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PHAR 557 > Anxiety > Flashcards

Anxiety Flashcards

1
Q

Define anxiety

A

normal emotion under circumstances of threat

thought to be part of evolutionary fight/flight rxn of survival

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2
Q

Core sx’s of anxiety disorders

A
  1. fear

2. worry

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3
Q

Brain structure associated w/ fear

A

amygdala

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4
Q

Brain structure assoc w/ worry

A

cortico-striato-thalamo-cortical circuitry (loop)

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5
Q

Key NT for reducing neuronal activity

A

GABA

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6
Q

Which NT is the main target for anxiety tx involving anxiolytics?

A

GABA

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7
Q

How is glutamate prevented from being released?

A

Drug (gabapentin/pregabalin) binds to alpha-2-delta subunit of presynaptic voltage-sensitive calcium channels (VSCC) > glutamate release is blocked > amygdala/CSTC neurotransmission is reduced > decreased fear and worry

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8
Q

T or F: The sx’s, circuits, and NTs for anxiety are very diff from those of MDD.

A

F

They overlap

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9
Q

Besides VSCC’s, glutamate, and GABA, what other NTs are involved in anxiety?

A

NE, serotonin

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10
Q

According to the DSM-5, anxiety sx’s must be present for at least this long for a GAD dx.

A

6 months

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11
Q

Name two GAD rating scales.

A

Generalized Anxiety Disorder Assessment-7 (GAD-7), Hamilton Anxiety Scale (HAM-A)

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12
Q

Non-pharm tx of GAD

A
  1. reduce/avoid EtOH/caffeine/nicotine
  2. avoid non-Rx stimulants and other meds known to induce anxiety
  3. Exercise
  4. Psychotx
  5. Relaxation techniques
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13
Q

1st line drug tx for GAD

A

SSRI: escitalopram, paroxetine, sertraline

SNRI: duloxetine, venlafaxine

pregabalin

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14
Q

If a pt wants to avoid sexual dysfn, which antidep would you AVOID when tx’ing GAD?

A

sertraline

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15
Q

What is used to tx ACUTE anxiety?

A

Benzodiazepines

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16
Q

How long should benzos be used for in GAD?

A

For about 2-4 wks while the SSRI/SNRI begins to work

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17
Q

What’re pregabalin/gabapentin used for mainly in GAD pts?

A

For helping pts with the withdrawal of stopping long term benzos

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18
Q

T or F: Escitalopram and venlafaxine are equally effective for tx’ing GAD, but venlafaxine is better tolerated.

A

F (escitalopram is better tolerated)

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19
Q

SSRI/SNRI maximal response for GAD

A

12 weeks

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20
Q

SSRI/SNRI onset of sx relief

A

2-4 weeks (benzos used in concurrently for physical sx’s)

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21
Q

SSRI/SNRI tx duration for GAD

A

12-24 months

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22
Q

BZD MOA

A

binds to BZD receptor on GABA(A) neurons > potentiates GABA activity in neurons by increasing chloride permeability > neurons become hyperpolarized > lower excitable state

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23
Q

BZDs are only effective for what?

A

Rapid initial relief of somatic anxiety sx’s

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24
Q

T or F: BZDs are effective for both the somatic sx’s and psychic features (e.g. ruminative worry) of GAD

