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Clinical 2 (Part B) > 9 - Anxiety > Flashcards

9 - Anxiety Flashcards

1
Q

Anxiety is a ____ response, it’s part of all of us

A

natural

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2
Q

When is anxiety considered a disorder?

A

Severity or Persistence MAY indicate a disorder

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3
Q

Adequate Tx of anxiety is ___

A

rare

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4
Q

Anxiety is often associated with what other comorbidities ?

A

depression, schizophrenia, bipolar disorder

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5
Q

What types of things do we look at when differentiating situational anxiety vs an anxiety disorder ?

A
  • Type of anxiety disorder
  • Psychiatric and medical disorders
  • Medication history
  • History of anti-anxiety drug response
  • Duration and acuity of symptoms
  • Expectation of patient for recovery
  • Stressors
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6
Q

What medications are associated with anxiety?

A

1) CNS Stimulants: amphetamines, caffeine, cocaine, red bull, methylphenidate, ephedrine, herbals, steroids
2) Withdrawal of CNS depressants: ethanol, anxiolytics, narcotics, sedatives
3) Adverse effects of other meds: anticholinergics, antidepressants, antipsychotics, thyroid supplements, OTC stimulants

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7
Q

Describe the diagnostic criteria for GAD (general anxiety disorder)

A

A) Excessive anxiety and worry occupying more days than not for at least 6 months, about a number of activities

B) Difficulty in controlling the worry

C) Anxiety + worry associated with 3 or more of:

  • restlessness, or on edge
  • easily fatigued
  • difficulty in concentration
  • irritability
  • muscle tension
  • sleep disturbance

D) Anxiety or worry not confined to another psychiatric illness

E) Constant worry causing significant distress and impairment in social and occupational functioning

F) Excessive anxiety and worry not caused by a drug substance, medical disorder, or psychiatric disorder

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8
Q

Onset of primary and secondary GAD

A

primary - early 20’s

secondary - later onset

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9
Q

GAD:

is it sudden or gradual onset?

A

gradual

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10
Q

GAD:

Describe the course of this disorder

A
  • chronic with multiple exacerbations

- rarely stable, waxing/waning

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11
Q

GAD:

Acute goals?

A

reduce the severity and duration of the anxiety symptoms and to improve overall function

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12
Q

GAD:

What is recovery?

A

minimal or no anxiety symptoms, no functional impairment…‘feeling of control’

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13
Q

GAD:

What is first line for acute anxiety?

A

Benzo

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14
Q

GAD:

What is first line for chronic anxiety?

A

antidepressant

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15
Q

GAD:

What antidepressant Tx is effective for GAD, a ___ month continuation is generally advised

A

12

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16
Q

GAD:

Non-pharms ?

A
  • psychoeducation, short-term counselling, stress management, psychotherapy, meditation, exercise
  • avoid caffeine, alcohol, substances
  • hopefully minimize PRN benzo use
  • CBT very effective once realistic (once patient is able to process it in an objective way and if the CBT resource is accessible to the patient)
  • Combo of pharm and non-pharm is the best
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17
Q

Describe what CBT (cognitive behavioural therapy) is

A
  • Our thoughts (not external events) are what determine the way we feel
  • Not the situation, but the perception of the situation that determine feelings
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18
Q

GAD:

Briefly describe the pharmacotherapy

A

Benzos: rapid relief of acute symptoms of anxiety, they are effective, safe, and commonly prescribed

Antidepressants: first line for long-term disorder management

Alternatives: Buspirone, Hydroxyzines, Pregabalin, Antipsychotics (SGAs)

Will discuss Benzos first

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19
Q

Describe the selection of an ideal Benzo

A
  • Quick, effective onset
  • OD dosing is desirable
  • Little cognitive effects
  • Little hangover effects
  • No tolerance
  • No dependence
  • No interaction with CNS depressants
  • No effect on respiratory system

Will also consider:

  • Cost
  • Onset
  • Duration
  • Metabolism
  • Interactions
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20
Q

Are any benzo’s better than others?

