Exam 4

Question 1

What NTs mediate anxiety

Answer 1

Increased NE

Decreased Gaba or seratonin

Question 2

Define GAD clinically

Answer 2

Excessive anxiety and worry for at least 6 months

Need anxiety plus:
Restlessness, fatigue, difficulty concentrating, irritabillity, muscle tension, sleep disturbance

Question 3

What is the treatment goal for GAD

Answer 3

To restore or agonize GABA and 5HT

Question 4

Define a panic attack

Answer 4

Discrete period of intense fear or discomfort with four or more symptoms setting in within 10 minutes:

Palpitatins, sweating, trembling, SOB, choking feeling, chest pain, NV, dizzy, derealization, fear of losing control, fear of dying, paresthesia, chills, hot flashes

Question 5

What drugs can induce panic symptoms

Answer 5

Lactate infusion, yohimbine (alpha 2 antagonist)

Question 6

What NTs may play a role in phobias or social phobia

Answer 6

Decreased seratonin in social phobia

Increased NE and DA in phobia

Question 7

What is the order of drugs used to treat anxiety disorders

Answer 7

SSRI- SNRI- TCA- MOAi

Gaba-ergic: benzos

Question 8

Name the 6 SSRIs

Answer 8

Escitalopram, citalopram, paroxetine, sertraline, fluoxentine,fluvcoamine

Question 9

Name 3 SNRIs

Answer 9

• increase NE and 5HT

Venlafaxine, dysyenlefaxine, duloxetine

Question 10

Name two TCAs

Answer 10

Clomiparinamine, imipramine

Question 11

Name an MAOi

Answer 11

Phenelzine

Question 12

What is the suffix for benzos

Answer 12

Pam

Question 13

What are non typical ways to treat anxiety

Answer 13

Beta blockers for performance anxiety- propanolol

Busprione - non benzo anxiolytic

Question 14

What is first line treatment of GAD

Answer 14

CBT, behavioral techniques, relaxation training, systematic desensatizaiton, exposure response prevention

SSRIs

Question 15

What brain centers drive the fear response and worry response. What NTs are used there

Answer 15

Fear- amygdala (panic and phobia), 5HT from raphe nuclues, NE from locus coerulues, GABA = inhibitory
Worry- cortical- strial- thalamic (anxious, OCD), 5HT, GABA= inhibitory

Question 16

How does GABA work

Answer 16

GABA is inhibit NT, binds to GABA-A receptor and increases the frequency of opening of choloride channel = inhibition

Question 17

What is MOA of SSRIs

Answer 17

SSRIs increase seratonin output by blocking SERT, increase 5HT = down regualtion of auto-receptors= more release 5HT at axon, increase at axon causes post-synaptic receptors to desensatize/downregulate and reduce side effects

Question 18

What is the MOA of SNRIs

Answer 18

Inhibit SERT and NET (directly increase 5HT NE, indirect increase in DA)

Question 19

What are the differences in SSRIs and SNRIs

Answer 19

Excessive NE from SNRIs can increase anxiety

They can be used people with panic disorder though

Question 20

Side effects of SNRI and SSRI include:

Answer 20

Sex dysfunction, GI upset, CNS- insominia or sedation, sweating, bruising easy, hyponatremia
RARE DANGEROUS- seizures, mania, increased Suicide in those less than 24

From NE only: urinary retention, increased BP, SIADH, nervousness, asthenia

Question 21

what is the side effects of too much 5HT. What is 5HT syndrome

Answer 21

-less DA release, emotional flattening, cognitive slowing, apathy

SS- confusion, flushing, diaphoresis, tremor, myoclonic jerks, hyperthermia, hypertonicity, rhabdomyolysis, renal failure, death

Question 22

What is MOA and SE of benzos

Answer 22

When GABA is present benzos increase the frequency of chloride channel opening- positive allosteric modulator

Work by reducing excessive amygadala action by increasing action of GABA

SE: sedation, fatigue, depression, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion, hyper-excitability, nervousness
Rare- hallucinations, manina, hypotension, hyper-salivation, dry mouth, hepatic or renal dysfunction, blood dysacrias
Withdrawl- grand mal seizures
Dangerous- respiratory depression

Question 23

What benzos are liver safe

Answer 23

LOT

Lorazopam, oxazepam, tomazapam

Question 24

What is MOA and SE of buspirone

Answer 24

seratonin 1 partial agonist at presynatpic autoreceptors and post-synaptic receptors, on set of action is delayed (downstream effects)

Tx GAD and anxiety

SE: Dizziness, headache, nervousness, sedation, excitement, nausea, restlessness, cardiac symptoms

Question 25

What is the MOA and SE of TCAs, name them

Answer 25

Block NE and 5HT reuptake, antagonist at 5HT - disinhibit DA and NE release Doxepin, chlordiazepoxide, amytrypline, clomipramine SE limit use: anti-histamine action- sedation and weight garin Anti-cholinergic- dry mouth, blurred vision, urinary retention, constipation Alpha1 antagonist- orthostatic hypotension and dizziness Interfere with insulin release DANGEROUS: block Na channels in heart and brain- overdose= seizures coma, cardiac arrythmias, cardiac arrest and death

