Anxiety Flashcards
What part of the brain handles fear?
amygdala to prefrontal
What part of brain handles worry?
cortico-striato-thalamo-cortical circuit
What general neurotransmittes are involved in fear?
serotonin, GABA, glutamate
What neurotransmitter is dominant in the pathway of worry?
dopamine
How are sodium channels involved with neurotransmitters and associated drugs?
gabapentin/pregabalin block release of glutamate
What is buspirone’s MOA compared to SSRI?
5-HT1A agonist and this is similar to antipsychotics
What is the reason for doctors wanting buspirone for immediate anxiety relief?
NONE just as slow as AD
if want speed use benzos
Since we know norepinephrine can cause flight or fight, how does SNRI’s actually help anxiety?
worsen at beginning but eventually beta receptors are down regulated
How can we limit nightmares and how do they occur?
alpha 1 stimulation
prazosin can block
What OTC/ commercial drugs can mimic anxiety?
decongestant, caffeine
GENERAL First line meds for GAD?
SSRI,SNRI, pregabalin
If a patient has anxiety and seizure which medication should we avoid?
bupropion
When should buspirone not be used?
comorbid depression
Which SSRI has less insomnia, agitation and DI?
citalopram
Which anxiety med are we concerned with QTc?
citalopram
When would duloxetine be an interesting add for anxiety?
comorbid pain
Which SSRI is most activating?
fluoxetine
Which medications can cause withdrawal?
SNRI
Why does fluvoxamine suck?
DI- CYP1A2 2C19
When is hydroxyzine an good add?
comorbid insomnia
When is mirtazipine helpful?
sleep
Issues with mirtazapine?
weight gain, appetite
Issues with paroxetine?
most sedating of SSRI, lots of weight gain, DI
Issues with sertraline?
more insomnia, agitation, dizziness than other SSRI
Which medications have issues with sex dysfunction?
SSRI-NOT sertraline
SNRI- Venlafaxine, duloxetine
What medication withdrawal can mimic GAD?
alcohol, sedatives, benzos
What antidepressant is best known to be prone to cause anxiety?
bupropion
What other medications can cause GAD sx?
CS, stimulants
Sx of anxiety?
worry, poor concentration, restless, irritable, issues with sleep, fatigue
What scale can we use in practice to assess anxiety?
GAD-7
Non pharm for anxiety?
exercise, reduce caffeine, CBT, relaxation
How good is CBT therapy?
comparable to drugs
Which of the SSRI’s and SNRIs are first line for GAD?
SSRI- paroxetine, sertraline, escitalopram
SNRI- duloxetine, venlafaxine
PREGABALIN
What is 2nd line for GAD?
Benzo- short term= alpraz, lorazepam, diazepam
bupropion
buspirone
hydroxyzine
Patient has GAD and old what option?
Escitalopram or sertraline
Patient has GAD and insomnia?
pregabalin or hydroxyzine
Patient pregnant and GAD?
NO benzo or paroxetine
Patient has GAD and bipolar mania?
quetiapine
Patient has GAD and bipolar depression?
pregabalin
What anxiety condition will probably utilize prazosin?
PTSD
When to see effect of buspirone?
2 weeks or LONGER
Why are antipsychotics not used in GAD?
bad s/e
AT what dose is venlafaxine more NE?
> 150
When to see improve of GAD and when at max, and duration?
Improve in2-4 weeks
max at 12 weeks
duration 1-2 years
When is benzos role useful?
anticipate acute attack
Although no evidence of clonazepam in GAD, why use?
longer half life and avoids peaks and troughs
Why not use alprazolam?
SUPER short duration
Benefits of clonazepam and diazepam?
longer half life
When to use lorazepam?
haptic issues
s/e of benzos?
ataxia, dizzy, sedation or even insomnia, depression
What benzos are better in elderly?
LOT
lorazepam
oxazepam
temazepam
What are signs of benzo withdrawal?
seizures, sweat, tremor, NV, anxiety
What is the antidote for benzos? Why is it not used often?
flumazenil
causes seizures
Why is venlafaxine not good in elderly?
HTN
Criteria for Panic disorder?
4 of palpitations, sweaty, tremble, N
What is the difference between panic attack and disorder?
attack- 4 or more sx come on suddenly and peak at 10 min
disorder-recurrent of at least 1 attack and a month of worrying of another attack
Which SSRI has more gi issues?
sertraline
What is first line for PD?
same as Gad just no pregabalin and add fluoxetine
What is second line for PD?
TCA (clomipramine and imipramine), BZD
When to get remission in PD?
6 months
When should we think of switching medications if not working in PD?
6-8 weeks
What is the working theory around Social Anxiety disorder?
DOPAMINE Dfx
How long must you have social anxiety to be diagnosed?
6 months
What’s the difference between generalized and not SAD?
generalized= all situations
non- a few
What is first line for SAD?
CBT, SSRI, SNRI, pregabalin
What can we give for performance anxiety and who are contraindicated?
atenolol, propanolol- asthma severe bronchorestriction
SNRI or SSRI for SAD?
SSRI first
What are the 6 stages of PTSD?
freeze, flight, fight, fright, flag, faint
What happens with long term stress or high stress situations?
breaks down ability for brain to consolidate memories
What are criteria for PTSD?
experience
reexperience
avoidance
What is nonpharm for PTSD?
TAILORED on trauma focused psychotherapy
What first line for PTSD?
Fluoxetine, paroxetine, sertraline
venlafaxine
prazosin
What drugs are NOT recommended in PTSD? WHY?
BENZOS
- no efficacy and more harms
Which SSRI has most sex dysfunction?
sertraline
When to see onset, max response and duration for PTSD?
onset 2-8 weeks
max-12 weeks
duration 1-2 years
What is diagnosis of OCD?
recurrent thoughts and urges
behaviours to prevent or reduce anxiety
What can cause OCD?
genetic, streptococcal infection
pregnancy, abuse
What is first line for OCD?
SSRI (escitalopram, fluoxetine, paroxetine, sertraline) for minimum 12 weeks and CBT for 13 sessions
What other Nonpharm for OCD?
deep brain stimulation- severe
radio frequency wave surgery- refractory
Which is CBT better for obsessions or compulsions?
compulsions
