Anxiety ClinMed and Pharm Flashcards
Definition of anxiety
fear or apprehension out of proportion to the situation
stress is ok, but anxiety is when it is more than needed
The function of anxiety and arousal systems is to increase ______ to a possibly dangerous situation
alertness
it ups motivation to get out of the danger
Anxiety disorder defined by:
excessive worry about life, worry uncontrolled, restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbances
Causes significant impairment to functioning. not due to substance or another psych condition
General anxiety disorder
GAD has _____ rates in females and <30 years old. Onset is typically by _____
higher, early 20s
What is the pathophysiology of GAD
GABAergic, serotonergic, norandrenergic in frontal/limbic lobes
Other things on the DDx for GAD
substance induced, other anxiety disorders, adjustment disorder
Treatment of GAD gold standard is ____ and ____
SSRI/SNRI and CBT
CBT= antecedents, beliefs, consequences. ID the maladaptive thoughts and create healthy alternatives
Medication that is rapidly effective for GAD but also not recommended
Benzodiazepines
tolerance, dependance, relapse in SUD, falls, sedation, worsened cognition, lethal with EtOH, HARD to stop. promotes avoiding anxiety symptoms
For GAD: ________ are the medication used but it can takes weeks to work. ___ and ____ are two commonly started
Antidepressants
low dose trazodone, hydroxyzine
Name that anxiety disorder:
fear about social situations, social interactions, being observed, and performing in front of others. Fears rejection. Social situations are avoided.
Social phobia
Social phobia has prevalence of ___%, affecting males/females ___, ____ have another psych disorder
13%, equally, 50%.
increased SUD risk, familial bc dopa
What is the treatment for social phobia?
SSRI/SNRI, β blockers, psychotherapy
lack of improvement if fears not confronted
Are panic attacks a disorder or a symptom?
symptom
What symptoms are associated with panic attacks
palpitations, sweating, trembling shaking, SOB, feeling of choking, nausea, dizziness, chills, parenthesis, fear of losing control, fear of dying
_____ is a sudden onset 5-60 minute duration symptom that can occur in the context of any anxiety disorder or other conditions
Panic Attack
Name that anxiety disorder
recurrent unexpected panic attacks, not substance, not explained by another mental condition
1 of: persistent concern or worry about another panic attack or significant maladaptive change in behavior
Panic disorder
Panic disorder lifetime prevalence of __ in women and __ in men.
Onset is ___
5, 2
mid 20s.
first one usually to ED but then becomes chronic illness with symptom fluctuation.
increased risk of death from SUD or depression
Panic disorder comorbidities include (medical conditions)
IBS, HTN, mitral valve prolapse, fibromyalgia, chronic fatigue, migraine, asthma, allergic rhinitis, sinusitis
Panic disorder can be hereditary, first degree relative up to __%
20
higher concordance with twins
Panic disorder treatment is to combine ___ and ___. Second line is _____, ______, and ______. Avoid caffeine
SSRI/SNRI, psychotherapy
β blocker, MAOIs, TCAs
Why are benzodiazepines unnecessary for panic disorders?
risks and the attack usually subsides before the med becomes bioavailable
Name that anxiety disorder:
Fear of inability escape quickly (public, open spaces, enclosed spaces, standing in lines), fear of being trapped. Can be comorbid with panic disorder
Agoraphobia
sitation cause anxiety-> avoid situation ->impairment
_____ and ______ stressful situations reinforces the anxiety
avoidance and fleeing. Treatment is aimed at staying in the stressful situations
When is an appropriate use of benzodiazepines
before imaging/radiation/flying, alcohol detox, anesthesia, seizures
Adequate treatment trial for GAD on SSRIs is _____.
If response then keep for ____
If no response then _____
4-6 weeks.
1 year
switch to another SSRI
_____ can be taken for GAD short term/as needed
Benzodiazepines. If cannot take those bc SUD, concurrent CNS depressants, then take hydroxyzine
Second line treatments for SUD include
benzodiazepines, buspirone, pregabalin, quetiapine.
As needed meds -> lorazepam, hydroxyzine
Benzodiazepines mechanism is binding ____ and _____ allosterically on post synaptic ____ -> enhances GABA CNS inhibitory
α and γ
GABA-A
increases frequency of CL ion channel opening
modulates neuronal excitability through amygdala and cortico-striato-thalamo-cortical loop-> helps anxiety symptoms
GAD
α 1 receptors target _____
α 2 receptors target _____
sedation
anxiolysis
BZ receptors are _____ so it can treat many physical symptoms such as ________
nonselective, restlessness, muscle tension, irritability, insomnia
Benzodiazepines anxiolytic effect can be seen within _______.
