ANXIETY

1. Introduction
Anxiety is an exaggerated feeling of apprehension, uncertainty and fear. It is an

unpleasant state of tension with an anticipation of imminent danger or fear about some

defined or undefined future threats. It is characterized by cognitive, somatic, behavioural and

physical symptoms such as sweating, palpitations, chest pain and tachycardia. It is closely

associated with endocrine, CVS, digestive and respiratory systems. Various types of anxiety

disorder are - generalized anxiety disorder, post-traumatic stress disorder panic disorder,

social anxiety disorder, obsessive compulsive disorder.

The amygdala is the primary modulator of the response to fear- or anxiety-inducing

stimuli. The amygdale receives input from neurons in the cortex. When activated, the

amygdala stimulates regions of the midbrain and brain stem, causing autonomic

hyperactivity, which can be correlated with the physical symptoms of anxiety. It may be

result of multiple interactions among various neurotransmitters i.e. nor epinephrine, Gamma

Amino Butyric Acid (GABA), Serotonin, Cholecystokinin (CCK), Neuropeptide (NPY),

Glutamate, corticotrophin-releasing factor (CRF) . The effect of most of the anxiolytic agents

acts by enhance the response to GABA by facilitating the opening of GABA activated

chloride channels as well as act on limbic system, hypothalamus and brain stem reticular

system18. BZP receptor is functionally linked GABA receptor and CL ion channels. GABA

system has a strong regulator or inhibitory effect on the 5 HT and NE system. When BZP

bind to their receptor GABA’s inhibitory effects are potentiated via on increase in the

frequency of chloride on channel opening.

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Fig: 1 Various stages of anxiety.

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 2. Involvement of brain

They are associated with multiple region of brain and it include some key brain areas.

Figure: 2 Major internal parts of the human brain

 The amygdala, a temporal lobe structure plays a critical role in the assessment of fear

stimuli and learned response to fear.

 The locus ceruleus (LC), located in brain stem, is the primary norepinephrine

containing site, with wide spread projection to areas responsible for implementing

fear responses e.g. vagus, lateral and paraventricular hypothalamus.

 The hippocampus is integral in the consolidation of traumatic memory and contextual

fear conditioning.

 The hypothalamus is the principle area for integrating neuroendocrine and autonomic

responses to a threat.

 Hippocampus and amygdala are of particular importance as they are interconnected

and also project to both subcortical and cortical nuclei.

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 In some people with post- traumatic stress disorder (PTSD), the hippocampus appears

to be smaller. This may be because of degeneration of dendrites. In this part of brain,

 this is thought to be caused by a stress- induced increase in the concentration of

glucocorticoids.

 Other brain structure involved in controlling emotions, such as hypothalamus, may

also be involved in the pathogenesis of anxiety disorder.

 People with obsessive –compulsive disorder (OCD) often show increased activity in

the basal nuclei in a particular the striatum and other frontal lobe areas of the fore

brain.

3. Serotonin Hypothesis

1. Role of serotonin the brain in particular its function influence in the synaptic cleft

2. Selective serotonin reuptake inhibitor (SSRI) which enhances serotonin mediated

neurotransmission in the brain. They are useful in threatening mood and anxiety

disorder lead to the hypothesis that serotonin dysfunction is important in the

aetiology of these disorders.

3. Pharmacological manipulation to enhance serotonin concentration in the brain

increases anxiety and a reduction in serotonin conc. Is associated with reduced

anxiety.

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 Figure: 3 Brain functions

4. Neurotransmitters involved in anxiety

4.1. GABA (gamma-amino butyric acid): This neurotransmitter has an inhibitor effect on

the nervous system-it slows down transmission of nerve impulses, relaxes muscles and also

forth

Medications which work on this:-

Benzodiazepines work by somehow activating GABA receptors, causing the relaxing

sedative effect.

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 Figure: 4 GABA (gamma-amino butyric acid)

4.2. Dopamine: This neurotransmitter is most commonly known for its relationship to

feeling of “pleasure” or “desire”. But is also involved in the body movement, memory,

and memory attention and so on.

