Anxiety Flashcards

Question

Imipramine

Answer 1

Anticholinergic; cardiotoxic in overdose. Not well tolerated.

Answer 2

SSRI - Withdrawal symptoms if not tapered. Risk for drug interactions due to inhibition of CYP1A2 and 2C19.

Answer 3

Useful for co-morbid insomnia. Dose-related anticholinergic effects limit clinical use.

Answer 4

Helpful with comorbid insomnia. Lower doses are more sedating. May increase appetite and lead to weight gain.

Answer 5

ompared 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.

Answer 6

Sedation and dizziness are common. Weight gain, especially with long-term use.

Answer 7

Compared to other SSRIs insomnia, agitation, dizziness.

Answer 8

Compared to other antidepressants greater risk for insomnia or agitation as well as increased blood pressure. Possible benefit for comorbid pain. Few drug interactions. Withdrawal symptoms if not tapered. Better evidence for psychological symptoms (e.g. ruminative worry of GAD).

Answer 9

Ratio of women: men with GAD is 2:1 Onset usually in late adolescents or early adulthood Cases in older adults as well

Answer 10

Unknown Likely combined effect of biological and psychological factors

Answer 11

Interplay of: Thoughts Emotions Behaviours

Answer 12

bupropion and norepinephrine reuptake inhibitor (STAR)

Answer 13

GAD frequently co-occurs with other mental health disorders which complicates diagnosis and tx Some studies have suggested up to 90% of patients with GAD present with comorbid mental disorders during their life MDD, other anxiety disorders, substance use disorders, bipolar, sleep disorders

Answer 14

GAD can also co-occur with physical health problems & may exacerbate these physical illnesses and interfere with a person’s ability to manage them: Chronic pain Diabetes Cardiovascular disease GI distress Headache Fatigue

Answer 15

Psychotherapy + pharmacotherapy Psychotherapy is least invasive and safest Pharm indicated if sxs severe enough to produce fxnal disability

Answer 16

Reduce/avoid alcohol, caffeine, nicotine use Avoidance of non-prescription stimulants & medications known to induce anxiety Exercise Psychotherapy +/- counselling Cognitive behavioral therapy (CBT) Relaxation techniques Meditation, yoga Biofeedback

Answer 17

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 The Psychopharmacology Algorithm Project at the Harvard South Shore Program (PAPHSS) provides guidance

Answer 18

Avoid Ad Quetiapine is effective for GAD and may be preffered Consider VPA in men with mania with GAD but not in women of childbearing potential due to teratogenicity

Answer 19

Paroxetine, escitalopram, sertraline all studied for GAD (others used in practice)

Answer 20

Venlafaxine and duloxetine both studied for GAD Escitalopram and venlafaxine equally effective but escitalopram better tolerated May have increased effect for ruminative worry

Answer 21

Imipramine and trazodone more effective than placebo but less tolerable Open label trials showing mirtazapine to be effective Bupropion found to have similar efficacy to escitalopram

Answer 22

Most often used for ACUTE anxiety 2-3 weeks until antidepressant begins to work (BRIDGE) Long-term use not recommended due to physiological/psychological dependence Not effective for depressive symptoms and may worsen depression (CNS depressant, can make depression sx worse)

Answer 23

Effective in short term GAD studies 1 trial found it is effective for use in patients stopping long term benzos (during withdrawal period)

Answer 24

Delayed onset of effect (2 weeks or longer), not useful for acute anxiety (misinformation here often, not a safer benzo) Inconsistent reports of efficacy for long term use May be more useful for patients who have not used benzos 5-HT1A partial agonist Rarely used in clinical practice

Answer 25

H1 and 5-HT2 antagonist Effective in studies up to 12 weeks 2nd/3rd line due to ADEs and lack of efficacy for comorbidities Anticholinergic, sedation (A LOT – 2nd or 3rd line) Very rarely used in clinical practice due to lack of tolerability

Answer 26

3rd line due to ADEs and limited evidence (reserve them for 3rd line due to s/e) Anxiolysis is mediated by 5-HT1A Olanzapine, risperidone, quetiapine effective as augmenting agents

Answer 27

Bind to the benzodiazepine receptors on the GABA(A) 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

Answer 28

Provides rapid initial relief of anxiety symptoms, but effects may not be significantly different from placebo after 4-6 weeks of treatment Primarily effective for relieving somatic symptoms (muscle tension, changes in sleep), rather than the key psychic features (ruminative worry) that are characteristic of GAD Magnitude of effect for GAD appears to be similar to that of cognitive therapy RCT evidence supports the efficacy of alprazolam, bromazepam, lorazepam and diazepam in GAD

Answer 29

While there are no RCTs evaluating the use of clonazepam in GAD, it is used extensively in clinical practice for the treatment of anxiety and it is likely that the benefits are similar to other benzodiazepines Used as it maintains its effect within the entire dosing window (longer half-life) and avoids the peaks and troughs as seen with other benzos

