Anxiety Disorders

Question 1

What are the symptoms of occasional anxiety?

Answer 1

Fear, worry, tachycardia palpitation, shortness of breath, stomach upset, chest pain or other pain, insomnia or fatigue

Question 2

What is the difference between occasional anxiety and an anxiety disorder?

Answer 2

With an anxiety disorder, the symptoms are chronic, severe and cause great distress. The disorder can interfere with the ability to do well at school or work and can harm relationships

Question 3

What are the major types of anxiety disorders?

Answer 3

The major types of anxiety disorders are generalized anxiety disorder (GAD), panic disorder (PD) and social anxiety disorder

Question 4

What are other disorders that have symptoms of anxiety?

Answer 4

Other disorders that have symptoms of anxiety include obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD)

Question 5

How is OCD and PTSD categorized?

Answer 5

OCD is categorized as “obsessive-compulsive and related disorders” and PTSD is categorized under “trauma and stressor-related disorders”

Question 6

What are some examples of drugs that can cause anxiety?

Answer 6

Albuterol (if used too frequently or incorrectly), antipsychotics, bupropion, caffeine (in high doses), decongestants, illicit drugs, levothyroxine (if therapeutic overdose occurs), steroids, stimulants, theophylline

Question 7

What are some lifestyle changes that can improve symptoms of anxiety?

Answer 7

Increasing physical activity, helping others, community involvement, yoga and meditation are some of the methods that can reduce stress

Question 8

What is cognitive behavioral therapy (CBT)?

Answer 8

Cognitive behavioral therapy (CBT) is a type of mental health treatment in which a trained clinician helps the patient explore patterns of thinking that lead to problem-solving, relaxation techniques, worry exposure and more

Question 9

What are some natural products that may provide benefit in treating anxiety?

Answer 9

St. John’s Wort, Valerian, Passionflower, Kava

Question 10

What is the benefit of St. John’s Wort and its safety concerns?

Answer 10

St. John’s Wort, used for depression and anxiety, is a strong CYP3A4 inducer and can decrease the concentration of other medications. St. John’s wort causes photosensitivity and is serotonergic, which increases the risk of serotonin syndrome when used in combination with other serotonergic medications

Question 11

What is the benefit of Valerian and its safety concerns?

Answer 11

Valerian is used for anxiety and sleep, but some products may be contaminated with liver toxins; if used, liver function should be monitored

Question 12

What is the benefit of Kava and its safety concerns?

Answer 12

Kava is a relaxant, but it can cause severe liver damage and is not recommended

Question 13

What medications are considered first-line for the treatment of anxiety?

Answer 13

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs)

Question 14

What are some counseling points associated with SSRIs and SNRIs?

Answer 14

• Start at half the initial dose used for depression and slowly titrate to minimize anxiousness and jitteriness (common during the first couple of weeks)
• Will not provide immediate relief; takes at least four weeks at higher doses for a noticeable effect
• Other SSRIs and SNRIs may be used off-label for anxiety disorder

Question 15

What medications are considered second-line for the treatment of anxiety?

Answer 15

Buspirone, Tricyclic Antidepressants, Hydroxyzine, Pregabalin, Gabapentin

Question 16

What are some counseling points about Buspirone?

Answer 16

• Can use in combination with antidepressants (e.g. when there is a poor response)
• Considered a more favorable add-on medication than benzodiazepines in elderly patients (less sedating) or if there is a risk for benzodiazepine abuse
• Does not provide immediate relief; takes 2-4 weeks for effect

Question 17

What are some counseling points about tricyclic antidepressants?

Answer 17

• Not FDA-approved for anxiety

- Risk of adverse effects (e.g. anticholinergic side effects) limit use

Question 18

What are some counseling points of Hydroxyzine?

Answer 18

• Sedating antihistamine with anticholinergic activity
• FDA-approved for anxiety but does not treat the underlying condition
• Should not be used long-term; use only short-term, as needed, as an alternative to benzodiazepines

Question 19

What are some counseling points of Pregabalin and Gabapentin?

Answer 19

• Not FDA-approved for anxiety but has shown benefit in patients with anxiety and neuropathic pain
• Has immediate anxiolytic effects similar to benzodiazepines

Question 20

Which medication can be used to treat anxiety in special situations?

Answer 20

Propranolol

Question 21

What are some counseling points of Propranolol?

Answer 21

• Not FDA-approved for anxiety but can reduce symptoms fo stage fright or performance anxiety (e.g. tremor, tachycardia)
• Dose: 10-40 mg one hour prior to an event (such as public speech)
• Can cause CNS side effects (e.g. dizziness, confusion)

Question 22

What is the MOA of Buspirone?

Answer 22

The mechanism of action of buspirone is unknown, but its effects may be due to its affinity for 5-HT1A and 5-HT2 receptors

Question 23

What are some contraindications of Buspirone?

Answer 23

Do not use with MAO inhibitors (or within 14 days of discontinuation), linezolid or IV methylene blue

Question 24

What are some warnings associated with Buspirone?

