Anxiety Flashcards
when does anxiety become a disorder?
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
what is the difference between fear and anxiety?
fear is the emotional response to real or perceived imminent threat
anxiety is anticipation of future threat
what are the core symptoms of anxiety?
fear and worry
which circuit regulates fear?
amygdala-centered circuit
which circuit regulates worry?
cortico-striato-thalamo-cortical circuit
what are the symptoms associated with a fear response?
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
which part of the brain is responsible for the motor responses of fear?
periaqueductal gray
which part of the brain is responsible for the respiratory responses of fear?
parabrachial nucleus
which part of the brain is responsible for the CV responses of fear?
locus coeruleus
which neurotransmitters regulate fear?
5HT
GABA
glutamate
CRF/PA
NE
voltage gated ion channels
which neurotransmitters regulate worry?
5HT
GABA
DA
NE
glutamate
voltage gated ion channels
which neurotransmitter is key for anxiety and role of anxiolytics?
GABA
how is GABA synthesized?
stored in presynaptic vesicles
released in synapse when needed
GABA transported back to vesicle or metabolized and inactivated by GABA transaminase
which subtypes of voltage sensitive calcium channels are relevant in psychopharmacology?
N and P/Q
which medications act on voltage sensitive calcium channels and alpha 2 delta ligands to decrease anxiety?
gabapentin and pregabalin
what is the MOA of gabapentin and pregabalin?
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
what role does serotonin play in anxiety?
innervates the amygdala and CSTC – assists with regulating fear and worry
what is the MOA of buspirone?
5-HT1A agonist
what role does NE play in anxiety?
regulator to the amygdala and to PFC/thalamus in CSTC circuits by attaching to α1 & β1 adrenergic receptors
which medication can be used to control nightmares?
prazosin
what is the usual age on onset in GAD?
late adolescents or early adulthood
what medical illnesses are associated with anxiety symptoms?
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
which medications can cause anxiety symptoms?
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
what are some symptoms of GAD?
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
which GAD rating scale is self rated?
GAD-7
what is the interpretation of GAD-7 score?
5 mild
10 moderate
15 severe
further evaluation needed if score >10
what are some non-pharm treatment options for GAD?
- reduce/avoid alcohol, caffeine, nicotine use
- avoidance of non-Rx stimulants and medications known to induce anxiety
- exercise
- psychotherapy +/- counselling
- relaxation techniques
- biofeedback
what are the first line treatments in GAD?
SSRIs/SNRIs and pregablin
which SSRIs are indicated for GAD?
escitalopram, paroxetine, sertraline
what agents are 2nd line in GAD treatment?
BZD (short use)
bupropion
buspirone
hydroxyzine
imipramine
quetiapine
vortioxetine
what agents are 3rd line in GAD treatment?
citalopram
fluoxetine
mirtazapine
trazodone
augment with SGA
what is the timeline of symptom relief in GAD treatment with SSRIs/SNRIs?
onset of symptom relief: 2-4 weeks
maximal response: 12 weeks
what is the MOA of benzodiazepines?
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
what is the efficacy of BZDs?
provides rapid initial relief of anxiety symptoms but may not be significantly different from placebo after 4-6 weeks of treatment
what symptoms of anxiety do BZDs treat?
somatic symptoms (muscle tension, changes in sleep)
which benzodiazepines have shown efficacy in GAD?
alprazolam, bromazepam, lorazepam, diazepam
which benzodiazepines do not have active metabolites?
LOT drugs
lorazepam, oxazepam, temazepam
what are some common AEs of BZDs?
ataxia
dizziness and lightheadedness
sedation and residual daytime sleepiness
psychomotor impairment
agitation, irritability, confusion
what are some serious AEs of BZDs?
anterograde amnesia
depression, confusion, bizarre behaviour, hallucinations
respiratory depression
what are the benefits of long acting BZDs vs short acting?
long acting are best for taper as less risk of withdrawal
short acting have better hypnotic and sedative properties but have more rebound anxiety
what are the symptoms of benzo withdrawal?
sweating, tremor, nausea, vomiting, rebound anxiety, increased HR, insomnia, agitation, twitching, visual/tactile hallucinations, seizures
what are some precautions in initiating BZD therapy?
substance use hx, sleep apnea, COPD, elderly, CNS depression, pregnancy, clozapine use
what is the antidote to benzos?
flumazenil
why is use of flamazenil limited?
risk of causing seizures in BZD dependent pts
what is a panic attack?
