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PHAR 358 > Anxiety > Flashcards

Anxiety Flashcards

1
Q

What is anxiety?

A

A normal emotion under circumstances of threat and is thought to be part of the evolutionary fight or flight reaction of survival

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2
Q

Is anxiety always harmful?

A

No, mild to moderate anxiety can help focus attention, energy, and motivation

But anxiety can become a disorder when it is overwhelming and affecting function & quality of life by causing feelings helplessness, confusion, and extreme worry that are out of proportion with the seriousness or likelihood of the feared event

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3
Q

What are the main features of anxiety disorders?

A

Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances

Fear is the emotional response to real or perceived imminent threat

Anxiety is anticipation of future threat

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4
Q

What are the core symptoms of anxiety?

A

Psychological
- Fear/anxiety, worry, apprehension, difficulty concentration

Somatic
- Increase HR, tremor, sweating, GI upset

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5
Q

What are some examples of anxiety disorders?

A

Generalized Anxiety Disorder (GAD)
Panic Disorder (PD)
Social Anxiety Disorder (SAD)

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6
Q

What is an example of a trauma and stressor-related disorder?

A

PTSD

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7
Q

What is the role of the amygdala on fear?

A

It is located near the hippocampus and it interprets sensory and cognitive information and determines if there will be a fear response

Affect response: feelings of fear
Motor response: Fight or flight

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8
Q

What neurotransmitters affect the function of amygdala?

A
  • 5HT
  • GABA
  • Glutamate
  • Corticotropin-releasing factor
  • NE
  • Voltage-gated ion channels
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9
Q

What is the role of GABA in anxiety?

A

Key neurotransmitter for anxiety and the role of anxiolytics. Benzodiazepines enhance the usage of GABA in the brain

Principal inhibitory neurotransmitter in brain that plays a role in reducing activity of neurons in amygdala (fear) and CSTC (worry)

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10
Q

What is the role of voltage-sensitive calcium channel ligands in anxiety?

A

These are gabapentin and pregablin and they block the release of glutamate when neurotransmission is excessive (amygdala and CSTC loop) to decrease fear and worry

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11
Q

What is the role of serotonin in anxiety?

A

5-HT is a key NT that innervates the amygdala and CSTC (assists with regulating fear and worry)

SSRI/SNRIs block 5-HT reuptake by blocking 5-HT transporter

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12
Q

What is the role of norepinephrine in anxiety?

A

NE is a regulator to amygdala and the PFC/thalamus in CSTC by attaching to alpha and beta receptors

Activation of beta receptors downregulate anxiety

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13
Q

What information should be collected to evaluate anxiety disorders?

A
  • Gather patient history
  • Review of systems
  • Rule out anxiety disorders due to general medical conditions or substance use
  • Suicidal ideation or intent
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14
Q

Review slide 29 for a review of all drugs used to treat anxiety disorders

A
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15
Q

Review slides 30 to 32 for the advantages of all anxiolytics

A
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16
Q

When is the onset of generalized anxiety disorder?

A

Late adolescence or early adulthood

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17
Q

What is the etiology of general anxiety disorder?

A
  • Medications
  • Natural products
  • Medical conditions
  • Medication withdrawal
  • Socioeconomic class
  • Stressful event in susceptible person
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18
Q

What are some common conditions associated with anxiety disorders?

A
  • CV
  • Endocrine and metabolic
    -Neurologic
  • Respiratory
  • Others
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19
Q

What are some important drug classes that are associated with anxiety symptoms?

A
  • Antidepressants (gold standard for treatment, but some patients can see anxiety)
  • Corticosteroids (increase catecholamines)
  • Stimulants
  • Sympathomimetics
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20
Q

What are some comorbidities associated with generalized anxiety disorder?

A

Up to 90% of GAD patients present with comorbid mental disorders during their life (MDD, other anxiety disorders, SUD, bipolar, insomnia)

Can also co-occur with physical health problems (chronic pain, diabetes, CV disease, GI stress)

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21
Q

What are some interview questions to screen for GAD?