Figure: 5 Dopamine neurotransmission

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Medications which work on this

Some multiple reuptake inhibitors block this chemical reuptake The SAM-e supplement

reportedly increase levels of dopamine and improves ‘binding’ to the receptors. Cocaine

blocks reuptakes of this neurotransmitter as well.

4.3. Epinephrine (Adrenaline): This neurotransmitter increases heart rate and blood

pressure

Figure: 6 Epinephrine neurotransmission

Medications which work on this

Beta blockers can block this neurotransmitter at “b-adrenergic receptors” in the message.

This can have the effect of lowering heart rate and blood pressure and producing “calming”

affects.

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 4.4. Norepinephrine: This neurotransmitters increases heart rate, blood pressure, raises

blood sugar levels etc

Figure: 7 Norepinephrine neurotransmission

Medication which work on this

SNRI medications and some multiple reuptake inhibitors block this from reuptake also Beta

blockers can blocks this neurotransmitter at “beta-adrenergic receptors” in the body, which

can have effect of lowering heart rate blood pressure and producing calming affects.

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 4.5. Serotonin: This neurotransmitter has been linked mood /emotion, anxiety, behaviour,

learning, sleep, sexuality, appetite etc.

Medication which work on this

SSRI medication and some multiple reuptake inhibiters block this from reuptake The SAM

–e supplement reportedly increases level of serotonin improves binding to the receptors also ,

the supplement 5- HTP, a precursor to serotonin , can increase serotonin level in the body .

Figure: 8 Serotonin neurotransmission

5. Types of Anxiety:

 Generalized anxiety disorder (GAD)

 Panic disorder

 Social anxiety disorder (SAD)

 Specific phobia

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5.1 Generalized anxiety disorder:-

The diagnostic criteria for GAD require persistent symptoms for most days for at least 6

months. The essential feature of GAD is unrealistic or excessive anxiety and worry and about

a no of events or activities.

Clinical presentation of GAD:-

 Psychological and cognitive symptoms:

 Excessive anxiety

 Worries that are difficult to control

 Feeling keyed up or on edge

 Poor concentration or mind going blank

 Physical symptoms

 Restlessness

 Fatigue

 Muscle tension

 Sleep disturbance

 Irritability

 Impairment

 Social, occupational or other important functional areas.

 Poor coping abilities.

The anxiety is accompanied by at least three pschycologic and physiologic symptoms.

Anxiety and worry are not confined to features of another psychiatric illness e.g. having a

panic attack being embarrassed in public. GAD has a gradual onset with an average age of21

years however, there is a bimodal distribution. Most patients present between the age of 35 &

45 years .GAD is usually the primary disorder in patient with a comorbid anxious depression.

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 Figure: 9

5.2 Panic disorder:-

Panic disorder begins as a series of unexpected (Spontaneous) panic attacks involving an

intense, terrifying fear similar to that caused by life threatening danger. The unexpected panic

attacks are followed by at least one month of persistent concern or a significant behavioural

change related to attacks.

Symptoms of panic attacks:

 Psychological symptoms:-

 Depersonalization

 Fear of losing control

 Fear of dying

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  Physical symptoms:-

 Abdominal distress

 Chest pain or discomfort

 Chills

 Feeling of choking

 Hot flushes

 Palpitations

 Nausea

 Tachycardia

 Trembling or shaking

Secondary to the panic attacks, many patients develops agoraphobia (it is an anxiety about

being in places or situation in which escape might be difficult).As a result, patient often avoid

specific situation (e.g. being in a crowd on flying in which they fear a panic attack might

occur). Panic disorder has an adverse impact on the patient’s quality of life (QOL) including

a significant degree of social and work impairment.

5.3 Social anxiety disorder (SAD):-

SAD is characterised by an intense, irrational and persistent fear of being negatively

evaluated in at least one social or performance situation.