Answer 30

Ataxia Dizziness, lightheadedness Sedation & residual daytime sleepiness Tolerance to sedation may develop (brain fog, can’t concentrated, impair coordination, confusion) Psychomotor impairment Agitation, irritability, confusion Variability in the way people respond to benzos Paradoxical responses (or in kids, brain injury  more irritable, agitated)

Answer 31

Anterograde amnesia (often does not persist) More common with lorazepam Memory impairment Depression, confusion, bizarre behaviour, hallucinations Respiratory depression

Answer 32

Tolerance may also develop to the anxiolytic effects, necessitating dosage increases with chronic use Psychological and physical dependence may develop with long-term use Withdrawal symptoms can occur following discontinuation of therapy with as little as one week of use (anxiety can come back)

Answer 33

Risk of dependence increases with higher dose and/or longer use Risk further increased with history of alcohol use disorder or other substance use disorders or personality disorders

Answer 34

Long Acting= good choice for tapering as less risk of withdrawal (i.e. diazepam, clonazepam), more daytime sedation Short Acting= better hypnotic and sedative properties but more rebound anxiety (i.e. lorazepam), inter-dose withdrawal, anterograde amnesia

Answer 35

LOT drugs (lorazepam, oxazepam, temazepam) preferred in elderly and liver dysfunction due to no active metabolites

Answer 36

sweating, tremor, nausea, vomiting, rebound anxiety, ↑ heart rate, insomnia, agitation, twitching, visual/tactile hallucinations, SEIZURES (onset within 1-2 days after BZD stopped)

Answer 37

Avoid by tapering BZD

Answer 38

30% of patients experience withdrawal if BZD stopped suddenly after 8 wks of tx.

Answer 39

Use diazepam for taper (unless contraindication), conservative schedule: decrease diazepam by 10-20% q1-2weeks (often switch to diazepam; too fast of taper (trial) can have breakthorough anxiety

Answer 40

Substance use history (concurrent use with opioids may cause profound respiratory depression, coma, death), sleep apnea, COPD, elderly, CNS depression, pregnancy (floppy infant syndrome; possible teratogen & can precipitate withdrawal in newborns if used in 3rd trimester), clozapine-use (may lead to significant sedation, excessive salivation, and rare respiratory arrest)

Answer 41

Rarely fatal alone but may be fatal when taken in combination with alcohol, opioids, barbiturates (strong CNS depressants).

Answer 42

Benzo antidote --> Flumazenil Reverses hypnotic-sedative effect of BZD but clinically use is limited due to risk of causing seizures in BZD dependant patients

Answer 43

Sertraline, Citalopram

Answer 44

A distinct period of intense fear or discomfort when 4 or more symptoms develop suddenly and achieve a peak within 10 minutes:

Answer 45

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 behavior designed to avoid having panic attacks

Answer 46

Females 2: Males 1 Rates increase during adolescents (especially in females) and peak during adulthood Median age at onset is 20-24 years If untreated disorder is chronic but waxing and waning (periods of stability; periods of debilitation)

Answer 47

Panic Disorder

Answer 48

Other anxiety disorders Depression 10-65% In 1/3 of patients the depression precedes panic disorder Bipolar disorder Alcohol use disorder Higher rates of suicide attempts and suicidal ideation Medical comorbidities (lead to disruption in catecholamines, neurotransmitters) Dizziness, cardiac arrhythmias, hyperthyroidism, asthma, COPD, IBS, Cushing’s syndrome, pheochromocytoma

Answer 49

Panic attacks vary in frequency and intensity Wax and wane over time and in response to stressors 1/3 of patients achieve remission 1/5 of patients have unremitting & chronic course Most patients require long-term treatment to achieve remission, prevent relapse, & reduce risks associated with co-morbidity

Answer 50

Long duration of illness Comorbidity with personality, mood, other anxiety disorders Excessive sensitivity to physical symptoms of anxiety

Answer 51

2nd line after several trials of antidepressants have failed Do not use as monotherapy if comorbid depression (will not treat mood disorder) Avoid if history of substance/alcohol use disorder Limited data support combo BZD + SSRI during first 1st few weeks of treatment for rapid symptom relief BZDs are NOT an effective strategy to treat an acute panic attack because the onset of BZD will typically occur after the panic attack

Answer 52

Most patients with PD are hypersensitive to medication ADEs at initiation 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 patients with significant avoidance, full remission may take up to 6 months or longer

Answer 53

Onset within hours for autonomic symptoms of anxiety, full benefit may take 4-6 weeks

Answer 54

Median age of onset: 13 years 75% have an age at onset between 8-15 years Onset can occur in early childhood (may follow a stressful or humiliating experience, e.g. being bullied) Prevalence decreases with age Higher rates in females than males

Answer 55

Unemployment is a strong predictor of persistence of SAD

Answer 56

Only ~50% of patients with SAD seek treatment and usually only after 15-20 years of symptoms

Answer 57

ay be used for performance related SAD Decreases tremor, palpitations, blushing Dosing Propranolol 10-80mg or atenolol 25-50mg 1-2 hour before performance Give test dose to assess tolerability Contraindications: cardiogenic shock, sinus bradycardia, cardiac failure, bronchial asthma, known hypersensitivity