A
  • In the past several months how you frequently been worried or anxious about a number of things in your life
  • What have you been worried about?
  • Do people tell you that you worry too much?
  • Do you think you do?
  • do you have difficulty controlling your worry, such that the worry affects functional status
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22
Q

What are the psychological and cognitive symptoms associated with GAD?

A

Excessive anxiety
Worries that are difficult to control
Feeling keyed up or on edge
Poor concentration
Restlessness
Irritability
Sleep disturbances

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23
Q

What are the physical symptoms associated with GAD?

A

Fatigue
Muscle tension
Trembling or shaking
Feeling of fullness in throat/chest
Sweating
Cold, clammy hands

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24
Q

What are some impairments associated with GAD?

A

Social, occupational or other important functional areas

Poor coping skills

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25
Q

What are the elements of the Mental Status Exam?

A

General Observations
- Appearance
- Speech
- Behaviour
- Cooperativeness

Thinking
- Thought process & Form
- Thought Content
- Perceptions

Emotion:
- Mood
- Affect

Cognition:
- Orientation/Attention
- Memory
- Insight/judgement

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26
Q

What is a commonly administered tool to assess GAD?

A

GAD-7 (self-delivered)

Takes 5 minutes to fill out

Available on Health app on IPhone

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27
Q

What are the goals of therapy for GAD?

A

Acute episode
- Decrease severity and duration of anxiety symptoms
- Improve overall function

Long-term goals
- Remission (with minimal symptoms, no functional impairment, and improve patient’s QOL)

Treat co-morbid conditions including SUD

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28
Q

What are the treatment principles for GAD treatment?

A

Psychotherapy+pharmacotherapy

Psychotherapy is the least invasive and safest

Pharm. is indicated if symptoms are severe enough to produce functional disability

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29
Q

What factors affect treatment plans for GAD?

A
  • Severity
  • Chronicity
  • Age
  • Medication history
  • Co-morbid conditions (medical and psychiatric)
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30
Q

What are some non-pharm treatment options for GAD?

A
  • CBT is the most effective, but can be hard to access
  • Reduce alcohol, caffeine, nicotine use
  • Avoid non-prescription stimulants and medications known to induce anxiety
  • Exercise
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31
Q

What are the first-line treatment options for GAD?

A

SSRIs: escitalo, parox, sertra

SNRIs: duloxetine, venlafaxine

Pregablin

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32
Q

What are the second-line treatment options for GAD?

A

Benzodiazepines (short-term use): alprazolam, lorazepam, and diazepam

Bupropion

Buspirone

Hydroxyzine

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33
Q

Review slide 55 for GAD treatment algorithm

A
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34
Q

Review slides 58 and 59 for advantages of different GAD treatment options

A
35
Q

What is the SSRI/SNRI treatment timeline for GAD?

A

Onset of symptom relief: 2-4 weeks

Maximal response: 12 weeks

Treatment Duration: 12-24 months

36
Q

What is the role of benzodiazepines in GAD treatment?

A

Provides effective initial relief of anxiety symptoms, but benefits wear off in most patients after 4-6 weeks of use

Primarily effective for relieving somatic symptoms, but psychic features are not affected

Usually used to bridge to SSRI/SNRI onset of symptomatic relief to kick in

37
Q

Which long-acting benzodiazepines are used in intial treatment of GAD?

A

Clonazepam and Diazepam

38
Q

Which short-acting benzodiazepine is used in intial treatment of GAD?

A

Lorazepam

39
Q

What are some common side effects associated with benzodiazepines?

A
  • Ataxia
  • Dizziness, lightheadedness
  • Sedation and daytime sleepiness
  • Psychomotor impairment
  • Agitationm irritability, confusion
40
Q

What are some less common side effects associated with benzodiazepines?

A
  • Anterograde amnesia
  • Depression, confusion, bizarre behaviour, hallucinations
  • Respiratory depression
41
Q

How does benzodiazepine dependence develop?

