anxiety Flashcards
What are some examples of an anxiety disorder?
1) Generalized anxiety disorder (GAD)
2) Panic disorder (PD)
3) Social anxiety disorder (SAD)
4) Obsessive compulsive disorder (OCD)
5) Post-traumatic stress disorder (PTSD)
6) Acute stress disorder (ASD)
What gender is anxiety disorders more common in?
Females
What are some of the causes of anxiety disorders
1) Neurochemical deregulation - increase norepinephrine in locus coeruleus (LC) region of the brain. Serotonin, Gamma-aminobutyric acid (GABA)
2) Alterations in brain structures involved in fear and worry circuitry
3) Genetics
4) Medical conditions
5) Drug-induced
What are the clinical presentations of GAD?
1) Excessive anxiety and worry about a number of events/activities occuring most of the days for ≥ 6 months
2) Sxs not caused by physiological effects of a substance or another medical condition.
3) Disturbance not better explained by another mental disorder
What are the symptoms are associated with anxiety and worry
1) Restlessness or feeling keyed up or on edge
2) Being easily fatigued
3) Difficulty concentrating or mind going blank
4) Irritability
5) Muscle tension
6) Sleep disturbances (Insomnia, unsatisfying sleep)
How many symptoms must be present to be considered anxiety and worry?
≥ 3 of the 6 symptoms
What are the clinical presentation of PD?
1) Recurrent unexpected panic attacks
2) Sxs not caused by physiological effects of a substance or another medical condition.
3) Disturbance not better explained by another mental disorder
4) ≥ 1 of the attacks has been followed by ≥ 1 month of ≥ 1 of the following: Persistent anticipatory anxiety about additional panic attack. A significant maladaptive change in behaviour related to the attacks
What is a panic attack described as?
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes during which time ≥ 4 symptoms occur
What are the common symptoms of panic attack
1) Palpitation
2) Trembling or shaking
3) Shortness of breath or smothering
4) Nausea, abdominal distress
5) Feeling dizzy, unsteady, light-headed, or faint
What are the clinical presentation of SAD?
1) Marked fear, anxiety or avoidance of ≥ 1 social/performance situations in which one is exposed to possible scrutiny by others typically lasting ≥ 6 months
2) Fears that he will act in a way that will be humiliating or embarrassing
3) Social situations almost always provoke fear or anxiety out of proportion
4) Sxs not caused by physiological effects of a substance or another medical condition.
5) Disturbance not better explained by another mental disorder
What is the specifier for SAD?
Specify if the fear is restricted to speaking or performing in public (performance only)
What are the clinical presentation of OCD?
1) Presence of either obsessions, compulsions or both
2) Obsession and compulsion are time consuming ( ≥ 1 hours/day) or cause significant distress/ functional impairment
3) Sxs not caused by physiological effects of a substance or another medical condition.
4) Disturbance not better explained by another mental disorder
Describe “obsessions”
Recurrent and persistent thought/ urges/ images that are sometimes intrusive and unwanted causing marked anxiety or distress
Describe “compulsions”
Repetitive behaviours or mental acts that a person performs in response to an obsession or according to rigid rules
What are the specificers for OCD?
1) Patient has insight/ no insight
2) Presence/ history of a tic disorder
If an individual suffers from symptoms of ASD for > 1 month, the diagnosis is reclassified as?
PTSD
Goals of anxiety treatment?
1) Remission of anxiety symptoms
2) Return to pre-morbid functioning
Duration of anxiety treatment?
Following adequate trial and good response, treatment should be continued for at least a year (1-2 years for OCD) before gradual tapering of meds
What are the first line meds for GAD?
SSRI, SNRI, Pregabalin
Special precaution for Pregabalin?
Avoid use in patients with concomitant alcohol/ substance abuse
What are the second line meds for GAD?
Mirtazapine, Imipramine
What are the non pharmacologic options for GAD?
1) CBT (1st line)
2) Supportive/ Dynamic psychotherapy
3) Relaxation exercise
4) Meditation
What are the first line meds for PD?
SSRI, Venlafaxine
What are the second line meds for PD?
Imipramine, Clomipramine
What are the non pharmacologic options for PD?
CBT
What are the first line meds for SAD?
SSRI, Venlafaxine
What are the second line meds for SAD?
Moclobemide
What are the non pharmacologic options for SAD?
CBT (1st line)
Social skill training
What are the meds for OCD?
1st line: SSRI
2nd line: Clomipramine
3rd line: Venlafaxine
What are the non pharmacologic options for OCD?
CBT (1st line)
Dialectical behavior therapy (DBT)
Surgery
What are the meds for PTSD?
1st line: SSRI/ SNRI
2nd line: Mirtazapine
3rd line: Amitriptyline, Imipramine
What med should be avoided in PTSD? Why?
Benzodiazepines. Poor outcome, can increase fear response in PTSD patients
What are the non pharmacologic options for PTSD?
CBT (1st line)
Exposure therapy
Eye movement desensitization and reprocessing (EMDR)
What are the adjunctive medications used in the treatment of anxiety?
1) Benzodiazepines PRN
2) Hydroxyzine PRN
Provides acute relief of acute anxiety
How can antidepressants help in the treatment of anxiety disorders?
