Anixety

Question 1

Anxiety

Answer 1

Feeling of worry or unease about the future, with psychological and physical symptoms.
Excessive or persistent = sign of an anxiety disorder.

Question 2

Psychological symptoms

Answer 2

Restlessness
Worry
Fear
Difficulty concentrating
Irritability

Question 3

Physical symptoms

Answer 3

Palpitation
Muscle aches + tension
Trembling or shaking
Excessive sweating
Shortness of breath
Insomnia

Question 4

Benzodiazepines

Answer 4

CD 4 Part 1
Split into longer-acting and shorter-acting
Only indicated for the short-term relief (2-4 weeks) of anxiety that is severe or disabling, occurring with or without insomnia.

Question 5

Long-acting BDZ

Answer 5

Diazepam
Clobazam (adjunct in epilepsy)
Chlordiazepoxide (adjunct in acute alcohol withdrawal)
Alprazolam

Question 6

Shorter-acting BDZ

Answer 6

TOLLL
Temazepam
Oxazepam
Lorazepam
Loprazolam
Lormetazepam

Use in elderly + liver impairment
Greater risk of withdrawal symptoms

Question 7

BDZ - Side effects

Answer 7

Drowsiness
Light-headedness (the next day)
Confusion
Ataxia

Question 8

BDZ - overdose

Answer 8

Drowsiness
Ataxia
Dysarthria
Nystagmus
Respiratory depression and coma (rare but can happen if loss of airway reflexes)
Sedation
Coma

Activated charcoal - given within 1 hour of ingesting. patient must be awake and airway protected.

Question 9

BDZ- Paradoxical effects

Answer 9

BDZ cause a paradoxical increase in hostility and aggression e.g. talkativeness, excitement and aggressive antisocial acts

Question 10

BDZ - Elderly

Answer 10

Should be avoided in the elderly.
Lower dose if used
Increased risk of confusion = falls and injury

Question 11

BDZ - Dependence and withdrawal

Answer 11

Used for 4+ weeks = risk of dependence and withdrawal reaction.
Avoid long-term use
Avoid abrupt withdrawal

Question 12

BDZ - Withdrawal syndrome

Answer 12

Occurs within a day of stopping a short-acting BDZ
Occurs within 3 weeks of stopping a long-acting BDZ

Increased:
- Anxiety
- Insomnia
- Weight loss
- Tremors
- Sweating
- Loss of appetite
- Perceptual disorders
- Tinnitus

Question 13

BDZ - Withdrawal management

Answer 13

1. Gradually convert (over 1 week) to equivalent Diazepam dose ON
2. Reduce Diazepam dose by 1-2 mg increments every 2-3 weeks (up to 1/10th every 1-2 weeks for higher doses)
3. Reduce diazepam dose further (can reduce in smaller steps of 500 mcg towards the end)

Question 14

BDZ - Avoid

Answer 14

Respiratory impairment
Neuromuscular disease
Liver failure - may precipitate hepatic encelopathy. If necessary, use lorazepam (elimination is less dependent on the liver)

Question 15

BDZ - Interactions (increased Cp)

Answer 15

Eliminated by CYP enzymes.
Avoid concurrent use with CYP inhibitors (reduced elimination = increased Cp):
- Amiodarone
- Diltiazem
- Macrolides
- Fluconazole
- Protease inhibitors

Question 16

BDZ - Interactions (increase sedation/CNS depressant effects)

Answer 16

Alcohol
Opioids
Antihistamines
Antidepressants
Barbiturates
Antipsychotics
Z drugs

Question 17

GAD - treatment (NICE)

Answer 17

1. Low-intensity psychology interventions (non-facilitated self help, guided self help, psychoeducational groups).
2. SSRI (sertraline)
3. Alternative SSRI (paroxetine, escitalopram) or SNRI (duloxetine, venlafaxine).

Question 18

Beta-blockers

Answer 18

Used for the management of autonomic symptoms e.g. palpitations
- Propranolol
- Oxprenolol

Question 19

Buspirone

Answer 19

5-HT1a agonist
Low potential for abuse and dependence
2 weeks to work

Question 20

Other drugs used to treat anxiety

Answer 20

Antidepressants
Antipsychotics
Antiepileptics