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PHAR 358 > Anxiety > Flashcards

Anxiety Flashcards

1
Q

when does anxiety become a disorder?

A

when it is overwhelming and affecting function and QoL by causing feelings of helplessness, confusion, and extreme worry that are out of proportion with the seriousness or likelihood of the feared event

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2
Q

what is the difference between fear and anxiety?

A

fear is the emotional response to real or perceived imminent threat
anxiety is anticipation of future threat

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3
Q

what are the core symptoms of anxiety?

A

fear and worry

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4
Q

which circuit regulates fear?

A

amygdala-centered circuit

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5
Q

which circuit regulates worry?

A

cortico-striato-thalamo-cortical circuit

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6
Q

what are the symptoms associated with a fear response?

A

motor responses: flight/fight or freeze
respiratory: increased RR, SOB and asthma
CV: increased atherosclerosis, cardiac ischemia, BP and MI, decreased HR variability and sudden death

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7
Q

which part of the brain is responsible for the motor responses of fear?

A

periaqueductal gray

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8
Q

which part of the brain is responsible for the respiratory responses of fear?

A

parabrachial nucleus

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9
Q

which part of the brain is responsible for the CV responses of fear?

A

locus coeruleus

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10
Q

which neurotransmitters regulate fear?

A

5HT
GABA
glutamate
CRF/PA
NE
voltage gated ion channels

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11
Q

which neurotransmitters regulate worry?

A

5HT
GABA
DA
NE
glutamate
voltage gated ion channels

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12
Q

which neurotransmitter is key for anxiety and role of anxiolytics?

A

GABA

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13
Q

how is GABA synthesized?

A

stored in presynaptic vesicles
released in synapse when needed
GABA transported back to vesicle or metabolized and inactivated by GABA transaminase

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14
Q

which subtypes of voltage sensitive calcium channels are relevant in psychopharmacology?

A

N and P/Q

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15
Q

which medications act on voltage sensitive calcium channels and alpha 2 delta ligands to decrease anxiety?

A

gabapentin and pregabalin

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16
Q

what is the MOA of gabapentin and pregabalin?

A

bind to the α2δ subunit of the presynaptic N and P/Q VSCC to block release of glutamate when neurotransmission is excessive (amygdala and CSTC loop) to decrease fear and worry

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17
Q

what role does serotonin play in anxiety?

A

innervates the amygdala and CSTC – assists with regulating fear and worry

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18
Q

what is the MOA of buspirone?

A

5-HT1A agonist

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19
Q

what role does NE play in anxiety?

A

regulator to the amygdala and to PFC/thalamus in CSTC circuits by attaching to α1 & β1 adrenergic receptors

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20
Q

which medication can be used to control nightmares?

A

prazosin

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21
Q

what is the usual age on onset in GAD?

A

late adolescents or early adulthood

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22
Q

what medical illnesses are associated with anxiety symptoms?

A

CV: angina, cardiomyopathy, CHF, HTN, IHD, MI

endocrine and metabolic: cushings, diabetes, hyperparathyroidism, hyperthyroidism, hypothyroidism, hypoglycemia, hyponatremia, hyperkalemia, phechromocytoma, vitamin B12 deficiency

neurologic: migraine, seizure, stroke, neoplasms, poor pain control

respiratory system: asthma, COPD, PE, pneumonia

others: anemia, lupus, cancer, vestibular dysfunction

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23
Q

which medications can cause anxiety symptoms?

A

anticonvulsants: carbamazepine, phenytoin
antidepressants: SSRIs, SNRIs, bupropion
antihypertensive: clonidine, felodipine
antibiotics: quinolones, isoniazid
bronchodilators: albuterol, theophylline
corticosteroids
dopa agonsts: amantadine, levodopa
herbals
illicit substances
NSAIDs
stimulates
sympathomimetics
levothyroxine

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24
Q

what are some symptoms of GAD?

A

psychological and cognitive symptoms
- excessive worry
- worries that are difficult to control
- feeling keyed up or on edge
- poor concentration
- restlessness
- irritability
- sleep disturbances

physical symptoms
- fatigue
- muscle tension
- trembling or shaking
- feelings of fullness in throat/chest
- sweating
- cold, clammy hands

impairment
- social, occupational or other important functional areas
- poor coping skills

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25
Q

which GAD rating scale is self rated?

A

GAD-7

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26
Q

what is the interpretation of GAD-7 score?

A

5 mild
10 moderate
15 severe

further evaluation needed if score >10

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27
Q

what are some non-pharm treatment options for GAD?

A
  • reduce/avoid alcohol, caffeine, nicotine use
  • avoidance of non-Rx stimulants and medications known to induce anxiety
  • exercise
  • psychotherapy +/- counselling
  • relaxation techniques
  • biofeedback
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28
Q

what are the first line treatments in GAD?

