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Diploma: Mental Health > Anxiety > Flashcards

Anxiety Flashcards

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1
Q

Define generalised anxiety disorder.

A

Excessive worry about every day issues that is disproportionate to any inherent risk
- chronic condition that may fluctuate in severity, with low rates of remission over the short- and medium-term

At least three of the following symptoms are present most of the time:
- Restlessness or nervousness
- Being easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance

Symptoms are present for at least 6 months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Most common in people aged 35-55

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2
Q

What are risk factors for GAD?

A
  • Female sex.
  • Comorbid anxiety disorders.
  • Family history of anxiety disorders.
  • Childhood adversity.
  • History of sexual or emotional trauma.
  • Sociodemographic factors
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3
Q

After how many weeks is anxiety classed as chronic?

A

4 weeks

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4
Q

If the anxiety symptoms are mild, a period of active monitoring should initially be undertaken. True or False?

A

True

If symptoms have not resolved following a period of active monitoring, offer non-pharmacological intervention

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5
Q

What is non-drug treatment for anxiety?

A

1st line: Low-intensity psychological
interventions such as education and self-help

2nd line: High-intensity psychological intervention such as CBT for 3-4 months (OR pharmacological therapy)

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6
Q

Management pathway for anxiety

A

1st line: Education and self-help

2nd line: CBT for 3-4 months OR drug treatment (equal effectiveness)
- Patient preference

3rd line: Specialist referral
- Complex treatment-refractory GAD and very
marked functional impairment, such as self-neglect or a high risk of self-harm

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7
Q

What is the drug treatment pathway for GAD/chronic anxiety?

A

1st line: SSRIs (usually sertraline, escitalopram, paroxetine)
- Sertraline most co-effective but off-label use (escitalopram and paroxetine licensed for GAD)
- No evidence that any one is more effective than the others

2nd line: SNRI (duloxetine, venlafaxine)

3rd line: Pregabalin

Review effectiveness every 2-4 weeks in first 3 months and then every 3 months

If no improvement after 4 weeks
- Ineffective
- Consider offering an alternative drug or high intensity psychological intervention

If partial effectiveness
- consider offering a high-intensity psychological intervention in addition to drug treatment

If effective, continue for at least 1 year
- Optimal efficacy may take up to 3 months

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8
Q

If SSRIs or SNRIs are started in someone under 30, they should be warned of what?

A

They should be warned that SSRIs/SNRIs are associated with an increased risk of suicidal ideation and self-harm in a minority of people under 30

Review them within 1 week of first prescribing and monitor the risk of suicidal ideation and self-harm weekly for the first month

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9
Q

Main side effects of SSRIs?

A
  • Abnormal appetite
  • Arrhythmias (QT prolongation)
  • Impaired concentration
  • Confusion
  • Gastrointestinal discomfort
  • Sleep disorders

Most common in first 2 weeks

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10
Q

What is serotonin syndrome?
What increases the risk?

A

Serotonin syndrome occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors

Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness

It is a serious side effect that can occur with the use of SSRIs and SNRIs
- Risk is higher if patients are taking other medicines that can increase serotonin levels (tramadol, metoclopramide, sumatriptan)

If a patient experiences symptoms of serotonin sydrome, they should contact their GP immediately. If this is unavailable, they should call NHS 111 for advice

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11
Q

How is GAD managed in pregnancy?

A

Offer a high-intensity psychological intervention first-line.

If pharmacological treatment needed be aware that:
- Data on the risk of congenital malformations with SSRIs or SNRIs in early pregnancy are conflicting so the teratogenic potential is unproven
- Treatment with an SSRI or SNRI after around 20 weeks of pregnancy may increase the risk of persistent pulmonary hypertension of the newborn (PPHN) and/or can lead to neonatal withdrawal
- Pregabalin use in pregnancy has not been shown to increase risk of malformations, or miscarriage, or adversely affects fetal growth.

If a woman becomes pregnant while on medication for GAD
- Discuss the option of stopping the medication and gradually switching to a psychological intervention
- In cases where drug treatment is continued in pregnancy, the lowest effective dose should be used

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12
Q

Can antipsychotics be used for treatment of GAD in primary care?

A

No

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13
Q

Can benzodiazepines be used for treatment of GAD in primary care?

A

No

Only for short term management of crisis (severe acute anxiety)

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14
Q

Management of acute anxiety involves the use of what drug classes?

A

Benzodiazepine or buspirone (contraindicated in epilepsy)

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15
Q

What benzodiazepines are used in crisis for GAD?

A

Diazepam

  • Long half life (less dependence)
  • Short term use only (2-4 weeks)
  • Not indicated for mild anxiety
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16
Q

Is diazepam short or long acting?

A

Long acting

Good if insomnia is associated with anxiety

17
Q

Is withdrawal is more common with the short or long acting benzodiazepines?

A

Short acting

18
Q

What kind of effect can happen as a result of taking benzodiazepines?

