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anxiety Flashcards

1
Q

how does anxiety pose as a risk factor for other disorders

A

1) CVS: increased HR, HTN
2) cerebrovascular: persistent HTN -> stroke
3) GI: V, D
4) respiratory

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2
Q

classifications of anxiety

A

1) generalised anxiety disorder (GAD)

  • excessive anxiety and worries > 6 months

2) panic disorder (PD)

  • anticipatory anxiety about recurrent panic attacks
  • causes agoraphobia (fear of going out)

3) Social anxiety disorder (SAD)

  • fear of being scrutinised/humiliated by others in public

4) obsessive compulsive disorder (OCD)

  • obsessive thoughts/impulses that cause anxiety
  • followed by compulsive behaviours to relieve anixety

5) post traumatic stress disorder (PTSD)

  • re-experiencing of trauma, persistent avoidance, increased arousal

6) phobias

  • fear + avoidance of behaviours
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3
Q

pathophysiology of anxiety

A

neurochemical dysregulation of neurotransmitters, defence system and behavioural inhibition system resulting in over running of fear and worry circuit

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4
Q

anxiety pathophysiology - over running of fear and worry circuit

A

1) Fear circuit

  • regulated by amygdala (Responsible for fear, fight/flight)

2) worry circuit

  • regulated by cortical-striatal-thalamic-cortical (CSTC) loop
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5
Q

anxiety pathophysiology - neurochemical dysregulation

A

1) defence system

  • originated in amygdala

2) behavioural inhibition system

  • originate in hippocampus

3) neurotransmitters

  • increased NE found between amygdala and CSTC loop
  • decreased serotonin = decreased inhibition of amygdala by serotonin = overactivation of amygdala
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6
Q

drug induced anxiety

A

drug classes
1) sympathomimetics: pseudoepinephrine
2) stimulants: amphetamines, cocaine, methylphenidate
3) methylxanthines: theophylline, caffeine
4) corticosteroids
5) antidepressants
6) dopamine agonist
7) beta-adrenergic agonist

drug withdrawal

  • caffeine, alcohol, sedative, benzodiazepine, antidepressants, nicotine

drug intoxication

  • anticholinergic, antihistamines, digoxin
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7
Q

conditions associated with anxiety

A

1) CVS: atherosclerosis and conditions below
2) endocrine: hyperthyroidism
3) neurologic: dementia, delirium
4) pulmonary: asthma, COPD

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8
Q

clinical presentation of GAD

A

> /= 3 of the following for >/= 6 months

1) restlessness or feeling on the edge
2) being easily fatigued
3) difficulty concentrating or mind going blank
4) irritability
5) muscle tension
6) sleep disturbances: insomnia, restless unsatisfying sleep

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9
Q

clinical presentation of panic disorder w/wo agoraphobia

A
  • recurrent unexpected panic attack
  • > /= 1 of panic attacks that have been followed by >/= 1 month of >/= 1 of

1) persistent anticipatory anxiety of having additional panic attack
2) worry about implications of panic attack
3) significant change in behaviour related to panic attacks

  • +/- agoraphobia
  • panic attack not caused by medical disorder, substance use, other schizoaffective or mood disorders
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10
Q

clinical presentation of social anxiety disorder (SAD)

A
  • marked and persistent fear of >/= 1 social/performance situations where person is exposed to unfamiliar people or possible scrutiny by others and patient fears that they will act/show anxiety symptoms that are humiliating/embarrassing
  • last for >/= 6 months
  • result in avoidance of situations -> significantly impair social functioning
  • need differential diagnosis with avoidant personality disorder
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11
Q

clinical presentation of obsessive compulsive disorder (OCD)

A
  • either obsession or compulsion

1) obsession
** recurrent and persistent thoughts/impulses/images that are intrusive and inappropriate, causing anxiety
** patient recognise that these are products of his own mind

2) compulsion
** repetitive behaviours or mental acts that are performed in response to an obsession to relieve anxiety
** behaviours or mental acts aimed at preventing/reducing distress but NOT connected in a realistic way or are clearly excessive

  • recognise at some point that these are excessive/unreasonable
  • obsessoin/compulsion maybe time consuming or significantly impair functioning
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12
Q

clinical presentation of PSTD

A

1) stressor

  • direct exposure, witness in person, indirectly, repeated/extreme indirect exposure

2) intrusion symptoms

  • re-experiencing traumatic event

3) avoidance of distressing trauma-related stimuli
4) negative alterations in cognition and mood
5) traumatic related alterations in arousal and reactivity

6) persistence of symptoms (2-4) for > 1 month
7) distress or functional impairment

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13
Q

diagnosis of anxiety

A

HAM-A scale (used in RCT)

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14
Q

treatment overview for each anxiety

A

1) GAD

  • SSRI, venlafaxine XR, pregabalin
  • CBT

2) panic disorder, SAD

  • SSRI
  • CBT

3) OCD

  • SSRI, clomipramine
  • CBT, exposure and response prevention (ERP)

4) PTSD

  • SSRI
  • CBT (1st line)
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15
Q

antidepressant dosing

A
  • start low then titrate
  • transient jitteriness in initial 1-2 wks initiation
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16
Q

benzodiazepine indication for anxiety

A

effective for physical symptoms (muscle tension)

17
Q

types of benzodiazepine for anxiety

A

clonazepam, lorazepam, alprazolam XR (For PD)

18
Q

treatment duration for benzodiazepine for anxiety

A

short term (3-4 month) PRN then taper dose

19
Q

comparing benzodiazepine for anxiety

A

1) alprazolam

  • more potent, lower dose required
  • short duration, no active metabolite
  • easier for addiction

2) clonazepam

  • long duration of action

3) diazepam

  • least potent so need higher dose
  • long duration of action

4) lorazepam

  • short duration, no active metabolites
  • most common
20
Q

tolerance to benzodiazepine for anxiety

A
  • tolerance to hypnotic effect within days
  • tolerance to anxiolytic action less common
21
Q

dependence on benzodiazepine for anxiety

A
  • avoid abrupt cessation after wks of continued use
  • gradual taper required (2mg every 2-3 wks)
22
Q

caution for benzodiazepine for anxiety

A
  • paradoxical excitement (esp young, old)
  • dependence and withdrawal symptoms if history of drug dependence
23
Q

other adjunctives for anxiety

A
  • antihistamines: hydroxyzine
  • beta blockers: propranolol
  • anticonvulsants: pregabalin (used for GAD if sexual dysfunction or GI SE intolerable
24
Q

DDI for anxiety medications

A

1) alcohol and other CNS depressants
2) anticholinergic agents
3) MAOis and SSRIs/TCAs combination that cause serotonergic syndrome
4) antidepressant specific (CYP interactions)
5) benzodiazepine specific

  • CNS depressant (alc 4-6hrs apart)
  • benzodiazepine + opioid = increased mortality
  • metabolised by CYP3A4 except lorazepam

mental (8 decks)

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