Anxiety Flashcards
What is anxiety?
A normal emotion under circumstances of threat and is thought to be part of the evolutionary fight or flight reaction of survival.
When does anxiety become a disorder?
When it is overwhelming and affecting function and quality of life
What are the core symptoms of anxiety? (2)
- Psychological
- Fear/anxiety, worry, apprehension, difficulty concentrating - Somatic (physical)
- Increased HR, tremor, sweating, GI upset
Which circuit in the brain primarily relates to fear?
Amygdala-centered circuit
Which circuit in the brain primarily relates to worry?
Cortico-striato-thalamo-cortical circuit
What are the neurotransmitters that regulate the brain circuits associated with anxiety? (6)
- 5HT
- GABA
- Glutamate
- CRF/HPA
- NE
- Voltage-gated ion channels
GABA _________ activity of neurons
decreases
True or False? Gabapentin and pregabalin work on GABA in the brain
False - despite their names they have no association with GABA, they work on the 𝜶2ẟ subunit of presynaptic N and P/Q voltage-sensitive calcium channel to block release of glutamate when neurotransmission is excessive
What happens with SNRIs and β1 receptors when initially starting the medication?
Symptoms can be worsened at initial dosing with SNRIs but as β1 receptors downregulate, fear/worry improves long term
What are 4 aspects to evaluation of anxiety disorders?
- Gather history
- Review of systems
- Rule out anxiety disorders due to general medical conditions or substance use
- Review substances used (caffeine, OTC use, herbal medications, recreational substances) - Suicidal ideation or intent
What classes of drugs are classified as serotonergic agents? (3)
- SSRIs
- SNRIs
- TCAs
What drugs are classified as 𝜶2ẟ ligand drugs? (2)
- Gabapentin
- Pregabalin
What drugs are classified as selective serotonin agents (5HT1A agonists) (2)?
- Buspirone
- Second generation antipsychotics (SGAs)
What drug is an 𝜶1-1 adrenergic antagonist?
Prazosin
What are unique considerations to remember for bupropion? (2)
- Activating.
- Risk of seizures, avoid if seizure history, head trauma, bulimia, anorexia, electrolyte disturbances
What are unique considerations to remember for buspirone? (3)
- Slow onset, modest efficacy.
- May be helpful to augment therapy in those with partial response to antidepressants.
- Avoid if comorbid depression
What is a unique consideration to remember for citalopram? (2)
- Lower risk for insomnia, agitation, drug interactions compared to other SSRIs.
- Dose dependent risk of QT prolongation
What is a unique consideration to remember for duloxetine? (3)
- May be useful for comorbid pain.
- Compared to SSRIs: increased withdrawal symptoms if not tapered, increased insomnia or agitation.
- Avoid if liver disease or heavy EtOH use.
What are unique considerations to remember for escitalopram? (1)
- Similar to citalopram, except QT risk is controversial
What are unique considerations to remember for fluoxetine? (3)
- More activating than other SSRIs
- Self-tapering due to long half-life
- Drug interactions
What are unique considerations to remember for fluvoxamine? (2)
- Withdrawal symptoms if not tapered.
- Risk for drug interactions due to inhibition of CYP1A2 and CYP2C19
What are unique considerations to remember for hydroxyzine? (2)
- Useful for co-morbid insomnia
- Dose-related anticholinergic effects limit clinical use
What are unique considerations to remember for imipramine? (2)
- Anticholinergic; cardiotoxic in overdose
- Not well tolerated
What are unique considerations to remember for mirtazapine? (3)
- Helpful with comorbid insomnia
- Lower doses are more sedating
- May increase appetite and lead to weight gain
What are unique considerations to remember for paroxetine? (4)
- Compared to other SSRIs, more sedating, less agitation, more constipation, withdrawal symptoms if not tapered.
- May be associated with greater weight gain.
