Anxiety Disorders Flashcards
Anxiety sx
Worry
panic attacks
phobic avoidance
compulsions
muscle tension
irritability
sleep
concentration
fatigue
Anxiety patho amygdala
Integrates sensory and cognitive information to determine fear response
Emotions
Motor responses
Endocrine reactions
Autonomic responses
Anxiety
Noradrenergic model of anxiety
ANS is hypersensitive to threat or fear
Locus Coeruleus: Alarm center
so
NE release
so
Stimulate SNS and PNS
GABA Receptor model of anxiety
GABA is the major inhibitory NT
Strong regulatory effects:
serotonin
norepinephrine
dopamine
Benzodiazepine ligands enhance the inhibitory effects of GABA
Serotonin Model of anxiety
Serotonin primarily an inhibitory NT
Serotonin activity reduces norepinephrine activity from the locus coeruleus
SSRI and SNRI action as tx for anx
SSRI
* Inc 5ht and dec NE which may help regulate anx
SNRI
* inc NE which means initially people may inc anx but in long term may dec. That’s why low and slow start
BZD as tx for anx
BZD bind to receptors ro inhibit NT release
BZD and Gaba A bind together to inc the Chloride channel even more
Buspirone as tx for anx
5HT1A receptor partial agonist
- Pre and post synapse receptor
Gabapentin and pregabalin as tx for anx
They block glutamate when its excessive
Anxiety Tx factors in decision making
age
previous tx response
risks (overdose, self harm)
Rx interaction
patient preference
cost
Panic Disorder DSM
Recurrent unexpected panic attacks
followed by 1+ mo of
-persistent concern about additional attacks
Maladaptive changes in behavior to avoid attacks
Not r/t SUD or other dx
Disturbance is not better explained by another mental disorder
1st line tx panic disorder (class)
CBT
SSRI
SNRI
some guidelines say TCA, BZD too
SSRI and SNRI tx for panic (PROS)
decent safety profile
no major difference b/t agents
fluoxetine, sertraline, paroxetine FDA approved
SSRI and SNRI tx for panic (CONS)
poss inc at first in anx, agitation, irritability, jittery
Assoc with GI, HA, sex, sleep, HTN
TCA tx for panic (PROS)
comparable efficacy to SSRI
TCA tx for panic (CONS)
Less tolerated than SSRI
high anticholinergic AE
Cardiac considerations and more lethal in overdose
BZD tx for panic (PROS)
useful adjunct to tx residual anxiety
preferred for very distressing or impairing sx
rapid anxiety control
BZD tx for panic (CONS)
combo with opioids
dependence
withdrawal
CNS depression
Panic attack tx onset of efficacy
Antidepressants
BZD
antidepressants:
-3-4 wks
-pt with significant avoidance, full remission may take 6+ mo
BZD:
onset in hrs for ANS sx of anx
Full benefit 4-6 wks when used as monotherapy
Panic attack duration of tx
Acute
Maint
discontinue
Acute phase
1-4 mo
Alter tx if no response at 12 wks at max tolerated dose
Maintenance
- minimum 12 mo
- cont if residual sx
Discontinue
- based on sx stability, stressors, motivation
- taper over 4-6 mo to reduce relapse
Social Anxiety Disorder DSM
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others
Fear of acting in a way or showing anxiety symptoms that will be negatively evaluated
Social situations almost always provoke fear or anxiety
—-Avoided or endured with intense fear or anxiety
Fear, anxiety, and avoidance are persistent
—->6 months
Significant distress or impairment
Not related to substance use or medical condition
Disturbance is not better explained by another mental disorder
1st line tx SAD (class)
CBT
SSRI
Some guidelines say SNRI too
Rx FDA approved for SAD (SSRI and SNRI)
Paroxetine
Sertraline
Venlafaxine
limited evidence for citalopram and escitalopram
SAD tx
Sx reduction time
Duration
Taper
Sx reduction
- 6-8 wks on tx
After response to prevent relapse
- cont rx for 12 mo
taper
- 3-4 mo
GAD DSM
Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities
Difficult to control the worry
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment
Not related to substance use or medical condition
Disturbance is not better explained by another mental disorder
1st line tx for GAD (class)
SSRI
Most guidelines
- SNRI
Some guidelines
CBT
Pregabalin
Buspirone
hydroxyzine
One guideline
TCA
BZD
Rx FDA approved for GAD
Escitalopram
paroxetine
duloxetine
venlafaxine
small initial daily doses for the first wk
- 50% recc starting dose
- to minimize AE
Alt rx for GAD
Pregabalin
- short term and long term
- rapid onset efficacy (1 wk)
- similar effect to BZD
Buspirone
- FDA approved and decent for short term
- inconsistent evidence for long term
- Mult AE
Hydroxyzine
- Sx relief of anxiety and tension
- up to 12 wks
- Mult AE though (CNS, psychomotor, anticholinergic)
BZD
-2-3 wks max or until SSRI starts to work
- most common for acute tx r/t rapid relief
- long term not recc
onset and duration of tx for GAD
antidepressant response
-4-12 wks
with good response
-cont 12+ mo
Discontinue
- gradual d/c to dec risk
Antidepressants and pregabalin shown safe for long term and preferred to dec relapse