A

SSRIs/SNRIs and pregablin

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29
Q

which SSRIs are indicated for GAD?

A

escitalopram, paroxetine, sertraline

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30
Q

what agents are 2nd line in GAD treatment?

A

BZD (short use)
bupropion
buspirone
hydroxyzine
imipramine
quetiapine
vortioxetine

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31
Q

what agents are 3rd line in GAD treatment?

A

citalopram
fluoxetine
mirtazapine
trazodone
augment with SGA

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32
Q

what is the timeline of symptom relief in GAD treatment with SSRIs/SNRIs?

A

onset of symptom relief: 2-4 weeks
maximal response: 12 weeks

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33
Q

what is the MOA of benzodiazepines?

A

bind to the benzodiazepine receptors on the GABAA neuron leading to an increase in the frequency of opening of the chloride by increasing binding affinity for the endogenous ligand GABA
the shift in chloride ions results in hyperpolarization and stabilization

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34
Q

what is the efficacy of BZDs?

A

provides rapid initial relief of anxiety symptoms but may not be significantly different from placebo after 4-6 weeks of treatment

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35
Q

what symptoms of anxiety do BZDs treat?

A

somatic symptoms (muscle tension, changes in sleep)

36
Q

which benzodiazepines have shown efficacy in GAD?

A

alprazolam, bromazepam, lorazepam, diazepam

37
Q

which benzodiazepines do not have active metabolites?

A

LOT drugs
lorazepam, oxazepam, temazepam

38
Q

what are some common AEs of BZDs?

A

ataxia
dizziness and lightheadedness
sedation and residual daytime sleepiness
psychomotor impairment
agitation, irritability, confusion

39
Q

what are some serious AEs of BZDs?

A

anterograde amnesia
depression, confusion, bizarre behaviour, hallucinations
respiratory depression

40
Q

what are the benefits of long acting BZDs vs short acting?

A

long acting are best for taper as less risk of withdrawal
short acting have better hypnotic and sedative properties but have more rebound anxiety

41
Q

what are the symptoms of benzo withdrawal?

A

sweating, tremor, nausea, vomiting, rebound anxiety, increased HR, insomnia, agitation, twitching, visual/tactile hallucinations, seizures

42
Q

what are some precautions in initiating BZD therapy?

A

substance use hx, sleep apnea, COPD, elderly, CNS depression, pregnancy, clozapine use

43
Q

what is the antidote to benzos?

A

flumazenil

44
Q

why is use of flamazenil limited?

A

risk of causing seizures in BZD dependent pts

45
Q

what is a panic attack?

A

a distinct period of intense fear or discomfort when 4 or more symptoms develop suddenly and achieve peak within 10 mins
- palpitations or increased HR
- sweating
- trembling
- feelings of SOB
- feeling of chocking
- chest pain or discomfort
- nausea or abdominal distress
- feeling dizzy, unsteady, faint
- feeling of unreality or being detached from oneself
- fear of going crazy or dying
- numbness or tingling sensation
- chilld or hot flashes

46
Q

what is panic disorder?

A

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
- maladaptive change in behaviour designed to avoid having panic attacks

47
Q

what is the clinical presentation of a panic attack?

A

psychological
- depersonalization
- derealization
- fear of losing control
- fear of going crazy
- fear of dying

physical
- abdominal distress
- chest pain
- chills
- dizziness
- feelings of choking
- hot flashes
- palpitations
- nausea
- paresthesias
- SOB
- sweating
- tachycardia
- trembling or shaking

48
Q

how many sessions of CBT are needed to help treat PD?

A

8-15

49
Q

what is first line treatment of PD?

A

SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) and venlafaxine

50
Q

what is second line treatment of PD?

A

TCAs: clomipramine, imipramine
BZDs: alprazolam, clonazepam

51
Q

what is the third line treatment of PD?

A

MAOI: phenelzine

52
Q

how long is treatment with pharmacotherapy in PD?

A

acute tx duration: 1-3 months
maintenance tx duration: 12 months

53
Q

what are the s/sx of social anxiety disorder?

A

fears
- scrutinized by others
- embarrassment
- humiliation

feared situations
- public speaking
- eating or drinking in front of others
- interacting with authority figures
- talking with strangers
- use of public washrooms

physical symptoms
- blushing
- “butterflies in stomach”
- diarrhea
- sweating
- trembling
- tachycardia

types
- generalised: fear and avoidance of a wide range of social situations
- nongeneralised: fear is limited to one or two situations

54
Q

what is the first line treatment of SAD?

A

CBT specifically designed for SAD
SSRIs: escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

55
Q

what is 2nd line treatment of SAD?

A

venlafaxine
clonazepam

56
Q

what is 3rd line treatment of SAD?

