Anxiety Flashcards
What are the major symptoms exhibited in a patient suffering from Generalised Anxiety Disorder (GAD) as defined in the DSM-5?
excessive anxiety and worry associated with >3 of the following symptoms for more days than not for the past 6 months and cause significant functional impairment:
- restlessness of feeling keyed up or on edge
- being easily fatigue
- difficulty concentrating or mind going blank
- irritability
- muscle tension
- sleep disturbance (insomnia, restless unsatisfying sleep)
What are the major symptoms exhibited in a patient suffering from Panic disorder (PD) as defined in the DSM-5?
recurrent unexpected panic attacks and (a) persistent anticipatory anxiety of having additional panic attacks (b) worry about implications of the panic attack (c) significant change in behavior related to the panic attacks
What are the major symptoms exhibited in a patient suffering from OCD as defined in the DSM-5?
either obsessions or compulsions
- recurrent and persistent thoughts that are experienced, at some time during the disturbance, as intrusive and inappropriate and causing marked anxiety/distress
- repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession
What are the major symptoms exhibited in a patient suffering from PTSD as defined in the DSM-5?
Person was exposed to and persistently re-experienced the traumatic event. Trauma related alterations in arousal and reactivity that began or worsened after the traumatic event.
What are the non-pharmacology therapies approved for the treatment of anxiety?
Cognitive behavioral therapy (CBT) used in combination with medications
Relaxation techniques
What are the pharmacological therapies approved for the treatment of GAD?
SSRIs
Venlafaxine XR
Pregabalin
What kind of antidepressants are useful for anxiety disorders?
Any antidepressant that promotes serotonin transmission can be helpful for anxiety disorders
What are anxiety disorders?
Severe, excessive, persistent anxiety and irrational fears that impairs functioning with everyday living
How long do anxiety disorders persist for?
typically more than 6 months
Which anxiety disorder is benzodiazepines not useful in?
PTSD - we want patients to be actively involved and processing their emotions instead of being slow and sleepy
What is GAD?
Excessive anxiety and worry, occuring more days than not for more than 6 months, about a number of events or activities
What are the possible pharmacotherapy for panic disorder?
SSRIs
What are the possible pharmacotherapy for social anxiety disorder?
SSRIs
What is the treatment for OCD?
SSRIs
Clomipramine (TCA with very prominant serotonin reuptake inhibition properties)
+ CBT
Exposure & response prevention
What is the treatment for PTSD?
SSRIs CBT (important 1st line tx)
Which antidepressants can be useful for long-term management of anxiety disorders, OCD, PTSD?
SSRIs
SNRIs
clomipramine
(Except OCD: 1st line SSRI > clomipramine > venlafaxine)
Why should starting dose be low when dosing for anxiety?
Start low go slow due to transient jitteriness in the initial 1-2 weeks of starting antidepressant
What should be done to prevent transient jitteriness during the initial few weeks of starting antidepressant?
Start antidepressant with low dose and consider benzodiazepine as adjunct
Does anxiety or depression have higher maintenance doses?
Anxiety
Maintenance dose may be at high end of the range (but still start low go slow)
When is the onset and full response of serotonergic antidepressants for anxiety?
Onset: 1-2 months (due to downregulation of autoreceptors)
Full response: generally 3 months
How long is the duration of treatment for anxiety?
At least 1-2 yrs, typically long term
What medications can be given as adjunctive for anxiety?
Benzodiazepines
Pregabalin
What are adjunctive benzodiazepines useful for? Which agents are preferred in anxiety disorders?
For physical symptoms of anxiety (eg muscle tension) - fast onset of action - can be within 30 minutes
High potency agents usually preferred in anxiety disorders - clonazepam, lorazepam, alprazolam XR
How long should a patient be started on benzodiazepine adjunctive therapy?
Aim for short term (3-4 months) of treatment, PRN dosing, then taper
What PD properties does benzodiazepines have that make it useful as adjunctive therapy?
Anxiolytic, hypnotic, muscle relaxation, anticonvulsant, amnesic properties
Is tolerance to anxiolytic actions for benzodiazepines common?
No, tolerance to anxiolytic action is less common
How can you prevent rebound anxiety with benzodiazepine treatment?
Gradual taper
What other adjunctive medication besides benzodiazepine can be considered for GAD and what is its mechanism of action?
Pregabalin - inhibit release of excitatory neurotransmitters
Which SSRIs are suitable for anxiety?
Escilatopram, fluoxetine, fluvoxamine, paroxetine, sertraline
Which SNRIs are suitable for anxietY?
Venlafaxine XR
Duloxetine
Which TCA is suitable for anxiety?
Clomipramine
Which benzodiazepines are suitable for anxiety?
Alprazolam
Clonazepam
Diazepam
Lorazepam
Which antihistamine and betablocker is suitable for anxiety?