A

Most are equally effective as anxiolytics

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21
Q

What type of symptoms are benzo’s more effective int treating ?

A

somatic/autonomic symptoms

physical symptoms such as GI, fatigue, insomnia

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22
Q

BZD:

Increased _____ solubility correlates with rapid absorption

A

lipid

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23
Q

BZD:

Describe the accumulation

A
  • consider half-life of parent and metabolite
  • loraz/alpraz: less accumulation with multiple dosing
  • loraz/oxaz: favoured metabolism (glucuronide)
  • shorter half life may cause increased rebound anxiety
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24
Q

BZD:

Describe an adequate therapeutic trial

A

4 weeks of diazepam 40mg daily or its equivalent

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25
Q

BZD:

CPS monographs suggest what duration?

A

2-3 weeks

  • should not exceed 4-6 months in general
  • for recurrent symptoms: intermittent therapy in 3-4 week “pulses”
  • for persistent symptoms: continuous treatment may be required
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26
Q

What are some adverse effects of BZD ?

A

1) CNS depression:
- sedation
- ataxia, incoordination
- anterograde amnesia
- paradoxical excitement, aggressiveness
- confusion

2) Respiratory depression (rarely serious unless taken with opiates)
3) CV depression
4) Tolerance
5) Dependence
6) Crosses placental barrier
7) Excreted into breast milk

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27
Q

Describe the drug interaction between:

BZD and CNS depressants

A

Increase sedation

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28
Q

List the drugs that will increase BZD levels

A
  • CYP 3A4 inhibitors
  • including erythromycin, fluvoxamine, other SSRI’s
  • grapefruit juice
  • amiodarone, protease inhibitors
  • ketoconazole, intraconazole
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29
Q

List the drugs that will decrease BZD levels

A
  • carbamazepine, ritonavir
  • rifampin, rifabutin, st. john’s wort
  • smoking
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30
Q

What are some common symptoms of BZD withdrawal?

A
  • anxiety
  • insomnia
  • restlessness
  • agitation
  • muscle tension
  • irritability
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31
Q

What are some less frequent symptoms of BZD withdrawal?

A
  • nausea
  • malaise
  • blurred vision
  • diaphoresis
  • nightmares
  • depression
  • ataxia
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32
Q

What are some rare symptoms of BZD withdrawal ?

A
  • tinnitus
  • confusion
  • paranoid delusion
  • hallucination
  • seizures (3 days - 1 week post d/c)
  • psychosis
  • delerium
  • myoclonus
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33
Q

When would BZD withdrawal symptoms be increased ?

A

In the incidence of:

  • regularly used for >3-4 months duration
  • “higher” doses were used for long period (>15 mg diazepam)
  • sudden cessation of the med (no tapering)
  • short-acting BZD used (t1/2 < 24 hours)
  • previous history of dependence on drugs or alcohol
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34
Q

When does BZD withdrawal occur?

A

few hours to a few days after d/c

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35
Q

How do you taper BZD for longer-term use ?

A
  • decrease dose by 10-25% every 3-7 days
  • for very high doses - taper over 6 months
  • can switch to a longer half-life agent like Diazepam (if they are failing when trying to withdraw from a short half-life agent)
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36
Q

Describe the patient education of BZD

A
  • What it is used for and what symptoms will be treated … useful for symptom reduction
  • Anticipated duration of treatment
  • Potential adverse effects and how to handle them
  • Drug interactions with CNS depressants
  • Do not decrease, increase or discontinue suddenly without consultation with health care provider !!!
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37
Q

GAD:

_______ are first line for long term treatment

A

antidepressants

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38
Q

GAD:

Antidepressants are more effective than BZD in treating the _____ symptoms

A

psychic symptoms (like apprehension and worry)

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39
Q

GAD:

Onset of response of antidepressants?