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
what is 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
- maladaptive change in behaviour designed to avoid having panic attacks
what is the clinical presentation of a panic attack?
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
how many sessions of CBT are needed to help treat PD?
8-15
what is first line treatment of PD?
SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) and venlafaxine
what is second line treatment of PD?
TCAs: clomipramine, imipramine
BZDs: alprazolam, clonazepam
what is the third line treatment of PD?
MAOI: phenelzine
how long is treatment with pharmacotherapy in PD?
acute tx duration: 1-3 months
maintenance tx duration: 12 months
what are the s/sx of social anxiety disorder?
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
what is the first line treatment of SAD?
CBT specifically designed for SAD
SSRIs: escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
what is 2nd line treatment of SAD?
venlafaxine
clonazepam
what is 3rd line treatment of SAD?
augmentation of SSRIs with buspirone
which medications can be used in SAD for performance anxiety?
beta blockers: atenolol and propranolol
what are some CIs of beta blockers?
cardiogenic shock, sinus bradycardia, cardiac failure, bronchial asthma, known hypersensitivity
what is the onset of symptom relief in SAD with treatment?
6-8 weeks
can be as early as 3 weeks with venlafaxine
how long is treatment duration of SAD?
continue for 1 year or longer after a response is attained
what are some risk factors for PTSD?
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
what is the command center for fear?
amygdala
what happens to the prefrontal cortex in times of stress?
shuts down the thinking brain
high levels of catecholamine release weaken dlPFC, strengthen amygdala and striatum and increase tonic firing of the LC
what happens after a trauma in PTSD?
- re-experiencing the event with distressing, recollections, dreams, flashbacks, physiological and physical distress
- persistent avoidance of stimuli that might invite memories or experiences of the trauma
- increased arousal
what is the core of PTSD treatment?
trauma-focused psychotherapy
what does trauma-focused psychotherapy include?
cognitive processing therapy
prolonged exposure therapy
eye movement desensitization and reprocessing
what are the goals of pharmacotherapy in PTSD?
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
what are the first line agents for PTSD?
SSRIs: fluoxetine, paroxetine, sertraline
SNRI: venlafaxine
prazosin for trauma related nightmares and to improve sleep
what are the 2nd line agents in PTSD?
fluvoxamine, mirtazapine, phenelzine
adjunctive: SGA
what are the 3rd line agents in PTSD?
in summary: all other antidepressants, anticonvulsants, antipsychotics, adj gapa, clonidine
which agents are not recommended in PTSD?
BENZOS
alprazolam, divalproex, citalopram, olanzapine, tigabine, clonazepam
why are benzos not recommended in PTSD?
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
what are indicators of a good prognosis in OCD?
good social and occupational adjustment
presence of precipitating event
episodic nature of the symptoms
what are indicators of a poor prognosis in OCD?
acting on compulsions
childhood onset
bizarre compulsions
need for hospitalisation
comorbid depression
comorbid personality disorder
delusional beleifs
what are the s/sx of OCD
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”
what is the Y-BOCS used to measure?
measures overall severity of obsessions/compulsions in OCD
what is the interpretation of a Y-BOCS score?
scored from 0 (nonexistent) to 4 (extreme)
response: 25-35% reduction in score
remission: score 8 or below
when is clomipramine recommended in OCD?
after failure of 2 SSRIs
what are the non-pharm treatments for OCD?
CBT
deep brain stimulation
radio frequency wave surgery
what is the first line treatment of OCD?
recommend psychotherapy + SSRI
SSRIs: escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
venlafaxine
adj: aripiprazole, risperidone
what is the second line treatment of OCD?
citalopram, clomipramine, mirtazapine
adj: memantine, quetiapine, topiramate
which agents are not recommended in OCD?
clonazepam, clonidine, desipramine
what is the relapse rate for OCD?
24-89%
when is lifelong therapy recommended in OCD?
after 2-4 severe relapses or 3-4 less severe relapses