A

F

BZDs do nothing for the psychic features of GAD

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25
Which BZD is specifically used in GAD if a pt needs a scheduled BZD tx? Why?
Clonazepam due to its longer t1/2 > reduced peaks/troughs as seen w/ the other benzos
26
BZD AEs
1. ataxia (loss of voluntary ctrl of body movement) 2. dizziness/lightheadedness 3. sedation/daytime drowsiness 4. psychomotor impairment 5. agitation/irritability 6. confusion 7. anterograde amnesia 8. resp depression 9. depression 10. hallucinations 11. hallucinations
27
BZD dependence risk factors
higher doses and longer use hx of alcohol use disorder (or other substance use disorder)
28
When are long acting benzos preferred?
when tapering
29
When are short acting benzos preferred?
for getting to sleep, dealing with acute anxiety
30
Which benzos are preferred in elderly and liver dysfn pts?
LOT lorazepam, oxazepam, temazepam >These have no active metabolites
31
T or F: Tapering benzos when discontinuing is not necessary.
F Must taper otherwise withdrawal sx's will occur
32
Which BZD is preferred when tapering to discontinuation?
Diazepam
33
Overdose consequences of BZDs?
Rarely fatal, but may be fatal if combined w/ EtOH/opioids/barbiturates
34
BZD antidote
Flumazenil
35
Why is flumazenil rarely used? (it's the BZD antidote)
It can cause seizures (and other withdrawal sx's) in BZD-dependent pts
36
T or F: There's an increase in BZD-receptor density in hippocampal and amygdala in pts who suffer from panic attacks.
F There's a DECREASE in BZD-receptor density in hippocampal and amygdala areas = less sensitvity to BZD effects and lower baseline GABA concs
37
1st line pharmacotx for panic disorder
SSRIs or venlafaxine (SNRI)
38
Panic disorder: What else can be used as 1st line when there's residual anxiety or when rapid sx ctrl is desired?
BZDs
39
2nd line pharmacotx for panic disorder
TCAs
40
T or F: TCAs are just as effective as SSRIs/SNRIs for panic disorder tx
T
41
Why are TCAs not first line (assuming similar efficacy as SNRIs/SSRIs)?
TCAs are less well-tolerated (antichol effects)
42
3rd line for panic disorder
phenelzine (irreversible MAOI)
43
T or F: Benzos are recommended for tx of an acute panic attack
F
44
Why or why aren't benzos used to tx an acute panic attack?
They are NOT bc their onset will usually occur after the panic attack is over
45
Antidep onset of action for panic disorder?
3-4 weeks
46
Why might there be a worsening of anxiety sx's in panic disorder pts at the beginning of antidep tx?
Panic disorder pts are hypersensitive to medication AEs at initiation > can lead to activation (worsening of anxiety, agitation, irritability) (Remember HANDS: "A" stands for anxiety)
47
Benzo onset of effect?
Within hours for autonomic sx's of anxiety
48
Panic disorder tx: acute tx duration?
1-3 mths
49
Panic disorder tx: maintenance tx duration
12 months
50
When should we consider maintenance tx in panic disorder pts?
If residual sx's continue after 3 months of tx, or if pt is at risk of relapsing (e.g. due to psychosocial stressors, low motivation to stop tx, etc.)
51
Panic disorder tx: Tapering duration
4-6 mths
52
2 subtypes of social anx disorder:
1. performance-only | 2. SAD w/ dopamine dysfn and 5HT2 receptor hypersensitivity
53
Describe dopamine dysfun in SAD.
There's decreased D2 receptor binding, low levels of dopamine metabolite
54
Why is there a high incidence of SAD in Parkinson's dz pts?
Due to dopamine dysfn
55
Why does SAD emerge during antipsychotic tx?
Because antipsychotics block DA receptors
56
SAD non-pharm tx
CBT, exposure, social skills training
57
SAD 1st line options:
a. CBT b. SSRI (escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) c. SNRI (venlafaxine)
58
SAD 2nd line options:
BZD (clonazepam, alprazolam) Gabapentin Citalopram Phenelzine (this was 3rd line for panic disorder)
59
SAD - other options for tx (besides 1st and 2nd lines)
Atenolol and propranol
60
social anx disorder: what're atenolol and propranolol useful for?
Performance-only SAD subtype
61
When is venlafaxine recommended in SAD pts?
When SSRIs fail
62
SAD onset of sx relief?
6-8 wks (w/ antidepressants)
63
For how long should SAD be tx'ed?
1 or more yrs
64
SAD tapering duration?
3-4 months
65
Withdrawal sx's when d/c'ing SSRIs/SNRIs (or anything w/ serotonin effects)?
FINISH ``` flu-like sx's insomnia nausea imbalance sensory sx's hyperactivity / hyperarousal ```
66
PTSD - 3 main risk predictors:
1. trauma severity 2. lack of social support 3. life stress
67
What is the pathophysiology is found in inds who are predisposed to suffering from PTSD?
HPA dysregulation and reduced cortisol (glucocorticoid) occur more often in this pop
68
After trauma, 3 dimensions of PTSD unfold:
1. re-experiencing of the traumatic event (dreams, flashbacks) 2. avoidance of stuff that'll remind one of the event 3. increased arousal/agitation
69
Non-pharm tx for PTSD
Trauma-focused psychotx
70
1st line tx for PTSD
1. SSRI (fluoxetine, paroxetine, sertraline) | 2. SNRI (venlafaxine)
71
What is used if PTSD pt has trauma-related nightmares and wants to improve sleep?
prazosin (alpha-1 blocker)
72
Which antidep has negative evidence for PTSD tx?
citalopram
73
What do we specifically avoid when tx'ing PTSD?
BZDs
74
What's the only medication that MAY prevent PTSD in an ind who has experienced a traumatic experience?
Hydrocortisone
75
Prazosin's place in tx for PTSD?
For nightmares/sleep sx's
76
If using prazosin for PTSD, what should be monitored?
BP
77
Onset of sx relief for PTSD?
2-8 wks
78
How long before maximum response achieved when tx'ing PTSD?
12+ weeks
79
Usual PTSD tx duration?
12-24 mths
80
Only drug that's actually Health Can.-approved for PTSD tx?
Paroxetine
81
What is necessary to be dx'ed with OCD?
Having obsessions and compulsions that reduce their anxiety
82
1st line for OCD
1. CBT 2. SSRI - -> Combo of both
83
Howl long should we tx OCD with an SSRI before concluding inadequate response?
12 wks
84
How many CBT sessions for OCD should take place before concluding inadequate response?
13 weekly sessions
85
For OCD tx, what should we do if there is little to no response to first SSRI?
Change to a diff SSRI OR switch to venlafaxine
86
For OCD, what should we do if pt fails on 2 SSRIs?
Switch to clomipramine (most potent TCA w/ SSRI effects)
87
T or F: For OCD, clomipramine is just as or more effective than SSRIs.
T (but it's 2nd line due to AEs, such as cardiac effects, antichol effects, sedation)
88
OCD: onset of sx relief
2-4 wks
89
OCD: maximal response
10-12 wks
90
OCD: tx duration
1-2 yrs
91
T or F: OCD tx should be indefinite for most pts.
T
92
What were 2 weaknesses of the Cipriani study that looked at PTSD tx?
Studies were short (10 wks avg) and most papers were placebo-ctrled (i.e. drugs were not directly compared)
93
In the Cipriani study that looked at PTSD tx's, what should we know about phenelzine?
It showed statistically sig effectiveness, but its data was based on a single, poor-quality study, so we should take its effectiveness with a grain of salt

PHAR 557 (36 decks)

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