)- A disorder characterized by failure to recover after experiencing or witnessing a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. 5  TYPES OF ANXIETY DISORDERS Substance-induced anxiety disorder is characterized by symptoms of intense anxiety or panic that are a direct result of misusing drugs, taking medications, being exposed to a toxic substance or withdrawal from drugs. Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Unspecified anxiety disorder are for anxiety or phobias that don't meet the exact criteria for any other anxiety disorders but are significant enough to be distressing and disruptive. 6  TYPES OF ANXIETY DISORDERS Phobia-related disorders A phobia is an intense fear of—or aversion to—specific objects or situations. People with a phobia: May have an irrational or excessive worry about encountering the feared object or situation Take active steps to avoid the feared object or situation. Experience immediate intense anxiety upon encountering the feared object or situation Endure unavoidable objects and situations with intense anxiety. 7  TYPES OF ANXIETY DISORDERS There are several types of phobias and phobia-related disorders: Specific phobias (sometimes called simple phobias): Phobias are abnormal fear of a specific object, animal, bird, insect, activity, or a certain situation. It is a type of anxiety disorder that can precipitate a panic attack. Some examples of specific phobias include the fear of: Flying Heights Specific animals, such as spiders, dogs, or snakes Receiving injections Blood Thunder 8  CLINICAL PRESENTATION OF GAD Psychological and cognitive symptoms ▪ Excessive anxiety ▪ Worries that are difficult to control ▪ Feeling keyed up or on edge ▪ Trouble concentrating or mind going blank Physical symptoms ▪ Restlessness ▪ Fatigue ▪ Muscle tension ▪ Sleep disturbance ▪ Irritability 9  CLINICAL PRESENTATION OF PANIC ATTACK Psychological symptoms ▪ Depersonalization (Being detached from oneself) ▪ Derealization (Feelings of being detached from one’s environment) ▪ Fear of losing control, going crazy or dying Physical symptoms ▪ Abdominal distress ▪ Chest pain or discomfort ▪ Chills ▪ Dizziness or light headedness ▪ Feeling of choking ▪ Heat sensations ▪ Sweating ▪ Shaking 10  CLINICAL PRESENTATION OF POST TRAUMATIC STRESS DISORDER Intrusion symptoms ▪ Recurrent, intrusive distressing memories of the trauma ▪ Recurrent, disturbing dreams of the event ▪ Feeling that the traumatic event is recurring ▪ Physiologic reaction to or psychological distress from reminders of the trauma Hyperarousal symptoms ▪ Decreased concentration ▪ Insomnia ▪ Irritability or anger outbursts Avoidance symptoms ▪ Avoidance of conversations, thoughts or feelings about the trauma ▪ Avoidance of people, places or activities that are reminders of the event. 11  EPIDEMIOLOGY ▪ The total estimated number of people living with anxiety disorders in the world is 264 million. ▪ Anxiety disorders in adults are seen in 22.3 percent of those aged 18–29 and 22.7 percent of people ages 30– 44. The prevalence of anxiety disorders drops to 20.6 percent for individuals ages 45–59. ▪ Anxiety disorders in women are more common than anxiety disorders in men. ▪ In India, the prevalence of anxiety disorders is 2.57% in the adult population. 12  ETIOLOGY The causes of anxiety disorders aren't fully understood. ▪ Life experiences such as traumatic events appear to trigger anxiety disorders in people who are already prone to anxiety. ▪ Genetics- Vulnerability genes such as 5-HT1A, 5-HTT, MAO-A, COMT, CCK-B, ADORA2A, CRHR1, FKBP5, ACE, RGS2/7 and NPSR1 can cause anxiety disorder. (protein coding) Anxiety may be linked to an underlying health issue like Heart diseases, Diabetes, Cancer, Respiratory disorders etc. ▪ Anxiety can be a side effect of medications like CNS Depressants and CNS Stimulants. ▪ Drug misuse or withdrawal ▪ Withdrawal from alcohol 13  PATHOPHYSIOLOGY In the central nervous system (CNS), the major mediators of the symptoms of anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Imbalance and/or abnormal functioning of nor epinephrine, serotonin, dopamine and GABA. Severe or long-lasting stress can change the chemical balance that controls the mood. Experiencing a lot of stress over a long period can lead to an anxiety disorder. 