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3153 IC9,10,11,12,14 Psychiatric > Anxiety > Flashcards

Anxiety Flashcards

1
Q

What are the key symptoms in anxiety disorders?

A
  • Severe, excessive, persistent anxiety and
  • irrational fears
  • that impair functioning of daily living

Anxiety is out of proportion to the actual danger/threat

Persists long after original trigger disappeared, typically >6m

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2
Q

Untreated anxiety can cause…

A
  • Untreated anxiety if an independent high risk factor for suicide
  • Untreated anxiety can increase risks for developing CVD, CBV, GI, and respiratory disorders (e.g., persistent tachycardia can cause ventricular hypertrophy and heart failure)
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3
Q

Anxiety circuits

A

Fear circuit - regulated by amygdala
Worry circuit - regulated by cortico-striatal-thalamic cortical (CSTC loop)

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4
Q

Neurotransmitter implicated in anxiety

A

Serotonin
GABA
Norepinephrine

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5
Q

Medical conditions associated with anxiety

A
  • Cardiovascular (e.g., angina, arrhythmias, CHF, IHD, MI)
  • Endocrine/Metabolic (e.g., Cushing’s disease, hyperthyroidism)
  • Neurologic (e.g., Dementia, delirium, parkinson’s, seizures, stroke, neoplasms, inadequate pain control)
  • Pulmonary (e.g., asthma, COPD, PE, pneumonia)
  • Others: anemias, SLE, vestibular dysfunction

Impt to check troponin, ECG, FBG, thyroid levels etc. to rule out medical conditions

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6
Q

Drug-induced anxiety

(Similar to the drugs that induce mania)

A
  • Sympathomimetics (e.g., pseudoephedrine)
  • Stimulants (e.g., amphetamines, cocaine)
  • Methylxanthines (e.g., caffeine, theophylline)
  • Thyroid hormones (e.g., Levothyroxine)
  • Corticosteroids (e.g., prednisolone - systemic)
  • Antidepressants (e.g., SSRI, TCAs, esp with rapid dose escalation due to sudden increase in neurotransmitters)
  • Dopamine agonists (e.g., Levodopa)
  • Beta-adrenergic agonists (E.g., Salbutamol)

Other drug-related causes:
- Withdrawal (caffeine, alcohol, sedatives, BZDs, antidepressants, nicotine)
- Intoxication (e.g., anticholinergics, antihistamines, digoxin)

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7
Q

What is a panic attack?

A

Discrete period of intense fear/discomfort, with 4 or more of the following symptoms, developed abruptly, reached a peak within 10 min, usually lasts no more than 20-30min

May be expected or unexpected

  • Palpitations, incr PR
  • Sweating
  • Trembling/shaking
  • Sensations of shortness of breath
  • Feeling of choking
  • Chest pain/discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, faint
  • Derealization or depersonalization
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesia (numbness, tingling sensation)
  • Chills or hot flushes
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8
Q

Name the 5 anxiety disorders that are most amendable to drug treatment

A
  • Panic disorder
  • Social anxiety disorder (SAD)
  • Generalized anxiety disorder (GAD)
  • Obsessive compulsive disorder (OCD)
  • Post traumatic stress disorder (PTSD)
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9
Q

Describe Generalized anxiety disorder (GAD)

(CIMSRF)

A

Excessive anxiety and worries 6m or more, over a pervasive spread of things, cause significant functional impairment

3 or more of the following symptoms:

  • Restlessness
  • Being easily fatigue
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (insomnia, restless unsatisfying sleep)
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10
Q

Pharmacotherapy for GAD

A

SSRIs: Escitalopram, Paroxetine
SNRIs: Venlafaxine XR, Duloxetine
Pregabalin

Others: TCA, BB, hydroxyzine, buspirone etc.

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11
Q

Non-pharmacotherapy for GAD

A

Cognitive behavioral therapy
Psychotherapy
Relaxation
Anxiety management

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12
Q

Describe Panic disorder

A

Anticipatory anxiety of recurrent panic attacks:

  1. Recurrent unexpected panic attacks

AND

  1. > =1 of the panic attacks has been followed by >=1m of >=1 of the following:
  • Persistent anticipatory anxiety about having panic attacks
  • Worry about implications of panic attack
  • Significant change in behavior related to panic attacks

May occur with or without agoraphobia

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13
Q

Pharmacotherapy for Panic Disorder

A

SSRIs: Fluoxetine, Paroxetine, Sertraline
SNRI: Venlafaxine
TCAs

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14
Q

Non-pharmacotherapy for Panic Disorder

A

CBT

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15
Q

Describe Social anxiety disorder (SAD)

A

Fear of being scrutinized or humiliated by others in public of >=1 social/performance situations, duration >6 months