Answer 24

Risk of serotonin syndrome alone or in combination with other serotonergic drugs

Question 25

What are some side effects associated with Buspirone?

Answer 25

Dizziness, drowsiness, headache, lightheadedness, nausea, excitement

Question 26

What are some notes associated with Buspirone?

Answer 26

- No potential for abuse, tolerance or physiological dependence - When switching from a benzodiazepine to buspirone, the benzodiazepine must be tapered off slowly - Avoid use in severe kidney or liver impairment

Question 27

What are some Buspirone drug interactions?

Answer 27

- Risk of serotonin syndrome is increased when used in combination with other serotonergic drugs - Avoid grapefruit and grapefruit juice, may increase buspirone levels - Buspirone is a major substrate of CYP3A4 (decrease the dose if used in combination with moderate and strong CYP3A4 inhibitors or increase in the buspirone dose may be required with CYP3A4 inducers)

Question 28

What is the MOA of BZDs?

Answer 28

BZDs enhance gamma aminobutyric acid (GABA), an inhibitory neurotransmitter which causes CNS depression, resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties

Question 29

How can BZDs be useful in anxiety?

Answer 29

They provide fast relief of symptoms (but do not treat the underlying causes of anxiety). BZDs can be useful for short-term treatment of acute anxiety that is preventing restful sleep and disrupting life

Question 30

What is the concern of BZDs when used for anxiety and what are the recommedations?

Answer 30

If taken long-term, patients can become addicted to BZDs and develop tolerance. Due to the risk of dependence, they should only be used for 1-2 weeks and then discontinued. If used for longer periods of time, they must be tapered off slowly to prevent withdrawal symptoms

Question 31

Why are BZDs on the Beers Criteria?

Answer 31

BZDs are potentially inappropriate in patients > 65 years old. BZDs have a high risk of confusion, dizziness and falls in the elderly, which is increased if used with other CNS depressants

Question 32

Which BZDs are preferred if used for anxiety?

Answer 32

If used, consider BZD with longer half-life and less risk of abuse

Question 33

If needed, what BZDs are recommended for anxiety for elderly or patients with liver impairment?

Answer 33

If used, consider BZDs that undergo glucuronidation: L-O-T drugs (Lorazepam, Oxazepam, Temazepam)

Question 34

What are some examples of BZDs?

Answer 34

Alprazolam, Clonazepam, Diazepam, Lorazepam, Chlordiazepoxide, Clorazepate, Oxazepam

Question 35

What are some boxed warnings associated with BZDs?

Answer 35

- Use with opioids can result in sedation, respiratory depression, coma and death - Risks for abuse, misuse and addiction which can lead to overdose or death - Continued use can lead to physical dependence; abrupt discontinuation can cause withdrawal symptoms

Question 36

What are contraindications of BZDs?

Answer 36

Acute narrow-angle glaucoma, sleep apnea, severe respiratory insufficiency, severe liver disease (clonazepam and diazepam), myasthenia gravis (diazepam), not for use in infants < 6 months of age (diazepam oral), premature infants (lorazepam parenteral products)

Question 37

What are some warnings associated with BZDs?

Answer 37

- Physiological dependence and tolerance develop with chronic use: do not discontinue abruptly (taper off slowly) - CNS depression, anterograde amnesia, potential for abuse, safety risks in patients age 65 years and older (impaired cognition, delirium, falls/fractures), extravasation with IV use, paradoxical reactions, severe renal or hepatic impairment - Pregnancy: crosses placenta; can cause birth defects and neonatal withdrawal symptoms

Question 38

What are some side effects of BZDs?

Answer 38

Somnolence, dizziness, ataxia, weakness, lightheadedness

Question 39

What are some notes about BZDs?

Answer 39

- C-IV - Diazepam: lipophilic, fast onset, long half life, high abuse potential - Alprazolam: fast onset, often abused due to quick action - Commonly used for alcohol withdrawal syndrome: lorazepam , diazepam and chlordiazepoxide - Antidote: flumazenil

Question 40

Describe the drug interactions of BZDs.

Answer 40

- Additive effects with CNS depressants - Diazepam, clonazepam, chlordiazepoxide and clorazepate: use cautiously with CYP3A4 inhibitors - Alprazolam is contraindicated with strong CYP3A4 inhibitors. Use with caution with moderate CYP3A4 inhibitors - Valproate increases the serum concentration of lorazepam

Question 41

What are some key counseling points of Buspirone?

Answer 41

- The tablets are scored to easily break in half or into thirds - Can cause dizziness, drowsiness, nausea

Question 42

What are some key counseling points of benzodiazepines?

Answer 42

- If used regularly for > 10 days, do not stop suddenly. Taper off slowly to avoid withdrawal symptoms - To reduce the risk of addiction, do not take doses more frequently or for a longer period than prescribed - Can cause drowsiness - Do not use with opioid medications (can cause profound sedation, respiratory depression, coma and death) - Do not use with alcohol (can increase risk of CNS depression)