Anxiety

Question 1

Anxiety

Answer 1

an uncomfortable feeling of vague fear or apprehension accomplished by characteristic physical sensations

Question 2

Drug induced anxiety

Answer 2

caffeine, methylphenidate, cocaine, nicotine, albuterol, stimulants, methamphetamine, ephedrine, pseudoephedrine, levodopa, metoclopramide, ACh, SSRIs

Question 3

Psychiatric conditions that induce anxiety

Answer 3

mood disorders, substance abuse, withdrawal, eating disorders, personality disorders

Question 4

Medical conditions that induce anxiety

Answer 4

angina, arrhythmias, anemia, electrolyte imbalances, hypoglycemia, COPD, Asthma, hypo/hyperthyroidism

Question 5

Drug withdrawal anxiety

Answer 5

barbiturates, benzo, narcs, EtOH, sedatives

Question 6

Types of anxiety

Answer 6

situational, general, panic disorder, OCD, PTSD, social phobia

Question 7

Generalized anxiety disorder

Answer 7

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

Question 8

Panic disorder

Answer 8

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

Question 9

Obsessions

Answer 9

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

Question 10

Compulsions

Answer 10

repetitive, intentional and purposeful behaviors in response to obsessions, sense of anxiety if not allowed to perform; washing hands, ordering, counting

Question 11

PTSD

Answer 11

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

Question 12

Social phobia

Answer 12

fear of social or performance situations, exposure provokes anxiety, pt recognizes as unreasonable, onset teenage years, usually continuous

Question 13

Locus coeruleus

Answer 13

brainstem nucleus containing 70% of noradrenergic neurons in the brain; implicated in GAD, panic, PTSD, OCD, social anxiety

Question 14

stimulation of the LC results in

Answer 14

a fear response and sx of anxiety

Question 15

GABA

Answer 15

inhibitory neurotransmitter for other neurotransmitters, GAD and panic

Question 16

Benzos

Answer 16

agonist that binds to the BZD receptor and enhances GABA receptor binding, GAD and panic

Question 17

Serotonin

Answer 17

neurons originate mostly in the raphe nucleus of brainstem and project into the cerebral cortex, limbic, and hypothalamus, GAD, panic, OCD, social anxiety

Question 18

Non pharm approaches for anxiety

Answer 18

psychotherapy, relaxation, situational avoidance, exss

Question 19

Pharm options

Answer 19

short term- BZDs, long term- buspirone, SSRIs, SNRIs, TCAs, resistant anxiety- BB, mood stabilizers

Question 20

Benzos anxiety and panic

Answer 20

Alprazolam (Xanax), Lorazepam (ativan), Clonazepam (klonopin), Diazepam (Valium), chlordiazepoxide (Librium), Cloazepate (Tranxene), Flurazepam (Dalmane), Oxazepam (Serax), Midazolam (Versed)

Question 21

Benzo sleep aids

Answer 21

temazepam (Restoril), Estazolam (Prosom), triazolam (Halcion)

Question 22

Benzo MOA

Answer 22

binds to benzodiazepine receptors; enhances the inhibitory effects of GABA

Question 23

Prodrugs Benzo

Answer 23

diazepam, chlordiazepoxide, clorazepate- T1/2 of metabolite, more than 100 hrs w/ chronic use, very long acting, avoid in elderly

Question 24

Active parent drugs Benzo

Answer 24

lorazepam, oxazepam, alprazolam, clonazepam, no active metabolites, short T 1/2 (except clonazepam, long T1/2)

Question 25

Benzo lipophilicity

Answer 25

higher fat solubility improves passage into CNS, faster onset

Question 26

Disadvantages of Benzos

Answer 26

tolerance, dependence, addiction, need for taper, cog impairment, only symptomatic tx

Question 27

Dosage of alprazolam (Xanax)

Answer 27

.5-2 mg po.iv.im 6-8 hrs, max 10 mg daily

Question 28

dosage of Clonazepam (Klonopin)

Answer 28

.25-1 mg po BID-TID

Question 29

Dosage of Diazepam (valium)

Answer 29

2-10 mg po TID-QID, max 30 mg/8hrs

Question 30

Dosage lorazepam (ativan)

Answer 30

.5-2mg PO/IM/IV TID-QID, max 10 mg/day

Question 31

Benzodiazpines ADRs

Answer 31

CNS depression, resp depression, impaired memory, impaired cog, dysphagia, tolerance/ dependence

Question 32

BZD tolerance and dependence

Answer 32

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

Question 33

Drug interactions of BZD

Answer 33

other CNS depressants, drugs that compete with or inhibit metabolism, drugs that decrease absorption, grapefruit juice

Question 34

Discontinuation of therapy of BZD

Answer 34

must taper slowly, example 5-10% of dose every 2 weeks, may take months to successfully and safely taper to discontinue therapy

Question 35

Prevention of withdrawal of BZD

Answer 35

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

Question 36

Withdrawal symptoms

Answer 36

irritability, muscle aches, nausea, hyperreflexia, could lead to seizures, coma or death if untreated

Question 37

Antidote for overdose of BZD

Answer 37

flumazenil (Romazecon), use is controversal, seizures

Question 38

Buspirone (BuSpar) MOA

Answer 38

mid brain modulator, has effects on norepinephrine, serotonin, dopamine, ACh, and GABA systems

Question 39

Clinical use of Buspirone (BuSpar)

Answer 39

GAD, social anxiety, OCD, PTSD (adjunct only)

Question 40

Buspirone (BiSpar) advantages

Answer 40

non-sedating, no interactions w/ CNS depressants, including EtOH, rare side effects, little or no effect on sexual function, no dependence

Question 41

Buspirone (BuSpar)

Answer 41

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

Question 42

SSRI dosing for anxiety

Answer 42

often higher than seen w/ depression, still start low and titrate

Question 43

Clinical use of SSRI

Answer 43

depression, OCD, panic, social anxiety, PTSD, more chronic

Question 44

Clomipramine (Anafranil)

Answer 44

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

Question 45

SNRI agents

Answer 45

Vanlafaxine, duloxetine

Question 46

SNRIs

Answer 46

avoid abrupt d/c, up to 4-6 weeks for benefit, titrate to full dose, benfit for chronic pain, initiate slowly

Question 47

SNRI uses

Answer 47

GAD, OCD, panic (if chronic), social anxiety

Question 48

Beta blockers used for

Answer 48

social anxiety (PRN), PTSD

Question 49

BB

Answer 49

reduces peripheral sx of anxiety, Propranolol (Inderal), non-selective BB, blunts norepi and epi, can cause drowsiness, fatigue, hypotension, N/V/D

Question 50

BB propranolol dosing

Answer 50

10 mg PO prior to event

Question 51

Mood stabilizers

Answer 51

augmenting agents following tx failure w/ 1st line agents, may reduce intrusive thoughts and sx of aggression, irritability, and hyperarousal in PTSD

Question 52

Mood stabilizing agents

Answer 52

Carbamazepine, divalproic acid, lamotrigine, gabapentin, topiramate, pregabalin, atypical antipsychotics

Question 53

Duration of tx of mood stabilizing agents

Answer 53

4-6 weeks, except BZD, anxiety disorders are often life-long, may require chronic tx, decision to D/C or taper must be individualized