What is used to treat it?

A

Paradoxical effects

A paradoxical increase in hostility, aggression, talkativeness, excitement, suicidal ideation

Treated with flumazenil (as often caused by overdose)

19
Q

Why are benzodiazepines cautioned in liver impairment?

If they are needed, are short or long acting ones recommended?

A

Can lead to a hepatic coma
- especially long actingg

Short acting benzos preferred in liver impairment
(However, in alcohol withdrawal, a long acting e.g. chlordiazepoxide or diazepam is used via fixed dosed regimen)

20
Q

What are the signs of benzodiazepine withdrawal?

A
  • Insomnia
  • Anxiety
  • Loss of appetite/weight loss
  • Tremor
  • Perspiration
  • Tinnitus
  • Perceptual disturbances

Symptoms may be confused with original symptoms of anxiety/insomnia

Some symptoms may last for weeks/months

21
Q

During benzodiazepine withdrawal, what 3 classes of drugs should be avoided if possible (in the case of additional therapy to help with withdrawal symptoms)?

A

Beta blockers
Antidepressants
Antipsychotics

22
Q

Give examples of long acting benzodiazepines.

A
  • Chlordiazepoxide (adjunct in acute alcohol withdrawal)
  • Diazepam
  • Clobazam (epilepsy)
  • Alprazolam

Used as sedatives

23
Q

Give examples of short acting benzodiazepines (M-CLOT)

A
  • Midazolam (shortest acting - used for status epilepticus and febrile convulsions due to fast onset)
  • Clonazepam
  • Lorazepam
  • Oxazepam
  • Temazepam

M-CLOT

24
Q

What is Buspirone?

A

A serotonin receptor agonist used for anxiety

Low potential for abuse or dependence however takes two weeks to work

Contraindicated in epilepsy

If on CYP3A4 inhib reduce dose to 2.5mg BD

25
Q

How would you reduce someone’s diazepam dose if on SHORT term therapy (2-4 weeks) to prevent withdrawal?

A

Taper off within 2 - 4 weeks

26
Q

How would you withdraw benzodiazepines if on long term therapy to prevent withdrawal?

If on high doses, how is this done?

A

1) Convert benzodiazepine to equivalent Diazepam dose
2) Reduce dose by 1–2 mg (up to 1/10th on larger doses) every 1-2 weeks as tolerated
3) Reduce by 0.5mg near the end

27
Q

What groups of patients are short acting benzodiazepines more suitable for?

A
  • Elderly
  • Liver impairment (however in acute alcoholic withdrawal a longer benzodiazepine is used)

However, higher risk of withdrawal

28
Q

What antihypertensive can be used to treat anxiety symptoms?

A

Propranolol

Reduces palpitations and tachycardia

29
Q

Mechanism of action of benzodiazepines?

A

Act directly on CNS and bind to GABA-A receptors increasing the inhibitory effect of GABA

This reduces the communication between neurons and, therefore, has a calming effect on many of the functions of the brain

30
Q

What is the main side effect of benzodiazepines?

How should patients be counselled?

A

Sedation

Avoid driving if drowsy (COLD FT benzos have legal driving limit)

Avoid:
- Alcohol, CNS depressants or CYP inhibitors

31
Q

Which benzodiazepines have a legal driving limit? (COLD-FT)

A

(COLD-FT)

Clonazepam
Oxazepam
Lorazepam
Diazepam

Flunitrazepam
Temazepam

32
Q

How should people with panic disorders be managed?

A

If present to A+E with chest pain
- Undertake physical tests to rule out cardiac causes
- Suspect panic disorder if tests negative, female or relatively young
- Refer to primary care for subsequent care, even if assessment has been undertaken in A&E
- Give written support materials

Management in primary care
If mild to moderate panic disorder
- Offer low-intensity psychological interventions (individual non-facilitated or facilitated self-help)
- Give information about support groups
- Benefit of exercise

If moderate to severe panic disorder (with or without agoraphobia)
- Consider referral for CBT or an antidepressant if the disorder is long-standing or the person has not
benefitted from or has declined psychological intervention

33
Q

What pharmacological treatment is used in panic disorder?

A

If moderate - severe panic disorder which hasn’t benefited from/declined psychological intervention

  1. Antidepressant (SSRI licensed for panic disorder)
    - Inform them about the delay in onset of effect, the potential for worsening symptoms in first week, time course of treatment, possible discontinuation withdrawal symptoms if not taken as prescribed
    - Should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered.
  2. Alternative antidepressant from a different class if no improvement after 12 weeks
  3. Imipramine or clomipramine
    - If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate
34
Q

Benzodiazepines are associated with a good outcome in the long term and should be prescribed for the treatment of individuals with panic disorder.

True or False?

A

False

Benzodiazepines should not be prescribed in panic disorder

Also avoid antipsychotics and antihistamines

Diploma: Mental Health (5 decks)

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