Anxiety Flashcards
What brain circuit regulates the fear response?
Amygdala-Centered Circuit
What brain circuit regulates the worry response?
Cortico-Striato-Thalamo-Cortical Circuit
If the amygdala senses a fear response is needed, where does it mobilize signals towards?
Prefrontal Cortex
Which brain structure initiates “fight or flight” or “freeze” motor responses?
Periaqueductal Gray
The Amygdala targets the ________ nucleus to increase RR during fear responses.
parabrachial
What are some of the long term repercussions of poorly managed anxiety?
-Increased atherosclerosis
-Increased cardiac ischemia
-Increased BP
Which neurotransmitter (unique to the worry response) influences experienced symptoms?
Dopamine… Others are the same across both fear & worry response pathways (ie. Serotonin, NE, GABA, Glutamate, Voltage-Gated Ca2+ Channels).
T or F: Gabapentin & Pregabalin work on the GABA pathway.
FALSE… Act upon voltage-gated Ca2+ channels.
What types of Voltage-Sensitive Calcium Channels (VSCCs) do Gabapentin & Pregabalin act upon? What subunits do they bind to?
N, P, Q
A2 Delta
What Serotonin receptor does Buspirone agonize?
5-HT1A
What is the only condition in which Buspirone shows effectiveness in?
Generalized Anxiety Disorder
T or F: SNRI initiation can actually worsen the fear / worry response of patients who struggle with anxiety.
True… LTU we see downregulation of B1 receptors & improved response, but initial NE activity increases can worsen anxiety.
Prazosin manages hyperarousal / nightmarish symptoms by blocking what receptor?
Alpha 1
Which class of medications should be avoided in the treatment of PTSD?
Benzos
In what situations should Bupropion use be avoided?
-Seizure Hx
-Head Trauma
-Eating Disorders
-Electrolyte Disturbances
Is Bupropion more sedating or activating?
Activating
Is Buspirone’s OOA fast or slow?
Slow (can take up to 2wks or even longer to see a response)
When should Buspirone use be avoided in the treatment of anxiety-related conditions?
Comorbid Depression
In comparison to other SSRIs, does Duloxetine cause more or less insomnia & agitation?
More
When should Duloxetine use be avoided?
-Liver Dx
-Heavy EtOH use
Mirtazapine & Hydroxyzine are useful in treating anxious patients with comorbid ______.
insomnia
Is Paroxetine more or less sedating compared to other SSRIs?
More
Paroxetine has been demonstrated to cause what prenatal defect?
Cardiac Septal Defects
What other unique side effect (compared to other SSRIs) does Paroxetine demonstrate?
Greater Wt Gain
For anxious patients with concerns about sexual dysfunction, what AD agents can be used?
Desvenlafaxine
Bupropion
Mirtazapine
Vortioxetine
Does Generalized Anxiety Disorder (GAD) affect men or women more?
Women (2:1)… However, very likely that stats are underreported.
Provide some examples of medications that can bring upon symptoms of anxiety.
Bupropion
Prednisone
Ecstasy
Marijuana
Ma Huang
Ginseng
Ephedra
Pseudoephedrine
Phenylephrine
Levothyroxine
What are the more common symptoms associated with GAD?
Racing Thoughts
Dizzy / Disoriented
Excessive Sweating
Trembling / Shaking
Irritable
Sleep Disturbances
What screening tool can we use in the pharmacy for those whom we suspect have GAD?
GAD-7
A score of >/= ____ on the GAD-7 indicates that a patient may have GAD & requires further evaluation by a psychiatrist.
10
What are good non-pharmacological interventions that can be used in treating somebody with GAD?
-Reduce substance use (ie. Caffeine, Alc, Nic)
-Routine Exercise
-CBT / Psychotherapy
What are the first line treatment options for GAD?
SSRIs: Escitalopram, Sertraline, Paroxetine
SNRIs: Duloxetine, Venlafaxine
VSCC: Pregabalin
What are the 2nd line options for treating GAD?
BZDs: Alprazolam, Lorazepam, Diazepam (short-term)
SNRI: Bupropion
5-HT1A: Buspirone
H1A: Hydroxyzine
What is considered to be an adequate trial for a therapy in treatment of GAD?
8-12wks
What is the MOA of Benzos?
Bind Benzo Receptor on GABAa neuron, increases frequency of Cl- channel opening, hyperpolarized state of neuron = less excitable.
Although no RCTs assessing Clonazepam use in GAD are published, what benefits might it have over other Benzos in practice?
Longer t1/2, so effects are maintained within the entire dosing window & avoid peaks / troughs in concentrations seen with other shorter acting Benzos.
What are the short-acting Benzos? Long-acting?
SA: Alprazolam, Lorazepam
LA: Clonazepam, Diazepam
Side effects of Benzos?
-Dizzy / Drowsy
-Ataxia
-Paradoxical (kids)
-Memory Impairment
-Worsening Depression
What some factors that increase the dependency risk of Benzos?
-LTU & increasing dose
-Hx SUD
-Hx Personality Disorders
Withdrawal Benzo symptoms can occur following discontinuation within as little as ____ week(s).
one week
What Benzos are preferred in those whom are either elderly or have liver dysfunction?
LOT
L - Lorazepam
O - Oxazepam
T - Temazepam
What are the signs of somebody going through Benzo withdrawal?
-Seizures (within 1-2d stop)
-Sweats
-Tremors
-N / V
-Rebound Anxiety
-Tachycardia
-Insomnia / Agitation
-Hallucinations
What percentage of patients experience Benzo withdrawals if their therapy is stopped suddenly within 8wks of starting?
