Anxiety Flashcards

1
Q

What is a drug that has a calming effect, relieving anxiety and tension.?

A

Sedative

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2
Q

What is A drug that produces sleep by depressing brain function?
Often cause hangover effects in the morning

A

Hypnotic

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3
Q

What is a drug that reduces anxiety?

A

Anxiolytic

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4
Q

What is a normal emotional state in response to a stressful situation that;s usually transient and commonly caused by the perception of real or potential danger?

A

Anxiety

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5
Q

What are the general medical conditions that cause anxiety?

A

MI, asthma, hyperthyroidism (usually when tx the anxiety improves), migraine, pain

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6
Q

What are the psychiatric disorders that cause anxiety?

A

Mood disorders, schizophrenia, delirium, dementia, substance abuse

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7
Q

What are the medication induced causes of anxiety?

A

Depressants, stimulants

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8
Q

When does anxiety become pathological?

A
  • Pathological anxiety occurs when safe stimuli acquire a meaning of danger
  • Anxiety is excessive, inappropriate or generalized
  • Responses to feared stimuli are maladaptive
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9
Q

When does anxiety become a disorder?

A

Becomes a DISORDER when source of significant subjective distress or functioning impaired

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10
Q

What are the neurochemical theories?

A
--Noradrenergic Model
Hypersensitive autonomic nervous system
--Benzodiazepine Receptor Model
Inhibitory pathway
Deficit in patients with anxiety disorders
--Serotonin Model
Primarily an inhibitory neurotransmitter
May help to reduce ANS hyperactive state
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11
Q

What are the anxiety associated neurotransmitter systems?

A

GABA
Norepinephrine model
Serotonin model

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12
Q

What is the gamma-aminobutyric acid (GABA) receptor?

A

High affinity sites, adjacent to GABA receptors, for benzodiazepine and barbiturates on the cell membrane in the CNS.

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13
Q

What is the MOA of benzodiazepines?

A

The binding of benzodiazepines enhances the action of GABA, resulting in a greater entry of chloride ion

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14
Q

What are the anxiety disorders?

A
Panic disorder (+/-)
Social anxiety disorder (SAD)
Specific phobia
Generalized anxiety disorder (GAD)
Obsessive-compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD)
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15
Q

What is literally the fear of market place or open spaces, also anxiety about being in situations that escape is difficult?

A

Agoraphobia

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16
Q

What do people with agoraphibia avoid?

A

Driving, bridges, tunnels, elevators, airplanes, malls, long lines, sitting in middle of row

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17
Q

Are males or females more affected by anxiety?

A

Females

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18
Q

What are panic attacks?

A
Sudden onset with no warning
Usually last no more than 20-30mins
Can occur at anytime
Overwhelming sense of doom
Fear of dying or losing control
Physical sx
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19
Q

What is a panic attack under the DSM-IV criteria?

A
Period of intense fear or discomfort, in which at least 4 of the following sx developed abruptly and peaked w/in 10 minutes:
Palpitation
Sweating
Trembling
Sensations of SOB
Feeling of choking
CP or discomfort
Nausea or abd distress
Dizziness, lightheadedness, feeling faint
Fear or losing control or going crazy
Fear of dying
Numbness or tingling
Chills or hot flashes
Derealization of depersonalization
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20
Q

What is Generalized anxiety disorder (GAD)?

A

Excessive anxiety and worry about a number of events or activities on most days for at least 6 mo.
Associated w/ 3 or more sx- restlessness, easily fatigued, difficulty concentration, irritability, muscle tension, sleep disturbance.
Significant distress at work and socially
Typically present with somatic complaints

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21
Q

What are the nonphamarcologic therapy options for GAB?

A

Lifestyle changes

CBT

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22
Q

What are the pharmacotherapy tx for GAD?

A
Antidepressants
Benzodiazepines
Buspirone
Pregabalin
Beta Blockers
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23
Q

What should patients with GAD avoid?

A

Caffeine
OTC cold preparations
Marijuana
Excess alcohol or use for sleep

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24
Q

What are the advantages of CBT?