Presentation

Fears:

 Being embarrassed.

 Being humiliated.

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Some feared situations:-

 Addressing a group of people

 Speaking in public

 Talking with strangers

 Use of public toilets

Physical symptoms:-

 Blushing

 Diarrhoea

 Sweating

 Tachycardia

 Trembling

Types of SAD:-

1. Generalized type:- Fear and avoidance extend to wide range of social situations.

2. Non generalized type: - Fear is limited to one or more situations.

In individuals younger than 18 years of age, the duration of symptoms must be at least 6

month to meet the diagnostic criteria.

5.4. Specific phobia

It is marked and persistent fear of a circumscribed object or situation (e.g. insects, heights or

injections).apart from contact with the feared object or situation, the patient is usually free.

Test on humans

Tests rely on measurement of the somatic and the autonomic effects associated with anxiety.

e..g. the galvanic skin response, in which the electrical conductivity of the skin is used as a

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measure of sweat production. Any novel stimulus, whether pleasant or unpleasant, cause a

response. This forms the basis of the lie detector test. If an innocuous stimulus is repeated at

intervals, the magnitude of the response decreases (habituation).the rate of habituation is less

in anxious patient than in normal subjects and in increased by anxiolytic drugs. A human

version of the conflict test described above involves the substitution of money for food

pellets, and the use of graded electric shocks as punishment. As with rats, administration of

diazepam increases the rate of button pressing for money during the periods when they

punishment was in operation, although the subjects reported no change in the painfulness of

the electric shock. Subtler forms of torment and reward are not hard to imagine.

6. Causes of anxiety

There is no one cause for anxiety disorders. Several factors can play a role:

• Genetics

• Brain biochemistry

• Overactive “fight or flight” response

Can be caused by too much stress

• Life circumstances

• Personality

People who have low self-esteem and poor coping skills may be more prone.

7. Treatment

 Allopathic Treatments

 Medications (drug Therapy):

 Behavioral Therapy

 Cognitive Behavioral

 Psychodynamic Psychotherapy

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 8. Anti anxiety drugs

These are the drugs that are used to treat anxiety.

Classification-

1. Benzodiazepines:

 Diazepam

 Chlordiazepoxide

 Oxazepam

 Lorazepam

 Alprazolam

2. Azapirones:

 Buspirone

 Gepirone

 Ispapirone

3. Sedative anti Histaminic:

 Hydroxyzine

4. Beta blocker:

 Propranolol

5. Selective serotonin reuptake inhibitors (SSRI)

 Fluoxetine

 Paroxetine

 Sertraline

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Benzodiazepine:

The first benzodiazepine, chlordiazepoxide was synthesized by accident in 1961, the unusual

seven membered ring having been produced as result of reaction that went wrong in

laboratories of Hoffman-la Roche.

Mechanism of action

Benzodiazepine act selectively on GABA receptors

Fast inhibitory synaptic transmission throughout the central nervous system.

It enhances the response to GABA by facilating the opening of GABA- activated chloride

channel.

At anti anxiety doses, CVS and respiratory depression is miner.

Side effects:

 sedation

 confusion state

 increase appetite

 alteration in sexual function

 impaired co-ordination

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  Major constraint in their long term use for anxiety disorders is their potential to

produce dependence.

 Rashes

 Light headedness

Benzodiazepine Action

The benzodiazepine have neither antipsychotic activity nor analgesic action, they do not

affect the autonomic nervous system. All Bzd exhibit the following actions to a greater or

lesser extend

(1) Reduction of anxiety: - At low doses, the benzodiazepine are anxiolytic. They are

thought to reduce anxiety by selectively enhancing GABA ergic transmission in

neurons having the alpha-2 submit in their GABA receptors, there by inhibiting

neuronal circuits in the limbic system of the brain.

(2) Sedative and hypnotic actions: - all the Benzodiazepine used to treat anxiety have

some sedative properties, and some can produce hypnosis at higher doses. Their

affects have been shown to be mediated by the Alpha1-GABAa receptors.