A

Psychological and physical dependence may develop with long-term use

Risk of dependence increases with higher doses and duration of treatment

Risk is higher in patients with a history of SUD or personality disorders

Withdrawal symptoms can develop following abrupt d/c of therapy with a little as 1 week of use

42
Q

What are the characteristics of long-acting benzodiazepines in GAD treatment?

A

Good choice for tapering as less risk of withdrawal

More daytime sedation

43
Q

What are the characteristics of short-acting benzodiazepines in GAD treatment?

A

Better hypnotic and sedative properties, but more rebound anxiety

44
Q

What are LOT drugs in the context of GAD treatment?

A

They are lorazepam, oxazepam, temazepam

Preferred in elderly and patients with liver dysfunction due to a lack of toxic metabolites

45
Q

What are the symptoms of benzodiazepine withdrawal?

A

Sweating
Tremor
Nausea
Vomiting
Rebound anxiety
Increased HR
Insomnia
SEIZURES

46
Q

How can benzodiazepine withdrawal be avoided?

A

Avoid by tapering benzodiazepines (reduce diazepam by 10-20% every 1-2 weeks)

Ashton Manual is a great resource to reference when tapering benzodiazepines

47
Q

What is a benzodiazepine antidote?

A

Flumazenil

Reverses hypnotic-sedative effect of benzodiazepine but clinically limited due to seizure risk

48
Q

Review slides 70 to 72 for GAD treatment escalation case

A
49
Q

What is the definition of panic attacks?

A

A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

  1. Papitations
  2. Sweating
  3. Trembling
  4. SOB
  5. Feelings of choking
  6. Chest pain
  7. Nausea
  8. Dizziness
50
Q

What are some risk factors for developing panic disorder?

A

Temperamental
- History of fearful spells
- Behavioural inhibition
- Learned behaviours

Personality Types
- Anxious personality types

Environmental
- Childhood sexual and physical abuse
- Smoking
- Identifiable stressors

Genetic and physiological
- Multiple genes
- Hereditary
- Hypersensitivities

51
Q

What are some comorbidities in patients with panic disorder?

A

Other anxiety disorders

Depression (10-65%)

Bipolar disorder

Alcohol use disorder

Higher rates of suicide attempts

Medical comorbidities

52
Q

What are the psychological manifestations of a panic attack?

A
  • Depersonalization
  • Derealization
  • Fear of losing control
  • Fear of going crazy
  • Fear of dying
53
Q

What are the physical manifestations of a panic attack?

A
  • Abdominal distress
  • Chest pain
  • Chills
  • Dizziness
  • Hot flashes
  • Nausea
  • SOB
  • Tachycardia
54
Q

What is the clinical course of panic disorder?

A

Panic attacks vary in frequency and intensity

Most patients require long-term treatment to acheive remission, prevent relapse, and reduce risks associated with co-morbidities

55
Q

What is an important scale used to assess severity of panic disorders?

A

Panic Disorder Severity Scale (PDSS)

56
Q

What are the treatment principles for panic disorders?

A
  • Initial treatment with medications or psychotherapy (equal efficacy)
  • 1st line pharmacotherapy: SSRIs or venlafaxine, benzos can be used to resolve residual anxiety/

-2nd line pharmacotherapy:
TCAs (similar efficacy to first line options, but less tolerated)

  • 3rd line pharmacotherapy:
    Phenelzine (if not responding to anything else)
57
Q

What are some examples of psychotherapies used to treat panic disorders?

A

CBT has shown comparable efficacy to pharmacotherapy

Limited by lack of availability of trained professionals

58
Q

Review slides 88 and 89for treatment options for panic disorder (highlighted options

A
59
Q

Review differences between antidepressants

A
60
Q

Are benzodiazepines effective in treating acute panic attacks?

A

No, because the onset of benzodiazepine will typically occur after the panic attack

61
Q

What is the onset of action for antidepressants in treatment of panic disorder?

