Anxiety Disorders

Dr. Roger Gibson

Lecturer in Psychiatry
UWI Mona
UWI, M
Objectives

At the end of this lecture, students should

be able to:
– Define anxiety disorders

– Describe the features of common anxiety

disorders

– Outline the management

g of anxietyy disorders
Anxiety
• Anxiety generally prepares us to face
threatening situations, rouses us to
action and helps us cope - normally
action,
helpful.
Anxiety Disorders
• Unhelpful,
Unhelpful disruptive anxiety
symptoms.

• Treatable medical conditions.

Some common features of anxietyy
disorders
• Restlessness
• Tension
• Irritability
• Poor concentration
• Physical manifestations, e.g. rapid heart
rate and
d breathing,
b hi sweating,
i tremors.
Anxiety disorders include:

• Panic Disorder;
• Phobias;
• Obsessive
Obsessive--Compulsive Disorder;
• Generalized Anxiety Disorder;
and
• Posttraumatic Stress Disorder.
Others:

• Acute Stress Disorder

• Secondary to General Medical Condition
• Substance-induced anxiety disorder
• Not otherwise specified
Panic Disorder

• Recurrent, unexpected panic attacks

• Panic attacks are marked by intense fear,

peaking in about 10 minutes and
associated physical symptoms

• With or without agoraphobia

Phobias

• Excessive or unreasonable fears related to

objects or situations

• Characterized by:
– Anxiety response, Avoidance, Insight
– May include panic attacks
Obsessive-Compulsive
Obsessive- p
Disorder (OCD)
• Obsessions (thoughts), compulsions
(behaviours) or both

• Anxiety state associated with presence of

thoughts and avoidance of thoughts and
behaviours

• Insight usually present

Generalized Anxietyy
Disorder (GAD)
• Pervasive and excessive worry

• Difficult to control worrying

• Fatigue, restlessness, irritability, muscle

tension,
i sleep
l disturbance,
di b impaired
i i d
concentration
Posttraumatic Stress
Disorder (PTSD)
• History of traumatic event

• Re-experiencing (e.g. nightmares, intrusive

thoughts)

• Avoidance

• Hyperarousal
Some mechanisms

• Hardwired responses
– Fight/
g Flight
g

– Sympathetic
y p Nervous System
y

– Hypothalamus & Stress

– Implications for metabolism, concentration and memory
• Learned anxiety
– phobias
p
Neurochemistryy of Anxietyy
states
• Noradrenaline
• Serotonin
• GABA
• (CCK)
• (CO2)
Noradrenaline

• Precipitates/ exacerbates anxiety states

Serotonin

• Acutely induces anxiety; chronically

relieves it
GABA

• Diminishes anxiety states

Approaches to management

• Cognitive Behaviour Therapy/ other

psychotherapy

• Antidepressants
– SSRIs, SNRIs, MAOIs, TCAs, Nefazadone
Cognitive Behaviour Therapy

• Identifying and challenging cognitive

distortions

• Testing new,
new alternative ideas
Behaviour Therapies

• Systematic desensitization

• Flooding
 When choosing
g an Antidepressant
p
consider:
• Previous response and tolerance, patient
preference.
• Age and physical health
• Suicidality
• Compliance issues
• Past
P hi
history off elevated
l d mood
d
Prescribing
g anti-
anti-depressants
p
• Mayy take upp to 4 weeks for anxiolytic
y
effects

• Advise patient of activation syndrome

• Maintain for at least 12 months

• May require higher doses

Anti--depressant dosages
Anti

DRUG Panic Disorder OCD

Fluoxetine 10
10--60 mg 20-
20-80 mg
Paroxetine 10
10--40 mg
g 20--60 mg
20 g
Phenelzine 45--90 mg
45
Imipramine
p 25-
25-250 mg g
Clomipramine 50-
50-275 mg
Benzodiazepines

PHARMACODYNAMICS
• GABA = main inhibitory NT

• GABA increases chloride channel

conductance

• BDZ enhances the action of GABA

Benzodiazepines:
p Adverse
effects
• Decrease REM sleep
• Clouding of consciousness
• Tolerance and dependence
• Toxicity in overdose
• Teratogenic, Neonatal resp depr.
Benzodiazepines: Prescribing
• Seldom advocated for first-
first-line Rx.
Rx
• Use lowest effective dose
• For Max. 22--4 weeks only
• Warn ppatient of risk for dependence
p
• Avoid repeat prescriptions
• Most useful for
– acute anxiety, one-
one-off uses, initial Rx
Beta Blockers

• Situational anxiety and GAD

• Ineffective in Panic disorder
• Useful in BDZ withdrawal
• Hypotension,
Hypotension excessive dreaming
dreaming, CCF
CCF,
depression, asthma
• 20
20--60 mg/d
/d