Hydroxyzine and propanolol (for tachycardia and hand tremors)
Which benzodiazepines used in anxiety have short half lives?
Alprazolam, lorazepam
Which benzodiazepines used in anxiety ahve long half lives?
Clonazepam, diazepam
Which benzodiazepine is not metabolised by CYP3A4?
Lorazepam (glucuronidation)
Which benzodiazepines have active metabolites?
Clonazepam, diazepam (lorazepam and alprazolam no active metabolites)
Effect of alcohol and CNS depressants?
Increases CNS depressant side effects of benzodiazepines and antidepressants - do not mix
Types of DDIs in anxiety
Alcohol + CNS depressants increase CNS depressant side effects
Anticholinergic agents cause excessive anticholinergic effects
MAOIs and SSRIs/TCAs combinations - serotonin syndrome
Benzodiazepines drug drug interactions?
CNS depressants effects with alcohol and other CNS depressants
Benzodiazepines + opioids = increased mortality due to CNS deprssion
Do benzodiazepines induce CYP3a4 enzymes?
No, but they are metabolised by CYP3a4 (except lorazepam)
What is the long term goal of treatment for GAD, Panic disorder, SAD and PTSD?
Remission of core anxiety symptoms, recovery of function
What is the long term goal of treatment of OCD?
Complete resolution of symptoms is often difficult to achieve - relapse rates very high with poor medication adherence
Objective assessment of anxiety outcomes
Psychiatric rating scales
Identify target symptoms for each type of anxiety disorders
Keep detailed diary to record fear levels, physical symptoms, cognitions and anxious behaviors
Non-pharmacological management in anxiety
Recommended in combination to medication treatment ESP in OCD
For which anxiety disorder is combination of non-pharmacological and pharmacological treatment highly recommended for?
OCD
CBT + (either SSRI or clomipramine) highly recommended because pharmacotherapy alone is very difficult to achieve complete remission
Recommendation duration of medication treatment for anxiety disorders
At least 1 year for all anxiety disorders
At least 1-2 year for OCD
Antidepressants that promote __ transmissions have efficacy for anxiety disorders
5-HT
What symptoms are antidepressants useful for in anxiety?
“worrying/apprehension” type of symptoms
How to dose for antidepressants?
Initiate at low dose and gradually titrate up to maximum dose to reduce initial jitteriness
Why is gradual tapering during discontinuation important?
To avoid discontinuation symptoms
Lower dose by 10-25% every 1-2 weeks
Are benzodiazepines recommended as monotherapy for anxiety disorders? What type of symptoms are they useful for?
No - limited duration of treatment preferred
Effective for “physical/somatic” aspects of symptoms - muscle tension, trembling
Which drugs are associated with rebound anxiety during discontinuation?
Benzodiazepine - gradual taper
Is onset of benzodiazepines fast or slow?
Quick onset of action
What are early adverse effects to pharmacotherapy?
Increased anxiety with antidepressants during first 1-2 weeks
Nausea, headache, insomnia/sedation usually subsides after 2-3 weeks of continued treatment
What are long-term adverse effects to pharmacotherapy?
Sexual dysfunction and weight gain are common with antidepressants
Jane is a 60 year-old female newly diagnosed with major depressive disorder. She has osteoarthritis, chronic musculoskeletal pain and asthma.
Which of the following is the most appropriate antidepressant for her?
(A)Amitriptyline
(B)Bupropion
(C)Clomipramine
(D)Duloxetine
(E)Escitalopram
Duloxetine
- also for chronic musculoskeletal pain
Minimum taken for at least 6 months
Emergent insomnia, nausea, flu-like symptoms and “electric shock sensations” over extremities.
Patient takes paroxetine 40mg ON for MDD. He stopped it two days ago as he achieved remission after taking it for two months. What is the most likely explanation?
Antidepressant discontinuation syndrome
- Common in drugs with short half-life eg paroxetine and venlafaxine
Symptoms of serotonin syndrome
restlessness, diaphoresis, tremor, shivering, myoclonus, confusion, convulsions, death
Joe is an otherwise healthy 30-year-old male who is distressed from a 3-month history of daily insomnia, fatigue and impaired concentration, anhedonia and loss of appetite. Which of the following is the most appropriate recommendation?
(A)Cognitive Behavioural Therapy
(B)Fluvoxamine 50mg ON
(C)Lorazepam 0.5mg TDS PRN to relax and sleep
(D)No treatment is indicated as patient is not suicidal.
(E)Promote sleep hygiene
CBT and fluvoxamine 50mg ON
INSADCAGES fulfilled over a duration of at least 2 weeks and causing functional impairment - start antidepressant (not mild)
Joanneis a 80-year old female on metoprolol50mg OM, digoxin62.5mcg OM, simvastatin10mg ON, aspirin 100mg OM and enalapril5mg BD. She is currently diagnosed with major depressive disorder. No history of gastritis.