A

Most patients with PD are hypersensitive (start low, and go slow with titration)
Reduction of panic attack frequency, anticipatory anxiety, and avoidance may start within the first 3-4 weeks

Full remission may take up to 6 months or longer

62
Q

What are some risk factors associated with social anxiety disorder?

A

Temperamental
- Behavioural inhibition and fear of negative evaluation

Environmental
- Childhood maltreatment
- Parental overcontrol, overprotection
- Life stressors
- Adverse life experiences

Genetic and physiological:
- Hereditary (dopamine dysfunction)

63
Q

What are some comorbidities associated with social anxiety disorder?

A

Chronic social isolation may lead to MDD

Substance use disorder

64
Q

What is the definition of social anxiety disorder?

A

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others

65
Q

What are the treatment principles for social anxiety disorder?

A

1st line: Individual CBT specifically designed for social anxiety disorder or SSRIs

Review slide 105 and 106 for pharmacotherapy options

66
Q

Review slide 107 for the onset of effect of pharmacotherapy in social anxiety disorder treatment

A
67
Q

What is the correlation between severity of trauma and development of PTSD?

A

More severe forms of trauma tend to be linked with higher PTSD diagnoses

ex. Rape, childhood abuse, combat

68
Q

What are some characterstics of PTSD?

A
  1. Re-experiencing the event with distressing recollections, dreams, flashbacks, psychological, and physical distress
  2. Persistent avoidance of stimuli that might invite memories or experiences of the trauma
  3. Increased arousal

Review slide 122

69
Q

What are some comorbidities associated with PTSD?

A
  • 75 to 80% of patients with PTSD will also have MDD
  • Substance use disorder (especially after trauma)

Increased rates of physical helath comorbidities (CVD, Respiratory disorders, autoimmune disorders)

70
Q

What is the mainstay of PTSD therapy?

A

Trauma-focused psychotherapy (helps reprocess traumatic memories into inactive consolidated memory states)

71
Q

What are the goals of therapy for PTSD?

A
  1. Decrease intrusive thoughtsa, avoidance of trauma related stimuli, and mood symptoms
  2. Improve sleep, quality of life, and participation in non-pharm treatments
  3. Minimize ADRs and comorbidities
72
Q

What is the role of benzodiazepines in PTSD treatment?

A

They are contraindicated due to CNS depressive effects (disrupts reorganization of traumatic memories)

73
Q

What is the role of Prazosin in the treatment of PTSD?

A

First line for PTSD with trauma related nightmares and can help improve sleep

74
Q

What are some risk factors associated with OCD?

A

Mix of genetics and environmental

Pregnancy

Temperamental

Environmental (physical and sexual abuse in childhood)

75
Q

What are some comorbidities associated with OCD?

A

Suicidal ideation (50% of patients)

MDD and bipolar

Anxiety disorders

76
Q

How are patients with OCD usually identified by healthcare professionals?

A

Usually due to injuries due to compulsions

Delay of diagnosis is usually around 5-10 years as patients keep symptoms secret

ex. chapped hands due to excessive hand washing

77
Q

What are some examples of obessions in OCD?

A
  • Fear of contamination
  • Unwanted sexual or aggressive thoughts
  • Doubts (ex. door left unlocked)
  • Concerns about throwing away something valuable
  • Need for symmetry
78
Q

What are some examples of compulsions in OCD?

A
  • Washing, cleaning
  • Checking, praying, “undoing actions”
  • Hoarding
  • Ordering, arranging, balancing, straightening until “just right”
79
Q

What is the OCD standardized scale to assess response to treatment?

A

Know for exam

Yale-Brown Obsessive Scale (Y-BOCS)

80
Q

What is the treatment approach to OCD?

A

Guidelines recommend CBT or pharmacotherapy with SSRIs as 1st line

Clomipramine can be use following failure of two SSRIs (second line)

81
Q

Review slide 149 for OCD pharmacotherapy treatment options

A
82
Q

Review slide 152 for OCD treatment timeframes

A
83
Q
A

PHAR 358 (3 decks)

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