- Concern for drug interactions
- Avoid in pregnancy due to cardiac septal defects
What are unique considerations to remember for pregabalin? (2)
- Sedation and dizziness are common
- Weight gain, especially with long-term use
What are unique considerations to remember for quetiapine? (1)
- Concerns for metabolic ADEs, sedation, EPS
What are unique considerations to remember for sertraline? (1)
- Compared to other SSRIs, insomnia, agitation, dizziness
What are unique considerations to remember for venlafaxine (5)
- Compared to other antidepressants, greater risk for insomnia or agitation as well as increased BP
- Possible benefit for comorbid pain
- Few drug interactions
- Withdrawal symptoms if not tapered
- Better evidence for psychological symptoms (e.g., ruminative worry of GAD)
Ratio of women:men with GAD is x:y
2:1
When is GAD onset usually?
Usually in late adolescence or early adulthood
- Cases in older adults as well
GAD etiology is not really know, but it is likely caused by what?
A combined effect of biological and psychological factors
What are other suspected causes of GAD? (6)
- Medications
- Natural products
- Medical conditions
- Medication withdrawal
- Alcohol, sedatives, benzos - Socioeconomic: poor minority classes
- Stressful event in susceptible person
What are some important drugs to know that are associated with anxiety symptoms? (4)
- Antidepressants - bupropion
- NSAIDs
- Stimulants
- Sympathomimetics - pseudoephedrine, phenylepherine
What are some psychological and cognitive symptoms of GAD? (7)
- Excessive anxiety
- Worries that are difficult to control
- Feeling keyed up or on edge
- Poor concentration
- Restlessness
- Irritability
- Sleep disturbances
What are some physical symptoms of GAD? (6)
- Fatigue
- Muscle tension
- Trembling or shaking
- Feeling of fullness in throat/chest
- Sweating
- Cold, clammy hands
Describe the Generalized Anxiety Disorder Assessment-7 (GAD-7).
That is, how many items, what is it used for, who does it, how long?
- 7-item scale
- Screens for GAD and severity
- Self-rated
- Brief (5 mins)
Describe the Hamilton Anxiety Scale (HAM-A).
That is, how many items, what is it used for, who does it, how long? (6)
- 14-item scale
- Assess severity of anxiety
- Clinician rated
- Brief (10-15 mins)
- Assess response to treatment
- Need trained rater
What are the GAD goals of therapy for an acute episode? (2)
- Decrease severity and duration of anxiety symptoms
- Improve overall function
What are the GAD goals of therapy for long-term goals? (4)
- Remission
- With minimal or no anxiety symptoms
- No functional impairment
- Improve patient QoL
What are the treatment principles to consider for GAD treatment? (3)
- Psychotherapy + pharmacotherapy
- Psychotherapy is least invasive and safest
- Pharm indicated if symptoms severe enough to produce functional disability - Treatment plan depends on severity and chronicity of symptoms, age, medication history, and comorbid medical and psychiatric conditions
- Consider: anticipated ADEs, history of prior response in patient or family member, patient preference, cost
What are some non-pharm treatment options that can be used for GAD? (6)
- Reduce/avoid alcohol, caffeine, nicotine use
- Avoidance of non-prescription stimulants & medications known to induce anxiety
- Exercise
- Psychotherapy +/- counselling (CBT most effective)
- Relaxation techniques
- Biofeedback
What are THE 1st-line treatment options for GAD? (6)
1.SSRI:
- Escitalopram
- Paroxetine
- Sertraline
2. SNRI:
- Duloxetine
- Venlafaxine
3. Pregabalin
What are the 2nd-line treatment options for GAD? (6)
- BZD (short-term use)
- Alprazolam
- Lorazepam
- Diazepam - Bupropion
- Buspirone
- Hydroxyzine
What does current evidence say about what to do when there has been a partial response to drug therapy?
Current data does not provide guidance as to whether it is best to increase to dose, augment, or switch when there has been a partial response to drug therapy
What is the main side effect to know for hydroxyzine?
