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Flashcards in Anxiety Deck (50):
1

What are the risk factors for anxiety?

- Women - Age: develops prior ro age 30 - Family history of anxiety or depression - Life stressors

2

Pathophysiology of Anxiety?

- Abnormal NT functioning in the amygdala, GABA, NE, Serotonin - Corticotrophin releasing factor - Cholecystokinin - Glutamate - Substance P

3

Classifications of anxiety

- Generalized anxiety disorder - Panic disorder - Social anxiety disorder - Obsessive-compulsive disorder - Post traumatic stress disorder - Specific phobias

4

Nonpharm treatment of Anxiety?

- Psychotherapy - Cognitive behavioral therapy - Meditation - Exercise - Avoid caffeine, stimulants, diet pills, or other meds that cause anxiety - Identify and remove causes of anxiety

5

Pharmacologic treatment of anxiety

- Antidepressants SSRI, ANRIs, TCAs - Benxodiazepines - Buspirone - Hydroxyzine - Pregabalin

6

GAD 1st and 2nd line?

1st: SSRIs/SNRIs 2nd: Benzos as needed, buspirone

7

Panic disorder first line?

SSRIs may need scheduled benzos for 2-4 weeks May need PRN benzo for attacks

8

OCD? 1st line and 2nd line?

1st: SSRIs (high dose) or CBT or both 2nd line: Clomipramine or antipsychotic augmentation

9

Social anxiety 1st and 2nd line

1st SSRI/ SNRIs 2nd: Benzos Beta blockers for performance anxiety

10

PTSD 1st line? Adjunctive agents? What not to give?

1st SSRIs, SNRIs, Add Prazosin or antipsychotic or mood stabalizer No benzos

11

Specific phobia treatment?

CBT

12

SSRIs first line for GAD, PD, OCD, Social anxiety, PTSD

- Start at a lower dose - Can initially cause anxiety - Slower onset than benzos - Need higher dosages for OCD

13

You need a higher when starting an SSRI with what disease?

OCD

14

Escitalopram is approved for the treatment of? 

Approved for GAD 

15

Fluoxetine is approved for?

 approved for PD

16

Fluvoxamine approved for the treatment of? 

OCD

17

Paroxetine approved for the treatment of? 

 treatment of GAD, OCD, PD, PTSD, SAD

18

Sertraline Approved for the treatment of?

treatment of OCD, PTSD

19

Venlafaxine XR approved for the treatment of? 

 GAD and SAD

20

Duloxetine treatment of? 

GAD 

21

What are the SEs of SSRIs?

S-Stomach (N/V/D) S- Sexual dysfunction R- Restlessness, Jitteriness I- Insomnia Headache, Weight gain, withdrawal from abrupt discontinuation

22

Antidepressant tips - If one SSRI/SNRI is ineffective what should be done? - Patients often become tolerant to what? - These medications require? - How many weeks does it take to see response? - When you stop an SSRI how do you do it?

- You should try another one - SEs usually stop within a few weeks expect for Sexual Dysfunction - These require daily administration - Often take 4 weeks or more to see effect - Upon discontinuation you have to taper

23

Benzo are ___ line or adjunct for? Most effective for? Shouldnt be used to treat?

2nd line for anxiety Most effective for acute symptoms Not effective for OCD or PTSD

24

What benzos have a very fast onset?

Alprazolam, Diazepam (super fast)

25

LOT what are the drugs and what are they good for?

Temazepam, Lorazepam, Oxazepam Good for the liver Little to no CYP metabolism

26

Benzos with slow onset?

Oxazepam, Clonazepam, Lorazepam

27

Im administration what benzo?

Lorazepam

28

Most benzos are substrates for?

CYP3A4

29

Substrate of 2C19

Diazepam

30

Inhibitors of CYP3A4

Amiodarone, Azoles, AIDS protease inhibitors, Cimetidine, Ciprofloxacin, Clarithromycin/Erythromycin, CCBs (Diltiazem/Verapamil) Fluvoxamine, Grapefruit, Nefazodone

31

SEs of benzos?

