Module 1.2.2 (Management of Anxiety)

Question 1

Why do anxiety disorders require ongoing treatment?

Answer 1

Axiety disorders are usually relapsing and chronic

Question 2

What are the THREE steps to general principles of management of anxiety disorders?

Answer 2

Step 1: Confirm diagnosis

• History assessment
• Physical examination to exclude underlying medical cause
• Identify features to define specific anxiety disorder (&/or co-existing psychiatric disorders)
• Assess degree of distress

Step 2: Identify and address factors that may exccerbate the disorder

• Psychological factors
• Lifestyle factors

Step 3: Initiate therapy –> if reuquired

• Psychoeducation
• Psychological treatments
• Pharmacological management

Question 3

What TWO types of exacerbating agents to avoid? Provide examples

Answer 3

1. Psychological factors

• Financial difficulties
• Relationship difficulties

2. Lifestyle factors

• Alcohol, nicotine and illicit drug use
• Excessive caffeine intake
• Excessive work
• Inadequate sleep

Question 4

What is psychoeducation about? What treatment options does it lead into?

Answer 4

• The nature of the anxiety
• It’s purpose
• How it can present

leads into relaxation techniques, yoga, exercise, CBT

Question 5

Psychological interventions are the most appropriate initial treatment choice in most cases. What do psychological interventions include?

Answer 5

• Cognitive behavioural therapy (CBT)
• Exposure therapy
• & many others

Many treatments are available as self-help therapies on-line and are referred to as e-therapy

Question 6

For Cognitive Behavioural Therapy (CBT) –> most effective therapy for anxiety 1st line intervention

​A) What is the focus on?

B) Based on what 2 key principles

C) How many sessions are there

D) What interferes with the effectiveness

Answer 6

A)

Focus is on changing maladaptive thinking patterns and behaviour

B)

1. Cognitions may control feelings and behaviour
2. Behaviours may affect thought patterns and emotions

C)

• Acute treatment 12 – 20 weekly sessions

> Individual, group therapy or selfdirected formats

> Follow-up booster sessions after 3 or 6 months useful

D)

• Benzodiazepine

Question 7

What is exposure therapy? What anxiety coniditons is it useful for?

Answer 7

Based on the principle of respondent conditioning

• Can be useful for PTSD, OCD and specific phobias

> Also, social phobia and panic disorder

> Sometimes used together with CBT

• 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” and challenge them in a controlled way

> can be done using virtual reality

Question 8

What is E-therapy for?

Answer 8

Generally CBT-based treatment approach

> Can be as effective as face-to-face therapies

• Mood gym
• Mindsport courses
• E-couch programmes

Question 9

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?

Answer 9

A)

• SSRIs (for all anxiety disorders) + SNRIs for some disorders

B)

• Benzodiazepines

C)

• TCAs
• MAOIs
• Buspirone
• Anticonvulsants
• Anttipsychotics
• Beta-blockers

Question 10

For the follwowing anxiety disorders;

A) What drugs are used for GAD

B) What drugs are used for SAD

C) What drugs are used for panic disorder

D) What drugs are used for specific phobias

E) what drugs are used for OCD

F) What drugs are used for PTSD

Answer 10

A)

1. An SSRI or duloxetine or venlafaxine
2. imipramine or buspirone

B)

1. An SSRI or venlafaxine

C)
1. An SSRI or venlafaxine

2. clomipramine or imipramine

D)

No ongoing pharmacotherapy recommended

E)

1. An SSRI
2. clomipramine

F)

1. An SSRI
2. mirtazepine or amitriptyline

Question 11

What is the MOA of SSRIs? What are the examples of them (CEFFPS)

Answer 11

Selectively inhibit the pre-synaptic reuptake of serotonin (5-hydroxytrytamine, 5HT)

• Citalopram
• Escitalopram
• Fluoxetine
• Fluvoxamine
• Paroxetine
• Sertraline

Question 12

What SSRIs and SNRIs are recommended for:

A) General Anxiety Disorder (GAD)

B) Social Anxiety Disorder (SAD)

C) Panic disorder

D) OCD

E) PTSD

Answer 12

A)

• Escitalopram, paroxetine, venlafaxine, duloxetine,

B)

• Escitalopram, paroxetine, sertraline, venlafaxine

C)

• Citalopram*, fluoxetine*, fluvoxamine*, paroxetine, sertraline, venlafaxine

D)

• Citalopram*, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

E)

• Fluoxetine*, paroxetine

* Not approved by TGA for indication listed in AMH

Question 13

All SSRI have similar efficacy, not every SSRI has TGA approval for each anxiety disorder, thus a favourable tolerability profile should be chosen. What qualities does the below SSRIs have?