The feared situations are avoided or endured with intense anxiety/distress, the avoidance or anxious anticipation or distress in the feared situation significantly impairs functioning

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16
Q

Pharmacotherapy for SAD

A

SSRIs: Fluvoxamine, Paroxetine, Sertraline
SNRI: Venlafaxine

Others: RIMA - Moclobemide or MAOi

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17
Q

Non-pharmacotherapy for Panic Disorder

A

Behavioral therapy

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18
Q

Describe Obsessive compulsive disorder (OCD)

A

Obsessional thoughts/impulses that causes anxiety, followed by compulsive behaviors to relieve that anxiety; person recognizes and is aware that the obsessions/compulsions are excessive and irrational and significantly impairs functioning (e.g., time-consuming >=1h a day)

  1. Obsession: recurrent and persistent thoughts/impulses/images, intrusive and inappropriate, causing marked anxiety/distress (e.g., contamination, dirt)
  2. Compulsion: repetitive behaviors or mental acts performed aimed at preventing/reducing the distress but NOT connected in a realistic way, and clearly excessive (e.g., washing hands)
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19
Q

Pharmacotherapy for OCD

A

SSRIs: Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
Clomipramine - TCA (2nd line for OCD)

20
Q

Non-pharmacotherapy for OCD

A

CBT
Exposure and response prevention (ERP)

21
Q

Describe Post traumatic stress disorder (PTSD)

(SIANA)

A

Re-experiencing of trauma, persistent avoidance, increased arousal

  1. Stressor
  2. Intrusive symptoms - persistent re-experience
  3. Avoidance - of distressing trauma-related stimuli
  4. Negative alterations in cognition and mood
  5. Alterations (increase) in arousal and reactivity

Persistence of symptoms for >1 month, significant functional impairment

22
Q

Pharmacotherapy for PTSD

A

SSRIs: Paroxetine, Sertraline

*DO NOT USE Benzodiazepines

  • numbs the brain, sedating
  • in PTSD, patient is encouraged to actively participate in sharing of traumatic event
23
Q

Non-pharmacological for PTSD

A

CBT (1st line)
Psychotherapy
Counseling

24
Q

Non-pharmacological in anxiety disorders should be used ________

A

Psychotherapy should be used in combination with medications

CBT/Psychotherapy is key (1st line), medications are adjunctive

25
Q

Which drug is used for physical or worrying symptoms in anxiety?

A

Physical symptoms (tremors, tense, palpitation, sweating):

  • Benzodiazepines

Worrying symptoms

  • SSRIs
26
Q

Which drugs used in acute stress disorder

A
  • Benzodiazapines (short-course, PRN)
  • Antihistamines (e.g., hydroxyzine)
27
Q

What scale is used to assess anxiety?

A

Clinician-rated Hamilton Anxiety Scale (HAM-A)

28
Q

Treatment goal for anxiety disorders:

A
  • Remission of anxiety symptoms
  • Functional recovery

Medications have a role for anxiety that is persistently severe and disabling

29
Q

[Antidepressant in anxiety]

Which antidepressants can be used?

A

All serotonergic antidepressants can be useful for long-term management of GAD, PD, SAD, OCD, PTSD

  • SSRIs > SNRIs > Clomipramine
  • In OCD, 1st line SSRI, 2nd line Clomipramine, 3rd line Venlafaxine
30
Q

[Antidepressant in anxiety]

Approach to dosing

A

Low starting dose

  • transient jitteriness in initial 1-2 weeks due to increase in neurotransmitters

Consider BZD as adjunct for acute anxiety symptoms

  • because antidepressants work slowly (gradual downregulation of presynaptic autoreceptors after chronic exposure to effects of the antidepressants)

High maintenance dose

  • E.g., fluoxetine for anxiety start as 10mg/day but can increase to max maintenance dose of 60-80mg/day (VS in depression - 20mg/day)
31
Q

[Antidepressant in anxiety]

Onset, efficacy, and duration of treatment

A

Onset: 1-2 months (recall 4-8 weeks for mood symptoms and anxiety)

  • 6-12 weeks to achieve initial efficacy, max/full response may require 3 months

Efficacy: effective for worrying symptoms, not effective for physical symptoms (tense, tremors, palpitations)

Duration: at least 1-2 years, may be lifelong

32
Q

[Adjuncts]

List the adjuncts used in anxiety disorders

A
  • Benzodiazapine
  • Antihistamine (hydroxyzine)
  • Beta blockers (propranolol)

Pregabalin may be used as well - not adjunct

33
Q

[Adjunctive benzodiazepines in anxiety]

Therapeutic action
Onset

A

BZDs effective for physical symptoms of anxiety (as an anxiolytic)

Fast onset of action, work vv fast to manage acute symptoms

  • E.g., Lorazepam (fast onset within 30min)

