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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
Q

Which BZD is specifically used in GAD if a pt needs a scheduled BZD tx? Why?

A

Clonazepam due to its longer t1/2 > reduced peaks/troughs as seen w/ the other benzos

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26
Q

BZD AEs

A
  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
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27
Q

BZD dependence risk factors

A

higher doses and longer use

hx of alcohol use disorder (or other substance use disorder)

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28
Q

When are long acting benzos preferred?

A

when tapering

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29
Q

When are short acting benzos preferred?

A

for getting to sleep, dealing with acute anxiety

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30
Q

Which benzos are preferred in elderly and liver dysfn pts?

A

LOT

lorazepam, oxazepam, temazepam

> These have no active metabolites

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31
Q

T or F: Tapering benzos when discontinuing is not necessary.

A

F

Must taper otherwise withdrawal sx’s will occur

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32
Q

Which BZD is preferred when tapering to discontinuation?

A

Diazepam

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33
Q

Overdose consequences of BZDs?

A

Rarely fatal, but may be fatal if combined w/ EtOH/opioids/barbiturates

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34
Q

BZD antidote

A

Flumazenil

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35
Q

Why is flumazenil rarely used? (it’s the BZD antidote)

A

It can cause seizures (and other withdrawal sx’s) in BZD-dependent pts

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36
Q

T or F: There’s an increase in BZD-receptor density in hippocampal and amygdala in pts who suffer from panic attacks.

A

F

There’s a DECREASE in BZD-receptor density in hippocampal and amygdala areas = less sensitvity to BZD effects and lower baseline GABA concs

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37
Q

1st line pharmacotx for panic disorder

A

SSRIs or venlafaxine (SNRI)

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38
Q

Panic disorder: What else can be used as 1st line when there’s residual anxiety or when rapid sx ctrl is desired?

39
Q

2nd line pharmacotx for panic disorder

40
Q

T or F: TCAs are just as effective as SSRIs/SNRIs for panic disorder tx

41
Q

Why are TCAs not first line (assuming similar efficacy as SNRIs/SSRIs)?

A

TCAs are less well-tolerated (antichol effects)

42
Q

3rd line for panic disorder

A

phenelzine (irreversible MAOI)

43
Q

T or F: Benzos are recommended for tx of an acute panic attack

44
Q

Why or why aren’t benzos used to tx an acute panic attack?

A

They are NOT bc their onset will usually occur after the panic attack is over

45
Q

Antidep onset of action for panic disorder?

46
Q

Why might there be a worsening of anxiety sx’s in panic disorder pts at the beginning of antidep tx?

A

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
Q

Benzo onset of effect?

A

Within hours for autonomic sx’s of anxiety

48
Q

Panic disorder tx: acute tx duration?

49
Q

Panic disorder tx: maintenance tx duration

50
Q

When should we consider maintenance tx in panic disorder pts?

A

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
Q

Panic disorder tx: Tapering duration

52
Q

2 subtypes of social anx disorder:

A
  1. performance-only

2. SAD w/ dopamine dysfn and 5HT2 receptor hypersensitivity

53
Q

Describe dopamine dysfun in SAD.

A

There’s decreased D2 receptor binding, low levels of dopamine metabolite

54
Q

Why is there a high incidence of SAD in Parkinson’s dz pts?

A

Due to dopamine dysfn

55
Q

Why does SAD emerge during antipsychotic tx?

A

Because antipsychotics block DA receptors

56
Q

SAD non-pharm tx

A

CBT, exposure, social skills training

57
Q

SAD 1st line options:

A

a. CBT
b. SSRI (escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)
c. SNRI (venlafaxine)

58
Q

SAD 2nd line options:

A

BZD (clonazepam, alprazolam)

Gabapentin

Citalopram

Phenelzine (this was 3rd line for panic disorder)

59
Q

SAD - other options for tx (besides 1st and 2nd lines)

A

Atenolol and propranol

60
Q

social anx disorder: what’re atenolol and propranolol useful for?

A

Performance-only SAD subtype

61
Q

When is venlafaxine recommended in SAD pts?

A

When SSRIs fail

62
Q

SAD onset of sx relief?

A

6-8 wks (w/ antidepressants)

63
Q

For how long should SAD be tx’ed?

A

1 or more yrs

64
Q

SAD tapering duration?

A

3-4 months

65
Q

Withdrawal sx’s when d/c’ing SSRIs/SNRIs (or anything w/ serotonin effects)?

A

FINISH

flu-like sx's
insomnia
nausea
imbalance
sensory sx's
hyperactivity / hyperarousal
66
Q

PTSD - 3 main risk predictors:

A
  1. trauma severity
  2. lack of social support
  3. life stress
67
Q

What is the pathophysiology is found in inds who are predisposed to suffering from PTSD?

A

HPA dysregulation and reduced cortisol (glucocorticoid) occur more often in this pop

68
Q

After trauma, 3 dimensions of PTSD unfold:

A
  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
Q

Non-pharm tx for PTSD

A

Trauma-focused psychotx

70
Q

1st line tx for PTSD

A
  1. SSRI (fluoxetine, paroxetine, sertraline)

2. SNRI (venlafaxine)

71
Q

What is used if PTSD pt has trauma-related nightmares and wants to improve sleep?

A

prazosin (alpha-1 blocker)

72
Q

Which antidep has negative evidence for PTSD tx?

A

citalopram

73
Q

What do we specifically avoid when tx’ing PTSD?

74
Q

What’s the only medication that MAY prevent PTSD in an ind who has experienced a traumatic experience?

A

Hydrocortisone

75
Q

Prazosin’s place in tx for PTSD?

A

For nightmares/sleep sx’s

76
Q

If using prazosin for PTSD, what should be monitored?

77
Q

Onset of sx relief for PTSD?

78
Q

How long before maximum response achieved when tx’ing PTSD?

79
Q

Usual PTSD tx duration?

A

12-24 mths

80
Q

Only drug that’s actually Health Can.-approved for PTSD tx?

A

Paroxetine

81
Q

What is necessary to be dx’ed with OCD?

A

Having obsessions and compulsions that reduce their anxiety

82
Q

1st line for OCD

A
  1. CBT
  2. SSRI
    - -> Combo of both
83
Q

Howl long should we tx OCD with an SSRI before concluding inadequate response?

84
Q

How many CBT sessions for OCD should take place before concluding inadequate response?

A

13 weekly sessions

85
Q

For OCD tx, what should we do if there is little to no response to first SSRI?

A

Change to a diff SSRI OR switch to venlafaxine

86
Q

For OCD, what should we do if pt fails on 2 SSRIs?

A

Switch to clomipramine (most potent TCA w/ SSRI effects)

87
Q

T or F: For OCD, clomipramine is just as or more effective than SSRIs.

A

T (but it’s 2nd line due to AEs, such as cardiac effects, antichol effects, sedation)

88
Q

OCD: onset of sx relief

89
Q

OCD: maximal response

90
Q

OCD: tx duration

91
Q

T or F: OCD tx should be indefinite for most pts.

92
Q

What were 2 weaknesses of the Cipriani study that looked at PTSD tx?

A

Studies were short (10 wks avg) and most papers were placebo-ctrled (i.e. drugs were not directly compared)

93
Q

In the Cipriani study that looked at PTSD tx’s, what should we know about phenelzine?

A

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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