Anxiety and Insomnia Flashcards
What are the major symptoms of GAD?
At least 3 of the Symptoms:
(1) Restlessness
(2) Fatigue
(3) Irritability
(4) Concentration Difficulty
(5) Muscle Tension
(6) Sleep disturbance (Insomnia)
Functional Impairment
Excessive anxiety and worry at least 6 months
What are the major symptoms of Panic Attack?
Last 10 min and no more than 20-30 min
At least 4 of the following symptoms:
- Sweating
- Trembling
- Palpitation (HR)
- Feeling of SOB
- Feeling of Choking
- Chest pain / discomfort
- Nausea, abdominal distress
- Dizzy and Lightheaded
- Derealization
- Fear of losing control
- Fear of dying
- Numbing and tingling
- Chills / Hot flushes
What are the major symptoms of Panic Disorders?
(1) Recurrent unexpected panic attacks
(2) At least 1 panic attack for 1 month that is:
- Persistent anticipatory anxiety
- Worry about implications of attack
- Significant behavior change
What are the major symptoms of social anxiety disorders?
Marked and persistent fear of one or more social performance situations over 6 months
Impaired functioning due to avoidance of situations
Fear of humiliation and embarrassment
What are the major symptoms of OCD?
Obsession = Recurring persistent intrusive thoughts and impulses
Compulsion = Repetitive behavior or mental acts (pray, count) to reduce the distress
Time-consuming > 1 hour and significantly impairs functioning
What are the major symptoms of PTSD?
- Stressor present
- Intrusive symptoms persistently re-experienced
- Avoidance of distress
- Negative alteration in cognition and mood
- Alteration in arousal and reactivity
What is the general approach the GAD treatment?
- Psychotherapy
- SSRIs > SNRIs > Clomipramine
(Note OCD: SSRI > Clomipramine > Venlafaxine) - BZD Adjuncts
- Hydroxyzine Adjunct
Explain the dosing initiation, duration and course of treatment of GAD using SSRIs
Excessive worrying symptom relief
- Onset: 1-2 months
- Full Response: 3 months
- Total duration 1-2 years (Long term)
Dosing - Start Low, Go Slow
- Start low (Transient jitteriness in the first 1-2 weeks) and may consider BZD adjunct
- Maintain at the high end of the dosing range
Explain the importance of starting low, going slow for antidepressants in anxiety disorders
Patient has anxiety to begin with = Pathological fear and anxiety is related to over-activation of the amygdala. The amygdala receives input from serotonergic neurons which can inhibit outputs
Adding high dose antidepressants initially can cause a surge in serotonin
This surge in serotonin can enhance the adverse effects. Already at low dose, there can be transient jitteriness.
Explain the effect of the therapeutic and adverse effect of BZDs on the role of BZDs
Therapeutic effect = Fast Acting within 30 min
- Role: Physical symptoms of anxiety
- Role: High potency preferred (Clonazepam, Lorazepam, Alprazolam)
Adverse effect = Tolerance and Dependence
- Role: Short term 3-4 month PRN dosing
- Role: Gradual Tapering required
Why is pharmacogenomic testing unnecessary when starting antidepressants?
The effect onset is already when to be delayed by 1 to 2 months
List the drugs and dosing used in GAD
Antidepressants:
- Fluoxetine 20 mg/day start, 80 mg max
- Sertraline 25 mg/day start, 200 mg max
- Escitalopram 10 mg/day, 20 mg max
Benzodiazepines:
- Alprazolam 0.5 - 4 mg/day
- Clonazepam 0.5 - 1 mg/day
- Lorazepam 1 - 3 mg/day
Hydroxyzine 100 - 400 mg/day (Usual: 10 mg)
Propranolol 10 - 80 mg/day
Why are short acting BZDs preferred to long acting ones?
Less drowsy
When patients develop tolerance to BZDs, tolerance to which action is more common
Hypnotic actions: Tolerance develops within days.
Less common to develop tolerance for anxiolytic action
What are high potency agents used in anxiety?
Clonazepam, Lorazepam, Alprazolam
