Management of anxiety disorder 1.2.1 (Anxiolytics & Hypnotics) Flashcards
(36 cards)
1
Q
What are the general principles of management?
A
Step 1: Confirm diagnosis
- hx assessment
- physical examination to exclude underlying medical cause
- identify features to define specific anxiety disorder (&/or co-existing psychiatric disorders)
Step 2: Identify and address factors that may exacerbate the disorder
- Psychological factors
- Lifestyle factors
Step 3: Initiate therapy
- Psychoeducation
- Psychological treatments
- Pharmacological management
2
Q
Why do anxiety disorders require ongoing management?
A
Anxiety disorders are usually relapsing and chronic and require ongoing treatment
3
Q
How do we avoid exacerbating anxiety disorders?
A
- avoiding exacerbating agents such as…
- financial difficulties
- relationship difficulties
- elcohol, nicotine
- illicit drug use
- excessive caffeine intake
- excessive work
- inadequate sleep
4
Q
What is the most appropriate psychological intervention for treatment of anxiety?
A
- psychological treatments
- includes CBT, exposure therapy & lots of others
- self help therapies online–> e therapy
5
Q
What is a 1st line intervention for anxiety? What does it do?
A
- CBT
- focuses on changing maladaptive thinking patterns and behaviour
- based on two key principles
- Cognitions may control feelings and behaviour
- Behaviours may affect thought patterns and emotions
- 12-20 weekly sessins
- individual or group therapy or self directed formats
- follow up booster sessions after 3 or 6 months useful
- Benzos can interfere with effectiveness of CBT
6
Q
What is exposure therapy? What anxiety conditions is it useful for?
A
- based on the principle of respondent conditioning
- useful for PTSD, OCD, specific phobias
- when people are fearful of something they often avoid what they fear however in the long term this can make fears worse
- exposure therapy= face fears & challenge them in a controlled way
- can be done using virtual reality
7
Q
What is E-therapy for?
A
- Generally CBT-based treatment approach
- Can be as effective as face-to-face therapies
- Mood gym
- Mindsport courses
- E-couch programmes
8
Q
For pharmacotherapy for anxiety- used when psychological interventions are ineffective or not available
A) What is first line?
B) What is used in exceptional circumstances?
C) What are other drugs used in anxiety?
A
A) SSRIs (for all anxiety disorders) + SNRIs for some disorders
B) Benzodiazepines
C) TCAs, MAOIs, Buspirone, Anticonvulsants, Anttipsychotics, Beta-blockers
9
Q
What drugs are used for GAD, general anxiety disorder?
A
- escitalopram, SSRI
- paroxetine, SSRI
- venlafaxine, SNRI
- duloxetine, SSRI
- imipramine
- busprirone
10
Q
What drugs are used for SAD, social anxiety disorder?
A
- escitalopram, SSRI
- paroxetine, SSRI
- sertraline, SSRI
- venlafaxine, SNRI
11
Q
What drugs are used for panic disorder?
A
- SSRI or venlafaxine
- clomipramine or imipramine
12
Q
What drugs are used for specific phobias?
A
- no ongoing pharmacotherapy recommended
13
Q
What drugs are used for OCD, obsessive compulsive disorder?
A
- Citalopram, SSRI
- escitalopram, SSRI
- fluoxetine, SSRI
- fluvoxamine, SSRI
- paroxetine, SSRI
- sertraline, SSRI
14
Q
What drugs are used for PTSD?
A
- fluoxetine, SSRI
- paroxetine, SSRI
15
Q
What are some common adverse effects for SSRIs?
A
- nausea, diarrhoea
- agitation
- insomnia, drowsiness
- tremor
- dry mouth
- dizziness
- headache
- sweating
- weakness
- anxiety
- sexual dysfunction
- rhinitis,
- myalgia
- rash
16
Q
What are some considerations with SSRIs?
A
- taper over several weeks to avoid withdrawal effects when ceasing
- Drug interactions: Several are potent inhibitors of CYP enzymes
- QT interval prolongation effects
- Risk of serotonin toxicity with other serotonergic drugs
- Effects on platelet aggregation → ↑ risk of bleeding n Risk of hyponatraemia
17
Q
How to dose SSRIs in patients who have anxiety? What is seen when starting SSRIS? What is the onset of action?
A
- Start patients on half the minimum strength tablet available –> continue at that dose for a few days to a week until patient feels confident enough to increase dose
- Increased anxiety when starting SSRIs
- Onset of action is slower for anxiety (4-6 weeks)
18
Q
How do benzodiazepines (BDZs) work?
A
- potentiate the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic, sedative, hypnotic, muscle relaxant and antiepileptic effects
19
Q
Which BZDs are used for the following and why:
A) For anxiety
B) For insomnia
C) For controlled drugs
A
A) Diazepam, lorazepam, oxazepam
- rapid onset of action and long half life –> less withdrawal symptoms
B) Temazepam
- >rapid onset of action but short half life
C) Alprazolam
Flunitrazepam
20
Q
What are the indications for BZDs? Provide THREE answers
A
- Can provide rapid symptomatic relief
- Reserved for short-term (2 to 4 weeks) use or intermittent use as part of a broader treatment plan
- (up to 2 weeks) to manage agitation or insomnia when starting antidepressants
21
Q
What to consider when prescribing BZD?
