Anxiety and related disorders

• Common anxiety/phobic (neuroses) disorders:

  • Panic disorder
  • Agoraphobia
  • GAD
  • Specific (understandable) phobias
  • Hypochondriasis
  • Social phobia
• Benzodiazepines:

  • Work by stimulating GABA receptors - has a relaxing effect on the brain
  • Prolonged use quickly results in down regulation of GABA receptors, leading to tolerance and dependence
  • Should not be offered for chronic anxiety
  • Can be used for a short duration during a crisis and stopping them as soon as possible
• Panic attacks:

  • Sudden onset of intense physical and emotional symptoms of anxiety
  • Come on quickly (minutes) and last a short time (e.g. 10 minutes)
  • Relatively common and do not always indicate a panic disorder
  • Physical symptoms - tension, palpitations, tremors, sweating, chest pain, shortness of breath
  • Emotional symptoms - panic, fear, danger, depersonalisation and loss of control
• The amygdala plays an important role in tempering fear and anxiety. Patients with anxiety disorders have been found to show heightened amygdala response to anxiety cues. The amygdala and limbic system structures are connected to prefrontal cortex regions, and prefrontal-limbic activation abnormalities may be reversed with psychological or pharmacologic interventions.
• Medication general principles:

  1. SSRI e.g. sertraline
  2. Alternative SSRI or SNRI e.g. venlafaxine
  3. Specialise referral for other therapies e.g. MAOI - moclobemide
• Before starting an SSRI or SNRI it is important that you:

  • Explain the likely benefits.
  • Advise patients when they might start experiencing anxiolytic effects: 2 weeks.
  • Advise patients what the likely treatment duration is: at least 6 months.
  • Inform about possible side effects (including a transient increase in anxiety).
  • Advise patient not to cease medication abruptly: there is a risk of discontinuation syndrome and relapse in symptoms.
• For individuals <30 years old who are starting an SSRI or SNRI, it is important to:

  • Warn them there is an association with an increased risk of suicidal thinking and self-harm.
  • Review within 1 week of prescribing.
  • Continue to monitor the risk of suicide and self-harm every week for the first month.
• Monitoring patients on SSRIs and SNRIs is important and should include monitoring of:

  • Therapeutic response: takes 2 or more weeks for anxiolytic effect.
  • Side effects: GI disturbance (loss of appetite, nausea, abdominal pain, diarrhoea, constipation), headaches, poor sleep, transient increase in anxiety, palpitations, sexual dysfunction (loss of libido, erectile dysfunction, inability to orgasm).
  • Advise them to remain on SSRI for at least 6 months after remission of symptoms: chance of relapse is high if medication is discontinued abruptly.
• Neurosis refers to a class of functional mental disorder involving distress but not delusions or hallucinations, where behavior is not outside socially acceptable norms.
• The unusual neuroses (outwith 'normal' experience)

  • Anxiety/phobic disorders e.g. non-understandable phobias e.g. dirt, feathers
  • hysterical conversion disorders
  • Dissociative/depersonalisation
  • Somatoform disorders - extreme focus on physical symptoms
• Culture specific disorders:

  • Seen in only certain populations
  • Chronic fatigue syndrome
  • Eating disorders
  • other 'culture-bound' disorders or cultural concepts of distress
• Key neurophysiological changes in anxiety:

  • Reduced functional connectivity between the prefrontal cortex and the limbic system - especially the amygdala - these connections help regulate emotional response
  • Single nucleotide polymorphism variations in serotonin transporter - monoamine hypothesis of anxiety and depression
  • Dysregulation of the hypothalamic-pituitary-adrenal axis