A

augmentation of SSRIs with buspirone

57
Q

which medications can be used in SAD for performance anxiety?

A

beta blockers: atenolol and propranolol

58
Q

what are some CIs of beta blockers?

A

cardiogenic shock, sinus bradycardia, cardiac failure, bronchial asthma, known hypersensitivity

59
Q

what is the onset of symptom relief in SAD with treatment?

A

6-8 weeks
can be as early as 3 weeks with venlafaxine

60
Q

how long is treatment duration of SAD?

A

continue for 1 year or longer after a response is attained

61
Q

what are some risk factors for PTSD?

A

trauma severity
lack of education
younger age
female
race
psychiatric history
low socioeconomic status
other adverse childhood factors
other previous trauma
family psychiatric history
lack of social support
childhood abuse
life stress
low intelligence

62
Q

what is the command center for fear?

A

amygdala

63
Q

what happens to the prefrontal cortex in times of stress?

A

shuts down the thinking brain
high levels of catecholamine release weaken dlPFC, strengthen amygdala and striatum and increase tonic firing of the LC

64
Q

what happens after a trauma in PTSD?

A
  1. re-experiencing the event with distressing, recollections, dreams, flashbacks, physiological and physical distress
  2. persistent avoidance of stimuli that might invite memories or experiences of the trauma
  3. increased arousal
65
Q

what is the core of PTSD treatment?

A

trauma-focused psychotherapy

66
Q

what does trauma-focused psychotherapy include?

A

cognitive processing therapy
prolonged exposure therapy
eye movement desensitization and reprocessing

67
Q

what are the goals of pharmacotherapy in PTSD?

A

symptom reduction
- decrease intrusive thoughts and images
- decrease avoidance of trauma related stimuli
- decrease mood symptoms: negative thoughts/feelings
- hyperarousal/reactivity

improve
- sleep
- quality of life
- participation in non-pharm treatment

minimize
- ADEs
- comorbidities

68
Q

what are the first line agents for PTSD?

A

SSRIs: fluoxetine, paroxetine, sertraline
SNRI: venlafaxine
prazosin for trauma related nightmares and to improve sleep

69
Q

what are the 2nd line agents in PTSD?

A

fluvoxamine, mirtazapine, phenelzine
adjunctive: SGA

70
Q

what are the 3rd line agents in PTSD?

A

in summary: all other antidepressants, anticonvulsants, antipsychotics, adj gapa, clonidine

71
Q

which agents are not recommended in PTSD?

A

BENZOS
alprazolam, divalproex, citalopram, olanzapine, tigabine, clonazepam

72
Q

why are benzos not recommended in PTSD?

A

lack of efficacy for treatment/prevention
potential harms specific to PTSD patients
- worse overall severity
- significantly increase risk for developing PTSD with use after recent trauma
- worse psychotherapy outcomes
- development of aggression, depression and substance use

73
Q

what are indicators of a good prognosis in OCD?

A

good social and occupational adjustment
presence of precipitating event
episodic nature of the symptoms

74
Q

what are indicators of a poor prognosis in OCD?

A

acting on compulsions
childhood onset
bizarre compulsions
need for hospitalisation
comorbid depression
comorbid personality disorder
delusional beleifs

75
Q

what are the s/sx of OCD

A

obsessions
- fear of contamination
- unwanted sexual or aggressive thoughts
- doubts (e.g. door left unlocked)
- concerns about throwing away something valuable
- need for symmetry

compulsions
- washing, cleaning
- checking, praying, “undoing actions”, asking for reassurance
- repeated checking behaviours
- hoarding
- ordering, arranging, balancing, straightening until “just right”

76
Q

what is the Y-BOCS used to measure?

A

measures overall severity of obsessions/compulsions in OCD

77
Q

what is the interpretation of a Y-BOCS score?

A

scored from 0 (nonexistent) to 4 (extreme)
response: 25-35% reduction in score
remission: score 8 or below

78
Q

when is clomipramine recommended in OCD?

A

after failure of 2 SSRIs

79
Q

what are the non-pharm treatments for OCD?

A

CBT
deep brain stimulation
radio frequency wave surgery

80
Q

what is the first line treatment of OCD?

A

recommend psychotherapy + SSRI

SSRIs: escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
venlafaxine
adj: aripiprazole, risperidone

81
Q

what is the second line treatment of OCD?

A

citalopram, clomipramine, mirtazapine
adj: memantine, quetiapine, topiramate

82
Q

which agents are not recommended in OCD?

A

clonazepam, clonidine, desipramine

83
Q

what is the relapse rate for OCD?

A

24-89%

84
Q

when is lifelong therapy recommended in OCD?

A

after 2-4 severe relapses or 3-4 less severe relapses

85
Q
A

PHAR 358 (10 decks)

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