A

2-4-6 weeks

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40
Q

GAD:

Duration of antidepressants if responsive ?

A

at least 12 months

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41
Q

GAD:

Which antidepressants do we use for anxiety?

A

SSRIs (paroxetine, sertraline, citalopram)
SNRIs (venlaflaxine, duloxetine)
TCAs (imipramine)

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42
Q

GAD:

Is there a clear fist choice of agent of antidepressant ?

A

Nope

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43
Q

Describe Buspirone

A

5-HT 1A partial agonist

-Binds to pre and post-synaptic receptors to serotonergic transmission (increases 5-HT)

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44
Q

What are some advantages of buspirone ?

A
  • No abuse, dependence or withdrawal symptoms
  • No interaction with alcohol
  • Fewer CNS side effects than benzos
  • Fewer GI effects than SSRI
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45
Q

Buspirone:

Start with low dose and ____

A

titrate

46
Q

Buspirone:

_____ symptoms respond better than physical

A

psychological

47
Q

Buspirone:

Onset ?

A

delayed onset (few weeks)

48
Q

Buspirone:

Max effect ?

A

4-6 weeks

49
Q

Buspirone:

Adverse effects ?

A
  • dizziness
  • nausea
  • headache
  • drowsiness
  • dysphoria
  • nervousness
50
Q

Buspirone:

What drugs increase the levels of buspirone?

A

verapamil, diltiazem, itraconazole, erythromycin

51
Q

Buspirone:

What drugs does buspirone increase the levels of ?

A
  • cyclosporine

- haloperidon

52
Q

Buspirone:

Combined with MAOi can cause _______

A

hypertension

53
Q

Buspirone:

Less experience than with ____

A

SSRI’s

54
Q

Buspirone:

What is a huge challenge to patient adherence ?

A

delayed onset

55
Q

Underlying mechanisms of ____ and ____ are very similar.

A

OCD and PTSD

56
Q

Describe the obsessions part of OCD

A 
The obsessions are persistent:
-Ideas
-Thoughts
-Images
-Impulses
Experienced as:
-Distressing
-Intrusive
-Senseless
-Marked anxiety
-Inappropriate
57
Q

What are some common themes of OCD ?

A
  • Contamination
  • Aggression
  • Religious
  • Safety/harm
  • Need for exactness or symmetry
  • Somatic (body) fears
58
Q

Describe the compulsions part of OCD

A
  • repetitive, intentional behaviour or mental progressions
  • in response to an obsession and/or according to rigid rules
  • excessive
  • may not realistically be connected with obsession
  • behaviors or mental acts aimed at preventing some dread event or situation
59
Q

What are some common examples of OCD ?

A
  • checing
  • cleaning/washing
  • counting
  • repeating
  • ordering/arranging
  • hoarding/collecting
60
Q

Describe the diagnostic criteria of OCD

A
  • Presence of either obsession +/- compulsions
  • Most have both
  • Causes marked distress/anxiety
  • Time consuming > 1 hour/day
  • Impairment in functioning
61
Q

OCD:

Onset

A
  • Bimodal peaks (onset) around age 10 and age 21, but almost 50% begin after age 20
  • Gradual onset
  • Chronic waxing and waning course
62
Q

OCD:

Treatment goals ?

A
  • Reduce frequency, severity and distress
  • Improve QOL
  • Decrease time spent in compulsive behavior
  • Minimize obsessive thought
  • Restore functioning
  • Minimize adverse effects
  • Enhance adherence
  • Education regarding disease and treatment
63
Q

Treatment of OCD:

______ is critical for anti-obsessional effects

A

serotonin

64
Q

Treatment of OCD:

What are some options?

A
  • Clomipramine (more serotonin specific of the TCA’s)
  • SSRI’s
  • CBT
  • CBT + meds
65
Q

Response of treatment of OCD:

What is more responsive, the obsessions or the compulsions?

A

obsessions more responsive than compulsions

66
Q

OCD:

When is the onset of response to treatment?