A) Citalopram, escitalopram and sertraline

B) Paroxetine

C) Fluoxetine

D) Citalopram, fluoxetine and escitalopram

Answer 13

A)

least potential for drug interactions by inhibition of CYP enzymes

B)

shortest half-life and no active metabolite. Highest potential for withdrawal symptoms

C)

Active metabolite and has a long half-life (up to 16 days). Adverse effects and interactions may persist after treatment is stopped. Low incidence of withdrawal symptoms

D)

May increase the QT interval

All SSRIs have similar adverse effects and are relatively safe in overdose

Question 14

How to dose SSRIs in patients who have anxiety? What is seen when starting SSRIS? What is the onset of action?

Answer 14

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)

Question 15

Why avoid high maintanence doses for anxiety patients on SSRIs?

Answer 15

Activating effects may exacerbate anxiety.

Question 16

What is the dose of OCD or eating disorders often higher than?

Answer 16

Often higher than that needed for depression or anxiety disoders

Question 17

What are some common AE for SSRIs? Include some precautions of the adverse effects that can be seen in patients with anxiety.

Answer 17

Common AE:

• Nausea, diarrhoea, agitation, insomnia, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety, sexual dysfunction, rhinitis, myalgia, rash

Precuations

• Most patients with anxiety are highly sensitive to the physiological effects of SSRIs
• Patients with anxiety disorders may experience suicidal ideation and risks with medication should be assessed

Question 18

What are some considerations with SSRIs?

Answer 18

• 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
• Risk of hyponatraemia

Question 19

What are examples of Serotonin and Noradrenaline Re-uptake Inhibitors (SNRIs)? What are they used for? What are the specific precautions for this drug? Long or short half life?

Answer 19

• Venlafaxine and duloxetine
• First line treatment options for GAD
• Similar adverse effects to SSRIs
• Cardiac precautions:

May cause palpitations, tachycardia, ↑ BP and orthostatic hypotension. Also associated with stress induced cardiomyopathy

• Short half life → withdrawal effects thus taper slowly (over 4 weeks) when discontinuing

Question 20

How do benzodiazepines (BDZs) work?

Answer 20

Potentiate the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic, sedative, hypnotic, muscle relaxant and antiepileptic effects

Question 21

Which BZDs are used for the following and why:

A) For anxiety

B) For insomnia

C) For controlled drugs

Answer 21

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

Question 22

What are the indications for BZDs? Provide THREEE answers.

Answer 22

• Can provide rapid symptomatic relief
• Reserved for short-term (2 to 4 weeks) use or intermittent use as part of a broader treatment plan
• Occasionally used short term (up to 2 weeks) to manage agitation or insomnia when starting antidepressants

Question 23

Which BZDs result in withdrawal syndrome which is frequently mistaken for ongoing anxiety?

Answer 23

Short acting drugs –> Alprazolam = rapid onset of action and short half life

• When patients have taken for a long time for anxiety try to wean off the drug –> extreme anxiety occurs when withdrawing
• Risk of benzos increase when aging - fall risk

Question 24

What conditions is there evidence of benefit/no benefit in for the use of BDZs?

Answer 24

Benzodiazepines have evidence of benefit in GAD, SAD and panic disorder, but not OCD or PSTD

Question 25

For BDZs use: A) What is used in GAD? Why is it used? How long to use for? B) What is used in SAD? Why is it used? C) What is used in Panic Disorder? D) What is used in specific phobias?

Answer 25

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. B) * A short-acting BDZ can be used just before a performance in instances of specific performance anxiety * However, side effects may inhibit the performance C) * Role of BZDs replaced by antidepressants * Most effective are high-potency BDZs (alprazolam and lorazepam) but these are also the most addictive D) * Diazepam can be used as a single dose prior to a necessary exposure to control anxiety (e.g. claustrophobia and MRI)

Question 26

What are the concerns with BZDs? What to consider if prescribing

Answer 26

Can lead to physical and psychological dependence, tolerance and misuse --\> **drug seeking behaviour, craving, disturbed work and personal functioning** If considering prescribing BZDs: * 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.