Sedation, Psychomotor, Impairment, Ataxia, Anterograde amnesia, Confusion, disorientation, Excitement/aggression, Addiction,

32

You can die from benzos if you take what?

Drink on them or take CNS depressants

33

Very new black box warnign for Benzos, opiod analgesics?

Serious risks associated with combined use of opioid medications and benzos Risk include extreme sleepiness, respiratory depression, coma and death

34

Less serious withdrawal symptoms of benzos?

  • Anxiety
  • Irritability 
  • Tremor
  • Insomnia
  • Muscle weakness
  • Nausea
    •  

35

Serious withdrawal symptoms of benzos?

  • Confusion
  • Delirium
  • Psychosis
  • Seizures

 

36

What types of benzos have an increased risk of addiction?

  • Short half life
  • Long duration of use

 

37

More severe withdrawal symptoms after ____ months but when can dependence start?

3 months 

Dependence can occur 3-6 weeks of treatment 

 

38

Slow tapering is necessary for what type of benzos?

Short half life due to withdrawal symptoms 

39

Guide to tapering Benzos

A image thumb
40

What are the 2 tapering methods for benzos?

  • Method 1
    • 25% decrease every few days (5-7) until 50% of original dose reached 
    • Then 1/8 dose reduction every 4-7 days 
    • Alprazolam cannot be tapered more than 0.5 mg Q3D
  • Method 2 
    • Subsitute a long half life agent (Diazepam, Clonazepam) using equivalent dosages 
    • Long acting benzos are easier to taper than short acting 

41

Guidelines for pregnancy and lactation with benzos

What should you use instead?

  • Benzos should be avoided
  • Cleft palate especially in the first trimester
  • Lethargy and poor temperature regualtion (floppy baby) in nursing mothers
  • SSRI if you need a PRN use Diphenhydramine, or Hydroxazine 

42

Tips for benzos

 

  • Weigh out the benefit vs. the risk
    • Risk of dependence, avoid in patients with history of substane abuse 

43

  • Benzos are especially useful during ___ treatment
  • Overall durations of benzos should not exceed? 
  • Benzos with what are generally preferred over ____ with the treatmetn of GAD
  • Higher doses are generally required for what disorder?

  • initial treatment 
  • 4-6 months
  • longer half life better
  • Panic disorder 

44

Buspirone indication? 

max dose?

SEs?

Good alternative for?

What is the onset?

  • GAD
  • 60 mg/day
  • Dizziness, Nausea, Headache, Dysphoria
  • Alternative to benzos for patients with substance abuse history
  • onset is slow 4-6 weeks

 

45

WHat other medications can be used for the treatment of anxiety?

  • Antihistamines, Hydroxazine (FDA approved), Diphenhydramine
  • Anticonvulsants
    • Pregabalin
    • Gabapentin 
  • Antipsychotics
    • Quintiapine
  • Beta blockers
    • Propranolol (public speeching)
  • TCAs
    • Chlorimipramine (OCD) 

 

46

When can you attempt to stop anxiety meds? 

GAD

PD and OCD

social anxiety

Resume if?

Lifelong treatmetn for?

  • 12 months GAD
  • 12-24 months in PD and OCD
  • 1 year for social anxiety 
  • Life long if 2-4 relapses

47

PTSD

The event is persistnetly reexperienced 

What to avoid

Symptoms for longer than?

Avoid stimulants

Symptoms longer than 1 month 

48

Non pharm treatment for PTSD?

  • Short term: Stress management, hypnosis
  • CBT
  • Eyemovement desensitization and reprocessing 

 

49

First line treatment for PTSD?

Second line?

SSRIs or venlafaxine 

Mirtazepine, or TCA, Adjunctive medications 

BENZOS are not effective 

50

Adjunctive therapy for PTSD?

  • Prazosin 
    • Stops nightmares 
  • Atypical antipsychotics 
    • Reserved for non-responders
    • Intrusive thoughts and hypervigilance
  • Anticonvulsants 
    • Anger and aggression 
    • Limited data, lamotrigine has some data