Anticholinergic, sedation
Should know the important GAD treatment timeframes for SSRIs/SNRIs:
1. Onset of symptom relief
2. Maximal response
3. Treatment duration
- 2-4 weeks
- 12 weeks
- 12-24 months
What is the MOA of benzodiazepines? (3)
- Bind to the benzodiazepine receptors on the GABA neuron
- Leads to an increase in the frequency of opening of the chloride channels by increasing binding affinity for the endogenous ligand GABA
- The shift in chloride ions results in hyperpolarization (a less excitable state) and stabilization
How efficacious are benzos in GAD?
Provides rapid initial relief of anxiety symptoms, but effects may not be significantly different from placebo after 4-6 weeks of treatment
RCT evidence supports the efficacy of which benzos in GAD specifically? (BALD)
- Bromazepam
- Alprazolam
- Lorazepam
- Diazepam
True or False? Clonazepam is not used in GAD
False? So, there are no RCTs evaluating its use in GAD, but it is used extensively in clinical practice.
The short acting benzos include? (3)
- Alprazolam
- Lorazepam
- Bromazepam (maybe, t1/2 is 8-30h which is a huge variation)
The long acting benzos include? (2)
- Clonazepam
- Diazepam
How fast is the onset for the following:
1. Alprazolam
2. Bromazepam
3. Clonazepam
4. Diazepam
5. Lorazepam
- 1-2h
- 1-2h
- 20-60 min
- 30-60 min
- 30-60 min
What are the common side effects of benzos? (5)
- Ataxia
- Dizziness/lightheadedness
- Sedation and residual daytime sleepiness
- Psychomotor impairment
- Agitation, irritability, confusion
What are some of the less common side effects of benzos? (6)
- Anterograde amnesia
- Depression
- Confusion
- Bizarre behaviour
- Hallucination
- Respiratory depression
Touch on benzodiazepine dependence. That is;
1. When might it develop?
2. What doses have a higher risk?
3. What else can increase the risk?
4. Withdrawal?
- Psychological and physical dependence may develop with long-term use
- Risk of dependence increases with higher dose and/or longer use
- Risk further increased with history of AUD or other SUD or personality disorders
- Withdrawal symptoms can occur following discontinuation of therapy with as little as one week of use
What are the LOT drugs (benzos)/why are they used?
Lorazepam, oxazepam, temazepam
Preferred in elderly and liver dysfunction due to no active metabolites
What is a pro and con of long acting benzos?
Pro:
- Good choice for tapering as less risk of withdrawal (i.e., diazepam, clonazepam)
Con:
- More daytime sedation
What is a pro of short acting benzos? What are the 3 cons?
Pro:
- Better hypnotic and sedative properties
Cons:
- More rebound anxiety
- Inter-dose withdrawal
- Anterograde amnesia
What are the benzo withdrawal symptoms? (11)
- Sweating
- Tremor
- Nausea
- Vomiting
- Rebound anxiety
- Increased heart rate
- Insomnia
- Agitation
- Twitching
- Visual/tactile hallucinations
- SEIZURES (onset within 1-2 days after BZD stopped)
To avoid benzo withdrawals, we should taper. Which benzo is best for tapering and what is a conservative tapering schedule we can follow?
Diazepam
Decrease dose by 10-20% q1-2 weeks
What are some precautions to giving benzos to someone? (7)
- SUD (concurrent use with opioids may cause profound respiratory depression, coma, or death)
- Sleep apnea
- COPD
- Elderly
- CNS depression
- Pregnancy (floppy infant syndrome; possible teratogen)
- Clozapine-use
Benzo withdrawal is rarely fatal alone, but may be fatal when taken in combination with _______, _______, ____________
alcohol, opioids, barbiturates
What is the benzo antidote?
Flumazenil
How does flumazenil work as a benzo antidote?
