9 - General Anxiety Disorder Flashcards
1
Q
Assessment of anxiety disorders
A
- Situational vs. anxiety disorder
- Type of anxiety disorder
- Psychiatric & medical disorders
- Medication hx
- Hx of anti-anxiety drug response
- Duration & acuity of sx
- Expectation of pt for recovery
- Stressors
2
Q
Briefly describe the anatomy and NTs involved in anxiety
A
- Brain amygdala appears key in modulating fear & anxiety
- Px w/ anxiety disorders often show heightened amygdala response to anxiety cues
- Major mediators = NE, serotonin, dopamine, & GABA (gamma-aminobutyric acid)
- Autonomic NS is key
3
Q
Medications associated w/ anxiety
A
- CNS stimulants (amphetamines, caffeine, cocaine, methylphenidate, steroids)
- Withdrawal of CNS depressants (ethanol, anxiolytics, narcotics, sedatives)
- Adverse effects of other meds (anticholinergics, antidepressants, antipsychotics, thyroid supplements, OTC stimulants)
4
Q
Describe the anxiety/ gut/ microbiome connection
A
- People w/ anxiety & mood disorders are prone to GI problems
- When GI (stomach) issues get worse, anxiety issues often do as well & vice versa
- When GI issues get better, anxiety is often reduced
- Evidence suggests that we can improve anxiety by improving the nature & diversity of gut flora or microbiome
5
Q
Generalized anxiety disorder (GAD) - onset, goals, recovery vs. remission
A
- Onset sx (primary GAD) in early 20s, later onset for secondary GAD
- Gradual onset
- Course = chronic w/ multiple exacerbations
- Rarely a stable condition
- Stress/ medical health has role in persistence
- Acute goals = reduce severity & duration of anxiety sx & improve overall function
- Recovery = minimal or no anxiety sx, no functional impairment; feeling of “control”
- Remission rates of 70% are achievable
6
Q
Medication choices for GAD
A
- Antidepressant tx may start concurrently or be pending response to BZD
- 2-4 weeks of BZD targets acute relief
- When antidepressant tx is effective for GAD, a 12-month continuation is generally advised
7
Q
GAD goals
A
- Short term = decrease sx (psychic sx – worrying, irritability; somatic sx – GI, fatigue, insomnia); decrease severity, duration, & frequency
- Long term = minimize or prevent sx, improve QOL, prevent adverse effects of meds, educate pt on disorder, tx, & reduction of sx
8
Q
GAD non-pharms
A
- Psychoeducation – short-term counseling, stress management, psychotherapy, CAM
- Meditation, exercise, yoga, acupuncture
- Avoid caffeine, alcohol, substances
- Hopefully minimize prn BZD (prefer scheduled use w/ some prn)
- CBT (cognitive behavioural therapy) very effective once realistic
9
Q
Basic principle of CBT
A
- Helps people separate thoughts, feelings, and situations
- We often react to perceptions of situations
- Thought (what we think affects how we act & feel), behaviour (what we do affects how we think & feel), & emotion (what we feel affects how we think & do)
- Helps clients identify, evaluate, & respond to their dysfunctional thoughts or beliefs
10
Q
GAD pharmacotherapy
A
- BZD – rapid relief of acute sx of anxiety; effective, “safe” & commonly prescribed
- Antidepressants – first-line for long-term disorder management
- Don’t start all people immediately on antidepressants b/c take a long time to work (4 weeks)
- Alternatives = buspirone, hydroxyzine, pregabalin, antipsychotics (SGAs)
11
Q
BZDs for GAD – onset, dosing, duration, SE
A
- Most are equally effective as anxiolytics
- More effective in treating somatic/autonomic sx (need antidepressants or buspirone to treat psychic sx)
- Selection may consider – cost, onset, duration, metabolism, interactions
- Onset – increased lipid solubility correlates w/ rapid absorption, may impact speed of onset, duration of effect, and may lengthen clearance t1/2
- Dosing – initiation is extremely variable and must be individualized; consider weekly dose review early on; adequate therapeutic trial may require 4-week trial of very high dose (ex: 40 mg diazepam)
- Duration – monographs suggest 2-3 weeks; shouldn’t exceed 4-6 months in general; for recurring sx = intermittent therapy in 3-4 week “pulses”
- Adverse effects – sedation, ataxia, confusion, respiratory depression (only a concern in overdose w/ other medications, particularly opioids; not really a problem w/ single BZD overdose), CV depression, tolerance, dependence
12
Q
BZD drug interactions
A
- CNS depressants increase sedation; alcohol increases BZD levels?
