Anxiety

Question 1

Drugs that cause anxiety

Answer 1

Albuterol
caffeine
decongestants
levothyroxine
steroids
stimulants

Question 1

Buspirone

Answer 1

5HT 1a receptor agonist
approved for generalized anxiety disorder
should be dosed with a target of 10-15mg three times daily or 2 times daily
may take 3-4 weeks to see full efficacy

Question 2

Benzodiazepines

Answer 2

These are not recommened as first line due to the potential of missuse with them but evidence shows they are more affective than SSRIs
Long term use is not recommened
Acute withdrawal can lead to life threatening seizures
Warning for the use of benzos in combo with other CNS depressants and overdose death risk

Question 3

what are the benzos without an active metabolite

Answer 3

Alprazolam, lorazepam, clonazepam, and oxazepam
without an active metabolite they are less likely to accumulate while they have a fall ask it is unlikely

Question 4

Benzos with an active metabolite

Answer 4

Diazepam, clorazepate, and chloridiazepoxide

these long acting metabolies may lead to a hangover feeling and fall risk in elderly

Question 5

Side effects of benzos
and considerations

Answer 5

sedation, paradoxical excitement, swallowing difficulties, impairment of memory and recall, and psychomotor impairment
Discontinuation requires a slow taper as abrupt discontinuation can lead to deathly stroke
BEERS criteria: may be inappropriate in the elderly
- when thinking of elderly think of LOT (lorazepam, oxazepam, temazepam)

Question 6

Hydroxyzine

Answer 6

FDA approved for general anxiety disorder
commonly used PRN for anxiety or insomnia instead of benzos
side effects: sedation, anticholinergic side effects are prominent, QTc prolongation risk
AVOID in elderly due to anticholinergic side effects and fall risk

Question 7

Propranolol

Answer 7

Decrease physiological symptoms of acute anxiety (tachycardia, sweating, flushing)
Used for performance and situational anxiety
low doses 10-20mg TID
Evaluation for history/current asthma and cardiovascular conditions

Question 8

Natural products

Answer 8

kava - not common due to its hepatotoxicity
st johns wort - 3A4 inducer so can decrease efficacy in antipsychotics
passionflower - avoid in pregnancy
valerian - avoid in pregnancy
chamomile - if allergic to ragweed or pollen avoid as it can cause allergic reaction

Question 9

Gabepentinoids and quetiapine in anxiety

Answer 9

Really good option if patient is experiencing neuropathic pain and anxiety***
Gabapentinoids can be used for bipolar disorders with anxiety symptoms
evidence shows anxiety and sleep medications does not endorse the use of quetiapine for insomnia

Question 10

General drug therapy principles for anxiety disorders

Answer 10

• SSRIs and SNRIs are first line therapy for all anxiety disorders
• buspirone is also first line for generalized anxiety disorder
• benzodiazepines are FDA approved to treat anxiety disorders but guidelines suggest using them only if necessary
• atypical antipsychotics are not FDA approved for anxiety disorder but clinical evidence suggest efficacy for treatment resistant OCD (aripiprazole and risperidone)

Question 11

General anxiety disorder diagnosis

Answer 11

Excessive anxiety/worry around a number of life events for at least 6 months
Must have 3 of the following symptoms
- restlessness, being easily fatigued, difficulty concentrating or mind going “blank”, irritability, muscle tension, sleep disturbance

Question 12

Treatment of GAD

Answer 12

First line SSRIs antidepressants (takes 2-4 weeks to see full effect)
SNRIs maybe be useful (CAN BE USED FOR PATIENTS with anxiety and also having pain syndrome
Benzos: bridge therapy to cover time until onset of SSRI/SNRI, MUST taper if the patient has been taking long term treatment to avoid withdrawal

Question 13

Social anxiety disorder

Answer 13

Persistent fear about social and or performance situations in which the patient fears embarrassment or humiliation that is unreasonable
Specific situations may be avoided in manner that interferes with the patients normal routine
duration of symptoms is at least 6 months

Question 14

Treatment of social anxiety

Answer 14

SSRIs are first line
SNRIs if SSRIs fail
Propranolol can be used as needed to help non generalized performance SAD (sweating, heart rate, flushing)

Question 15

Panic disorder diagnosis

Answer 15

Abrupt surge of intense fear or discomfort
at least 4 physical and psychological symptoms including sweating, palpitations, nausea, dizziness, fear of losing control, going crazy, or dying

At least one attack has been followed by one month or more of at least one of the following (persistent concern about additional attacks of their consequences)

Question 16

Treatment of panic disorders

Answer 16

SSRIs are first line treatment
SNRIs- venlafaxine is FDA approved
Benzodiazepines should not be considered first line maintenance therapy unless there is inadequate response to serotonergic drugs

Question 17

Obsessive compulsive disorder diagnosis

Answer 17

Obsessions: recurrent thoughts or images that are intrusive and cause anxiety; patient attempts to ignore, suppress or neutralize with other thoughts or actions

Compulsions:Repetitive behavior or mental action performed in a response to obsession; aimed at reducing or preventing distress; not always connected in a realistic way to the fear

Question 18

treatment of OCD

Answer 18

SSRIs are first line and you can expect a 25-50% reduction in symptoms

Clomipramine is considered second line treatment

Antipsychotics can be used as adjunct with SSRIs/SNRIs (risperidone and aripiprazple)

Question 19

Post traumatic stress disorder diagnosis

Answer 19

Exposure to real or threatened death serious injury or sexual violence
flashbacks

flashbacks, reexperiencing, avoidance, hypervigilance

negative alterations in mood or cognition

Question 20

Treatment of PTSD

Answer 20

SSRIs/SNRIs are first line treatment, only class of drugs FDA approved for PTSD

Prazosin may be helpful for sleep of nightmares

Polytherapy is common in PTSD

Substance use is common in PTSD

bezodiazepines are not recommended in PTSD

Cognititve behavioral therapy and eye movement desensitization and reprocessing

Question 21

Selected drug therapy issues in anxiety disorders

Answer 21

Jitteriness syndrome can result from the use of the SSRIs and SNRIs when treating anxiety disorders because of this the initial dose should be lower than doses used for depression to minimize this jitteriness EXAM Q

Onset of action for SSRIs/SNRIs is 2 to 4 weeks

Evaluate the severity of impact on functionality by the anxiety disorder before considering using bridge therapy with beznodiazepines

Abrupt d/c of benzodiazepines can be life threatening

Question 22

Non-pharmacologic treatment of anxiety disorders

Answer 22

Psychotherapy and cognitive behavioral therapy

In PTSD - drug therapy may be more effective in civilian trauma (usually one time event) versus combat trauma so non-drug treatment are especially useful