A
It works
It may have low relapse rate when d/c
MOst people like it
TIme-limietd
Overall low price
few side effects
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25
What are the disadvantages of CBT?
``` Harder to admin than meds Limited availability More effort than taking meds Lack of 3rd party coverage Not all patients willing or able ```
26
What are the benzodiazepines used to tx anxiety?
``` Alprazolam (Xanax) Clonazapam (Klonopin) Chlordiazepoxide (Librium) Cloraze[ate (Tranxene) Diazepam (Valium) Halazepam (Paxipam) Lorazepam (Ativan) Oxazepam (Serax) ```
27
What are the most effective and safe medications for acute anxiety sx?
Benzodiazepines
28
Benzodiazepines (-pams)- ROA and absorption
``` Route of Admin Oral, IV, IM, rectal Absorption Rapidly and completely Lipophilic agents-distributed throughout the body ```
29
Benzodiazepines (-pams)- duration of action and metabolism
``` Short, intermediate, long Long-acting form active metabolites with long half-lives Metabolism Hepatic (active metabolites) Excreted in urine; redistributed ```
30
What are the long acting 1-3 day benzodiazepines?
Clorazepate- not used often don’t worry about this one. Chlordiazepoxide Diazepam Flurazepam
31
What are the intermediate 10-20 hour acting benzodiazepines?
Alprazolalm Lorazepam Temazepam
32
What are the short acting 3-8 hour acting benzodiazepines?
Oxazepam | Triazolam
33
Benzodiazepine (-pams)- MOA
Potentiate the inhibitory activity of GABA Binds to the GABA-BDZ receptor complex -Facilitates the opening of Cl- channels Prevents further release of excitatory neurotransmitters (hyperpolarization) *Bind to the allosteric site!
34
What should dosing of benzos be related back to?
Lorazepam
35
What is the onset of high potency benzos?
Fast
36
Benzodiazepine (-pams)- ADRs
SEDATION Fatigue Weakness Psychomotor impairment (decreased memory and decreased recall, ataxia and mental confusion) Paradoxical reactions (mostly in special populations like elderly, brain injured, MR, kids) Rebound anxiety and insomnia
37
Benzodiazepines (-pams)- tapering
<10-25% every 1-2 wks At 50% initial dose, slow taper further Maintain multiple dosing to minimize taper-related plasma level fluctuations Discontinuation is less difficult over the first 50% of the dose A longer taper period is needed for the final 50% of the dose to avoid potentially severe withdrawal sx
38
Benzodiazepines (-pams)- drug interactions
--Other CNS depressants -- ETOH, opiates --Cimetidine --Inhibits metabolism of longer acting BZDs --Fluoxetine--Decreases clearance of diazepam --CYP3A4 inhibitors (fluoxetine, fluvoxamine, grapefruit juice, ketoconazole, nefazodone) Decrease clearance of alprazolam
39
What are the three big disadvantages of benzodiazepines?
Physiologic dependence Risk for withdrawal reactions with abrupt discontinuation Concern over abuse potential
40
What results from abrupt withdrawal from benzodiazepines?
Abrupt withdrawal results in withdrawal symptoms-- confusion, anxiety, agitation, restlessness, insomnia, tension Long-acting tend to withdrawal themselves Short-acting more severe withdrawal treatment = long t1/2 benzo
41
When is a benzo overdose lethal?
Benzo overdose seldom lethal unless combined with other central depressants ie., ETOH
42
What is The antidote for a benzodiazepine overdose?
FLUMAZENIL** rapidly reverses effects of benzos IV May require frequent administration May precipitate withdrawal in dependent patients or cause seizures in epileptics
43
Are barbutrates used for insomnia and anxiety?
No
44
Barbiturates- ADRs
Induce tolerance, physical dependency, severe withdrawal symptoms Potentially Fatal Respiratory Depression Suppresses hypoxic and chemoreceptor response to CO2 narrow therapeutic range
45
Why do barbiturates have alot of drug interactions?
They are p450 inducers
46
Barbiturates- indications
Ultra-short t1/2: IV General Anesthesia thiopental Sedative/hypnotic At low doses, sedation (calming, reduced excitement) higher doses hypnosis anesthesia coma and death Amobarbital (amytal), pentobarbital, secobarbital Anticonvulsant --Treatment of tonic-clonic, status epilepticus, eclampsia --DOC in children with recurrent febrile SZ Phenobarbital
47
What is the drug of choice for a child with recurrent febrile sz?
Phenobarbital
48
Barbiturates- MOA
Potentiates GABA action on chloride entry into neuron ->hyperpolarization Barb receptor on GABA different than Benzo Block excitatory glutamate receptors Anesthetic concentrations block Na+ channels
49
What are the long acting (1-2days) barbiturates?
Phenobarbital
50
What are the short-acting (3-8 hours) barbiturates?
Pentobarbital Secobarbital Amobarbital
51
What are the ultra short-acting (20 min) barbiturates?
Thiopental
52
