Anxiety Disorders Flashcards
What is the usual age of onset for anxiety disorders?
Early adulthood
Most common ages 45-59, drops after 60 y/o
What are the general signs of anxiety?
Excessive or pervasive and uncontrollable worry which occurs for period =/> 6 months
What are some symptoms of anxiety?
Restlessness
Irritability
Fatigue
Muscle tension
Difficulty concentrating
Sleep disturbances
What mechanisms are involved in the pathophysiology of anxiety?
Anxiety and fear - malfunctioning amygdala
Serotonin = ?enhances release/abnormal uptake, ? super-sensitivity of receptors
Gaba - regulate NA and 5HT (type C) somewhat
Corticotrophin releasing factor (CRF)
What are the non-pharm treatment strategies of anxiety?
Always managed with psych intervention throughout varying severities (adults and young people)
Exercise may be useful adjunct for those w/ anxiety
- dec panic sx - lower pt sensitivity to internal symptoms similar to panic
What is step 1 of the anxiety stepped care model?
All known and suspected presentation of GAD
- Educate and active monitoring
What is step 2 of the anxiety stepped care model?
Diagnosed GAD that has not improved after step 1
- low-intensity psychological intervention
What is step 3 of the anxiety stepped care model?
GAD with marked functional impairment or that has not improved after step 2
- high intensity psych intervention
- drug treatment
How are benzos used in anxiety disorders?
Short term only - used for up to two weeks followed by gradual reduction to 0 in 6 weeks
*Can cause anxiety once removed
Useful for immediate relief from anxiety symptoms
What are some short and very short duration benzos?
V/ Short = midazolam
Short = alprazolam, oxazepam, temazepam
What are some long duration benzos?
Clobazam, clonazepam, diazepam, flunitrazepam, nitrazepam
What are the main drugs used in anxiety maintenance therapy?
SSRIs are most effective
SNRIs are effective but not good for underlying conditions
TCAs are effective but use with caution
How do the antidepressant doses used to treat anxiety differ from depression?
Doses at lower end of range
Start low and titrate to adequate effect or max recommended dose
Concerned about ADRs:
- Begin with half the normal starting dose, avoid using high maintenance
What are dose examples of SSRIs used to treat anxiety?
Citalopram, paroxetine, fluoxetine = 10 mg
Escitalopram = 5 mg
Fluvoxamine = 50mg
Sertraline = 25 mg
What are the third line therapies for non-responsive anxiety?
Pregabalin = rapidly effective (20-30% improvement in a week)
Quetiapine = antihistamine at low dose
Other = agomelatine and mirtazapine (sedation, weight gain, metabolic)
What are the considerations/down sides to pregabalin in anxiety?
Severe ADRs
Potential for dependence and abuse
Toxicity in overdose
Can alter/worsen mood, emergent suicidal thoughts and behaviours
What are the considerations/down sides to quetiapine in anxiety?
Use is limited by cardiometabolic ADRs, problem use, overdose
How is anxiety diagnosed?
DSM-V = presence of obsessions, compulsions, or both
Obsessions = Recurrent & persistent thoughts, urges, images experienced as intrusive & and unwanted and cause marked anxiety and distress
Compulsions = repetitive behaviours or mental acts in response to an obsession or according to rigid rules
Generally, how is OCD treated? Dose considerations?
Combination of psychological and pharmacological treatment
SSRIs = effective (1st line)
SNRI = limited efficacy (2nd line)
Doses are higher compared to both anxiety and depression
How long does it take for OCD symptoms to improve? Any monitoring?
May need cardiac monitoring due to QT prolongation
Response = 6-12 weeks, treated for 6-12 month
May relapse when drug is withdrawn
What are the third line therapies for non-responsive OCD?
Clomipramine (TCA) = other TCAs not work
Quetiapine
What are the considerations/down sides to Quetiapine in OCD?
Antihistamine at low doses
Use limited by:
- risk of cardiometabolic ADRs, overdose, problem use
What are the considerations/down sides to clomipramine in OCD?
Uniquely effective in some
Intolerance limits use
Toxicity in overdose
Changes in cardiac conduction = do ECG before starting tx, repeat when dose stabilised (usually after 6 weeks)
How does PTSD differ from anxiety?
They don’t anxiety
Sx of anhedonia or dysphoria, anger, aggression, or dissociation
What is the difference between Acute stress disorder and PTSD?
ASD = begins immediately after trauma and lasts for 3 days to 1 month
PTSD = lasts for >1 months as continuation or as separate occurrence up to 6 months after trauma
What are the four major symptoms clusters of PTSD?
Re-experiencing the event
Heightened arousal
Avoidance
Negative thoughts and moods or feeling
Outline (generally) the treatment for PTSD and ASD
Specialist psychological intervention
Minimal evidence for pharmacotherapy
SSRI 1st line, SNRI 2nd line (due to heightened arousal)
Limited evidence for mirtazapine and TCA
How long does it take to see a response when pharmacotherapy is used in PTSD/ASD?
8-12 weeks
If tx beneficial, use for 12 months
PTSD px also more sensitive to SNRI ADRs
How are PTSD nightmares treated?
Psychological interventions - imagery rehearsal therapy or CBT
Pharmacotherapy: Prazosin - evidence is conflicting