A

3-4 weeks

*likely 12 weeks to see full clinical impact

67
Q

OCD:

Both ___ and ___ implicated in the pathogenesis

A

5-HT and DA

68
Q

OCD:

Potent ____ have solid efficacy data

A

SRI’s

69
Q

OCD:

When would antipyschotics maybe have a role in augmentation ?

A

if partial response to SRI, Tics, or concurrent Tourette’s

70
Q

OCD:

What is the treatment target ?

A

At least 4-6 weeks at maximum tolerated dose and 8-12 weeks in total

71
Q

OCD:

Important to ____ dose, if tolerated.

A

push/maximize

*Goal of maximum dose by week 4-8

72
Q

OCD:

If first SSRi isn’t working, then ?

A

switch to another SSRI

73
Q

OCD:

After 2 SSRI’s, consider switch to _____

A

clomipramine

74
Q

OCD:

What can we augment SSRI with ?

A
  • CBT
  • Clomipramine (watch for increased levels of clomipramine)
  • 2nd gen antipsychotic
75
Q

OCD:

Duration of treatment?

A

If responsive:

-1-2 years, then gradually taper, may choose to remain on medication for longer

76
Q

OCD:

How do we taper?

A

decrease dose by 10-25% every 2 months + observe for changes in function

77
Q

OCD:

Clomipramine is a ____

A

TCA

78
Q

OCD:

SE of clomipramine ?

A
  • antihistaminic
  • alpha-adrenergic
  • antimuscarinic
  • serotonin side effects (ex. sexual dysfunction)
  • increased cardiac toxicity if overdose
  • seizure risk at high dose
79
Q

OCD:

What do we need to monitor when on Clomipramine ?

A
  • serum levels

- QT interval esp at higher doses or on other QT impacting meds

80
Q

PTSD:

Incidence in general public has been largely _____

A

neglected

81
Q

PTSD:

When can it occur?

A
  • after horrific life event such as assault or vehicle accident (may or may not occur)
  • may lie very deep until it is “reawakened” by an experience or trigger
82
Q

PTSD:

Is associated with a high incidence of ?

A
  • alcohol and substance abuse/dependence

- suicide

83
Q

PTSD:

Describe how the neurotransmitters are affected.

A
  • Central Noradrenergic Hyperactivity Response: Overactive alarm centre may lead to prolonged and excessive NE release (will increase HR)
  • HPA (hypothalamary pituitary adrenal axis) dysregulation
  • Neurotransmitter imbalance may impact 1 or more of: NE, glutamate, dopamine, GABA, serotonin
84
Q

PTSD:

No role for _____ immediately following event to reduce “downstream” symptoms

A

propranolol

85
Q

PTSD:

Describe the treatment

A
  • Initially, focus on presenting symptoms with pharmacologic and non-pharm approaches
  • Psychotherapy including CBT and psychoeducation
  • PsychoTx + Hypnotics (caution with benzos)
  • Antidepressants = SSRIs, SNRIs, TCA, Mirtazapine

**really like to avoid Benzos bc they can precipitate PTSD symptoms

86
Q

PTSD:

What is the treatment target?

A

decreasing hyperarousal, re-experience, avoidance/numbing

87
Q

PTSD:

How long should we do a trial of antidepressants?

A

12 week trial

88
Q

PTSD:

How long should we continue for maintenance ?

A

12 months

89
Q

Panic Disorder:

-Benzo use should be _____

A

scheduled (not PRN)

90
Q

Panic Disorder:

Is St. John’s wort affective for anxiety?

A

No way, only useful for mild-moderate depression

91
Q

Panic Disorder:

Describe it

A

-Usually a relapsing, remitting disorder, index attacks from “out of the blue”
-Agoraphobia (you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed) in 70% of patients
-20% have chronic course
-Only 60-80% achieve full remission with SSRI and BZD treatment
-

92
Q

Panic Disorder:

What can be major functional impacts and are targets for long-term management?