Labs last month: TG 0.6mmol/L, LDL 1.7mmol/L.
Which of the following is the most appropriate antidepressant for her?
(A)Fluvoxamine
(B)Bupropion
(C)Escitalopram
(D)Mirtazapine
(E)Vortioxetine
40
digoxin = for congestive heart failure or atrial fibrillation (cardiac problems)
controlling blood pressure
on antiplatelets, blood thinning. metoprolol is a 2d6 substrate. want to avoid anything that would prevent it from being broken down. simva is 3a4 substrate.
D is the choice, because it avoids the dangerous interactions, and it is cheap (SDL).
fluvoxamine is bad because will increase the levels of simva
buproprion will increase level of metoprolol, also metabolised into amphetamine, which will make bp control worse.
escitalopram is a good choice but the main consideratino is that patient is 50 and using aspriin, afraid of the risk of gi bleeding.
vortioxetine is SSRI, afraid of gi bleeding.
Jess is 30 year-old housewife diagnosed with Generalized Anxiety Disorder and initiated on oral Sertraline 50mg ON and Lorazepam 0.5mg BD PRN (to relieve anxiety) for 2 weeks till the next appointment.
Jess complained of emergent increased jitteriness with Sertraline 50mg ON.
Which of the following is the most appropriate recommendation?
(A)Discontinue Sertraline
(B)Reduce Sertraline to 25mg ON
(C)Increase Sertraline to 100mg ON
(D)Increase Lorazepam to 0.5mg TDS PRN
(E)No changes to current medication
B
For D, might take lorazepam instead of AD and also need to plan for taper off
For E, patient might stop taking medications themselves
we do not expect sertraline to work very fast, so its fine to push down the dose and wait for response and at the same time reduce the excitatory side effect.
Jess is 30 year-old housewife diagnosed with Generalized Anxiety Disorder and initiated on oral Sertraline 50mg ON and Lorazepam 0.5mg BD PRN (to relieve anxiety) for 2 weeks till the next appointment.
Subsequently, Jess complained of emergent sexual dysfunction whilst on her medications.
Which of the following antidepressants is the most appropriate for her?
(A)Amoxapine (TCA)
(B)Bupropion
(C)Escitalopram
(D)Duloxetine
(E)Mirtazapine
E
we do not use it because we want AD with serotonergic properties to treat anxiety, and bupropion does not have any serotonergic properties. only inhibits reuptake of NE and dopamine. so not suitable for this case.
Juliette is a 40 year-old female on Hydromorphone 32mg OM for her chronic lower back pain, and currently requesting a hypnotic for her frequent insomnia.
Which of the following is the most appropriate recommendation?
(A)Zolpidem CR 12.5mg HS PRN
(B)Lorazepam 0.5mg HS PRN
(C)Duloxetine 60mg ON
(D)Sleep hygiene
(E)Melatonin PR 2mg HS PRN
D
We want to avoid giving opioid together with benzodiazepine → profound cardiopulmonary depression
Patient cannot sleep at night could be due to the pain; opioid is sedating, we should focus on optimising pain control rather than giving a sleeping pill
Should choose D.
James is an underweight 21-year-old male diagnosed with Major Depressive Disorder, along with bothersome insomnia and poor appetite.
Which of the following is the most appropriate antidepressant for him?
(A)Amitriptyline
(B)Bupropion
(C)Mirtazapine
(D)Moclobemide
(E)Trazodone
C
21 years old. counselling point for <24 years old.
BBB: emphasise for watching out for any emergent thoughts of suicidality.
Jacky is a 50-year-old diagnosed with severe Major Depressive Disorder and distressed by psychomotor agitation and anxiety. His medical history is significant for uncontrolled hypertension .
Which of the following is the most appropriate treatment for him?
(A) Amitriptyline
(B) Bupropion
(C) Venlafaxine
(D) Sertraline
(E) Moclobemide
D
A increase NE, which can affect BP. TCAs are also not the first line due to toxicity.
B can increase NE, stimulant which will make BP worse
C is known to worsen uncontrolled htn.
E increases dopamine, NE and serotonin,
Joseph is a 60-year-old male who has been compliant with Venlafaxine extended-release 375mg ON. He developed acute confusion, diaphoresis, hypertension, hyperreflexia and tremors after taking his fourth dose of Tramadol 100mg QDS PRN (pain), a new medication he acquired today. Identify this emergent condition. (A)Akathisia (B)Neuroleptic Malignant Syndrome (C)Cholinergic rebound (D)Panic attack (E)Serotonin Syndrome
E
Venlafaxine is at max dose; tramadol is an opioid with serotonergic property. SER + SER = SER syndrome.
if change the qn to antipsychotic instead of venlafaxine, and instead of hyperreflexia he put muscle rigidity, we r expected to know it is something more sinister and is neuroleptic malignant syndrome
