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3153 IC9,10,11,12,14 Psychiatric > Anxiety > Flashcards

Anxiety Flashcards

(47 cards)

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1
Q

What are the key symptoms in anxiety disorders?

A
  • Severe, excessive, persistent anxiety and
  • irrational fears
  • that impair functioning of daily living

Anxiety is out of proportion to the actual danger/threat

Persists long after original trigger disappeared, typically >6m

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2
Q

Untreated anxiety can cause…

A
  • Untreated anxiety if an independent high risk factor for suicide
  • Untreated anxiety can increase risks for developing CVD, CBV, GI, and respiratory disorders (e.g., persistent tachycardia can cause ventricular hypertrophy and heart failure)
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3
Q

Anxiety circuits

A

Fear circuit - regulated by amygdala
Worry circuit - regulated by cortico-striatal-thalamic cortical (CSTC loop)

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4
Q

Neurotransmitter implicated in anxiety

A

Serotonin
GABA
Norepinephrine

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5
Q

Medical conditions associated with anxiety

A
  • Cardiovascular (e.g., angina, arrhythmias, CHF, IHD, MI)
  • Endocrine/Metabolic (e.g., Cushing’s disease, hyperthyroidism)
  • Neurologic (e.g., Dementia, delirium, parkinson’s, seizures, stroke, neoplasms, inadequate pain control)
  • Pulmonary (e.g., asthma, COPD, PE, pneumonia)
  • Others: anemias, SLE, vestibular dysfunction

Impt to check troponin, ECG, FBG, thyroid levels etc. to rule out medical conditions

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6
Q

Drug-induced anxiety

(Similar to the drugs that induce mania)

A
  • Sympathomimetics (e.g., pseudoephedrine)
  • Stimulants (e.g., amphetamines, cocaine)
  • Methylxanthines (e.g., caffeine, theophylline)
  • Thyroid hormones (e.g., Levothyroxine)
  • Corticosteroids (e.g., prednisolone - systemic)
  • Antidepressants (e.g., SSRI, TCAs, esp with rapid dose escalation due to sudden increase in neurotransmitters)
  • Dopamine agonists (e.g., Levodopa)
  • Beta-adrenergic agonists (E.g., Salbutamol)

Other drug-related causes:
- Withdrawal (caffeine, alcohol, sedatives, BZDs, antidepressants, nicotine)
- Intoxication (e.g., anticholinergics, antihistamines, digoxin)

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7
Q

What is a panic attack?

A

Discrete period of intense fear/discomfort, with 4 or more of the following symptoms, developed abruptly, reached a peak within 10 min, usually lasts no more than 20-30min

May be expected or unexpected

  • Palpitations, incr PR
  • Sweating
  • Trembling/shaking
  • Sensations of shortness of breath
  • Feeling of choking
  • Chest pain/discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, faint
  • Derealization or depersonalization
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesia (numbness, tingling sensation)
  • Chills or hot flushes
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8
Q

Name the 5 anxiety disorders that are most amendable to drug treatment

A
  • Panic disorder
  • Social anxiety disorder (SAD)
  • Generalized anxiety disorder (GAD)
  • Obsessive compulsive disorder (OCD)
  • Post traumatic stress disorder (PTSD)
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9
Q

Describe Generalized anxiety disorder (GAD)

(CIMSRF)

A

Excessive anxiety and worries 6m or more, over a pervasive spread of things, cause significant functional impairment

3 or more of the following symptoms:

  • Restlessness
  • Being easily fatigue
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (insomnia, restless unsatisfying sleep)
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10
Q

Pharmacotherapy for GAD

A

SSRIs: Escitalopram, Paroxetine
SNRIs: Venlafaxine XR, Duloxetine
Pregabalin

Others: TCA, BB, hydroxyzine, buspirone etc.

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11
Q

Non-pharmacotherapy for GAD

A

Cognitive behavioral therapy
Psychotherapy
Relaxation
Anxiety management

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12
Q

Describe Panic disorder

A

Anticipatory anxiety of recurrent panic attacks:

  1. Recurrent unexpected panic attacks

AND

  1. > =1 of the panic attacks has been followed by >=1m of >=1 of the following:
  • Persistent anticipatory anxiety about having panic attacks
  • Worry about implications of panic attack
  • Significant change in behavior related to panic attacks

May occur with or without agoraphobia

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13
Q

Pharmacotherapy for Panic Disorder

A

SSRIs: Fluoxetine, Paroxetine, Sertraline
SNRI: Venlafaxine
TCAs

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14
Q

Non-pharmacotherapy for Panic Disorder

A

CBT

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15
Q

Describe Social anxiety disorder (SAD)

