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PR - CNS > ANXIETY > Flashcards

ANXIETY Flashcards

1
Q

What are the 3 types of Anxiety?

A
  1. Generalised anxiety disorder
  2. Panic disorder
  3. Social anxiety
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2
Q

WHAT ARE THE PSYCHOLOGICAL SYMPTOMS

A
  • Irritability
  • Restlessness
  • Sense of dread
  • Difficulty concentrating
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3
Q

WHAT ARE THE PHYSICAL SYMPTOMS

A
  • Tiredness
  • Fast/irregular heartbeat
  • Muscle aches and tension
  • Trembling
  • Dry mouth
  • Excessive sweating
  • Feeling sick
  • Pins and needles
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4
Q

How long should symptoms be present for to have GAD (and cause clinically significant distress, impairment in social, occupational or other important areas of functioning)

A

at least 6 months

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5
Q

What are the symptoms of GAD?

A

Symptoms for at least 6 months
* Excessive worry about a number of issues
* Preoccupation/seeking reassurance for somatic symptoms or chornic physical health problem
* Over-arousal and irritability
* Insomnia + poor conc

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6
Q

at least 3 of the following symptoms are present most of the time

A

restlessness or nervousness
easily fatigues
poor concentration
irritability
muscle tension
sleep disturbance

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7
Q

First line treatment

A

CBT

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8
Q

it is defined by, and its severity characterised, by one of two main classification systems

A

DSM5TR
ICD11

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9
Q

Pharmacological therapy for GAD

A
  1. SSRI - sertraline
  2. Alternative SSRI/SNRI
  3. Pregabalin
    * Benzos for short term use only in severe anxiety state
    * Do not use antipsychotics
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10
Q

WHAT ARE HYPNOTICS?

A

Most hypnotics will sedate when given during the day

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11
Q

What to do if pt has GAD + comorbid depressive or other anxiety disorder

A

treat primary disorder first i.e. the one that is more severe and in which is it more likely that treatment will improve overall functioning

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12
Q

NICE stepped approach in management of GAD (step 1)

A
  1. Communicate diagnosis, provide into about it,
    - arrange active monitoring of pt symptoms and functioning at intervals based on clinical judgement
    - if other comorbid anxiety or depression then treat the primary disorder
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13
Q

NICE stepped approach in management of GAD
step 2

A
  • If symptoms not improved, offer low-intensity psychological interventions guided by pt pref
  • e.g. individual non-facilitated self help, individual guided self help, psychoeducational groups
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14
Q

drug treatment of GAD (step 3 of NICE stepped approach)

include 1st line options + alternatives

A

1st line SSRI
if sertraline ineffective, offer alternative or SNRI (dulox, venla)
If above not tolerated then consider pregabalin

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15
Q

NICE stepped approach in management of GAD - step 3

A
  • if GAD + marked functional impairment, of GAD that has not improved following step 2 (low intensity psychological intervention)
  • offer individual high intensity psychological intervention e.g. CBT or applied relaxation
  • or can offer drug treatment
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16
Q

If pt is being given SSRI or SNRI for GAD, what should you counsel them on?

A
  • Adverse effects early in treatment with SSRI or SNRI may include increased anxiety, agitation, sleeping problems
  • Will be gradual improvement in symptoms over 1 week or more before they experience full anxiolytic effect
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17
Q

Benefit for drug treatment is usually seen within

A

6 weeks and continues to increase over time

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18
Q

How often to review drug treatment

A
  • review effectiveness and adverse effects every 2-4 weeks during first 3 months
  • every 3 months thereafter
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19
Q

can you use BENZOS for treatment of GAD in primary care

A

Do not offer this except as short term measure during crises

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20
Q

Ideal treatment (step 3) for pregnant woman with GAD

A
  • ideally offer high intensity psychological intervention
  • decision on drug treatment should take into account benefit and harms of treatment in pregnancy incl risk of not treating condition and risks to woman and baby
21
Q

advice about reviewing patients under 30 who are receiving SSRI or SNRI for GAD

A

review within 1 week of first prescribing and monitor risk of suicidal thinking and self harm weekly for the first month

22
Q

How often to review people (over 30) who are recieving SSRI or SNRI

A

after 4-6 weeks of treatment

23
Q

SHORT ACTING HYPNOTICS

A
  • Sleep ONSET insomnia
  • Less sedation, for elderly
  • No hang over effect
  • Loprazolam
  • Lormetazepam
  • temazepam
24
Q