Reverses hypnotic-sedative effect of BZD but clinically use is limited due to risk of causing seizures in BZD dependent patients
For which of the following antidepressant classes would it be especially important to counsel patients that their activity may get worse before it starts to improve?
a. SSRI
b. SNRI
c. SARI
d. 5HT1a agonist
b
Which of the following is a first-line option for GAD?
a. Mirtazapine
b. Quetiapine
c. Buspirone
d. Pregabalin
e. Lorazepam
d
Define panic disorder
Recurrent unexpected panic attacks with at least 1 of the attacks being followed by a month or longer of at least 1 of the following:
- Constant concern about having another attack
- Being anxious about the implications of the attack or its consequences (e.g., losing control, having a heart attack)
- Maladaptive change in behaviour designed to avoid having panic attacks
The ratio of females:males with panic disorder is x:y
2:1
What are the categories of risk factors that can lead to panic disorder? (5)
- Tempermental (i.e., learned behaviours)
- Personality types
- Environmental
- Genetic and physiological
- Medications
What are some comorbidities of panic disorder? (6)
- Other anxiety disorders
- Depression
- Bipolar disorder
- AUD
- Higher rates of suicide atempts and suicidal ideation
- Medical comorbidities
What are the clinical psychological presentations of a panic attack? (5)
- Depersonalization
- Derealization
- Fear of losing control
- Fear of going crazy
- Fear of dying
What are the clinical physical presentations of a panic attack? (13, obvs dont need to memorize every last one of them)
- Abdominal distress
- Chest pain
- Chills
- Dizziness
- Feeling of choking
- Hot flashes
- Palpitations
- Nausea
- Paresthesias
- Shortness of breath
- Sweating
- Tachycardia
- Trembling or shaking
What is the clinical course of panic disorder? (4)
- Panic attacks vary in frequency and intensity
- 1/3 of pts achieve remission
- 1/5 of pts have unremitting & chronic course
- Most pts require long-term treatment to achieve remission, prevent relapse, and reduce risks associated with co-morbidity
What are some predictors of a chronic course of panic disorder? (3)
- Long duration of illness
- Comorbidity with personality, mood, other anxiety disorders
- Excessive sensitivity to physical symptoms of anxiety
What are the 2 standardized rating scales for panic disoder?
- Panic Disorder Severity Scale (PDSS)
- Panic and Agoraphobia Scale (PAS)
What are the non-pharm treatment options for panic disorder? (5)
CBT. Types:
- Applied relaxation
- Exposure through imagery
- Panic managment
- Breathing retraining
- Cognitive restructuring
How effective is non-pharm treatment when compared to pharmacotherapy when it comes to panic disorder? (3)
- Effectiveness comparable to pharmacotherapy
- Limited by lack of availability of trained professionals
- Studies indicate 8-15 sessions needed
What are the 1st line medications for PD? (2 classes, 8 meds total)
SSRIs:
1. Citalopram
2. Escitalopram
3. Fluoxetine
4. Fluvoxamine
5. Paroxetine
6. Sertraline
SNRIs:
1. Duloxetine
2. Venlafaxine
What are the 2nd line medications for PD? (2 classes, 4 meds total)
TCAs:
1. Clomipramine
2. Imipramine
BZDs:
1. Alprazolam
2. Clonazepam
What is the 3rd line med for PD? (1)
MAOI: Phenelzine
True or False? BZDs are useful for treating acute panic attacks?
False - they are not, because the onset of BZDs will typically occur after the panic attack
What is the onset of action of antidepressants in panic disorder? (3 things to know about)
- Most pts with PD are hypersensitive to medication ADEs at initation and this can lead to activation (early worsening of anxiety, agitation, irritability)
- Reduction of panic attack frequency, anticipatory anxiety, and avoidance may start within first 3-4 weeks
- For pts with significant avoidance, full remission may take up to 6 months or longer
What is the onset of action of BZDs in panic disorder?
Onset within hours for autonomic symptoms of anxiety, full benefit may take 4-6 weeks
Should know the important panic disorder treatment timeframes for:
1. Acute treatment duration
2. Maintenance treatment duration
3. Tapering duration
- 1-3 months (alter treatment if no response after 6-8 weeks)
- 12 months
- 4-6 months (taper slowly to reduce risk of relapse)
Females or males, who has a higher rate of social anxiety disorder (SAD)?