A

Fear of being scrutinized or humiliated by others in public of >=1 social/performance situations, duration >6 months

The feared situations are avoided or endured with intense anxiety/distress, the avoidance or anxious anticipation or distress in the feared situation significantly impairs functioning

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16
Q

Pharmacotherapy for SAD

A

SSRIs: Fluvoxamine, Paroxetine, Sertraline
SNRI: Venlafaxine

Others: RIMA - Moclobemide or MAOi

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17
Q

Non-pharmacotherapy for Panic Disorder

A

Behavioral therapy

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18
Q

Describe Obsessive compulsive disorder (OCD)

A

Obsessional thoughts/impulses that causes anxiety, followed by compulsive behaviors to relieve that anxiety; person recognizes and is aware that the obsessions/compulsions are excessive and irrational and significantly impairs functioning (e.g., time-consuming >=1h a day)

  1. Obsession: recurrent and persistent thoughts/impulses/images, intrusive and inappropriate, causing marked anxiety/distress (e.g., contamination, dirt)
  2. Compulsion: repetitive behaviors or mental acts performed aimed at preventing/reducing the distress but NOT connected in a realistic way, and clearly excessive (e.g., washing hands)
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19
Q

Pharmacotherapy for OCD

Study These Flashcards
A

SSRIs: Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
Clomipramine - TCA (2nd line for OCD)

20
Q

Non-pharmacotherapy for OCD

Study These Flashcards
A

CBT
Exposure and response prevention (ERP)

21
Q

Describe Post traumatic stress disorder (PTSD)

(SIANA)

Study These Flashcards
A

Re-experiencing of trauma, persistent avoidance, increased arousal

  1. Stressor
  2. Intrusive symptoms - persistent re-experience
  3. Avoidance - of distressing trauma-related stimuli
  4. Negative alterations in cognition and mood
  5. Alterations (increase) in arousal and reactivity

Persistence of symptoms for >1 month, significant functional impairment

22
Q

Pharmacotherapy for PTSD

Study These Flashcards
A

SSRIs: Paroxetine, Sertraline

*DO NOT USE Benzodiazepines

  • numbs the brain, sedating
  • in PTSD, patient is encouraged to actively participate in sharing of traumatic event
23
Q

