Anxiety & Anxiety-Related Disorders Flashcards
Noradrenergic model
- Autonomic nervous system is hypersensitive and overreactive to various stimuli
- Stimulants release of glutamate (excitatory)
GABA-receptor model
- GABA has a strong inhibitory effect on 5-HT, NE, and DA
- Proposed to be lower GABA concentrations in anxiety disorders
Serotonin (5-HT) Model
- Data suggest dysregulation of serotonin in those with anxiety disorders
- May lead to imbalance of other neurotransmitter
What is the GAD Diagnostic Criteria?
At least six months of the following:
* Excessive anxiety or worry on most days
* PLUS three of the following:
- Restlessness
- Poor concentration
- Easily fatigued
- Irritability
- Sleep changes
- Muscle tension
What is the DOC of GAD?
SSRIs
What are some adverse effects of SSRIs?
- Stomach upset
- Nausea
- Diarrhea
- Appetite changes
- Sexual dysfunction
- Weight gain
- GI bleed
- SIADH
SNRIs
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor)
- Desvenlafaxine (Pristiq)
- Levomilnacipran (Fetzima)
What are the adverse effects of SNRIs?
- Increased blood pressure
- Nausea
- Constipation
- Sexual dysfunction
What is the mechanism of action benzodiazepine?
- Bind to GABA receptors in the brain which allows the opening of chloride channels and an influx of chloride into the cell
- Hyperpolarization and decreased action potentials
What is the place in therapy of benzodiazepines?
- PRN short-term relief in patients with severe anxiety that limits their ability to complete daily tasks
What are the adverse effects of benzodiazepines?
- Sedation
- Confusion
- Memory impairment
- Physical dependence
- Risk of respiratory depression
What is the discontinuation of benzodiazepines?
- May take weeks-months if done as an outpatient or if on high doses for long periods of time
- ** DECREASE dose by 10-25% every 1-3 weeks**
What is the withdrawal of benzodiazepines?
- Concern if taking for > 2 weeks
- Onset: 1-2 days if short half-life, 3-8 days if long half-life
- Symptoms usually last 1-2 weeks
What are some common symptoms of withdrawal of benzodiazepines?
- Anxiety
- Restlessness
- Insomnia
- Muscle tension
- Tremor
- Elevated BP
What are some less common symptoms of withdrawal of benzodiazepines?
- Nausea
- Blurry vision
- Diaphoresis
- Depression
- Hyperreflexia
What are some rare symptoms of withdrawal of benzodiazepines?
- Tinnitus
- Confusion
- Seizures
- Psychosis
Buspirone (Buspar)
- 5-HT-1A partial agonist
- Delayed onset of action
- No potential for dependence
- Dose: 10-60 mg/day divided BID-TID
- GAD
Hydroxyzine (Vistaril)
- H1 antagonist
- Useful for mild anxiety symptoms
- Dose: 25-100 mg as needed
- Max: 400 mg/day
- GAD
Vilazodone (Viibryd)
- SSRI/5-HT-1A partial agonist
- Useful in those with comorbid depression
- Dose: 20-40 mg/day
- GAD
Diphenhydramine (Benadryl)
- H1 antagonist
- Useful for mild anxiety symptoms
- Dose: 25-50 mg as needed
- Max: 300 mg/day
- GAD
What are the diagnostic criteria of Panic Disorder?
At least four of the following symptoms:
* Palpitations
* Sweating
* Shaking
* SOB
* Choking
* Chest pain
* Stomach upset
* Dizziness
* Chills or heat
* Sensations
* Etc.
AND
At least one month of worry about future panic attacks with maladaptive behavior changes
What is the first line of therapy for Panic Disorder?
- SSRIs
What is the second line therapy for Panic Disorders?
SNRIs
What other medications can treat panic disorder?
- Alprazolam
- Clonazepam
- Imipramine
- Clomipramine
What is the diagnostic criteria of social anxiety disorder?
- At least six months of the following:
- Marked fear or anxiety about social situations is which the individual is exposed to possible scrutiny by others
- Fear of others witnessing
- Provokes fear or anxiety
- Causes avoidance or endurance with great fear
- Out of proportion to actual threat
- Social or occupational dysfunction
What is the first line of therapy for Social Anxiety Disorder?
SSRI
Which SNRI is not indicated for Social Anxiety Disorder?
Duloxetine
Monoamine Oxidase Inhibitors
- Isocarboxazid (Marplan)
- Phenelzine (Nardil)
- Selegiline (Emsam)
- Tranylcypromine (Parnate)
- Third line for SAD, generally avoided
What are some other agents for SAD?
- Alprazolam and clonazepam
- Propranolol
What is the first line treatment for OCD?
SSRIs
Clomipramine
- Similar efficacy as compared to SSRIs for OCD
What are some adverse effects of Clomipramine?
- Dizziness
- Drowsiness
- Headache
- Orthostatic hypotension
Which SSRIs are NOT approved for OCD?
- Citalopram
- Escitalopram
What is the treatment for refractory OCD?
- Dual therapy with SSRI + clomipramine
- Venlafaxine or mirtazapine
- Deep brain stimulation
Which medications should be avoided for pregnancy and lactation for OCD?
Clomipramine and paroxetine
Which medications should be avoided for elderly patients for OCD?
Avoid clompramine
Acute Distress Disorder
Symptoms for at least 2 days but less than 1 month
PTSD
Symptoms for at least 1 month
What are some other treatments for PTSD?
- TCAs
- Mirtazapine
- Phenelzine
- Mood stabilizers
- Antipsychotics
- Clonidine
What medication can help with PTSD nightmares?
Prazosin