14  PATHOPHYSIOLOGY ▪ There are two parts of the brain that are thought to be key players in the production and processing of anxiety – the amygdala and the hippocampus. ▪ The amygdala is an almond-shaped structure deep in the brain that is believed to be a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret these signals. It can alert the rest of the brain that a threat is present and trigger a fear or anxiety response. ▪ The hippocampus is the part of the brain that encodes threatening events into memories. 15  PATHOPHYSIOLOGY Non adrenergic Model: ▪ The Autonomic Nervous System of anxious patients is hypersensitive and overreacts to various stimuli. ▪ Stress exposure is associated with an increase in firing of the locus coeruleus and with associated increased release and turnover of norepinephrine in brain regions which receive noradrenergic innervation. ▪ Increased firing of the locus coeruleus is also associated with behavioral manifestations of fear. ▪ Exposure to chronic stress results in long-term alterations in locus coeruleus firing and norepinephrine release in target brain regions of the locus coeruleus. 16  PATHOPHYSIOLOGY Serotonin Model: ▪ The 5 HT system is disturbed in patients with anxiety disorders. ▪ Chronic stress is known to affect serotonin (5HT) neurotransmission in the brain and to alter body temperature. ▪ Low levels of serotonin in the brain may cause depression, anxiety, and sleep trouble. 17 PATHOPHYSIOLOGY When stress occurs, onset and aggravation of anxiety the hormones cortisol and adrenaline are released into the bloodstream to prepare the body to fight or flee danger. Chronic activation of stress hormones over time causes death of neurons in the hippocampus Hippocampus shrinks in size and abnormally process the threat 18  RISK FACTORS Trauma. Those who endured abuse or trauma or witnessed traumatic events are at higher risk of developing an anxiety disorder at some point in life. (Sexual abuse, Natural disaster etc.) Stress due to an illness. Having a health condition or serious illness can cause significant worry about issues such as the treatment and future. Stress buildup. A big event or a buildup of smaller stressful life situations may trigger excessive anxiety — for example, a death in the family, work stress or ongoing worry about finances. Other mental health disorders. People with other mental health disorders, such as depression, often also have an anxiety disorder. Having blood relatives with an anxiety disorder. Anxiety disorders can run in families. Drugs or alcohol. Drug or alcohol use or misuse or withdrawal can cause or worsen anxiety. 19  COMPLICATIONS Having an anxiety disorder does more than a worry. It can also lead to other mental and physical conditions, such as: Depression Substance misuse Trouble sleeping (insomnia) Digestive or bowel problems Headaches and chronic pain Social isolation Problems functioning at school or work Poor quality of life Suicide 20  DIAGNOSIS To diagnose an anxiety disorder, mental health provider may: Give a psychological evaluation. This involves discussing thoughts, feelings and behavior to help pinpoint a diagnosis and check for related complications. There are several assessment tools available to assess or screen for anxiety disorders. These include the Beck's Anxiety Inventory, the Depression Anxiety Stress Scales, the Hamilton Anxiety Scale. Compare symptoms to the criteria in the DSM-5. Doctors use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, to diagnose an anxiety disorder. 21  DIAGNOSIS DSM-5 Diagnostic Criteria- Generalized Anxiety Disorder A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. B. The individual finds it difficult to control the worry. C. C. The anxiety and worry are associated with three (or more) of the following six symptoms Note: Only one item required in children. 1. Restlessness, feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). 22  DIAGNOSIS DSM-5 Diagnostic Criteria- Generalized Anxiety Disorder D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). DSM-5 criteria for panic disorder include the experiencing of recurrent panic attacks, with 1 or more attacks followed by at least 1 month of fear of another panic attack or significant maladaptive behavior related to the attacks. 