- Increased BZD levels – CYP 3A4 inhibitors (erythromycin, fluvoxamine, other SSRIs), grapefruit juice, amiodarone, ketoconazole
- Decreased BZD levels – carbamazepine, rifampin, smoking
13
Q
BZD withdrawal – sx, incidence, prevention
A
- Common sx = anxiety, insomnia, restlessness, irritability (most often the sx that the BZD was originally being used to treat)
- Less frequent = nausea, blurred vision, depression
- Rare = confusion, paranoid delusion, hallucination, seizures (depends on how much they were taking & how abruptly they stop)
- Increased incidence of sx if regularly used for > 3-4 months, “higher” doses used for long period (> 15 mg diazepam equivalent), sudden cessation of med, short-acting BZD used (t1/2 < 20 h), previous hx of dependence on drugs or alcohol
- 2/3 of people will have some sx on withdrawal from sustained ingestion
- Prevention – limit duration & dose of BZD tx when realistic to 2-3 weeks
- For longer-term use – decrease dose 10-25% every 3-7 days; very high doses taper over 6 months
- If difficulty withdrawing, switch to longer half-life agent (ex: diazepam)
14
Q
BZD pt education
A
- What it is used for & what sx will be treated
- Anticipated duration of tx
- Potential adverse effects
- Drug interactions w/ CNS depressants
- Don’t decrease, increase, or d/c suddenly w/o consultation w/ HCP
15
Q
GAD – antidepressants
A
- First line for long term tx
- More effective than BZD in treating psychic sx (apprehension, worry)
- Onset of meaningful anxiety response 2-6 weeks
- Duration if responsive = at least 12 months
- No clear “first choice” of agent; can use SSRIs, SNRIs, or TCAs
16
Q
Buspirone - MOA, advantages, SE
A
- 5-HT 1A partial agonist – binds to pre- & post-synaptic receptors to serotonergic transmission (increase 5-HT)
- Effective agent for chronic, persistent anxiety
- Advantages:
- No abuse, dependence, withdrawal sx
- No interaction w/ alcohol
- Fewer CNS side effects than BZDs
- Fewer GI effects than SSRI
- More helpful w/ psychological sx than physical
- Delayed onset; maximal effect in 4-6 weeks (huge challenge to pt adherence)
- Efficacy maintained at least 1 year
- Adverse effects = dizziness, nausea, headache, nervousness
- Less overall evidence than w/ SSRIs +/- BZD
17
Q
Buspirone drug interactions
A
- Increased buspirone levels (verapamil, diltiazem, erythromycin)
- Increased levels of cyclosporine & haloperidol
18
Q
Panic disorder
A
- Usually a relapsing, remitting disorder
- Index attacks from “out of the blue”
- Only about 60-80% achieve full remission w/ SSRI & BZD tx
- Relapse is common
- Worry & behaviour change can be major functional impacts, & the targets for long-term management
19
Q
Medical conditions associated w/ panic disorder
A
- Hypo/hyperthyroidism
- Asthma
- “Excessive” intake of caffeine or stimulants
- Withdrawal from alcohol or other CNS depressants
20
Q
Panic attack sx
A
- Abrupt development of at least 4 sx
- Intense fear, “sense of doom”
- Palpitations, pounding heart, high HR
- Sweating, trembling, shaking
- Sensation of SOB or smothering
- Feeling of choking
- Chest pain or discomfort
- Feeling dizzy, lightheaded or faint
21
Q
Panic disorder goals of tx
A
- Decrease frequency of panic attacks, level of anticipatory anxiety, level of phobic avoidance, physical sx w/ attacks
- Avoid substances that may precipitate panic attacks (caffeine, drugs of abuse, non-Rx stimulants)
22
Q
Algorithm for panic disorder tx
A
- BZD targets acute relief
- SSRI or venlafaxine 1st line, most often started concurrently w/ BZD
- 12-24 months duration should follow a favourable response to antidepressant tx
23
Q
BZD for panic disorder
A