Question 26

What is hydroxyzine MOA, use, and SE

Answer 26

Hydroxyzine- antagonist at H1 receptor, treat anxiety, shows skeletal muscle relaxation, bronchodilator activity, analgesic, and anti-emetic effects SE- anti-muscarinic (blurred vision, constipation, memory problems, dry mouth)

Question 27

What is MOA of MAOi and SE

Answer 27

MOA= inhibit the breakdown of 5HT DA and NE Treat- 2nd line, panic disorder, social anxiety, PTSD, OCD SE= dizziness, sedation, headache, sleep problems, fatigue, weakness, tremor, movement problems, blurred vision, increased sweating -constipation, dr moutch, nausea, change in appetite, weight gain, sex dysfunction, ortho hypothensiion, and syncope DANGEROUS: HTN crisis, mania, suicidiality, seizures, hepatotoxicity So avoid high tyramine foods

Question 28

Treatment for social anxiety

Answer 28

BB are second line

Question 29

Tx for OCD

Answer 29

SSRI first line Clomiparamine- TCA second line Lithium buspirone, antipyschotics as add on Deep brain stimulation

Question 30

Tx for PTSD

Answer 30

SSRI and SNRI - first line Benzos are not used or used with caution Pre-emptive treatment with BBs

Question 31

What TCA at low doses can be used for sedation

Answer 31

Doxepin- at low doses it is selective for histamine receptors and is used as hypnotic

Question 32

What is the dx criteria for PTSD

Answer 32

Exposure to actual or threatened death, serious injury, or sex violence in one or more way: directly experiencing event, witnessing event, learning of event to close friend or family, repeated exposure to events Presence of one or more INTRUSIVE SYMPTOMS associated with the traumatic event beginning after the event occurred: recurrent distressing memories of the event, dreams of event, dissociative reactions (flashbacks) which they believe the event is recurring, pyschological distress and reactions at cues of the event or trauma Persistant AVOIDANCE of stimuli associated with event: memores or reminders of the event Negative alterations in cognitions and mood associated with the trauma as two or more: inability to remember all of event, persistent negaitive beliefs about self or others, persistent cognitions about the cause or consequences of the trauma that lead the individual to blame self or others, persistent negative emotional states (fear, horror, anger, guilt, shame), markedly diminished interest or participation in activities, feelings of detachment of estrangement from others, persistent inability to experience positive emotions Marked alterations in arousal and reactivity associated with the trauma, as evidence by 2 or more: irritable outburts, reckless behavior, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbances MUST BE GREATER THAN 1 months and clinically significant impairment Can be with or without dissociative symptoms Delayed onset after 6 months

Question 33

What are co-morbid conditions of PTSD

Answer 33

SUD, interpersonal problems, sleep disturbance, somatization and chronic pain, suicidality, self destructive or impulsive behavior, anger and hostility, ID problems, TBI, anxiety disorders and phobias 20-40% have SUD, 40-60% of SUD have PTSD or three times more prevalent, makes treatment and sx worse

Question 34

What are risk factors for PTSD

Answer 34

PRE TRAUMA Ongoing life stress, lack of social support, young age at time of trauma, SUB or pysch disorder, Hx of traumatic events Female, Low SES, low education and IQ, FHx of pysch disorders POST TRAUMA Life stress, lack of support, bereavement of traumatic grief, major loss of resources, negative social support, poor coping skills

Question 35

What are the tx for PTSD

Answer 35

1) pyschotherapy- CBT or trauma focused therapy (prolonged exposure, congitive processing therapy, eye movement desensitization and reprocessing) 1) SSRIs - sertraline, fluoxetine, paroxetine SNRI- venlafaxine 2)antidepressants- mirtazepine, tricyclics- imipramine, amitripyline, MAOis - phenelzine Alppha 1 anatonists- prazosin for sleep or arousal symptoms 3) Risperidone- global symptoms, mood stabalizers Benzos are not recommended but sometimes used

Question 36

What is acute distress disorder

Answer 36

Very similar to PTSD but lasts 3 days to 1 month

Question 37

What is adjustment disorder

Answer 37

Development of emtional or behavioral symptoms in response to stressors within 3 months, less severe stressor than PTSD Symptoms: marked distress out of proportion to stressor, significant impairment in social or occupational functioning Symptoms not longer than 6 months Need to describe mood: depressed, anxious, mixed, disturbed conduct, mixed emotions and disturbed conduct

Question 38

What are the MAOis and the MOA

Answer 38

Phenelzine, tranycypormine, isocarboxazid, selegilline (NON SELECTIVE MAO-A and B)

Question 39

What are uses and contraindications to MAOi

Answer 39

Mood disorders- unipolar or bipolar depression, ATYPICAL DEPRESSION, OCD PTSD Neuro disorders- PD, fibromyalgia, chronic fatigue syndrome Contraindication: epilepsy, cardiac disease, DM, pheochromocytoma

Question 40

What are the names of the two Seratonin modulators and stimulators

Answer 40

Voritoxetine- SSRI + agonist at 5HT1A and 1B | Vilazodone- SSRI + partial agonist 5HT1A