30-60 minutes
What are the 4 FDA approved benzodiazepines? What is the difference?
lorazepam, clonazepam, alprazolam, diazepam.
Pharmacokinetic differences.
Benzodiazepines are highly (lipophilic/hydrophilic)
lipophilic
Benzodiazepines are largely metabolized by _____
CYP450-> 3A4 and 2C19
Caution in: old ppl, decreased liver, drug drug, active metabolites
_______ is a benzo that goes through glucuronidation to inactive metabolites (this makes it safer)
lorazepam
Benzodiazepines with rapid onset of effect risk _____, ______, unpleasant feeling of loss of control
euphoria, excitement
The most common adverse effects of benzodiazepines are _______, _______, psychomotor impairment, and ataxia.
drowsiness, sedation
this can stay around for a few days then tolerance
Do not give benzodiazepines to _______ or _______ because there is a risk of confusion, disorientation, delirium, and risk of falls
geriatric patients or pts with cognitive disorder (beer’s criteria)
There is an increased risk of ______ with benzodiazepine use. This is dose dependent and also make sense why you would give benzos to someone right before an invasive procedure
anterograde amnesia
Benzodiazepines (can/cannot) be abused psychologically and physiologically
can. overuse leads to dependence and withdrawal
There is respiratory depression and should be avoided with other depressants (opioids, alc)
Benzodiazepines are pregnancy category __
D
Withdrawal from benzodiazepines is the original symptoms but worse. The thing to really watch for is ______.
Onset of withdrawal depends on ______
seizures. half life (may need a long taper w longer bz use)
Is it likely to OD on benzodiazepine alone? why not?
no, it has a wide therapeutic index.
ODs happen when combined with other CND depressants
________ is a competitive benzodiazepine receptor antagonist (α and γ)-> reverse binding of BZ
Flumaznil
use cautiously because could cause seizure
Buspirone (Buspar) MOA: _________ at pre and post synaptic 5HT-1A receptors-> overtime this will lead to 5HT receptor _______
partial agonist
downregulation
Is buspirone a controlled substance? Why not?
not a controlled substance. There is no abuse or dependence, hypnotic, euphoric effect, or withdrawal.
Who would buspirone be indicated for in GAD?
Patients with SUD, older, failed other treatments, pregnancy category B
Why wouldn’t you use buspirone on everyone for GAD?
inconsistent efficiency. It is less effective than BZ. slow onset (4-6 weeks) and short half life (3x daily)
The main medications used for Panic Disorder are ____. ______ can be used for breakthrough panic attacks
SSRIs (fluoxetine, paroxetine, sertraline) or SNRI (venlafaxine)
Benzodiazepines (might not work bc not bioavailable yet)
Acute treatment phase for panic disorder is ______. Duration of treatment is recommended _______
1-3 months
12-24 months
The main medications used for social anxiety disorder are______. Maintain appropriate treatment for ______
SSRIs (paroxetine, sertraline) and venlafaxine. Benzos used as needed
6-12 months
if not enough response, can add buspirone or clonazepam
Full remission for OCD is ____ with medication.
rare
Partial remission is best bet
The first and second line treatments for OCD is ________. The third line treatment is _______ because of greater anticholinergic adverse effects
SSRIs!!
Clomipramine, a tricyclic antidepressant
DO NOT USE BENZOS
For OCD, _______ is combined with SSRIs in patients with tic disorder
atypical antipsychotics
Mediation trial for OCD is _______. Prescribed max dose for _____.
Treat for ______ years
8-12 weeks, 4-6 weeks. OCD responds well to high doses of SSRI
1-2 years
Firstline for PTSD treatment is ______, start 3-4 weeks after trauma in combination with ______.
Antidepressants, psychotherapy
trial 8-12 weeks, max dose 4-6 weeks. NO BENZOS
Additional medication for residual symptoms in PTSD can be used. For sleep difficulties use _____. For anger, intrusive thoughts, and hypervigilance use _______.
Prazosin (HTN drug) Atypical antipsychotics (lamotrigine, risperidone, quetiapine)
