Anxiety Disorders Flashcards
What are the different Anxiety disorders?
- Generalised anxiety disorder (GAD)
- Obsessive compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Panic disorder
- Phobic anxiety disorders
–Specific phobias
–Social phobias (Social Anxiety Disorder; SAD)
– Agoraphobia
Which of the following group is NOT a main treatment for anxiety disorders?
a) SSRI’s
b) Benzo’s
c) Anti-emetics
d) Antipsychotics (e.g Risperidone, olanzapine, quetiapine, pericyazine)
e) Anti-cholinergics
f) Venlafaxine and Duloxetine
g) TCA (e.g Clomipramine, Imipramine)
h) Pregabalin
Answers are C and E
What is the first line treatment in ALL anxiety disorders?
SSRI’s are considered first line in all anxiety disorders
- Escitalopram and Paroxetine are licensed, however other SSRI’s have similar efficacy and are used widely.
- with anxiety/GAD and SSRI’s, the symptoms tend to get worse before getting better, so to minimise this start with low dose (half of the normal dose)
- Increase dose every two weeks as tolerated then on. (short term benzo’s can help with this initial anxiety and if only used for a few weeks carry little to no dependence liability.
What are some non-pharma interventions used for anxiety disorders?
Psychotherapeutic approach:
- Counselling, CBT, Anxiety management
Self help:
- Dietary :- caffeine avoidance or atleast reduction
- relaxation techniques
- self help groups/books
- lifestyle changes
What is GAD defines as?
GAD is where the anxiety doesn’t go away, lasts for at least 6 months and where the worry is blown out of proportion to the risk. it is the most common anxiety disorders and almost always has a symptoms of depression as well, fully managing the depression is the priority.
People with GAD (+- depression) can be desperate and have suicidal ideation. so don’t miss that and inadvertently think they can pull themselves together
Onset: early adulthood, tends to change with age as the subject of the anxiety evolves with time.
GAD Symptoms include:
How many of the following symptoms are needed for a diagnosis of GAD (DMS IV):
Major symptoms:
- Excessive anxiety and worry about a number of events and activities.
- Difficulty controlling the worry.
Additional Symptoms:
- Restlessness or feeling keyed up or on edge
- Being easily fatigues
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
The patient must have BOTH major symptoms, occurring more days than not for at least 6 months
The patient must also have atleast 3 out of the 6 additional symptoms.
Which of the following treatments is first-line in GAD?
a) Fluoxetine
b) Quetiapine
c) Aripiprazole
d) Phenobarbital
Answer is A, even though its not licensed its used off-license for GAD
For licensed SSRI’s:
-Paroxetine 5-10 mg OD / Escitalopram 5mg OD for ONE week, then increasing stepwise over several weeks as tolerated, allow 8/52 for response
-Paroxetine target dose 20-50 mg OD (good relapse prevention)
- Escitalopram target dose 10-20 mg OD (may be superior to paroxetine, as relapse prevention has also been shown)
Below is the Stepped-Care model for GAD
What are sone short-term, adjunct and second line therapies that can be used?
Short term use:
- Benzo’s
- Beta-blocker low dose
- Antihistamine low dose
- Anti psychotics low dose
Adjuncts:
- Beta-Blocker (Somatic symptoms) (e.g. Propranolol 10-40 mg TDS)
- Buspirone (for delayed onset of action) (Gradually increase dose to 10mg TDS, continue for at least 6 months.
Second line:
- Venlafaxine / Mirtazapine
- Pregabalin
- Benzo’s long term (Addiction problem)
What is the definition of OCD?
Obsessive compulsive disorder is characterised by repeated intrusive compulsive acts. Resisting the ‘thoughts’ leads to anxiety and performing the ritual relieves the tension. usually starts in adolescence or early adulthood.
- Obsessions: thoughts, impulses, ideas which re recurrent and persistent. e.g. fear of contamination
- Compulsions: repetitive behaviours / actions performed in response to an obsession (e.g. handwashing, counting, checking)
- First line pharmacological treatment: SSRI’s or Clomipramine
What are the first line treatments for OCD?
First line treatments are SSRI;s or clomipramine (a TCA)
Drug:
- Only central serotonin enhancers are effective (SSRI’s and clomipramine are effective and both superior to non-serotonergic drugs but other antidepressants seem ineffective.
Dose:
- Daily dose usually needs to be very high, e.g. clomipramine 250-300 mg/d, Fluoxetine 60-80mg/d, Sertraline 100-200mg/d ; Less tolerable but HIGH efficacy.
- In resistant OCD, even higher doses may be needed
Duration:
- If there is adequate response then the maximum tolerated dose of an SSRI or clomipramine for THREE months. (over 25% respond given adequate dose and duration, most of the rest will respond significantly)
- Relapse is common on discontinuation, so 1-2 recommended for relapse prevention.
Discontinuation:
- Gradual discontinuation over several months is widely recommended.
what is the definition and treatment of social anxiety?
Define as excessive anxiety which is evoked by a specific object or situation. It can be accompanied by panic attacks.
It can also include agoraphobia (the fear of public places or crowds)
First line pharmacological treatment:
- SSRI’s (e.g Escitalopram) and Venlafaxine (an SNRI) are licensed
- Meta-analysis shows them to be more effective than placebo
- The only predictor of response is length of treatment, which should at least be 12 weeks
Medicines management of panic disorders
- Symptoms include shortness of breath, palpitations, chest discomfort, sweating, nausea, trembling, and fear of dying.
- Self help and CBT should be encouraged (esp for mild panic disorder)
For Mod - Severe Panic Disorder
- SSRI’s first line :- Escitalopram, Sertraline, Citalopram, Paroxetine are licensed.
- Venlafaxine is also licensed
- Second line :- Imipramine or Clomipramine (unlicensed), if an SSRI is not suitable or no improvement after 12 week course
- NICE does not recommend Benzo’s for panic disorder but in practice may be used for emergency management.