(3) Anterograde amnesia: - The temporary impairment of memory with use of the

benzodiazepine is also mediated by the alpha1-GABAa receptors.

(4) Anticonvulscent: - Several of the Benzodiazepine have anticonvulscent activity & are

used to treat epilepsy and other seizure disorder. This effect is partially, although not

completely, mediated by alpha1-GABAa receptors.

(5) Muscle relaxant:- At high doses the benzodiazepine relax the spasticity of skeletal

muscle, probably by increasing presynaptic inhibition in the spinal cord, where the

alpha2-GABAa receptor are largely located

9. Profile of drugs

Chlordiazepoxide:

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It was first benzodiazepine to be clinically .oral absorption is slow; it produces a smooth long

lasting effect. It is preferred in chronic anxiety states. Often combined with other drugs in

psychosomatic diseases .its t1/2 is 5-15 hours.

Daily dose: 20-100 mg, LIBRIUM 10,25mg tab.

Diazepam:

It is quickly absorbed, produces a brief initial phase of strong action followed by prolonged

milder effect due to a two phase plasma concentration decay curve (distributive phase t1/2 -1

hour, elimination phase t1/2 20-30 hrs.) the biological effect t1/2 still longer due to

production of active metabolites .it is preferred in acute panic state and anxiety .

Daily dose: 5-30 mg VALIUM 2, 5, 10 mg tab.

Buspirone:

It is partial agonist at 5-HT1A receptors. This is used to treat anxiety disorders.

Mechanism of Action

It binds to DA receptors but is likely that is 5 HT related actions are important in relation to

anxiety suppression because related compound e.g. ispapirone & gepirone.

5-HT1A receptors are inhibitory auto receptors that reduce the release of 5HT and other

mediators.

They also inhibit the activity of noradrenergic locus ceruleus neurons.

Buspirone is ineffective in controlling panic attacks or severe anxiety states. It does not cause

sedation or motor in co-ordination, nor have withdrawal effects been reported. Buspirone is

rapidly absorbed, undergoes extensive first pass metabolism, one metabolite is active and

excretion occur both in urine and faeces, t1/2 -2-3.5 hrs.

Side effects:

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  Nausea

 Dizziness

 Headache

Daily dose: - 5-15 mg OD-TDS BUSPIN, 5-10 mg tab.

5- HT1A agonist as anxiolytic drugs

Buspirone is a potent agonist at 5-HT1A receptors. Anxiolytic effects take days or weeks to

develop.

Beta blockers

Many symptoms of anxiety (palpitation, rise in blood pressure, shaking, tremor etc.) due to

sympathetic over activity. Propranolol and other non selective beta-blocker help anxious

patients troubled by these symptoms, by cutting the vicious cycle & provide symptomatic

relief. They do not affect psychological symptoms such as worry, tension and fear but are

valuable in acutely stressful situations (examination fear, unaccustomed public appearance

etc.) They may be used for performance/situational anxiety or as adjuvant to

benzodiazepines. Their effectiveness depends on block of peripheral sympathetic responses

rather than on any central effects

Other potential anxiolytic drugs:

Selective serotonin reuptake inhibitors such as Fluoxetine, Paroxetine, Sertraline. They are

used to treat certain anxiety disorders including obsessive compulsive disorder and panic.

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10. Management of Anxiety disorder

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 Figure: 10 Management of Anxiety disorder

11. Animal models of anxiety

In addition to the subjective (emotional) component of human anxiety, there are measurable

behavioural and the physiological effects that also occur in experimental animals. In

biological terms, anxiety induces a particular form of behavioural inhibition that occur in the

response to novel environmental events that are non-rewarding (under condition where

reward is expected) threatening or painful. In animals this behavioural inhibition may take the

form of immobility or suppression of behavioural responses such as bar pressing to obtain

food. e.g. a rat is placed in an unfamiliar environment normally responds by remaining

immobile although alert (behavioural suppression) for a time ,which may represent ‘anxiety’

produced by the strange environment. The immobility is reduced if anxiolytic drugs are

administered.