Non-pharmacological for PTSD

Study These Flashcards
A

CBT (1st line)
Psychotherapy
Counseling

24
Q

Non-pharmacological in anxiety disorders should be used ________

Study These Flashcards
A

Psychotherapy should be used in combination with medications

CBT/Psychotherapy is key (1st line), medications are adjunctive

25
Which drug is used for physical or worrying symptoms in anxiety?
Physical symptoms (tremors, tense, palpitation, sweating): - Benzodiazepines Worrying symptoms - SSRIs
26
Which drugs used in acute stress disorder
- Benzodiazapines (short-course, PRN) - Antihistamines (e.g., hydroxyzine)
27
What scale is used to assess anxiety?
Clinician-rated Hamilton Anxiety Scale (HAM-A)
28
Treatment goal for anxiety disorders:
- Remission of anxiety symptoms - Functional recovery *Medications have a role for anxiety that is persistently severe and disabling*
29
[Antidepressant in anxiety] Which antidepressants can be used?
All serotonergic antidepressants can be useful for long-term management of GAD, PD, SAD, OCD, PTSD - SSRIs > SNRIs > Clomipramine - *In OCD, 1st line SSRI, 2nd line Clomipramine, 3rd line Venlafaxine*
30
[Antidepressant in anxiety] Approach to dosing
**Low starting dose** - transient jitteriness in initial 1-2 weeks due to increase in neurotransmitters **Consider BZD as adjunct for acute anxiety symptoms** - because antidepressants work slowly (gradual downregulation of presynaptic autoreceptors after chronic exposure to effects of the antidepressants) **High maintenance dose** - E.g., fluoxetine for anxiety start as 10mg/day but can increase to max maintenance dose of 60-80mg/day (VS in depression - 20mg/day)
31
[Antidepressant in anxiety] Onset, efficacy, and duration of treatment
**Onset: 1-2 months** (recall 4-8 weeks for mood symptoms and anxiety) - 6-12 weeks to achieve initial efficacy, max/full response may require 3 months Efficacy: **effective for worrying symptoms**, not effective for physical symptoms (tense, tremors, palpitations) Duration: **at least 1-2 years**, may be lifelong
32
[Adjuncts] List the adjuncts used in anxiety disorders
- Benzodiazapine - Antihistamine (hydroxyzine) - Beta blockers (propranolol) *Pregabalin may be used as well - not adjunct*
33
[Adjunctive benzodiazepines in anxiety] Therapeutic action Onset
BZDs effective for physical symptoms of anxiety (as an anxiolytic) Fast onset of action, work vv fast to manage acute symptoms - E.g., Lorazepam (fast onset within 30min) *They can be used in acute stress disorder or adjustment disorders*
34
[Adjunctive benzodiazepines in anxiety] Duration
Short-term **3-4 months** of treatment, PRN dosing *But typically supply only 2-4 weeks for short-term basis
35
[Adjunctive benzodiazepines in anxiety] Choice of BZD in anxiety disorders
High potency agents preferred in anxiety disorders - Clonazepam - Lorazepam - Alprazolam XR (for panic disorder) - short-acting therefore XR formulation, most potent, most abuse and death
36
[Adjunctive benzodiazepines in anxiety] Short acting vs Long acting BZDs
Short-acting (~6h): Lorazepam, Alprazolam Long-acting (~10h): Diazepam (less preferred as can cause drowsiness throughout the day, affect cognition, cause falls esp in elderly), Clonazepam FYI: very short acting: Midazolam (~2h)
37
[Adjunctive benzodiazepines in anxiety] Tolerance
Tolerance to anxiolytic action is less common Tolerance to hypnotic actions more common, develops within days (same dose less effective overtime) *May develop if used continuously for >1-2 weeks*
38
[Adjunctive benzodiazepines in anxiety] Dependence, withdrawal
- **Avoid abrupt cessation** after weeks of continued use (withdrawal) - Gradual taper required BZD withdrawal symptoms: - Incr HR - Agitation - Rebound Anxiety - Tremors - Insomnia - Seizures - Hallucinations
39
[Adjunctive benzodiazepines in anxiety] Dosing (general principles)
- Lowest effective dose PRN for 1-2 weeks (prevent risk of dependence) - Intermittently (once every 2 or 3 nights for insomnia)
40
[Adjunctive benzodiazepines in anxiety] Cautions
- **Paradoxical excitement/disinhibition** - i.e., agitation, tachycardia (esp in children elderly, head injury) - **Dependence** and **withdrawal symptoms** can occur esp in pt with history of drug dependence
41
[Adjunctive benzodiazepines in anxiety] Doses of the following: - Alprazolam - Clonazepam - Diazepam - Lorazepam
Alprazolam (anxiety) - **0.25mg** - 0.5mg BD-**TDS**, max 4-6mg/day - Short duration of action - No major active metabolite Clonazepam (anxiety) - **0.5mg BD**, max 4mg/day Diazepam (anxiety, insomnia) - **2-10mg BD-QDS** Lorazepam (anxiety, insomnia) - 2mg/day (in divided doses), titrate to 2-3mg/day; max dose 6mg/day, do not exceed 10mg/day (elderly/debilitated - 0.5mg/day, max 2mg/day) - short duration of action - primarily hepatic metabolism: glucuronidation - no interaction with cyp enzymes - no active metabolites
42
[Adjunctive benzodiazepines in anxiety] Lorazapam metabolism and CYP interaction
Lorazepam metabolized via hepatic glucuronidation, no active metabolites Not a substrate of CYP enzymes (unlike other BZDs - CYP3A4 substrates)
43
[Adjunctive benzodiazepines in anxiety] BZD use in panic disorder
Do not stop regular dosing, do not stop abruptly, or might go into withdrawal
44
[Other adjunctives - Antihistamines] - Hydroxyzine
Sedating antihistamine - hydroxyzine (labelled for anxiety and insomnia) - **Does NOT cause dependence** - Watch for anticholinergic side effects - Careful with doses, typically use 10-25mg; high doses of 100mg cause QTc prolongation (sudden cardiac death) - Active metabolite: Cetirizine
45
[Other adjunctives - Beta blockers] - Propanolol
Propanolol (non-selective BB) - Caution in pt with history of asthma (bronchoconstriction)
46
[Other - Pregabalin] - GAD only *Also comment on its risk for dependence*
Anticonvulsant - Pregabalin - Indication: may be used as an anxiolytic in **GAD only** - Onset: 1-2 weeks (doe not work immediately) - Pregabalin can increase expression of enzymes that produce GABA (promote GABA transmission) - **Some potential for dependence**
47
General DDIs to look out for:
- Alcohol and other CNS depressants: incr CNS depressant side effects of benzodiazepines and antidepressants - Anticholinergic side effects - MAOIs, SSRIs, TCAs => watch for serotonin syndrome (mental status change, autonomic instability, neuromuscular changes)

3153 IC9,10,11,12,14 Psychiatric (10 decks)

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