Barbiturates- pharmakokinetics
``` PO Redistribute in body from brain to splanchnic areas to skeletal muscle then adipose tissue Metabolized in liver P450 inducer drug-drug interactions Renal excretion ```
53
Barbiturates- ADRs
Drowsiness, impaired concentration, mental/physical sluggishness Synergizes ETOH Drug hangover Nausea and dizziness
54
Are barbiturates a P450 inducer?
Increase porphyrin synthesis contraindicated in patients with acute intermittent porphyria
55
What happens with abrupt withdrawal of barbiturates?
Abrupt withdrawal-> tremors, anxiety, weakness, restlessness, N/V, SZ, delerium, cardiac arrest More severe than opiate withdrawal, can result in death
56
What occurs with OD of barbiturates?
Severe respiratory depression coupled with CV depression-> shock; shallow, infrequent breathing
57
What is the tx of a barbiturate OD?
No antagonist available | Ventilation; purge stomach; hemodialysis; alkalinization of urine with phenobarbital
58
What components of anxiety does a beta blocker help with?
Physiologic component of anxiety: tachycardia, palpitations, tremor, sweating No CNS depression non-addicting, no drowsiness Do not use in asthma, diabetes, CHF monitor BP, pulse Helpful for performance anxiety: propranolol 10 mg prn
59
When should beta blockers be used to tx anxiety?
When you have a patient that has stage fright or anxiety in front of a crowd. Not a regular medication to manage anxiety
60
Buspirone (Buspar®)- indications
Treat anxiety d/o
61
Buspirone (Buspar®)- MOA
Reduce 5-HT transmission by acting as partial agonist at these receptors Some affinity for DA receptors also
62
Buspirone (Buspar®)- advantages and disadvantages
Advantages: Dependence unlikely; minimal sedation Disadvantages: Only effective in GAD; doesn’t work in severe anxiety Slow onset of action CAUSES HYPOTHERMIA; INCREASED PROLACTIN/GH P450 metabolism- chance of drug interactions.
63
Buspirone (Buspar®)- ADRs
HA, dizziness, nausea
64
How long does it take for buspirone to start working?
1 week
65
Pregabalin-MOA
Similar to gabapentin Site of action- Alpha(2) delta subunit of voltage dependent calcium channels Reduces calcium influx into the neuron and inhibits neuronal excitability Reduces the release of glutamate, NE, and substance P
66
Pregabalin- ADRS (in GAD)
``` Dizziness Somnolence Dry Mouth Abnormal Thinking Blurred vision Diarrhea Incoordination Ataxia ```
67
What type of antidepressant is able to be used in all anxiety disorders?
SSRIs
68
What is considered the DOC for GAD?
SSRI
69
What is DOC for panic disorder?
SSRI (FLX, SERT, PAR)
70
What can a combination of benzos and antidepressants cause?
Jitteriness syndrome or hyperrsensitivity reaction-- jitteriness, shakiness, increased anxiety, and insomnia. Start low and go slow!
71
What are the advantages of SSRI/VLFX in panic disorder treatment?
Effective for comorbid depression Effective in managing mixed patients- especially with PD, GAD, OCD Lower risk in suicidal patients Generally well tolerated and no abuse potential Once daily dosing Relapse prevention
72
What are the disadvantages of SSRI/VLFX for treating panic disorder-GAD?
Delayed onset (days to weeks) Transient activation early in therapy SE: GI, sexual dysfunction, discontinuation syndrome Withdrawal reactions when discounted
73
What is SSRI induced anxiety?
Enhanced 5-HT release or have supersenstive 5-HT2 receptors, which increases glutamate High potency BZDs have rapid anxiolytic effects and also reduce early SSRI-induced anxiety
74
Who needs long term medications for anxiety?
The majority of anxiety and panic disorder patients need long-term tx Relapse rates after discontinuation of medication are significant Tapering needs to be very gradual (3-6mo)
75
What antihistamines are used to tx anxiety and insomnia?
Diphenhydramine (Benadryl) | Hydroxyzine (Atarax)
76
What are the side effects of antihistamines?
Non- addicting | Some anticholinergic effects
77
ETOH- MOA
Antianxiety and sedative effects CNS depressant producing sedation then hypnosis with increasing doses Shallow dose-response curve Sedation over wide dose range
78
ETOH- pharmacokinetics
``` PO; readily absorbed Vd close to total body water Metabolized by liver ETOH->acetaldehyde-> acetate Eliminated via kidneys and lungs Synergizes other sedative agents Severe CNS depression with barbs and antihistamines ```
79
ETOH- ADRs
Chronic consumption: gastritis, nutritional deficiencies, severe liver disease, cardiomyopathy
80
What medications are involved with the treatment of alcohol withdrawal?
-Benzodiazepines -Carbamazepine for SZ during withdrawal -Disulfiram (Antabuse) Conditioned avoidance response Blocks oxidation of acetaldehyde to acetate Accumulation of acetaldehyde flushing, TACHY, hyperventilation, nausea