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Various models that is used in animals are divided into two

 Exteroceptive stimuli models

 Interoceptive stimuli models

11.1. Exteroceptive Stimuli Models: These models employ a procedure in which a

Classically conditioned “fear” stimulus is introduced by introducing the animal to The novel

environment, which is the aversive stimulus. When the animals cannot escape from these

stimuli, they freeze and show the signs of anxiety.

Models: (a) Elevated Plus Maze test

(b) Mirrored Chamber test

(c) Staircase exploration test

11.2. Interoceptive Stimuli Models: These models are more recent than Exteroceptive

Stimuli models. These models are more rational because of their analogy to Human anxiety.

Dunn and Fielding 1987 have demonstrated that antagonism against Yohimbine & PTZ

induced seizures in mice is considered to be a model predictive of potential anxiolytic and

GABA-mimetic agents.

Models: (a) Antagonism of Yohimbine induced convulsion in mice

(b) Antagonism of PTZ induced convulsion in mice

1. Exteroceptive Stimuli Models

a) Elevated Plus Maze

Purpose and Rationale

Elevated plus-maze is the simplest apparatus to study anxiety response and the effect of

almost all type of antianxiety agent. Exposure of the animals to novel maze alley evokes an

approach avoidance conflict which is stronger in open arm as compared to enclosed arm.

Rodents for high and open space and prefer enclosed arm and therefore spend greater amount

of time in enclosed arm when animals enter open arm, they freeze, become immobile,

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defecate and show fear-like movements. The test has been proposed for selective

identification of anxiolytic and anxiogenic drugs. Anxiolytic compounds, by decreasing

anxiety, increase the open arm exploration time; anxiogenic compounds have the opposite

effect.

Major advantages of this test procedure are

(a) It is simple fast and less time consuming

(b) No prior training or noxious stimuli (sound or light) required.

(c) It is predictable and reliable procedure for studying anxiety response as well as anti

anxiety action of drugs.

Procedure

The plus-maze consists of two open arms, 50 × 10 × 40 cm, and two enclosed arms, 50 × 10

× 40 cm, with an open roof, arranged so that the two open arms are opposite to each other.

The maze is elevated to a height of 50 cm. The rats (200–250 g body weight) are housed in

pairs for 10 days prior to testing in the apparatus. Groups consist of 6 rats for each dose.

Thirty min after i.p. administration of the test drug or the standard, the rat is placed in the

centre of the maze, facing one of the enclosed arms. During a 5 min test period the following

measures are taken:

 The number of entries into and time spent in the open and enclosed arms

 The total number of arm entries.

The procedure is conducted preferably in a sound attenuated room, with observations made

from an adjacent room.

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 Fig 11: Elevated maze for rat

Evaluation

Motor activity and open arm exploratory time are registered. The values of treated groups are

expressed as percentage of controls. Benzodiazepines and valproate decrease motor activity

and increase open arm exploratory time.

b) Staircase Test

Purpose And Rationale

The staircase test for evaluating anxiolytic activity was originally described for rats by

Thiebot et al. (1973). When introduced into a novel environment, rodents experience a

conflict between anxiety and exploratory behaviour manifested by increased vigilance and

behavioural activity. In the staircase paradigm, step-climbing is purported to reflect

exploratory or locomotor activity, while rearing behaviour is an index of anxiety state. The

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number of rearings and steps climbed are recorded in a 5 min period. The dissociation of

these parameters is considered to be characteristic for anxiolytic drugs.

Procedure

For experiments with mice the staircase is composed of five identical steps 2.5 cm high, 10

cm wide and 7.5 cm deep. The internal height of the walls is constant along the whole length

of the staircase. Male mice (Charles River strain) with a weight between 18 and 24 g are

used. Each animal is used only once. The drug or the standard is administered orally 1 h or 30

min subcutaneously before the test. The animal is placed on the floor of the box with its back

to the staircase. The number of steps climbed and the number of rears are counted over a 3-

min period. A step is considered to be climbed only if the mouse has placed all four paws on

the step. In order to simplify the observation, the number of steps descended is not taken into

account. After each test, the box has to be cleaned in order to eliminate any olfactory cues

which might modify the behaviour of the next animal.

