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Anxiety Disorders

Anxiety is the state of apprehension, tension or uneasiness that stems from the anticipation of danger, the source of which is largely unknown or unrecognized
-Most common psychiatric diagnosis
-Common comorbidities include depression, alcohol abuse and drug abuse
-Imbalances in norepinephrine, serotonin, dopamine and GABA are thought to contribute to symptoms of anxiety


Biopsychosocial Approach

Assumes hat biological (genes/evolution), socio-cultural (roles/expectation), and psychological factors (stress/trauma) combine and interact to product psychological disorders


Types of anxiety disorders

Situational Anxiety: stressful environment or situation; can be motivational (take action)
Generalized Anxiety: Excessive anxiety lasting > 6 months; interferes with daily activities
Panic disorder: immediate feeling is apprehension, fearfulness, terror, impending doom
Phobias: fear associated with specific objects or situations

OCD and PTSD are related disorders


Treatment of Anxiety Disorders

Combination of
Psychotherapy (cognitive behavior therapy, biofeedback, counseling, etc) and Pharmacotherapy (anxiolytics) - when anxiety interferes with every day.
Antidepressant (SSRI)
CNS Depressants (sedatives/hypnotics)
-Misc. Meds


Use of Antidepressants

-Overlapping features between depressive disorders and anxiety disorders
-May have initial worsening of anxiety, agitation and irritability when treatment is started
-Can take 4-6 weeks for full effect
-Adverse effects noticed with initiation of therapy or does changes typically resolve within days to week s


CNS Depressants

-Used as adjunct to antidepressants
-Helpful for acute attacks, short term use
-Can lead to physical and psychological dependence (withdrawal symptoms when stopped abruptly) - benzo, barbs, misc. meds



Indications- anxiety, insomnia, seizures, muscle relaxation, sedation, induction of anesthesia, alcohol withdrawal
Intended for short term use
-Useful in acute anxiety situation or as a bride until SSRI takes effect
Drugs in this class are similar in effect, but differ in their onset and duration of action
Intensify effect of GABA (inhibitory neurotransmitter)
Avoid use with other CNS depressants
Schedule IV
Reversal agent - flumazenil (Romazicon)
EXAMPLES: Lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), alprazolam (Xanax), midazolam (Versed)
**increased risk of falling in elderly**



Indications: anxiety, insomnia, seizures
Replaced mostly by benzodiazepines due to safety profile
Serious adverse effects - respiratory depression, hypotension, shock
Intensify action of GABA
Schedule II
Withdrawal symptoms can be severe, even fatal
EXAMPLES: phenobarbital (Luminol), pentobarbital (Nembutal)


Misc. Drugs for Anxiety

Valproate Acid (Depakene): indications include panic disorder, bipolar disorder, seizures, migraine prevention
Atenolol (Tenormin): Indications include performance anxiety, social anxiety, HTN, MI, angina
Buspirone (BuSpar): indications include generalized anxiety disorder, OCD, depression



A disturbance of electrical activity in the brain that may alter consciousness, motor activity or sensation
-Caused by abnormal neuronal discharges
-May remain focal or move to other areas of the brain
-Symptom of an underlying disorder
Status Epilepticus: seizure lasts too long or seizure recurs without recovery in between (life threatening)


Causes of Seizures

Drug abuse/withdrawal (ETOH and sedatives)
Hypoxia/altered perfusion
Severe HTN in preg (eclampsia)
Strobe/flickering lights
Electrolyte imbalances
High fever in children


Electroencephalogram (EEG)

Electronic monitoring that measures and records electrical activity in the brain


Pharmacotherapy for Seizures

-Depends on type of seizure and associated pathology
-Started on one medication; dose is increased until seizure is controlled or adverse effect limit the dose
-If a second drug is needed, the first drug is tapered off while the second drug is increased
-Abrupt withdrawal of a medication may precipitate seizures
-Serum drug levels are often monitored
-Other conditions may be treated with anti-seizure medications: various psychiatric diagnoses, migraines, neuropathic pain, ADHD, PTSD (calms the nerves)


Pregnancy and Epilepsy

Several anti-seizures drugs decrease effectiveness of oral contraceptives
Most anti-seizure drugs are associated with high fetal risk in pregnancy (category D)
May require high doses of folic a acid due to deficiency caused by medication
Encourage registration with anti-epileptic drug pregnancy registry


Valproate Syndrome

Prenatal exposure to vampiric acid during the first trimester
Distinctive facial features
Neural tube defects
Congenital heart disease
Cleft lip and/or palate


Pharm for Seizures

Goal is to suppress neuronal activity just enough to prevent abnormal firing
-influx of sodium or calcium increases neuronal activity
-influx of chlorine suppresses neuronal activity
MOA ( 1+ of the following): delay influx of sodium ions, calcium ions stimulate influx of chlorine ions (assoc. with increasing action of GABA) - GABA is an inhibitory neurotransmitter
CLASSES: Barbs, Benzos, Hydantoins, Succinimides, etc


Phenobarbital (Luminal)

Thera: anti-seizure drug, sedative
Pharm: barbiturate, GABA-a receptor drug
Indications: seizure, sedation
MOA: enhances action of GABA, suppressing abnormal neuronal discharges
Adverse: drowsiness, respiratory depression, vitamin deficiencies (D, folate, B9, B12), N/V
Implications: sched IV drug, preg category D. Avoid use with other CND depressants. Overdose: CNS depression, coma, death


Diazepam (Valium)

Thera: anti-seizure, sedative, anxiolytics, skeletal muscle relaxant
Pharm: benzodiazepine, GABA receptor drug
Indications: seizure, sedation, anxiety, muscle spa Sam, alcohol/benzo withdrawal
MOA: enhances action of GABA, suppressing abnormal neuronal discharges
Adverse: hypotension, muscle weakness, drowsiness, respiratory depression, adverse effects are more pronounced when given IV
Implications: Schedule IV, preg cat D, may take 1-2 weeks to reach max conc when taken orally. Quick onset and lasts ~20 minutes when given IV. Avoid use with other CNS depressants. For short term use. Can be given rectally


Phenytoin (Dilantin)

Thera: anti-seizure drug, antidysrhythmic
Pharm: Hydantoin
Indications: Seizures
MOA: desensitized sodium channels in CNS preventing abnormal neuronal discharges
Adverse: drowsiness, nausea, gingival hypertrophy (extra gums), hirsutism (facial hair), suicidal thoughts, ataxia (lack muscle coordination), hematologist toxicities (RBC, WBC, platelets)
Implications: many drug-drug interaction. NEVER administer IV in same line as another drug or with dextrose solution (normal saline only). Monitor drug levels. Can cause tissue necrosis if there is IV infiltration. IV administration requires a filter. Hold tube feeding for 2 hours before and after administration


Purple Glove Syndrome

-Typically within 2-12 hours after infusion, erythema and blue-purple discoloration occur around the intravenous site and there may. Be petechiae not he fingers and palms.
-12-24 hours after infusion spreading discoloration, edema, skin blistering. Sloughing, and ulceration may occur with possible extension thereafter
-Resolution may take weeks to months, with discoloration receding toward the original intravenous site


When taking antiseizure meds

Never abruptly stop
Avoid alcohol
May cause drowsiness
May require dosage adjustments
Important to keep lab appointments
Consult before becoming pregnant
Report excess fatigue, drowsiness, agitation, confusion or suicidal thoughts