23  GOALS OF TREATMENT To reduce severity, duration and frequency of symptoms Improve functioning Prevention of recurrence Improved quality of life Increased competency to face life stress 24  NON PHARMACOLOGICAL TREATMENT Psychotherapy (Talk therapy) Short term counseling Cognitive behavioral therapy Hypnotherapy Hypnosis does not work for everyone. A trained and certified hypnotist guides into this deep state of focus and relaxation with verbal cues, repetition and imagery. Conscious mind is quieted. Are able to tap into the part of brain where thoughts, beliefs, perceptions, sensations, emotions, memory and behaviors originate. 25  NON PHARMACOLOGICAL TREATMENT Meditation Physical Exercise Doing 30 minutes or more of exercise a day for three to five days a week may significantly improve anxiety symptoms. Running is a great way to clear mind while reducing stress. Hiking is a great way to break free from the daily grind. Weightlifting helps to improve mental health. Swimming is one of the best weapons against anxiety symptoms. Improve sleep quality Avoid harmful intakes 26  ANTIDEPRESSANTS SNRIs work to influence both serotonin and norepinephrine by preventing a person's brain cells from rapidly absorbing these neurotransmitters. By stabilizing these neurotransmitters, SNRIs can help improve a person's mood, reduce feelings of anxiety, and help alleviate panic attacks. SSRIs work by raising the levels of serotonin in the brain — a chemical signal important for regulating mood and anxiety. 27  PHARMACOLOGICAL TREATMENT- ANTIDEPRESSANTS Drug Initial dose Usual range (mg/day) Duloxetine 30 or 60 mg/day 60-120 Escitalopram 10 mg/day 10-20 Imipramine 50 mg/day 75-200 Paroxetine 20 mg/day 20-50 Sertraline 50 mg/day 50-200 Venlafaxine 37.5 or 75 mg/day 75-225 Vilazodone 10 mg/day 20-40 Vortioxetine 5 mg/day 5-20 28  MECHANISM OF ACTION-ANXIOLYTICS Buspirone impacts neurotransmitters in the brain, such as serotonin and dopamine. Specifically, it is a serotonin receptor agonist, which means that it increases action at serotonin receptors in the brain. This, in turn, helps to alleviate anxiety. Hydroxyzine is an antihistamine that is used to treat anxiety. It can cause drowsiness, which may be helpful for people struggling with insomnia. Pregabalin is related to the calming brain chemical gamma aminobutyric acid (GABA). It reduces the release of brain chemicals that have a stimulating effect. Quetiapine is an antipsychotic that calms and sedates, helping to relieve psychotic thoughts and manic and depressive behavior. 29  PHARMACOLOGICAL TREATMENT Drug Initial dose Usual range (mg/day) Azapirone Buspirone 7.5 mg BD 15-60 Diphenylmethane Hydroxyzine 25 or 50 mg QID 200- 400 Anticonvulsant Pregabalin 50 mg TID 150-600 Atypical antipsychotic Quetiapine 50 mg at bedtime 150-300 30  PHARMACOLOGICAL TREATMENT- BENZODIAZEPINES Drug Approved dosage Maximum dosage for range (mg/day) Geriatric patients (mg/day) Alprazolam 0.75-4 2 Chlordiazepoxide 25-400 40 Clonazepam 1-4 3 Diazepam 2-40 20 Lorazepam 0.5-10 3 Oxazepam 30-120 60 Benzodiazepines works by decreasing abnormal excitement in the brain. They are second line agents for panic disorder except when rapid response is essential. 31  DRUG CHOICES FOR ANXIETY DISORDERS Anxiety disorder First line drugs Second line drugs Alternatives Generalized anxiety Duloxetine Benzodiazepines Hydroxyzine disorder Escitalopram Buspirone Quetiapine Paroxetine Imipramine Sertraline Pregabalin Venlafaxine Panic disorder SSRIs Alprazolam Phenelzine Venlafaxine Citalopram Clonazepam Clomipramine Imipramine 32  IMPLANTATION OF DEEP BRAIN STIMULATION DEVICE ❖ To implant the device, the surgeon makes a small opening in the skull and inserts a thin, insulated wire with electrodes at the tip. ❖ He or she passes the wire under the skin of the head, neck, and shoulder. ❖ Surgery to implant the electrode takes about four hours. It requires general anesthesia and an overnight hospital stay. ❖ The electrode delivers a low level impulse that aids in regulating mood. 33 34