- Advantages –> rapid onset (1-2 weeks; continued improvement over 4-6 weeks), no tolerance to anti-panic effect, favourable side effect profile
- Disadvantages –> sedation, dependence, abuse, withdrawal sx
- Increased dose in comparison to tx of GAD
24
Q
Antidepressants for panic disorder
A
- SSRIs first choice tx for panic disorder
- Advantages –> no abuse or dependence, antidepressant activity (many people have both anxiety & depression), alter underlying mechanisms not just sx control
- Disadvantages –> delayed onset (3-5 weeks, up to 8-12 weeks), “mild” hyperstimulation (anxiety, insomnia, jitteriness, irritability), sleep disturbance, sexual disturbances
- Tx duration after good response = 12-24 months then taper over 4-6 months
- Combination tx (BZD & antidepressant)
- Rapid onset if needed
- Greater adherence w/ combo
- Ideal if supervised tapering of BZD after response, but may be challenging to take BZD away
25
Q
Obsessive compulsive disorder
A
- Compulsions = repetitive, intentional behaviour or mental progressions in response to an obsession and/or according to rigid rules; may not be realistically connected w/ obsession; behaviours or thinking aimed at preventing some dread event or situation
- Common examples = checking, cleaning/ washing, counting, repeating, hoarding/ collecting
- DSM -V definition = presence of either obsession +/- compulsions (most px have both), time consuming > 1 h/day, impairment in functioning
- Both serotonin & dopamine implicated in pathogenesis
- Antipsychotics may have a role in augmentation, esp. if partial response to SRI, tics, concurrent Tourette’s
26
Q
OCD tx
A
- Identify specific targets (sx)
- Serotonin critical for anti-obsessional effects
- Clomipramine (more serotonin specific than SSRIs), SSRIs, CBT, CBT + meds
- Response – obsessions more responsive than compulsions, sx often reduced by 40-60% w/ a single agent, complete control quite rare …
- *Instead of increasing dose of BZD, we increase dose of antidepressants
27
Q
Caution w/ clomipramine
A
- TCA
- TCA side effect profile (antihistaminic, alpha-adrenergic, antimuscarinic)
- Serotonin side effects
- Very high cardiac toxicity in overdose
- Seizure risk, especially at high dose
- Cautiously decrease dose during maintenance tx
- Monitor serum levels, QT interval (especially at higher doses or w/ other QT-impacting meds)
28
Q
PTSD
A
- May anticipate following a horrific life event (ex: assault, sexual assault, motor vehicle accident)
- High incidence of another mental health disorder (80% meet depression or anxiety criteria)
- May lie very deep until “reawakened” by experience, stressors, or sensory “déjà vu”
- Re-experiencing, hyperarousal, avoidance
- High incidence of EtOH or substance abuse/ dependence
- High suicide attempt rate (~20% if no improvement in sx)
- NT imbalance may impact 1 or more of NE, glutamate, DA, GABA, or serotonin
29
Q
Benefits of prazocin for nightmares
A
- Alpha-1 antagonist, crosses BBB
- Non-sedating
- Reduces nightmares & disturbed arousals
- Benefits on suicidality are uncertain
30
Q
PTSD tx
A
- Initially, focus on presenting sx w/ pharm & non-pharm approaches
- Psychotherapy including CBT, psychoeducation
- Antidepressants – SSRIs, SNRIs, TCAs, mirtazapine
- Target is decrease of hyperarousal, re-experience, avoidance/ numbing
- Antidepressants – 12-week trial/ 12-month maintenance supported by evidence
- Dosing similar to that for depression appears appropriate
31
Q
Describe accumulation of BZDs
A
- Accumulation – consider t1/2 of parent and metabolite
- Lorazepam and alprazolam –> less accumulation w/ multiple dosing
- Lorazepam and oxazepam –> favoured metabolism (glucuronide); preferred for elderly (not diazepam b/c long half-life so will accumulate)