Question 27

What are the common AE of BZDs?

Answer 27

Drowsiness, over-sedation, light-headedness, hypersalivation, ataxia, slurred speech, dependence, effects on vision,

Question 28

What are the symptoms of BZD withdrawal syndrome?

Answer 28

Anxiety, insomnia, irritability, myoclonic jerks, palpitations and sensory disturbances, & occasionally seizures

Question 29

How to do dose reduction for BZDs? What are the peak effects at weak 2 of withdrawal?

Answer 29

Dose reduction at a rate of 15% per week is usually tolerated * Titrate dose decrease depending on symptoms n * 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

Question 30

For other drugs used for anxiety, whhen should TCAS be avoided?

Answer 30

**Need to be avoided with any patient at risk of suicide or those with underlying cardiac disease** * clomipramine, imipramine, amitriptyline * risk of anxiety increases when started like SSRIs \> 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

Question 31

For other drugs used for anxiety, MAOIs, explain why they may be used?

Answer 31

(phenelzine = irreversible, moclobemide = reversible) * **Occasionally used by specialists in social phobia following failure of SSRI. Phenelzine also used rarely in PTSD** * Phenelzine → tyramine interactions, less interactions with moclobemide orthostatic HtN common dose limiting factor with both phenel and Moclo.

Question 32

What are common adverse effects of TCAs?

Answer 32

Sedation, dry mouth, blurred vision, mydriasis, decreased lacrimation, constipation, weight gain, orthostatic hypotension, sinus tachycardia, urinary hesitancy or retention, reduced GI motility, anticholinergic delirium (particularly in the elderly and in Parkinson’s disease), impotence, loss of libido, other sexual adverse effects, tremor, dizziness, sweating, agitation, insomnia, anxiety, confusion

Question 33

When may mirtazapine be used for anxiety? Side effects?

Answer 33

Alpha-adrenoreceptor antagonist (antidepressant) **An option in PTSD** * Less nausea vomiting and sexual dysfunction than SSRIs but more weight gain and sedation

Question 34

Which antipsychotics are used for anxiety? Why are they used?

Answer 34

Antipsychotics (risperidone\*, quetiapine\*, olanzapine) Evidence limited and side effects risk high * Most evidence of effect\* in OCD when used in combination with an SSRI n * Olanzapine with SSRI has been used for PTSD and social phobia

Question 35

When may buspirone used for anxiety? MOA and when is it appropriate to use?

Answer 35

* 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** * *Dose: 5mg 3 times daily increase by 5mg every 2 to 3 days up to max 60mg daily (usual dose 15-30mg ddd) --\> put in word document* * May take 2 weeks for optimal benefit * Avoid use with MAOIs = increases BP \> avoid eating graepfruit \> causes drowsiness

Question 36

When is pregabalin used for anxiety? What is the MOA? AE?

Answer 36

Pre-synaptic inhibitor of the release of excitatory neurotransmitters * **Effective for GAD (not licensed in Aust)** * *Dosing: Initial dose 150mg daily and ↑ gradually after 1-2 weeks to 450 to 600mg daily.* * Commonly causes somnolence, nausea, dizziness, dry mouth and also expensive * No rebound anxiety when discontinued but need to withdraw slowly to avoid precipitating a seizure Limited to when there is treatment failure in GAD

Question 37

when are beta blockers used for anxiety? Which patient is not appropriate in?

Answer 37

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 \> *Doses used: propranolol 10 to 40mg, 30-60 minutes before the social event or performance* * Avoid use in patients with asthma, severe peripheral vascular disease and some patients with heart failure * Caution in patients with diabetes

Question 38

What are some examples of natural remedies used in anxiety

Answer 38

Widely used, potential role in anxiety but remarkable paucity of data and evidence * 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

Question 39

Summary for Anxiety

Answer 39

* Use key symptoms to differentiate between types of anxiety disorders and determine effective treatment * Trial non-drug therapy including psychological therapy as first line * 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 * Reserve benzodiazepines for short term use in selected circumstances