Anxiety

Question 1

What are the risk factors for anxiety?

Answer 1

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

Question 2

Pathophysiology of Anxiety?

Answer 2

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

Question 3

Classifications of anxiety

Answer 3

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

Question 4

Nonpharm treatment of Anxiety?

Answer 4

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

Question 5

Pharmacologic treatment of anxiety

Answer 5

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

Question 6

GAD 1st and 2nd line?

Answer 6

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

Question 7

Panic disorder first line?

Answer 7

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

Question 8

OCD? 1st line and 2nd line?

Answer 8

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

Question 9

Social anxiety 1st and 2nd line

Answer 9

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

Question 10

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

Answer 10

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

Question 11

Specific phobia treatment?

Answer 11

CBT

Question 12

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

Answer 12

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

Question 13

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

Answer 13

OCD

Question 14

Escitalopram is approved for the treatment of?

Answer 14

Approved for GAD

Question 15

Fluoxetine is approved for?

Answer 15

approved for PD

Question 16

Fluvoxamine approved for the treatment of?

Answer 16

OCD

Question 17

Paroxetine approved for the treatment of?

Answer 17

treatment of GAD, OCD, PD, PTSD, SAD

Question 18

Sertraline Approved for the treatment of?

Answer 18

treatment of OCD, PTSD

Question 19

Venlafaxine XR approved for the treatment of?

Answer 19

GAD and SAD

Question 20

Duloxetine treatment of?

Answer 20

GAD

Question 21

What are the SEs of SSRIs?

Answer 21

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

Question 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?

Answer 22

• 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

Question 23

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

Answer 23

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

Question 24

What benzos have a very fast onset?

Answer 24

Alprazolam, Diazepam (super fast)

Question 25

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

Answer 25

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

Question 26

Benzos with slow onset?

Answer 26

Oxazepam, Clonazepam, Lorazepam

Question 27

Im administration what benzo?

Answer 27

Lorazepam

Question 28

Most benzos are substrates for?

Answer 28

CYP3A4

Question 29

Substrate of 2C19

Answer 29

Diazepam

Question 30

Inhibitors of CYP3A4

Answer 30

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

Question 31

SEs of benzos?

Answer 31

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

Question 32

You can die from benzos if you take what?

Answer 32

Drink on them or take CNS depressants

Question 33

Very new black box warnign for Benzos, opiod analgesics?

Answer 33

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

Question 34

Less serious withdrawal symptoms of benzos?

Answer 34

* Anxiety * Irritability * Tremor * Insomnia * Muscle weakness * Nausea *

Question 35

Serious withdrawal symptoms of benzos?

Answer 35

* Confusion * Delirium * Psychosis * Seizures

Question 36

What types of benzos have an increased risk of addiction?

Answer 36

* Short half life * Long duration of use

Question 37

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

Answer 37

3 months Dependence can occur 3-6 weeks of treatment

Question 38

Slow tapering is necessary for what type of benzos?

Answer 38

Short half life due to withdrawal symptoms

Question 39

Guide to tapering Benzos

Answer 39

Question 40

What are the 2 tapering methods for benzos?

Answer 40

* 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

Question 41

Guidelines for pregnancy and lactation with benzos What should you use instead?

Answer 41

* 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

Question 42

Tips for benzos

Answer 42

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

Question 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?

Answer 43

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

Question 44

Buspirone indication? max dose? SEs? Good alternative for? What is the onset?

Answer 44

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

Question 45

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

Answer 45

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

Question 46

When can you attempt to stop anxiety meds? GAD PD and OCD social anxiety Resume if? Lifelong treatmetn for?

Answer 46

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

Question 47

PTSD The event is persistnetly reexperienced What to avoid Symptoms for longer than?

Answer 47

Avoid stimulants Symptoms longer than 1 month

Question 48

Non pharm treatment for PTSD?

Answer 48

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

Question 49

First line treatment for PTSD? Second line?

Answer 49

SSRIs or venlafaxine Mirtazepine, or TCA, Adjunctive medications BENZOS are not effective

Question 50

Adjunctive therapy for PTSD?

Answer 50

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