Anxiety - Block 3 Flashcards
Uncomfortable feeling of vague fear or apprehension accompanied by characteristic physical sensations
Anxiety
What are the types of ax disorders?
- Panic Dx
- OCD
- PTSD
- Phobias
- GAD
What is the first diagnostic step of diagnosing ax?
Consider the possible differential diagnoses such as med conditions/meds
What is the diagnostic criteria for GAD?
6 months or more of excessive worry or anx with unidentified cause
What are the assessment tools for GAD?
Generalized Anxiety Disorder 7-Item scale (GAD-7)
Penn State Worry Questionnaire
What is the scores associated with GAD7?
Greater than 10: GAD
5,10, 15: mild, moderate, severe
Penn State Worry Questionnaire scores?
Low: 16–39
Moderate: 40–59
High: 60–80
What are somatic sx of ax?
- Muscle aches/tension
- HA
- Backaches
- GI issues
- Sleep problems
- Fatigue
Psychological tx for ax?
- CBT
- relaxation therapy, stimulus control
- Cognitive restructuring
- Self monitoring
How do we determine what therapies to use?
- Sx intensity and duration
- Imapct of patients ability to function in daily life
- Comorbid conditions such as depression
- Medical condition
- Patient preference
What are the pharm first lines for GAD?
SSRI:
* Paroxetine
* Escitalopram
* Sertraline
* Fluoxetine
SNRI:
* Venlafaxine XR
* Duloxetine
What are the second line agents for GAD?
BZD:
* Diazepam
* Alprazolam
* Lorazepam
* Clonazepam
TCA:
* Imipramine
Buspirone
Hydroxyzine
What do you do if a patient has a poor response to tx?
Change to another AD (SSRI or SNRI)
What do you do if a patient has a partial response to tx?
- Can augment first antidepressant with buspirone,hydroxyzine, pregabalin, or short course of BZD
- change toanotherantidepressant
- add CBT, depending on clinical and patientpreference
How do you initiate SSRI/SNRI for anxiety?
Start half the initial dose of depression and titrate slowly to minimize anxiousness and jitteriness which can occur during the first 2 weeks of therapy
6-8 weeks to see effect after patient reaches therapeutic levels
How long does it take Buspirone to work?
2-4 weeks
Why is TCA second line?
Anticholinergic ADRs limit use
What are the 5 effects of BZD?
anxiolytic, anticonvulsant, muscle relaxing, and sedative-hypnotic,amnesic actions
How should you administer BZD?
- Dependence after >6 wks
- Potential for abuse or dependence
- Abrupt cessation can lead to withdrawal
- Treatment period should be limited to 1-2 weeks
- Requires tapering if been on for a long time
What are common withdrawal sx from BZD?
Seizures, psychotic rx
What are the recommendations for tapering BZDs?
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BZD with short half life and high potency are indicated for?
Quicker contol of sx -> acute management that is eventually replaced with long acting agents
BZD with long half life and low potency are indicated for?
Interdose breakthrough symptoms are less likely, however, can cause hangover sx
* Accumulation in older adults
BZD with short half life? long?
SHort: Alprazolam, Lorazepam
Long: Chlordiazepoxide, clonazepam, clorazepate and diazepam
What BZD have low hepatic metabolism and have no active metabolites?
Lorazepam, oxazepam and alprazolam
What BZD has the most rapid onset but greatest abuse potential?
Diazepam and clorazepate
Describe the progressions of BZD effects as dose increases?
Most common BZD for anxiety?
CLAD- Clonazepam, Lorazepam, Alprazolam, Diazepam
BZD commonly used for alcohol withdrawal?
ordiazepoxide,Diazepam, Lorazepam
BZD used to control sz?
Diazepam
What BZD formulation is used for anxiety?
short acting with high potency acutely or max 1-2weeks
CI of BZDs?
- Elderly
- Substance and alcohol abuse history
- Chronic opiods
- Pregnancy (cleft lip)
BZDs safe for elderly?
Lorazepam, Oxazepam, Temazepam
Alprazolam CI?
- Acute narrow angle glaucoma
- Ketoconazole, itraconazole, CYP3A4 inhibitors
Diazepam CI?
- Untreated open angle glaucom
- Infants <6 months
- Myasthenia gravis
- Severe respiratory impairment
- Sever hepatic impairment
- Sleep apnea syndrome
What is the BBW for BZDs?
Avoid conmitant use with opioids -> respiratory depression and death
ADR of BZD?
CNS depression: : fatigue,drowsiness, muscle weakness, ataxia
Respiration: resp depression
CV: orthostatic hypotension, tachycardia
What are alternatives for anxiety?
Hydroxyzine: short term, anticholinergic effects
Pregabalin: immediate anxiolytic effectsm C-V, used for neuropathic pain
Beta blockers: Propranolol
OTC products for anxiety?
- St johns worts
- SAM-e
- Folate
- Omega 3
Tx for OCD?
Non-Pharm: behavioral therapy
Pharm: SSRI and SNRI, BZ, Buspirone, TCA
Effective if patient does both
Last resort: Neurosurgery, ECT
Causes of OCD?
Serotonergic dysfunction
Neurology problem
Genetics
How long does it take OTC tx to work?
4-12 wks
What class of drugs fail to control OCD completely?
SSRI
What is the only effective TCA for OCD?
Clomipramine
What are the augemnetation agents for OCD?
Haloperidol
SGA: olanzapine, quetiapine, risperidone
How long does it take for PTSD tx to work?
8-10 weeks
How long of PTSD patients on treatment for?
12-24 months for 75% reduction of sx for 3 months
First line for PTSD
SSRI: fluoxetine, sertraline, and paroxetine
Augemtation therapy for PTSD?
antiadrenergic – prazosin- PTSD associated with nightmares
Anticonvulsants-valproic acid, carbamazepine, lamotrigine, topiramate-PTSD associated with aggression, anger, depression
anxiolytics (no benzo), buspirone
Antipsychotics-olanzapine, quetiapine, risperidone- PTSD associated with psychotic symptoms
β-blockers or mood stabilizers- in intermittent explosive behavior
BDZ are acutely used for sleep disturbances, should be very limited
What are specific phobias?
fear of objects or situations:
1. Animals
2. Blood injection type
3. Natural environment
4. Situational
5. Other
What is the tx for phobias?
- CBT
- Avoidance
- No meds
- Systematicdesensitization
Nonpharm tx for social phobias?
- Psychotherapies
- Exposure
- Social skills training
- Cognitive behavioral therapy
How long is the onset of AD for social phobia tx?
12 weeks
What are the pharm tx for social phobias?
First line: SSRI (escitalopram, fluvoxamine, paroxetine, sertraline) andvenlafaxine
Second/third: Gabapentin and pregablin
Adjunct: Clonazepam
Other: Benzos, beta blockers, MAOI
What are the target sx of panic dx?
Chest pain, SOB, DZ, depersonalization
Tx for panic disorders?
Non pharm: CBT
First line: SSRI (escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)
* SNRI: venlafaxine, and duloxetine
Other: BZD, alprazolam, lorazepam, clonazepam
Higher doses than in GAD , use lowest effective dose
What are not effective agents for panic disorders?
- Buspirone
- B-blockers
- Antihistamines
- Antipsychotics
- Bupropion
- Trazodone