Females
What is the epidemiology of SAD? (5)
- Older adults may show concern about disability due to declining sensory functioning (sensory, hearing) or embarrassment about one’s appearance (e.g., tremor from Parkinson’s disease) or functioning due to medical conditions (e.g., urinary incontinence)
- Associated with increased rates of school dropouts; and decreased well-being, employment, workplace productivity, SES, and QoL
- Associated with being single, unmarried, divorced and not having children
- Only ~50% of pts with SAD seek treatment and usually only after 15-20 years of symptoms
- Unemployment is a strong predictor of persistence of SAD
What are the classes of risk factors associated with SAD? (3)
- Tempermental
- Environmental
- Genetic and physiological
What are some comorbidities associated with SAD? (6)
- Females report greater number of social fears and comorbid depressive, bipolar, and anxiety disorders
- Males are more likely to fear dating, have oppositional defiant disorder or conduct disorder, and use alcohol or recreational drugs to relieve symptoms of disorder
- Chronic social isolation may lead to MDD
- Comorbid MDD higher in older adults
- Substances may be used to self-medicate for social fears but symptoms of intoxication or withdrawal may be a source of further social fear
- 70-80% have history of concurrent anxiety, depression, and SUD
What are the classes of signs and symptoms of SAD? (4)
- Fears
- Feared situations
- Physical symptoms
- Types
What are some of the “fears” of SAD? (3)
- Scrutinized by others
- Embarrassment
- Humiliation
What are some of the “feared situations” of SAD? (5)
- Public speaking
- Eating or drinking in front of others
- Interacting with authority figures
- Talking with strangers
- Use of public washrooms
What are the physical symptoms of SAD? (6)
- Blushing
- “Butterflies in stomach”
- Diarrhea
- Sweating
- Tachycardia
- Trembling
What are the types of SAD? (2)
- Generalized: fear and avoidance of a wide range of social situations
- Nongeneralized: fear is limited to one or two situations
Name the 2 standardized rating scales for SAD
- Liebowitz Social Anxiety Scale
- Social Phobia Inventory (SPIN)
What are the non-pharm treatment options for SAD? (2)
- CBT - education, exposure, cognitive restructuring
- Treatment for at least 12 weeks
- Individual treatment more effective than group therapy
- Similar efficacy to pharmacotherapy for acute treatment
- Effects may last for 6-12+ months - Social Skills Training
What are the 1st line treatment options for SAD? (1 non-pharm, 3 classes, 7 meds total)
- CBT
- SSRIs
- Escitalopram
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline - SNRIs
- Venlafaxine - Pregabalin
What agents are used in SAD only for performance situations?
Beta-blockers, such as atenolol and propranolol
What is the treatment timeframes for SAD for the following:
1. Onset of symptom relief
2. Treatment duration
3. Tapering duration
- 6-8 weeks
- 1+ years (continue for 1 year or longer after response attained)
- 3-4 months
Men vs. women. Who is PTSD more prevalent in?
Women 2x more than men
What is the neuropathophysiology of PTSD?
Insufficient glucocorticoid signaling at the time of trauma results in unopposed sympathetic nervous system activation that enhances the consolidation of the traumatic memory
After trauma, 3 dimensions of PTSD unfold. What are they?
- Re-experiencing the event with distressing recollections, dreams, flashbacks, psychological, and physical distress
- Persistent avoidance of stimuli that might invite memories or experiences of the trauma
- Increased arousal
75-80% of pts with PTSD will have other psychiatric disorders, such as? (Thinking co-morbidities here) (6)
- MDD
- SUD and AUD
- Anxiety disorders (GAD)
- Personality dysfunction
- Bipolar
- Psychosis
PTSD comes with increased rates of medical co-morbidities, such as? (3)
- CVD
- Respiratory disorders
- Autoimmune disorders
True or False? There are no specific screening tools specific to PTSD
False - obviously there are
The core of PTSD treatment is trauma-focused psychotherapy. What does that include? (3)
- Cognitive Processing Therapy
- Prolonged Exposure Therapy
- Eye Movement Desensitization & Reprocessing
What are the limitations to the core treatment of PTSD (trauma-focused psychotherapy)? (3)
- 30-50% of pts have residual symptoms
- High drop out rates
- Resources
What are the 3 goals of pharmacotherapy in PTSD?
