Anxiety d/os, trauma and stress-related d/os Flashcards
What are the major mediators of sx of anxiety d/os?
Norepinephrine
Serotonin
Dopamine
GABA
Etiology of GAD
Psychoanalytic, behavioral, and existential theories
Increased sympathetic tone
Slow adaptation to repeated stimuli
Excessive response to moderate stimuli
Excessive ans sustained cortisol secretion
Corticotropin-releasing hormone
Low NPY
Low galanin
Genetics
Increased activity in the septohippocampal pathway
DSM-5 criteria for panic d/o
Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following sx occur:
-Palpitations, pounding heart, or accelerated heart rate
-Sweating
-Trembling or shaking
-Sensations of SOB or smothering
-Feelings of choking
-CP or discomfort
-Nausea or abdominal distress
-Feeling dizzy, unsteady, light-headed or faint
-Chills or heat sensations
-Paresthesias
-Derealization or depersonalization
-Fear of losing control or going crazy
-Fear of dying
At least one of the attacks has been followed by 1 mo or more of one or both of the following:
-Persistent concern or worry about additional panic attacks or their consequences
-A significant maladaptive change in behavior related to the attacks
Etiology of panic d/o
Autonomic imbalance
Decreased GABA
Allelic polymorphism of the COMT gene
Increased adenosine receptor function
Increased cortisol
Diminished benzodiazepine receptor function
Disturbances in serotonin, serotonin transporter and promoter genes, NE, dopamine, cholecystokinine and interleukin 1-beta
Chronic hyperventilation and carbon dioxide receptor hypersensitivity
Genetics
Etiology of panic d/o- other theories
Serotonergic model Catecholamine model Locus coeruleus model Lactate model Neuroanatomic model involving amygdala, hypothalamus, and brainstem centers Cognitive theory
Workup for panic d/o
Serum electrolytes to exclude hypokalemia and acidosis
Serum glucose to exclude hypoglycemia
Cardiac enzymes in pts suspected of acute coronary syndromes
Serum hemoglobin in pts with near syncope
TSH in pts suspected of hyperthyroidism
Urine tox screen for amphetamines, cannabis, cocaine and phencyclidine
D-dimer assay to exclude pulm embolism
Tx for panic d/o
CBT, with or without pharmacotherapy is tx of choice
Other psychological tx modalities
Educate pt regarding the importance of longer-term pharm management with SSRIs
Only provide benzos in very limited quantities to emphasize the emergency aspect of them
ED management of panic d/o
Pts with CP, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or Fowler position
Educate the pt that their sx are neither from a serious medical condition nor from a psychotic d/o
Pts may require frequent reassurance and explanation
What are second line meds for panic d/o after SSRIs?
TCAs, such as imipramine or clomipramine may be considered for the management of panic disorder if an SSRI is not suitable or if there is no improvement after a 12-wk course of SSRI tx
What is a good med choice in panic d/o for pts with complicated medical regimens or for those who are concerned with drug interactions?
Citalopram and escitalopram
What is suggested for use in panic d/o with co-occurring depression?
Fluoxetine
What is usually prescribed in panic d/o to help improve with sleep?
Paroxetine, mirtazapine, and TCAs
Paroxetine is category D
DDx of panic d/o: cardiovascular dz
Anemia Angina CHF Hyperactive beta-adrenergic state HTN Mitral valve prolapse MI Paradoxical atrial tachycardia
DDx of panic d/o- pulm dz
Asthma
Hyperventilation
Pulmonary embolus
DDx of panic d/o- neurological dz
Cerebrovascular dz Epilepsy Huntington's dz Infection Meniere's dz Migraine Multiple sclerosis TIA Tumor Wilson's dz
DDx of panic d/o- endocrine diseases
Addison's Carcinoid syndrome Cushing's syndrome DM Hyperthyroidism Hypoglycemia Hypoparathyroidism Menopausal d/os Pheochromocytoma PMS
DDx of panic d/o- drug intoxications
Amphetamine Amyl nitrite Anticholinergics Cocaine Hallucinogens Marijuana Nicotine Theophylline
DDx of panic d/o- drug withdrawal
Alcohol
Antihypertensives
Opiates and opioids
Sedative-hypnotics
DDx of panic d/o- other conditions
Anaphylaxis B12 deficiency Electrolyte disturbances Heavy metal poisoning Systemic infections SLE Temporal arteritis Uremia
Duration of pharmacotherapy for panic d/o
8-12 mos
Acrophobia
Fear of heights
Agoraphobia
Fear of open places