Anxiety

Question 1

What medications can cause anxiety?

Answer 1

-anticonvulsants
-antihypertensives
-BRONCHODILATORS
-dopamine agonists (ILLICIT SUBSTANCES)
-STIMULANTS
-LEVOTHYROXINE

Question 2

What is first line therapy for generalized anxiety disorder(GAD)?

Answer 2

SSRI/SNRI or anticonvulsants

Question 3

What SSRIs/SNRIs are FDA approved for the treatment of generalized anxiety disorder(GAD)?

Answer 3

escitalopram, sertraline, paroxetine, venlafaxine, and duloxetine

Question 4

What are the second line treatment options for generalized anxiety disorder?

Answer 4

-benzodiazepines (good efficacy but 2nd line due to SE and dependence)
-Imipramine (TCA)
-bupropion
-vilazodone and vortioxetine
-quetiapine ER
-buspirone
-hydroxyzine (good efficacy PRN)

Question 5

What are the recommended follow up guidelines for generalized anxiety disorder?

Answer 5

-assess medication tolerability 1-2 weeks after initiation/change of therapy
-assess efficacy ~4 weeks after patient has been on a stable dosage of medication

Question 6

What is the first line pharmacotherapy for panic disorder?

Answer 6

SSRI/SNRI

Question 7

Which anxiety disorder is most likely to experience paradoxical increase in symptoms with initiation of SSRI/SNRIs?

Answer 7

Panic disorder

Question 8

How can paradoxical increase in anxiety symptoms be managed with SSRIs?

Answer 8

Start with lower doses and titrate slowly or benzodiazepines PRN early on in therapy

Question 9

Way is the best treatment for PTSD?

Answer 9

Psychotherapy

Question 10

What is first line pharmacotherapy for PTSD?

Answer 10

SSRI/SNRIs

Question 11

What PTSD symptoms can be relieved with SSRI/SNRIs?

Answer 11

Re-experiencing, avoidance, hyperarousal

Question 12

What drugs may be used for sleep disturbances in PTSD?

Answer 12

-mirtazapine= sleep/nightmares
-prazosin (anti adrenergic agents)= sleep/nightmares
-trazodone= sleep/nightmares

Question 13

What is the second line treatment for PTSD?

Answer 13

-anticonvulsants (not monotherapy)
-antipsychotics

Question 14

In what anxiety disorders are benzodiazepines highly discouraged due to lack of evidence and even worsening of symptoms?

Answer 14

PTSD & OCD

Question 15

What is the first line treatment for OCD?

Answer 15

SSRIs= fluoxamine

Question 16

What is the dosing of SSRIs in OCD?

Answer 16

higher dosing than depression

Question 17

What are the second line treatment options for OCD?

Answer 17

-clomipramine (TCA)
-venlafaxine XR
-mirtazipine

Question 18

What are the third line treatment options in OCD?

Answer 18

antipsychotics or anticonvulsants

Question 19

How long to experience benefit with SSRI/SNRI treatment in anxiety?

Answer 19

2-4 weeks

Question 20

What antidepressant may worsen anxiety symptoms?

Answer 20

bupropion

Question 21

What is the dosing of Buspirone?

Answer 21

10-15mg BID-TID (max 60mg/day), best if scheduled and at least BID

Question 22

What are the common side effects of Buspirone?

Answer 22

dizziness, drowsiness, nausea

Question 23

What is the place in anxiety therapy for benzodiazepines?

Answer 23

panic disorder or severely distressing situations as “pill-in-pocket” approach- may be used in treatment refractory cases (scheduled with long-acting agents)

Question 24

What are the side effects of Benzodiazepines?

Answer 24

-sedation
-hypotension
-cognitive/motor impairments
-respiratory depression

Question 25

What are some pharmacokinetic parameters that are significant to benzodiazepines?

Answer 25

-faster time to peak effect= rapid symptom reduction but also increase euphoria in abuse) -shorter t1/2= increased potential for withdrawal symptoms -tolerance can develop

Question 26

What are the preferred benzodiazepines in hepatic dysfunction?

Answer 26

-lorazepam -oxazepam -temazepam

Question 27

What are the withdrawal symptoms of benzodiazepines?

Answer 27

-increased anxiety -tremors -tachycardia -hallucinations -seizures

Question 28

What are the risk factors for withdrawal of benzodiazepines?

Answer 28

long-term use (>4 weeks), high doses, short t1/2

Question 29

What benzodiazepine is preferred for tapering off strategies?

Answer 29

clonazepam

Question 30

What anticonvulsants may be used in anxiety disorders?

Answer 30

pregabalin or gabapentin

Question 31

Why may pregabalin be specifically useful in some patients?

Answer 31

improvement in sleep disturbance or somatic complaints (secondary physical symptoms of anxiety)

Question 32

What are the common side effects of pregabalin?

Answer 32

dizziness, drowsiness, headache

Question 33

What is the dosing regimen for hydroxyzine in anxiety disorders?

Answer 33

25-50mg PRN up to 4 times a day

Question 34

What are the side effects of hydroxyzine?

Answer 34

*SEDATION* anticholinergic, blurred vision, confusion

Question 35

What antipsychotics are FDA approved for anxiety disorders?

Answer 35

none

Question 36

What is the use of beta-blocker (propranolol) in anxiety disorders?

Answer 36

performance anxiety, helpful for autonomic symptoms (tremors, tachycardia)