30% (hence why tapering is very important)
Which Benzo is favored in situations where a taper is needed?
Diazepam (decrease 10-20% q1-2wks)
What patient demographics would we caution against using Benzos?
Sleep Apnea / COPD (increased risk of respiratory drive depression)
Opioid Users (same as above)
Old (fall risk)
Pregnancy (multiple risk factors & teratogenic)
Name of Benzo antidote using in the emergency department?
Flumazenil
What are some of the clinical presentations of a ‘panic attack’?
-Abdom / Chest Pains
-Chills
-Dizzy
-Choking Feeling
-Palpitations
-Nauseous
-SOB
-Sweating
-Increase HR
-Trembles / Shakes
What is the likelihood of a patient with Panic Disorder achieving remission?
1/3 (most require LT treatments, but possible someone can go into remission without therapies).
A score of </= ___ on the Panic Disorder Severity Scale (PDSS) indicates a patient may have achieved remission.
3
1st line options for Panic Disorder?
SSRIs: Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline
SNRIs: Duloxetine, Venlafaxine
2nd line options for Panic Disorder?
TCAs: Clomipramine, Imipramine
Augmented Benzos: Alprazolam, Clonazepam
3rd line option for Panic Disorder?
Phenelzine (if no response to anything else)
T or F: Benzos are effective in the treatment of acute panic attacks.
FALSE… OOA of the drugs are often too slow (kick in after the panic attack has passed).
What is a suitable timeframe for tapering maintenance therapies used in Panic Disorder?
4 - 6mths (greatly reduces risk of relapse)
What percentage of patients with Social Anxiety Disorder (SAD) seek treatment, and after what length of time would they consider seeking out treatment?
~50%; 15 - 20yrs of living with symptoms
What are some proposed dysregulated neurotransmitter theories for why people experience SAD?
Dopamine - Reduced D2 receptor binding, lower levels
Serotonin - Hypersensitive 5HT2 receptors
___ - ___ % of patients with SAD have a history of concurrent anxiety, depression, and SUD.
70 - 80%
How does Generalized SAD differ from Non-Generalized SAD?
Generalized: Fear & avoidance of wide range of social situations
Non-Generalized: Fear limited to one or two situations
CBT treatment for those with SAD should be initiated for at least what length of time?
12wks
In addition to CBT / SSRIs / SNRIs, what other pharmacological therapy is considered 1st line in treating SAD?
Pregabalin
What other unique agents can be used for performance-induced SAD situations?
Atenolol, Propranolol (as they can help to reduce tremors, palpitations, blushing)
Are Canadian men or women more commonly affected by PTSD?
Women
What types of traumatic events show the highest rates of PTSD prevalence?
Childhood Trauma / Rapes
What are the strongest predictors of PTSD?
1) Lack of Social Support following exposure to trauma
2) Life Stressors following exposure to trauma
3) Severity of the trauma itself
Describe what happens in various brain regions (ie. PFC, LC, Amygdala) during a PTSD stressor response.
Amygdala - Activate catecholamines, target Periaqueductal Gray to induce “freezing” response.
Locus Coeruleus - Tonic firing increases, which strengthens memory consolidation.
Prefrontal Cortex - Weakened response in presence of high NE levels (leading to less regulation of behavior & emotions).
What is the PTSD triad?
1) Re-experience of the event
2) Avoidance of stimuli that invite memories or experiences of the trauma
3) Increased arousal
1st line PTSD drugs?
SSRIs: Fluoxetine, Paroxetine, Sertraline
SNRI: Venlafaxine
Prazosin (trauma-related nightmares & sleep improvements)
Which drugs would NOT be recommended for treating PTSD?
Benzos (no evidence, worsens severity of PTSD, increased risk of developing PTSD if used shortly after trauma, development of SUD / aggression / depression).
PTSD treatment timelines (OOR, max response, duration)?
OOR: 2-8wks
Max Response: 12wks
Duration: 12-24mths
What are some of the theorized pathologies underlining OCD?
-Serotonin Neurotransmission
-Dopamine Transmission (espec. comorbid tics & Tourette’s)
-Glutamate
What are some known / suspected OCD causes?
PANDAS (Peds Autoimmune Neuropsychiatric Disorder Assoc. with Strep Infections)
Pregnancy
Temperamental
Environmental (abuse, trauma)
In what percentage of OCD patients do suicidal thoughts occur at some point?
50% (attempts in 25%)
Who is more likely to have comorbidities associated with OCD: Males or Females?
Males
In kids, a comorbid triad of OCD, __ ______, and ____ is often seen.
Tic Disorder; ADHD
What other disorders are more often seen in OCD patients?
Body Dysmorphia
Skin Picking
Hair Plucking
What is the 1st line treatment strategy for OCD?
SSRIs: Escitalopram, Fluoxetine, Paroxetine, Sertraline
SNRI: Venlafaxine
CBT (or combo of both)
What is an appropriate length of time to have considered CBT an ‘adequate trial’ in managing OCD? SSRI?
CBT: 13 OW sessions
SSRI: 12wks
What pharmacotherapy is recommended in OCD treatment upon failure of two different SSRIs?
Clomipramine (TCA)
T or F: CBT has a stronger effect on OCD “obsessions” than it does on “compulsions”.
False… Stronger effect on compulsions.
The underlying dopamine effects of what two drugs gives them more of an adjunctive role in treating OCD than other mental health disorders?
Aripiprazole, Risperidone
Timeframes for OCD (OOR, Max Response, Duration)?
OOR: 2-4wks
Max Response: 10-12wks
Duration: 1-2yrs
