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Chapter 4 - Nervous System > Anxiety > Flashcards

Anxiety Flashcards

1
Q

What are the psychological and somatic symptoms of anxiety?

A

Psychological:
Feelings of apprehension, fear, tension, panic
Outbursts of hostility, insomnia
Circling thoughts, inability to concentrate, easily distracted, lapses of memory

Somatic: 
Cardiovascular - palpitations, brady/tachycardia, hypertension
Respiratory - rapid shallow breathing
GI - diarrhoea dysphagia
Musculoskeletal - agitation , tremor
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2
Q

What is the 1st, 2nd and 3rd drug treatment for generalised anxiety? If non-pharmacological treatments not working/wanted.

A
  1. Selective serotonin reuptake inhibitor (SSRI) e.g. sertraline, paroxetine, or escitalopram
  2. A selective serotonin-noradrenaline reuptake inhibitor (SNRI), e.g. duloxetine or venlafaxine possible alternative
  3. Pregabalin can be offered if SSRIs or SNRIs are contraindicated or not tolerated
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3
Q

What is the drug treatment option for moderate/severe short term or crisis anxiety?

A

Benzodiazepines e.g

  1. Alprazolam (Xanax) not prescribable in primary care on the NHS.
  2. Chlordiazepoxide hydrochloride (Librium)
  3. Diazepam
  4. Oxazepam
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4
Q

What happens in a benzodiazepine overdose? (6)

A
  1. Drowsiness
  2. Ataxia (Lack of voluntary coordination of muscle movement)
  3. Dysarthia (difficulty speaking)
  4. Nystagmus (involuntary eye movement/dancing eyes)
  5. Respiratory depression
  6. Coma
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5
Q

Name the benzodiazepine antidote?

A

Flumazenil - benzodiazepine antagonist

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6
Q

Cautionary advise with bezodiazepine use?

A
  1. Not for prolonged use and should not be abruptly stopped

2. Driving and skilled tasks - due to drowsiness which may persist to the next day

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7
Q

Mechanism of action of benzodiazepines?

A

Benzodiazepines enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties.

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8
Q

What can Chlordiazepoxide hydrochloride be used for in addition to anxiety?

A

Treatment of alcohol withdrawal in moderate and in severe dependence

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9
Q

Chlordiazepoxide hydrochloride dose for short term use in anxiety?

A

10mg TDS increased if needed to 60-100mg daily.

Elderly & debilitated patients 5mg TDS increased to 30-50mg if needed in divided doses.

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10
Q

Chlordiazepoxide hydrochloride dose for alcohol withdrawal?

A

Moderate dependence: 10-30mg QDS - dose to be gradually reduced over 5-7 days

Severe: 10-50mg QDS & 10-40mg PRN during first 2 days. then reduce over 5-7 days.
Max dose 250mg daily

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11
Q

Chlordiazepoxide use is not recommended for…? (3)

A

Chlordiazepoxide is not recommended;

  1. for long term use (i.e. longer than 4 weeks),
  2. mild anxiety
  3. children.
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12
Q

What is the diazepam dose for anxiety?

A

2mg TDS then increased if necessary to 15-30mg daily in divided doses.

Elderly & debilitated patients:
1mg TDS and increased if necessary to 7.5-15mg

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13
Q

What is the diazepam dose for insomnia associated with anxiety?

A

5-15mg daily at night

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14
Q

What is the diazepam dose for severe acute anxiety/acute panic attack/acute alcohol withdrawal?

A

IM injection or slow intravenous injection:

10mg then 10mg after at least 4 hours if needed. intravenous injection at a rate of not more than 5mg/min

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15
Q

Diazepam rectal formulation is not licensed for use in which age group?

A

children under 1 years

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16
Q

Which warning labels does Diazepam have?

A
  1. This medication may make you sleepy. if this happens do not drive or use tools or machines. do not drink alcohol.
  2. This medicine makes you sleepy. if you still feel sleepy the next day, do not drive or use tools or machines. do drink alcohol.
17
Q

What is the Oxazepam dose for short term anxiety?

