Anxiety - Block 3 Flashcards by Hannah Lapos

Uncomfortable feeling of vague fear or apprehension accompanied by characteristic physical sensations

Anxiety

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What are the types of ax disorders?

Panic Dx
OCD
PTSD
Phobias
GAD

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What is the first diagnostic step of diagnosing ax?

Consider the possible differential diagnoses such as med conditions/meds

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What is the diagnostic criteria for GAD?

6 months or more of excessive worry or anx with unidentified cause

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What are the assessment tools for GAD?

Generalized Anxiety Disorder 7-Item scale (GAD-7)
Penn State Worry Questionnaire

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What is the scores associated with GAD7?

Greater than 10: GAD
5,10, 15: mild, moderate, severe

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Penn State Worry Questionnaire scores?

Low: 16–39
Moderate: 40–59
High: 60–80

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What are somatic sx of ax?

Muscle aches/tension
HA
Backaches
GI issues
Sleep problems
Fatigue

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Psychological tx for ax?

CBT
relaxation therapy, stimulus control
Cognitive restructuring
Self monitoring

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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

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What are the pharm first lines for GAD?

SSRI:
* Paroxetine
* Escitalopram
* Sertraline
* Fluoxetine

SNRI:
* Venlafaxine XR
* Duloxetine

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What are the second line agents for GAD?

BZD:
* Diazepam
* Alprazolam
* Lorazepam
* Clonazepam

TCA:
* Imipramine

Buspirone
Hydroxyzine

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What do you do if a patient has a poor response to tx?

Change to another AD (SSRI or SNRI)

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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

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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

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How long does it take Buspirone to work?

2-4 weeks

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Why is TCA second line?

Anticholinergic ADRs limit use

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What are the 5 effects of BZD?

anxiolytic, anticonvulsant, muscle relaxing, and sedative-hypnotic,amnesic actions

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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

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What are common withdrawal sx from BZD?

Seizures, psychotic rx

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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

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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 1-2 weeks

CI of BZDs?

1. Elderly 2. Substance and alcohol abuse history 3. Chronic opiods 4. Pregnancy (cleft lip)

BZDs safe for elderly?

Lorazepam, Oxazepam, Temazepam

Alprazolam CI?

1. Acute narrow angle glaucoma 2. Ketoconazole, itraconazole, CYP3A4 inhibitors

Diazepam CI?

1. Untreated open angle glaucom 2. Infants <6 months 3. Myasthenia gravis 4. Severe respiratory impairment 5. Sever hepatic impairment 6. 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?

1. St johns worts 2. SAM-e 3. Folate 4. 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?

1. CBT 2. Avoidance 3. No meds 4. Systematic desensitization

Nonpharm tx for social phobias?

1. Psychotherapies 2. Exposure 3. Social skills training 4. 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) and venlafaxine **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?

1. Buspirone 2. B-blockers 3. Antihistamines 4. Antipsychotics 5. Bupropion 6. Trazodone