They can be used in acute stress disorder or adjustment disorders

34
Q

[Adjunctive benzodiazepines in anxiety]

Duration

A

Short-term 3-4 months of treatment, PRN dosing

*But typically supply only 2-4 weeks for short-term basis

35
Q

[Adjunctive benzodiazepines in anxiety]

Choice of BZD in anxiety disorders

A

High potency agents preferred in anxiety disorders

  • Clonazepam
  • Lorazepam
  • Alprazolam XR (for panic disorder) - short-acting therefore XR formulation, most potent, most abuse and death
36
Q

[Adjunctive benzodiazepines in anxiety]

Short acting vs Long acting BZDs

A

Short-acting (~6h): Lorazepam, Alprazolam

Long-acting (~10h): Diazepam (less preferred as can cause drowsiness throughout the day, affect cognition, cause falls esp in elderly), Clonazepam

FYI: very short acting: Midazolam (~2h)

37
Q

[Adjunctive benzodiazepines in anxiety]

Tolerance

A

Tolerance to anxiolytic action is less common

Tolerance to hypnotic actions more common, develops within days (same dose less effective overtime)

May develop if used continuously for >1-2 weeks

38
Q

[Adjunctive benzodiazepines in anxiety]

Dependence, withdrawal

A
  • Avoid abrupt cessation after weeks of continued use (withdrawal)
  • Gradual taper required

BZD withdrawal symptoms:

  • Incr HR
  • Agitation
  • Rebound Anxiety
  • Tremors
  • Insomnia
  • Seizures
  • Hallucinations
39
Q

[Adjunctive benzodiazepines in anxiety]

Dosing (general principles)

A
  • Lowest effective dose PRN for 1-2 weeks (prevent risk of dependence)
  • Intermittently (once every 2 or 3 nights for insomnia)
40
Q

[Adjunctive benzodiazepines in anxiety]

Cautions

A
  • Paradoxical excitement/disinhibition - i.e., agitation, tachycardia (esp in children elderly, head injury)
  • Dependence and withdrawal symptoms can occur esp in pt with history of drug dependence
41
Q

[Adjunctive benzodiazepines in anxiety]

Doses of the following:

  • Alprazolam
  • Clonazepam
  • Diazepam
  • Lorazepam
A

Alprazolam (anxiety)

  • 0.25mg - 0.5mg BD-TDS, max 4-6mg/day
  • Short duration of action
  • No major active metabolite

Clonazepam (anxiety)

  • 0.5mg BD, max 4mg/day

Diazepam (anxiety, insomnia)

  • 2-10mg BD-QDS

Lorazepam (anxiety, insomnia)

  • 2mg/day (in divided doses), titrate to 2-3mg/day; max dose 6mg/day, do not exceed 10mg/day (elderly/debilitated - 0.5mg/day, max 2mg/day)
  • short duration of action
  • primarily hepatic metabolism: glucuronidation
  • no interaction with cyp enzymes
  • no active metabolites
42
Q

[Adjunctive benzodiazepines in anxiety]

Lorazapam metabolism and CYP interaction

A

Lorazepam metabolized via hepatic glucuronidation, no active metabolites

Not a substrate of CYP enzymes (unlike other BZDs - CYP3A4 substrates)

43
Q

[Adjunctive benzodiazepines in anxiety]

BZD use in panic disorder

A

Do not stop regular dosing, do not stop abruptly, or might go into withdrawal

44
Q

[Other adjunctives - Antihistamines]

  • Hydroxyzine
A

Sedating antihistamine - hydroxyzine (labelled for anxiety and insomnia)

  • Does NOT cause dependence
  • Watch for anticholinergic side effects
  • Careful with doses, typically use 10-25mg; high doses of 100mg cause QTc prolongation (sudden cardiac death)
  • Active metabolite: Cetirizine
45
Q

[Other adjunctives - Beta blockers]

  • Propanolol
A

Propanolol (non-selective BB)

  • Caution in pt with history of asthma (bronchoconstriction)
46
Q

[Other - Pregabalin] - GAD only

Also comment on its risk for dependence

A

Anticonvulsant - Pregabalin

  • Indication: may be used as an anxiolytic in GAD only
  • Onset: 1-2 weeks (doe not work immediately)
  • Pregabalin can increase expression of enzymes that produce GABA (promote GABA transmission)
  • Some potential for dependence
47
Q

General DDIs to look out for:

A
  • Alcohol and other CNS depressants: incr CNS depressant side effects of benzodiazepines and antidepressants
  • Anticholinergic side effects
  • MAOIs, SSRIs, TCAs => watch for serotonin syndrome (mental status change, autonomic instability, neuromuscular changes)

3153 IC9,10,11,12,14 Psychiatric (10 decks)

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