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CNS Module > Anxiety > Flashcards

Anxiety Flashcards

1
Q

Clinical Presentation of General Anxiety Disorder includes:

A

excessive worry & anxiety and

  • restlessness
  • easily fatigued
  • poor concentration
  • irritability
  • muscle tension
  • insomnia
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2
Q

GAD Diagnostic Criteria

A

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

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3
Q

DSM-V Criteria

A

anxiety & worry causing distress or functional impairment not due to another psychiatric illness or drug substance, general disorder

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4
Q

Severity & Action appropriate for 0-5 (GAD-7 score)

A

anxiety severity: none to minimal

action: no treatment

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5
Q

Severity & Action appropriate for 5-9 (GAD-7 score)

A

anxiety severity: mild

action: watchful waiting, repeat scoring at follow-up

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6
Q

Severity & Action appropriate for 10-14 (GAD-7 score)

A

anxiety severity: moderate

action: may be clinically significant –> further evaluation, possible treatment

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7
Q

Severity & Action appropriate for 15-21 (GAD-7 score)

A

anxiety severity: severe

action: probably clinically significant, treat

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8
Q

Non-pharm Treatment

A

Stress management
Psychotherapy (CBT)
Exercise
Avoid: caffeine, OTC stimulants, XS ETOH, diet pills

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9
Q

(T/F) CBT + antidepressant is better than either agent alone?

A

True!

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10
Q

When do we want to use Benzodiazepines (BZ)?

A
  • acute anxiety sx (short term <8 wks!)
  • not effective for long-term remission
  • initial tx IN ADDITION to SSRI/SNRI
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11
Q

Why do we want to add BZ to SSRI/SNRI tx initially?

A

It minimizes possible increase in anxiety/agitation seen with initiation of SSRI/SNRI agents.

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12
Q

Benzodiazepines: Adverse Effects

A
  • 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
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13
Q

Why do BZ effect elderly?

A

decrease capacity for oxidation & alterations in plasma volume of distribution

drug accumulates and results in excessive sedation

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14
Q

How do BZ effect patients with hepatic disease?

A

drug accumulation

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15
Q

What could increase the likelihood of BZ dependence?

A
  • 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
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16
Q

How do we minimize BZ withdrawal?

A
  • 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

17
Q

How do we reverse overdoses of BZs?

A

Flumazenil (Romazicon)

18
Q

When do we want to use selective serotonin reuptake inhibitors (SSRI)?

A

1st line for long term management of GAD

no superiority of one agent over another

19
Q

SSRI: Adverse Effects

A
  • N/V, diarrhea
  • insomnia
  • sweating
  • decr. libido
  • ED
  • HYPONATREMIA
  • paroxetine: wt gain
  • citalopram: QTc prolongation
20
Q

When do we want to use selective norepinephrine reuptake inhibitors (SNRIs)?

A

1st line for long term management of GAD

co-morbid pain (NON-cancer)

21
Q

SNRI: Adverse Effects

A
  • N/V, constipation
  • sedation
  • sweating
  • dry mouth
  • initial anxiety/agitation
22
Q

When do we want to use tricyclic antidepressants (TCADs)?

A

1st line for long term management of GAD

good for chronic pain or migraines

23
Q

TCAD: Adverse Effects

A
  • 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
24
Q

How does Buspar fit into treatment?

A
  • 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
25
Q

Buspar: Adverse Effects

A
  • headaches
  • dizziness
  • nervousness
  • nausea
  • dysphoria (unhappy, general dissatisfaction with life)
26
Q

When do we use hydroxyzine?

A

helpful for acute sx

  • does NOT treat depression or improve psychic features of anx.
27
Q

Hydroxyzine: Adverse Effects

A
  • wt gain
  • sedation
  • dry mouth
28
Q

What about Lyrica and Gabapentin?

A
  • not FDA approved for GAD, inconsistent

- may be used if unable to take SSRI/SNRI

29
Q

Lyrica & Gabapentin: Adverse Effects

A
  • sedation
  • tremors
  • ataxia (impaired coordination)
  • edema
30
Q

When do we use second generation antipsychotics (SGAs)?

A

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

31
Q

SGA: Adverse Effects

A
  • wt gain
  • QTc prolongation
  • incr. BG
  • DLP
  • EPS (extrapyramidal side effects): tremor, slurred speech, paranoia, etc.
32
Q

What is the most evidence based approach to achieving remission?

A

CBT + SSRI/SNRI

33
Q

If a patient needs long-term tx of GAD should we use SSRI/SNRI or BZs?

A

SSRI/SNRI

  • avoid long-term use of BZs!
34
Q

What is the main counseling point?

A
  • length of therapy; to avoid early d/c and withdrawal sx (serotonin withdrawal syndrome)
35
Q

What is anxiety?

A

an emotional state caused by real or potential threats to our security

  • severe symptoms and irrational fears may significantly impair normal daily function
36
Q

What happens if my anxiety spins out of control?

A

may experience uncomfortable and incapacitating psychological and physical arousal

CNS Module (9 decks)

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