Anxiety Disorders

Question 1

What is the usual age of onset for anxiety disorders?

Answer 1

Early adulthood
Most common ages 45-59, drops after 60 y/o

Question 2

What are the general signs of anxiety?

Answer 2

Excessive or pervasive and uncontrollable worry which occurs for period =/> 6 months

Question 3

What are some symptoms of anxiety?

Answer 3

Restlessness
Irritability
Fatigue
Muscle tension
Difficulty concentrating
Sleep disturbances

Question 4

What mechanisms are involved in the pathophysiology of anxiety?

Answer 4

Anxiety and fear - malfunctioning amygdala

Serotonin = ?enhances release/abnormal uptake, ? super-sensitivity of receptors

Gaba - regulate NA and 5HT (type C) somewhat

Corticotrophin releasing factor (CRF)

Question 5

What are the non-pharm treatment strategies of anxiety?

Answer 5

Always managed with psych intervention throughout varying severities (adults and young people)

Exercise may be useful adjunct for those w/ anxiety
- dec panic sx - lower pt sensitivity to internal symptoms similar to panic

Question 6

What is step 1 of the anxiety stepped care model?

Answer 6

All known and suspected presentation of GAD
- Educate and active monitoring

Question 7

What is step 2 of the anxiety stepped care model?

Answer 7

Diagnosed GAD that has not improved after step 1
- low-intensity psychological intervention

Question 8

What is step 3 of the anxiety stepped care model?

Answer 8

GAD with marked functional impairment or that has not improved after step 2
- high intensity psych intervention
- drug treatment

Question 9

How are benzos used in anxiety disorders?

Answer 9

Short term only - used for up to two weeks followed by gradual reduction to 0 in 6 weeks

*Can cause anxiety once removed

Useful for immediate relief from anxiety symptoms

Question 10

What are some short and very short duration benzos?

Answer 10

V/ Short = midazolam

Short = alprazolam, oxazepam, temazepam

Question 11

What are some long duration benzos?

Answer 11

Clobazam, clonazepam, diazepam, flunitrazepam, nitrazepam

Question 12

What are the main drugs used in anxiety maintenance therapy?

Answer 12

SSRIs are most effective

SNRIs are effective but not good for underlying conditions

TCAs are effective but use with caution

Question 13

How do the antidepressant doses used to treat anxiety differ from depression?

Answer 13

Doses at lower end of range

Start low and titrate to adequate effect or max recommended dose

Concerned about ADRs:
- Begin with half the normal starting dose, avoid using high maintenance

Question 14

What are dose examples of SSRIs used to treat anxiety?

Answer 14

Citalopram, paroxetine, fluoxetine = 10 mg

Escitalopram = 5 mg

Fluvoxamine = 50mg

Sertraline = 25 mg

Question 15

What are the third line therapies for non-responsive anxiety?

Answer 15

Pregabalin = rapidly effective (20-30% improvement in a week)

Quetiapine = antihistamine at low dose

Other = agomelatine and mirtazapine (sedation, weight gain, metabolic)

Question 16

What are the considerations/down sides to pregabalin in anxiety?

Answer 16

Severe ADRs

Potential for dependence and abuse

Toxicity in overdose

Can alter/worsen mood, emergent suicidal thoughts and behaviours

Question 17

What are the considerations/down sides to quetiapine in anxiety?

Answer 17

Use is limited by cardiometabolic ADRs, problem use, overdose

Question 18

How is anxiety diagnosed?

Answer 18

DSM-V = presence of obsessions, compulsions, or both

Obsessions = Recurrent & persistent thoughts, urges, images experienced as intrusive & and unwanted and cause marked anxiety and distress

Compulsions = repetitive behaviours or mental acts in response to an obsession or according to rigid rules

Question 19

Generally, how is OCD treated? Dose considerations?

Answer 19

Combination of psychological and pharmacological treatment

SSRIs = effective (1st line)
SNRI = limited efficacy (2nd line)

Doses are higher compared to both anxiety and depression

Question 20

How long does it take for OCD symptoms to improve? Any monitoring?

Answer 20

May need cardiac monitoring due to QT prolongation

Response = 6-12 weeks, treated for 6-12 month

May relapse when drug is withdrawn

Question 21

What are the third line therapies for non-responsive OCD?

Answer 21

Clomipramine (TCA) = other TCAs not work

Quetiapine

Question 22

What are the considerations/down sides to Quetiapine in OCD?

Answer 22

Antihistamine at low doses

Use limited by:
- risk of cardiometabolic ADRs, overdose, problem use

Question 23

What are the considerations/down sides to clomipramine in OCD?

Answer 23

Uniquely effective in some

Intolerance limits use

Toxicity in overdose

Changes in cardiac conduction = do ECG before starting tx, repeat when dose stabilised (usually after 6 weeks)

Question 24

How does PTSD differ from anxiety?

Answer 24

They don’t anxiety

Sx of anhedonia or dysphoria, anger, aggression, or dissociation

Question 25

What is the difference between Acute stress disorder and PTSD?

Answer 25

ASD = begins immediately after trauma and lasts for 3 days to 1 month

PTSD = lasts for >1 months as continuation or as separate occurrence up to 6 months after trauma

Question 26

What are the four major symptoms clusters of PTSD?

Answer 26

Re-experiencing the event

Heightened arousal

Avoidance

Negative thoughts and moods or feeling

Question 27

Outline (generally) the treatment for PTSD and ASD

Answer 27

Specialist psychological intervention

Minimal evidence for pharmacotherapy

SSRI 1st line, SNRI 2nd line (due to heightened arousal)

Limited evidence for mirtazapine and TCA

Question 28

How long does it take to see a response when pharmacotherapy is used in PTSD/ASD?

Answer 28

8-12 weeks

If tx beneficial, use for 12 months

PTSD px also more sensitive to SNRI ADRs

Question 29

How are PTSD nightmares treated?

Answer 29

Psychological interventions - imagery rehearsal therapy or CBT

Pharmacotherapy: Prazosin - evidence is conflicting