Anxiety Flashcards
Clinical Presentation of General Anxiety Disorder includes:
excessive worry & anxiety and
- restlessness
- easily fatigued
- poor concentration
- irritability
- muscle tension
- insomnia
GAD Diagnostic Criteria
excessive anxiety and worry occurring more days than not for 6+ months; difficult to control
clinical presentation of anxiety & worry AND 3+ of the additional presentation
DSM-V Criteria
anxiety & worry causing distress or functional impairment not due to another psychiatric illness or drug substance, general disorder
Severity & Action appropriate for 0-5 (GAD-7 score)
anxiety severity: none to minimal
action: no treatment
Severity & Action appropriate for 5-9 (GAD-7 score)
anxiety severity: mild
action: watchful waiting, repeat scoring at follow-up
Severity & Action appropriate for 10-14 (GAD-7 score)
anxiety severity: moderate
action: may be clinically significant –> further evaluation, possible treatment
Severity & Action appropriate for 15-21 (GAD-7 score)
anxiety severity: severe
action: probably clinically significant, treat
Non-pharm Treatment
Stress management
Psychotherapy (CBT)
Exercise
Avoid: caffeine, OTC stimulants, XS ETOH, diet pills
(T/F) CBT + antidepressant is better than either agent alone?
True!
When do we want to use Benzodiazepines (BZ)?
- acute anxiety sx (short term <8 wks!)
- not effective for long-term remission
- initial tx IN ADDITION to SSRI/SNRI
Why do we want to add BZ to SSRI/SNRI tx initially?
It minimizes possible increase in anxiety/agitation seen with initiation of SSRI/SNRI agents.
Benzodiazepines: Adverse Effects
- TOLERANCE/ DEPENDENCE/ ABUSE
- CNS depression (drowsiness, sedation, psychomotor impairment, impaired coordination (ataxia))
- impaired memory/recall
- Incr. fall/fracture risk in elderly
- Fatal with ETOH or other CNS depressants (opioid, gabapentoids)
- Abrupt withdrawal = seizures!
- Long term tx = worsening anxiety, insomnia, restlessness, muscle tension, irritability
Why do BZ effect elderly?
decrease capacity for oxidation & alterations in plasma volume of distribution
drug accumulates and results in excessive sedation
How do BZ effect patients with hepatic disease?
drug accumulation
What could increase the likelihood of BZ dependence?
- tx doses for up to 3-6 weeks or for extended periods of time
- rebound sx more intense after short elimination t1/2 BZs
- tx lasting > 3 months
How do we minimize BZ withdrawal?
- decr. dose 25% per week until at 50% of dose
- then decr. by 1/8 q4-7d
if tx >6 wks: slow taper over weeks
How do we reverse overdoses of BZs?
Flumazenil (Romazicon)
When do we want to use selective serotonin reuptake inhibitors (SSRI)?
1st line for long term management of GAD
no superiority of one agent over another
SSRI: Adverse Effects
- N/V, diarrhea
- insomnia
- sweating
- decr. libido
- ED
- HYPONATREMIA
- paroxetine: wt gain
- citalopram: QTc prolongation
When do we want to use selective norepinephrine reuptake inhibitors (SNRIs)?
1st line for long term management of GAD
co-morbid pain (NON-cancer)
SNRI: Adverse Effects
- N/V, constipation
- sedation
- sweating
- dry mouth
- initial anxiety/agitation
When do we want to use tricyclic antidepressants (TCADs)?
1st line for long term management of GAD
good for chronic pain or migraines
TCAD: Adverse Effects
- sedation
- orthostatic hypotension (70/50)
- anticholinergic SE (tachycardia, constipation, confusion, dry: mouth, eyes, skin)
- wt gain
- angle closure glaucoma
- fatal in overdose
- in men with BPH: urinary retention
How does Buspar fit into treatment?
- non BZ axiolytic; lack anticonvulsant, muscle relaxant, hypnotic, motor impairment, and dependence properties
- GAD sx with or without depressive sx
- effective as BZ after 4 weeks
- usually 2nd line/treatment resistant
Buspar: Adverse Effects
- headaches
- dizziness
- nervousness
- nausea
- dysphoria (unhappy, general dissatisfaction with life)
When do we use hydroxyzine?
helpful for acute sx
- does NOT treat depression or improve psychic features of anx.
Hydroxyzine: Adverse Effects
- wt gain
- sedation
- dry mouth
What about Lyrica and Gabapentin?
- not FDA approved for GAD, inconsistent
- may be used if unable to take SSRI/SNRI
Lyrica & Gabapentin: Adverse Effects
- sedation
- tremors
- ataxia (impaired coordination)
- edema
When do we use second generation antipsychotics (SGAs)?
meant to be used with SSRI/SNRI, but augment SE
- may decr. anx. but incr. rate of d/c due to AE
- -> if they’ve tried EVERYTHING ELSE, last ditch effort :(
Seroquel, olanzapine, risperidal
SGA: Adverse Effects
- wt gain
- QTc prolongation
- incr. BG
- DLP
- EPS (extrapyramidal side effects): tremor, slurred speech, paranoia, etc.
What is the most evidence based approach to achieving remission?
CBT + SSRI/SNRI
If a patient needs long-term tx of GAD should we use SSRI/SNRI or BZs?
SSRI/SNRI
- avoid long-term use of BZs!
What is the main counseling point?
- length of therapy; to avoid early d/c and withdrawal sx (serotonin withdrawal syndrome)
What is anxiety?
an emotional state caused by real or potential threats to our security
- severe symptoms and irrational fears may significantly impair normal daily function
What happens if my anxiety spins out of control?
may experience uncomfortable and incapacitating psychological and physical arousal