A

Worry and behavioural change

93
Q

Panic Disorder:

What medical conditions are associated with panic disorder ?

A
  • Hypo or hyper-thyroidism
  • Temporal lobe epilepsy
  • Asthma
  • Cardiac arrhythmias
  • Pheochromocytoma
  • Excessive intake of caffeine or other stimulants
  • Withdrawl from CNS depressants (ex. alcohol)
  • Treatment with high dose corticosteroids
94
Q

Panic Disorder:

What are some panic attack symptoms?

A

Abrupt development of at least 4 symptoms:

  • Intense fear
  • Palpitations, pounding heart, accelerated HR
  • Sweating
  • Trembling or shaking
  • Sense of SOB
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, lightheaded or faint
  • Derealization
  • Paresthesias
  • Chills or hot flashes
95
Q

Panic Disorder:

Describe the criteria for a panic disorder

A

1) Recurrent unexpected panic attacks

2) At least 1 attack followed by > 1 month of:
- Persistent concern for more attacks
- Worry about the implications
- Significant change in behaviour

3) May or may not meet criteria for agoraphobia
- Anxiety in places in which escape is difficult
- Situations are avoided

4) Not due to another medical disorder, mental disorder or substance abuse

96
Q

Peak and duration of a panic attack

A 
Peak = 10 mins
Duration = 20-30 mins
97
Q

Panic Disorder:

Goals of treatment ?

A
  • decrease frequency of panic attacks
  • decrease level of anticipatory anxiety
  • decrease level of phobic avoidance
  • decrease physical symptoms with attacks
98
Q

Panic Disorder:

People should avoid substances that may precipitate panic attacks such as ?

A
  • caffeine
  • drugs of abuse
  • non-Rx stimulants
99
Q

Panic Disorder:

___ targets acute relief

A

BZD

100
Q

Panic Disorder:

What antidepressants are first line ?

A

SSRI or venlafaxine (most often started concurrently with BZD)

101
Q

Panic Disorder:

How long should we treat with antidepressant ?

A

12-24 months Tx should follow a favourable response to antidepressant Tx

102
Q

Panic Disorder:

Advantages of treatment with BZD?

A
  • Rapid onset: 1-2 weeks, continued improvement over 4-6 weeks
  • No tolerance to anti-panic effect
  • Favorable side effect profile
  • 60-80% response rate
103
Q

Panic Disorder:

Disadvantages of treatment with BZD?

A
  • Sedation
  • Dependence, abuse
  • Withdrawal symptoms
  • Rapid re-emergence of panic after abrupt discontinuation
104
Q

Panic Disorder:

_____ dose in comparison to Tx of GAD

A

increase

105
Q

Panic Disorder:

Which antidepressants are first choice Tx for panic disorder?

A

SSRI’s (ex. sertraline, paroxetine)

106
Q

Panic Disorder:

Advantages of SSRI’s

A
  • No abuse, no dependence
  • Antidepressant activity
  • Alter underlying mechanisms, not just Sx control
107
Q

Panic Disorder:

Disadvantages of SSRI’s

A
  • Delayed onset: 3-5 weeks, up to 8-12 weeks
  • Mild hyper stimulation as initial adverse effect (anxiety, insomnia, jitteriness, irritability)
  • Sleep disturbances
  • Sexual disturbances
108
Q

Panic Disorder:

What other antidepressants can be used?

A
  • TCAs (imipramine, desipramine, nortriptyline, clomipramine)
  • Venlafaxine
  • MAOi (phenelzine)
109
Q

Panic Disorder:

Treatment duration?

A

12-24 months then taper over 4-6 months

110
Q

Panic Disorder:

Describe the combo Tx of bento and antidepressant

A
  • Rapid onset often needed
  • Greater adherence with combination
  • Ideal is supervised tapering of BZD after response but it may be CHALLENGING to take benzos away

Clinical 2 (Part B) (30 decks)

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