1) Serotonergic AD are effective for “worrying” symptoms
2) AD decrease NE activity in the LC, decreasing output from amygdala
When are anxiolytic effects of antidepressants observed?
1) Early anxiolytic effects can be observed after 2-4 weeks
2) Improvements generally take 4-6 weeks, may take 3 months for full response
What side effect can be observed during initiation of antidepressants? What can be added to help prevent this side effect?
Transient jitteriness. Short course PRN BZD can be added to ameliorate this excitatory SE
What are benzodiazepines indicated for?
Short-term relief of severe anxiety. (Exception: PTSD)
How are BZD useful in treatment of anxiety disorders?
They are useful for physical symptoms of anxiety (muscle tension/insomnia)
They can also help reduce excitatory side effects of AD
How are BZDs metabolised?
Hepatically, via oxidation by CYP3A4. Use with caution in patient with liver impairment
What are the common SEs of BZD?
1) CNS effects such as drowsiness, ataxia, muscle weakness
2) Hypotension
What are some counselling points for BZD?
1) BZD is useful for symptomatic relief, but does not treat underlying problem
2) If using BZD daily for several weeks, do not stop abruptly. Can lead to withdrawal symptoms
3) Avoid taking alcohol at the same time
4) Can cause drowsiness
5) Usually prescribed short-term PRN to prevent development of tolerance and dependence
How should BZD dose be tapered?
1) Gradual dose reduction of 25% weekly till half of original dose, then reduce by 1/8th every 4-7 days
2) May switch to a LA BZD (e.g. Diazepam) at a equivalent dose, then taper gradually to facilitate smoother withdrawal (though evidence is not strong)
What are the symptoms of BZD withdrawal reaction
1) Sweating
2) Hallucination
3) Increased heart rate
4) Tremors
5) Insomnia
6) Nausea/vomiting
7) Agitation
8) Rebound anxiety
9) Seizure may occur
What is the dose for Pregabalin?
Initial: 150 mg/day given BD-TDS
Dose range: 300-600mg/day
What is the MOA of Pregabalin?
Inhibits alpha-2-delta subunit of voltage dependent Ca channel within CNS, modulating Ca influx and decrease excessive excitatory neurostimulator release
ADR of Pregabalin
1) Dizziness, sedation, Ataxia
2) Weight gain
3) Blurred vision
4) Euphoria (Potential for dependence and misuse)
5) Withdrawal effects
6) Peripheral edema, thrombocytopenia. myopathy (Idiopathic)
Does Pregabalin need to be renally adjusted?
Yes, when CrCl < 60 ml/min
What is the dose for Hydroxyzine?
25mg BD
Max: 400mg/day given BD-QDS
ADR of hydroxyzine?
1) Sedation
2) Dry mouth
3) Constipation
4) Blurred vision
What is the dose for Propranolol?
Initial: 10-20mg taken 30-60 mins before anxiety-provoking situation
ADR of Propanolol?
1) Hypotension
2) Bradycardia
3) Fatigue
4) Dizziness
5) Contraindicated in asthma (Bronchospasm)
What is the dose for Buspirone?
Initial: 7.5mg BD
Dosage range: 15-60mg/day in 3 divided dose
MOA of Buspirone?
5HT1A partial agonist
ADR of Buspirone?
1) Dizziness
2) Headache
3) Nausea
How does smoking affect metabolism of drugs?
Smoking is a strong inducer of CYP1A2
What are some of the significant DDI in treatment of anxiety?
1) Alcohol + CNS depressants (BZD/AD/Antihistamine) can cause additive CNS depressant side effects
2) Serotonin syndrome when combining serotonergic agents
How is serotonin syndrome presented?
As a clinical triad
1) Mental status changes (Agitation, confusion)
2) Autonomic hyperactivity (Fever, flushing, hypertension)
3) Neuromuscular abnormalities (Rigidity, tremors)
How long do we need to establish the therapeutic effects of serotonergic ADs?
2-3 months
What do we need to monitor for the treatment of anxiety disorder?
1) Characteristics of anxiety episodes/ panic attacks
2) Frequency and durations of attacks
3) Associated mood or physical symptoms
4) Triggers
5) Suicidal/ Homicidal thoughts
6) ADRs
What are the rating scales used in GAD monitoring?
1) HAM-A (Clinician rated)
2) GAD-7 (Self rated)
What is the rating scale used in PD monitoring?
Panic disorder severity scale (Clinician rated)
What is the rating scale used in SAD monitoring?
Liebowitz-social anxiety scale (Clinician rated)
What is the rating scale used in OCD monitoring?
Yale-Brown Obsessive compulsive scale (Y-BOCS) (Clinician rated)
What is the rating scale used in PTSD monitoring?
Clinician administered PTSD scale (Gold-standard)
What are the psychological symptoms of anxiety disorder?
1) Worrying
2) Fear
What are the somatic symptoms of anxiety disorder?
1) Palpitation
2) Trembling
3) Muscle tension
Which class of drug is recommended as initial treatment for GAD, PD, SAD, OCD, PTSD
Serotonergic ADs
Which drugs require gradual tapering? Why?
1) Pregabalin
2) AD
3) BZD
To minimise risk of discontinuation syndrome
