Anxiety Flashcards
Anxiety
an uncomfortable feeling of vague fear or apprehension accomplished by characteristic physical sensations
Drug induced anxiety
caffeine, methylphenidate, cocaine, nicotine, albuterol, stimulants, methamphetamine, ephedrine, pseudoephedrine, levodopa, metoclopramide, ACh, SSRIs
Psychiatric conditions that induce anxiety
mood disorders, substance abuse, withdrawal, eating disorders, personality disorders
Medical conditions that induce anxiety
angina, arrhythmias, anemia, electrolyte imbalances, hypoglycemia, COPD, Asthma, hypo/hyperthyroidism
Drug withdrawal anxiety
barbiturates, benzo, narcs, EtOH, sedatives
Types of anxiety
situational, general, panic disorder, OCD, PTSD, social phobia
Generalized anxiety disorder
unrealistic or excessive anxiety about 2 or more life events for majority of days for more than 6 months, 2:3 m:f, onset late adolescence
Panic disorder
1-4% lifetime prevalence, women 2-3x more likely, onset late adolescence-30s, chronic but wax and wanes, recurrent and unexpected attacks, develop and peak withing 10 mins, 20-30 mins, agorophobia common
Obsessions
persistent ideas, thoughts, images or impulses that cause anxiety, pts attempt to ignore or suppress, pt often acknowledge the thoughts are product of mind; fear of germs, was an act performed
Compulsions
repetitive, intentional and purposeful behaviors in response to obsessions, sense of anxiety if not allowed to perform; washing hands, ordering, counting
PTSD
reaction of intense fear, helplessness, horror after exposure to traumatic event, persistent re-experience of the event, nightmares, flashbacks, avoidance of stimuli, acute 3 months, M:F 1:2, onset withing 3 months of event
Social phobia
fear of social or performance situations, exposure provokes anxiety, pt recognizes as unreasonable, onset teenage years, usually continuous
Locus coeruleus
brainstem nucleus containing 70% of noradrenergic neurons in the brain; implicated in GAD, panic, PTSD, OCD, social anxiety
stimulation of the LC results in
a fear response and sx of anxiety
GABA
inhibitory neurotransmitter for other neurotransmitters, GAD and panic
Benzos
agonist that binds to the BZD receptor and enhances GABA receptor binding, GAD and panic
Serotonin
neurons originate mostly in the raphe nucleus of brainstem and project into the cerebral cortex, limbic, and hypothalamus, GAD, panic, OCD, social anxiety
Non pharm approaches for anxiety
psychotherapy, relaxation, situational avoidance, exss
Pharm options
short term- BZDs, long term- buspirone, SSRIs, SNRIs, TCAs, resistant anxiety- BB, mood stabilizers
Benzos anxiety and panic
Alprazolam (Xanax), Lorazepam (ativan), Clonazepam (klonopin), Diazepam (Valium), chlordiazepoxide (Librium), Cloazepate (Tranxene), Flurazepam (Dalmane), Oxazepam (Serax), Midazolam (Versed)
Benzo sleep aids
temazepam (Restoril), Estazolam (Prosom), triazolam (Halcion)
Benzo MOA
binds to benzodiazepine receptors; enhances the inhibitory effects of GABA
Prodrugs Benzo
diazepam, chlordiazepoxide, clorazepate- T1/2 of metabolite, more than 100 hrs w/ chronic use, very long acting, avoid in elderly
Active parent drugs Benzo
lorazepam, oxazepam, alprazolam, clonazepam, no active metabolites, short T 1/2 (except clonazepam, long T1/2)
Benzo lipophilicity
higher fat solubility improves passage into CNS, faster onset
Disadvantages of Benzos
tolerance, dependence, addiction, need for taper, cog impairment, only symptomatic tx
Dosage of alprazolam (Xanax)
.5-2 mg po.iv.im 6-8 hrs, max 10 mg daily
dosage of Clonazepam (Klonopin)
.25-1 mg po BID-TID
Dosage of Diazepam (valium)
2-10 mg po TID-QID, max 30 mg/8hrs
Dosage lorazepam (ativan)
.5-2mg PO/IM/IV TID-QID, max 10 mg/day
Benzodiazpines ADRs
CNS depression, resp depression, impaired memory, impaired cog, dysphagia, tolerance/ dependence
BZD tolerance and dependence
does not usually occur to anxiolytic effect, may occur if higher daily doses for several weeks, smaller daily doses over several months, fast onset agent being utilized, avoid by using a slower onset drug, longer acting drug
Drug interactions of BZD
other CNS depressants, drugs that compete with or inhibit metabolism, drugs that decrease absorption, grapefruit juice
Discontinuation of therapy of BZD
must taper slowly, example 5-10% of dose every 2 weeks, may take months to successfully and safely taper to discontinue therapy
Prevention of withdrawal of BZD
taper doses by switching to an agent w/ a shorter T1/2 or taper a certain percentage of daily dose/week until weaned off, taper over 4-12 weeks, monitor for relapse or rebound anxiety, monitor for withdrawal
Withdrawal symptoms
irritability, muscle aches, nausea, hyperreflexia, could lead to seizures, coma or death if untreated
Antidote for overdose of BZD
flumazenil (Romazecon), use is controversal, seizures
Buspirone (BuSpar) MOA
mid brain modulator, has effects on norepinephrine, serotonin, dopamine, ACh, and GABA systems
Clinical use of Buspirone (BuSpar)
GAD, social anxiety, OCD, PTSD (adjunct only)
Buspirone (BiSpar) advantages
non-sedating, no interactions w/ CNS depressants, including EtOH, rare side effects, little or no effect on sexual function, no dependence
Buspirone (BuSpar)
pts, often do not feel it is effective due to slow onset and lack of buzz, may take 2-6 weeks to get full effect, multiple daily dosing, chronic med
SSRI dosing for anxiety
often higher than seen w/ depression, still start low and titrate
Clinical use of SSRI
depression, OCD, panic, social anxiety, PTSD, more chronic
Clomipramine (Anafranil)
TCA, used for OCD, not well tolerated (ACh side effects, 8-12 week for benefit), combo w/ SSRIs, benefit in chronic pain, avoid in heart disease, suicidal pts
SNRI agents
Vanlafaxine, duloxetine
SNRIs
avoid abrupt d/c, up to 4-6 weeks for benefit, titrate to full dose, benfit for chronic pain, initiate slowly
SNRI uses
GAD, OCD, panic (if chronic), social anxiety
Beta blockers used for
social anxiety (PRN), PTSD
BB
reduces peripheral sx of anxiety, Propranolol (Inderal), non-selective BB, blunts norepi and epi, can cause drowsiness, fatigue, hypotension, N/V/D
BB propranolol dosing
10 mg PO prior to event
Mood stabilizers
augmenting agents following tx failure w/ 1st line agents, may reduce intrusive thoughts and sx of aggression, irritability, and hyperarousal in PTSD
Mood stabilizing agents
Carbamazepine, divalproic acid, lamotrigine, gabapentin, topiramate, pregabalin, atypical antipsychotics
Duration of tx of mood stabilizing agents
4-6 weeks, except BZD, anxiety disorders are often life-long, may require chronic tx, decision to D/C or taper must be individualized