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 Fig 12: Stair case for mice.

Evaluation

Twelve mice are used for the untreated control group, each drug group, and for the group

receiving the standard. The average number of steps and rearings of the control group is taken

as 100%. The values of treated animals are expressed as percentage of the controls.

c) Mirrored chamber

Purpose and rational

Mirrored chamber apparatus for which mice show an extended latency to enter. This

extended latency to enter the chamber of mirrors is used as a parameter for the anxiety.

Procedure

Mirrored chamber apparatus for mice contains mirrored cube 30 x 30 x 30 cm and Outer

container box 40 x 40 x 30.5 cm. Mice are exposed to the chamber of mirrors and evaluated

only once to avoid habituation problems. During 30 minute session, the time it takes the

mouse to enter into the chamber of mirrors can be assessed.

Figure: 13 Mirrored chamber

Evaluation

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When mouse approaches the mirrored chamber, it initially does not touch the surface but

retreats to the corridor and circles the entire corridor. Then it exhibits a series of partial

entries in succession- one foot, two feet and three feet onto the mirrored surface.

2. Interoceptive Stimuli Model

a) Pentylenetetrazole (Metrazol) induced convulsions

Purpose and Rationale

This assay has been used primarily to evaluate antiepileptic drugs. However, it has been

shown that most anxiolytic agents are also able to prevent or antagonize Metrazol-induced

convulsions.

Procedure

Mice of either sex with a body weight between 18 and 22 g are used. The test compound or

the reference drug is injected sc. or i.p. or given orally to groups of 10 mice. Another group

of 10 mice serves as control. Fifteen min after sc.-injection, 30 min after i.p.-injection, or 60

min after oral administration 60 mg/kg MTZ (Metrazol) are injected subcutaneously. Each

animal is placed into an individual plastic cage for observation lasting 1 h. Seizures and

tonic-clonic convulsions are recorded. At least 80% of the animals in the control group have

to show convulsions.

Evaluation

The number of protected animals in the treated groups is calculated as percentage of affected

animals in the control group. ED50-values can be calculated. Furthermore, the time interval

between MTZ-injection and occurrence of seizures can be measured. The delay of onset is

calculated in comparison with the control group.

b) Yohimbine-induced convulsions

Purpose and Rationale

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Antagonism against Yohimbine-induced seizures in mice is considered to be a model

predictive of potential anxiolytic and GABA-mimetic agents (Dunn and Fielding 1987).

Procedure

Male Swiss-Webster mice (20–30 g) are individually placed in clear plastic cylinders and test

compounds are administered i.p. 30 min prior to 45 mg/kg s.c. of Yohimbine HCl. The

animals are observed for the onset and number of clonic seizures for 60 min.

Evaluation

ED50 values with 95% confidence limits are calculated for the antagonism of yohimbine-

induced clonic seizures by means of the Lichtfield-Wilcoxon procedure.

Critical Assessment of the Method

The antagonism against Yohimbine-induced seizures can be regarded as an useful test

amongst a battery of tests for anxiolytic activity.

12. Reference
1. Dipiro T. Joseph , Talbert L.Robert ,Wells G.Barbara Pharmacotherapy A

pathophysiologic approach ,7th edition, Page no.1161-1164.

2. Rang P.H, Dale M .M, Ritter M.J. Rang and Dale’s pharmacology 6th Edition, Page

no. 535-543.

3. Howland. D Richard Mycek . J Mary Pharmacology 3rd ,Page no.104

4. Tripathi K.D,Essential of Medical Pharmcology, Jaypee Brothers Medical

Publishers(P)Ltd. ,Page no.449-451

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