Anxiety Flashcards
Define anxiety
normal emotion under circumstances of threat
thought to be part of evolutionary fight/flight rxn of survival
Core sx’s of anxiety disorders
- fear
2. worry
Brain structure associated w/ fear
amygdala
Brain structure assoc w/ worry
cortico-striato-thalamo-cortical circuitry (loop)
Key NT for reducing neuronal activity
GABA
Which NT is the main target for anxiety tx involving anxiolytics?
GABA
How is glutamate prevented from being released?
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
T or F: The sx’s, circuits, and NTs for anxiety are very diff from those of MDD.
F
They overlap
Besides VSCC’s, glutamate, and GABA, what other NTs are involved in anxiety?
NE, serotonin
According to the DSM-5, anxiety sx’s must be present for at least this long for a GAD dx.
6 months
Name two GAD rating scales.
Generalized Anxiety Disorder Assessment-7 (GAD-7), Hamilton Anxiety Scale (HAM-A)
Non-pharm tx of GAD
- reduce/avoid EtOH/caffeine/nicotine
- avoid non-Rx stimulants and other meds known to induce anxiety
- Exercise
- Psychotx
- Relaxation techniques
1st line drug tx for GAD
SSRI: escitalopram, paroxetine, sertraline
SNRI: duloxetine, venlafaxine
pregabalin
If a pt wants to avoid sexual dysfn, which antidep would you AVOID when tx’ing GAD?
sertraline
What is used to tx ACUTE anxiety?
Benzodiazepines
How long should benzos be used for in GAD?
For about 2-4 wks while the SSRI/SNRI begins to work
What’re pregabalin/gabapentin used for mainly in GAD pts?
For helping pts with the withdrawal of stopping long term benzos
T or F: Escitalopram and venlafaxine are equally effective for tx’ing GAD, but venlafaxine is better tolerated.
F (escitalopram is better tolerated)
SSRI/SNRI maximal response for GAD
12 weeks
SSRI/SNRI onset of sx relief
2-4 weeks (benzos used in concurrently for physical sx’s)
SSRI/SNRI tx duration for GAD
12-24 months
BZD MOA
binds to BZD receptor on GABA(A) neurons > potentiates GABA activity in neurons by increasing chloride permeability > neurons become hyperpolarized > lower excitable state
BZDs are only effective for what?
Rapid initial relief of somatic anxiety sx’s
T or F: BZDs are effective for both the somatic sx’s and psychic features (e.g. ruminative worry) of GAD
F
BZDs do nothing for the psychic features of GAD
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
BZD AEs
- ataxia (loss of voluntary ctrl of body movement)
- dizziness/lightheadedness
- sedation/daytime drowsiness
- psychomotor impairment
- agitation/irritability
- confusion
- anterograde amnesia
- resp depression
- depression
- hallucinations
- hallucinations
BZD dependence risk factors
higher doses and longer use
hx of alcohol use disorder (or other substance use disorder)
When are long acting benzos preferred?
when tapering
When are short acting benzos preferred?
for getting to sleep, dealing with acute anxiety
Which benzos are preferred in elderly and liver dysfn pts?
LOT
lorazepam, oxazepam, temazepam
> These have no active metabolites
T or F: Tapering benzos when discontinuing is not necessary.
F
Must taper otherwise withdrawal sx’s will occur
Which BZD is preferred when tapering to discontinuation?
Diazepam
Overdose consequences of BZDs?
Rarely fatal, but may be fatal if combined w/ EtOH/opioids/barbiturates
BZD antidote
Flumazenil
Why is flumazenil rarely used? (it’s the BZD antidote)
It can cause seizures (and other withdrawal sx’s) in BZD-dependent pts
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
1st line pharmacotx for panic disorder
SSRIs or venlafaxine (SNRI)