- Symptom reduction
- Improve sleep, QoL, participation in non-pharm treatment
- Minimize ADEs and comorbidities
What are the 1st line treatment options for PTSD? (3 classes, 5 meds total)
SSRIs:
1. Fluoxetine
2. Paroxetine
3. Sertraline
SNRIs:
1. Venlafaxine
Prazosin (for trauma related nightmares and to improve sleep)
Which PTSD medication is specifically used for trauma related nightmares and to improve sleep?
Prazosin
What medications are NOT recommended in use to treat PTSD?
Benzos such as alprazolam and clonazepam
What are the important timeframes to remember in the treatment of PTSD?
1. Onset of symptom relief
2. Maximal response
3. Treatment duration
- 2-8 weeks
- 12 weeks+
- 12-24 months
Men vs. women, which has a higher prevalence of OCD?
Females affected slightly more than males
The pathophysiology of OCD is not well understood, but it could possibly be related to abnormalities in: (3)
- Serotonin neurotransmission
- Dopamine transmission (especially in cases with co-morbid tics and Tourette’s)
- Glutamate
The etiology of OCD is unknown, but what are some potential risk factors to be aware of? (5)
- PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections)
- Pregnancy
- Tempermental
- Environmental
- Genetics
What are the comorbidities associated with OCD? (7)
- Males more likely to have comorbidities
- Suicidal thoughts occur at some point in ~50% of patients with OCD, suicide attempts are reported in 25% of patients with OCD
- MDD and bipolar
- Anxiety disorder
- Tic disorder
- A triad of OCD, tic disorder, and attention-deficit/hyperactivity disorder can also be seen in children
- Body dysmorphic disorder, trichotillomania, excoriation occuring more likely in pts with OCD than other disorders
What are some indicators of good prognosis of OCD? (3)
- Good social and occupational adjustment
- Presence of precipitating event
- Episodic nature of the symptoms
What are some indicators of poor prognosis of OCD? (7)
- Acting on compulsions
- Childhood onset
- Bizarre compulsions
- Need for hospitalization
- Comorbid depression
- Comorbid personality disorder
- Delusional beliefs
What are some signs/symptoms of obsessions in OCD? (5)
- Fear of contamination
- Unwanted sexual or aggressive thoughts
- Doubts (e.g., left door unlocked)
- Concerns about throwing away something valuable
- Need for symmetry
What are some signs/symptoms of compulsions in OCD? (5)
- Washing, cleaning
- Checking, praying, “undoing actions,” asking for reassurance
- Repeated checking behaviours
- Hoarding
- Ordering, arranging, balancing, straightening until “just right”
What is the OCD standardized rating scale?
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
- Clinician-rated
What are the 3 non-pharm treatment options for OCD?
- CBT
- Found to be as effective as pharmacotherapy
- Stronger effects on compulsions vs. obsessions - Deep Brain Stimulation (DBS)
- Surgically implanted device - Radio Frequency Wave Surgery
- Destroy small amount of brain tissue in the corticostriatal circuit
What are the 1st line treatment options for OCD? (3 classes, 8 meds total)
SSRIs:
1. Escitalopram
2. Fluoxetine
3. Fluvoxamine
4. Paroxetine
5. Sertraline
SNRI:
1. Venlafaxine
Adjunct:
1. Aripiprazole
2. Risperidone
What is the 2nd line treatment option for OCD?
Clomipramine
How often is the acute phase of OCD treatment monitored?
Monitor weekly x 4 weeks then biweekly. Once stable, monitor q1-2 months
What are the important OCD treatment timeframes for the following:
1. Onset of symptom relief
2. Maximal response
3. Treatment duration
- 2-4 weeks
- 10-12 weeks
- 1-2 years