A
- Always check for a history of problem alcohol or drug use
- Be wary of prescribing to unfamiliar patients, especially if asking for a particular drug by name (may indicate drug-seeking behaviour)
- Carefully discuss the potential for addiction with the patient
- Avoid using short-acting drugs as they are the most highly addictive
- Only prescribe small quantities of medication at a time
- Use only as short-term treatment
- Ensure regular review of the patient and continuity of care.
22
Q
Which BZD used for GAD?
A
- diazepam
- 2mg to 5mg as a single dose repeated up to twice daily
- Short term measure only during a crisis for severe or disabling anxiety
- Up to 2 weeks treatment then reduce dose to zero by 6 weeks
- Long term use only in rare instances where other therapies have failed.
23
Q
Which BZD used for SAD?
A
- A short-acting BDZ can be used just before a performance in instances of specific performance anxiety
- alprazolam
- However, side effects may inhibit the performance
24
Q
What conditions is there evidence of benefit/no benefit in for the use of BDZs?
A
- benzodiazepines have evidence of benefit in GAD, SAD and panic disorder, but not OCD or PSTD
25
What are the common ADV of BZDs?
* drowsiness
* over-sedation
* light-headedness
* hypersalivation
* ataxia
* slurred speech
* dependence
* effects on vision
26
What are the symptoms of BZD withdrawal syndrome?
* Anxiety
* insomnia
* irritability
* myoclonic jerks
* palpitations
* sensory disturbances
* occasionally seizures
27
How to do dose reduction for BZDs? What are the peak effects at weak 2 of withdrawal?
* Dose reduction at a rate of 15% per week is usually tolerated
* Titrate dose decrease depending on symptoms
* Higher dose preparations – stabilise on equivalent dose (ddd) of diazepam before reducing dose (not \> 80mg/day)
* e.g. 5mg of diazepam = 0.5 mg of alaprozalam
* May need to withdraw in inpatient setting
* Peak effects at week 2- anxiety, panic, insomnia, muscle spasms, vomitting, diarrhoea, seizures
28
For other drugs used for anxiety, when should TCAS be avoided?
* need to be avoided with any patient at risk of suicide or those with underlying cardiac disease
* Second line after SSRIs (prolong QT interval and increase arrythmias)
* Cardiotoxicity in overdosage
* Efficacious but more side effects than SSRIs – anticholinergic effects, hypotension and weight gain
* Sedation can sometimes be useful in anxiety disorders
* doses of TCA’s for treating panic are often higher than those for depression
29
MAOIs used for anxiety...
* occasionally used by specialists in social phobia following failure of SSRIs
* phenelzine also used rarely in PTSD
* phenelzine → tyramine interactions, less interactions with moclobemide
30
When may mirtazapine be used for anxiety? Side effects?
* option in PTSD
* less N, V and sexual dysfunction than SSRIs but more weight gain and sedation
31
Which antipsychotics are used for anxiety? Why are they used?
* risperidone, quetiapine, olanzapine- SGA, atypical
* evidence limited and side effect risk is high
* most evidence of effect in OCD when used in combination with an SSRI
* olanzapine with SSRI has been used for PTSD and social phobia
32
When may buspirone used for anxiety? MOA and when is it appropriate to use?
* Partial agonist of serotonin 5HT1A receptors
* Not currently available but may be obtained as an SAS drug
* May be preferable to BDZs for management of GAD in patients with a history of substance misuse – less potential for dependence
* May take 2 weeks for optimal benefit
* Avoid use with MAOIs = increases BP
* avoid eating graepfruit
* causes drowsiness
33
When is pregabalin used for anxiety? What is the MOA? ADV?
* GAD
* pre-synaptic inhibitor of the release of excitatory neurotransmitters
* somnolence, nausea, dizziness, dry mouth
* expensive
* no rebound anxiety when discontinued but need to withdraw slowly to avoid precipitating a seizure
34
When are beta blockers used for anxiety? Which patient is it not appropriate in?
* used for physical symptoms (manifestations of sympathetic overactivity) including tremor, palpitations and sweating which can be distressing and unpleasant
* does not relieve the mental aspects of social phobia
* little evidence to support their use even in SAD
* avoid use in patients with asthma, severe peripheral vascular disease and some patients with heart failure
* caution in patients with diabetes
35
What are some complementary medicines that can be used for anxiety?
Kava Kava may cause liver failure = not recommended
St John’s Wort for depression
Passionflower\* GAD
Inositol\* panic disorder & OCD
Valerian root
Melatonin
Omega-3-fatty acids
5-Adenosyl-L-Methionine
36
When to consider an antidepressant for anxiety disorder?
* consider an antidepressant for those who do not respond to non-drug therapy, selecting on the basis of evidence of efficacy in the diagnosed anxiety disorder