A

15-30mg TDS-QDS

Elderly/Debilitated patients - 10-20mg TDS-QDS

18
Q

Which 4 groups of patients should benzodiazepines be used in caution or not at all?

A
  1. Elderly - reduced dose as they are more susceptible to adverse effects
  2. Significant respiratory impairment
  3. Neuromuscular disease
  4. Liver failure - as they precipitate hepatic encephalopathy
19
Q

Are benzodiazepines suitable for use in:

  1. Renal impairment
  2. Hepatic impairment
  3. Pregnancy
  4. Breastfeeding
A
  1. Dose adjustments - start with small doses in severe impairment
  2. Can precipitate coma. If treatment necessary - use one with a short half-life such as temazepam or oxazepam. Or use lorazepam as it depends less on the liver for elmination. Avoid in severe impairment
  3. Avoid regualr use in pregnancy - use only if clear indication and need such as seizure control. Risk of neonatal withdrawal symptoms.
  4. Avoid if possible - present in breast feeding
20
Q

What are the signs of abrupt withdrawal of benzodiazepines? (9)
Severe (3)

A 
Headache
Muscle pain 
Exreme anxiety
Tension 
Nervousnes
Sweating
Confusion and Irritability 
Depression
Diarrhoea.
Severe cases:
feeling of unreality 
being separated from the body
hypersensitivity to light 
numbness and tingling sensation of extremities
21
Q

Common side effects of benzodiazepines? (5)

A

Side effects are usually dose dependent

Fatigue
Sedation
Dizziness
Headache
Vertigo
22
Q

What CD class is diazepam and Oxazepam?

A

CD4 -1

23
Q

What drug class does buspirone hydrochloride belong to?

A

Serotonin receptor agonists

24
Q

buspirone hydrochloride is used for anxiety short term. What is the dose?

When should dose be adjusted?

A

5mg 2-3 times a day increased if necessary to 45mg daily.

Dose should be reduced to 2.5mg BD daily if taken with potent inhibitors of CYP34A.

25
Q

Generalised anxiety disorder is managed using a step by step approach…describe it

A
  1. Assess GAD - severity, factors, co-morbidities etc
  2. Low intensity psychological interventions based on cognitive behavioural therapy e.g. Individual guided self help, psychoeducational groups
  3. High intensity CBT, or applied relaxation or drug treatment
    First line SSRI - Sertraline
    Second line SNRI - venlafaxine
    Third line Pregabalin
  4. Complex, treatment refractory GAD
    Refer to mental health team/specialist
26
Q

What is there a risk of in under 30s taking SSRIs and SNRIs

A

Increased risk of suicidal thinking and self-harm

Should be seen within 1 week of prescribing and monitored weekly for the 1st month

27
Q

What would you advise a patient newly started on SSRI or SNRI (3)

A
  1. Potential adverse effects and withdrawal symptoms - include increased anxiety, agitation and sleeping problems
  2. Reviewed every 2- 4 weeks in the first 3months of treatment and then every 3 months after
  3. May take up to 12 weeks to see full effect of drug
28
Q

If pregnant woman needs step 3 treatment - what ideally should be offered first?

what would happen in these cases regarding SSRI and SNRI use

a. if already stabilised and reports pregnancy?
b. if treatment considered necessary for first trimester
c. what’s the risk of SSRI and SNRI after 20 weeks of pregnancy?

A

High intensity psychological intervention should be offered first.

a. risk of relapse taken into account when considering discontinuing or switching meds. If continued - lowest effect dose should be used
b. unsure if risk of infant congenital defect. Specialist referral to discuss benefits vs risk.
c. risk of persistent pulmonary hypertension of the new-born & or can lead to neonatal withdrawal. Women should be advised to give birth at facilities that can support this

Chapter 4 - Nervous System (15 decks)

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