LONG ACTING HYPNOTICS

A
  • For poor sleep MAINTENANCE
  • When anxiolytic effect is needed during the day
  • Nitrazepam
  • Flurazepam
25
Q

Z-DRUGS

A

Zolpidem, zopiclone
- Short duration of action, not for long-term use

26
Q

USE IN THE ELDERLY

A
  • AVOID benzodiazepines and Z-drugs
  • greater risk of becoming ataxic and confused = falls and injury.
27
Q

ANXIOLYTICS

A

Most anxiolytics (‘sedatives’) will induce sleep when given at night

28
Q

BENZODIAZEPINES (Schedule 4 part 1 drugs)

A

Diazepam
Alprazolam
Chlordiazepoxide
Clobazam
Lorazepam
Midazolam

29
Q

LONG ACTING BENZODIAZEPINES

A

Chlordiazepoxide Diazepam Alprazolam

Used as sedatives

30
Q

SHORT ACTING BENZODIAZEPINES

A

Midazolam - Used for epileptic seizures (SE) and febrile convulsions due to its fast onset

31
Q

INTERMEDIATE ACTING BENZODIAZEPINES

A

Clonazepam Lorazepam Oxazepam Temazepam

CLOT (Hence why some of these are used for agitation in our patients: As long-acting ones increase drowsiness)

32
Q

BENZOS MOA

A
  • Act on benzodiazepine receptors which are associated with (GABA) receptors.
  • For short-term relief (2-4 weeks) of anxiety or insomnia that is severe, disabling or causing the patient distress and not for mild anxiety
33
Q

DIAZEPAM

A

For insomnia associated with day-time anxiety - single dose at night

34
Q

MHRA/CHM advice: BENZOS

A
  • Reminder of risk of potentially fatal respiratory depression
  • Patients should be informed of the signs and symptoms of respiratory depression and sedation
35
Q

BENZODIAZEPINES CONTRAINDICATIONS

A
  • Pulmonary insufficiency, respiratory weakness, not used alone for psychosis or depression
  • Obsessional states, phobic states
  • Sleep apnoea syndrome
36
Q

WHAT ARE THE PARADOXICAL EFFECTS OF BENZODIAZEPINES?

A

A paradoxical increase in hostility, aggression, anxiety may be reported.
Adjust dose.

37
Q

SIGNS OF OVERDOSE OF BENZODIAZEPINES

A
  • drowsiness
  • ataxia
  • dysarthria
  • nystagmus
  • respiratory depression
  • coma
38
Q

BENZODIAZEPINES AND DRIVING

A

May cause drowsiness, impair judgement and increase reaction time

39
Q

BENZODIAZEPINE WITHDRAWAL (DEPENDENCE SYMPTOMS)

A
  • Anxiety
  • Sweating
  • Weight loss
  • Tremors
  • Loss of appetite
  • Insomnia
40
Q

WHEN WILL WITHDRAWAL SYMPTOMS DEVELOP?

A
  • Any time up to 3 weeks after stopping long-acting nezodiazepine
  • Within a day in short-acting
41
Q

WITHDRAWAL PROTOCOL FOR LONG TERM BENZOS

A
  1. Convert all meds to a nightly dose of diazepam
  2. Reduce by 1-2 mg (1/10th on larger doses) every 2-4 weeks
    * Only further withdraw if the patient has overcome any withdrawal symptoms
  3. Reduce further (0.5mg near the end)
  4. Stop completely
42
Q

OTHER TREATMENTS

A

Buspirone
Beta-blockers
Barbiturates
Clomethiazole
AntihistamineS

43
Q

BUSPIRONE

A

serotonin 5HT1A receptor agonist
* Response to treatment takes up to 2 weeks
* Low dependence and abuse potential

44
Q

BETA BLOCKERS

A

used for palpitations and tremor

45
Q

BARBITURATES

A

avoided in elderly

46
Q

CLOMETHIAZOLE

A

useful hypnotic for elderly because of its freedom from hangover

47
Q

ANTIHISTAMINES

A

occasional insomnia- may cause headache, psychomotor impairment and anti-muscarinic effects

48
Q

TREATMENT FOR CHRONIC ANXIETY

A

SSRI
o Sertraline
o Citalopram
o Escitalopram
o Fluoxetine
o Propranolol – alleviates physical symptoms only (e.g. tremors, rapid heart rate)

49
Q
A

PR - CNS (61 decks)

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