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Psychiatric Pharmacotherapy > Anxiety Disorders > Flashcards

Anxiety Disorders Flashcards

1
Q

*Under the DSM-5 criteria, how might a patient with Generalized anxiety disorder (GAD) present?

A

Excessive anxiety and worries >6m

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2
Q

*Under the DSM-5 criteria, how might a patient with Panic disorder (PD) present?

A

Anticipatory anxiety of recurrent panic attacks

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3
Q

*Under the DSM-5 criteria, how might a patient with Social anxiety disorder (SAD) present?

A

Fear of being scrutinized or humiliated in public

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4
Q

*Under the DSM-5 criteria, how might a patient with Obsessive compulsive disorder (OCD) present?

A

Obsessional thoughts/impulses that causes anxiety

+/- compulsive behaviors to relieve anxiety

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5
Q

*Under the DSM-5 criteria, how might a patient with Acute stress disorder (ASD)/ Post traumatic stress disorder (PTSD) present?

A

Re-experiencing, persistent avoidance, negative cognitions and ↑ arousal after exposure to trauma

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6
Q

What are some medical illnesses that can contribute to symptoms similar to anxiety disorders?

A

Cardiovascular diseases
Hypothyroidism
Electrolyte imbalances

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7
Q

What are some drugs associated with anxiety symptoms?

A

Herbs, Antidepressants, illicit substances and Anti-hypertensives
(HAIA)

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8
Q

Before diagnosing anxiety disorders, it is important to exclude: __

A

Medical disorders, drug induced causes or Other mental disorders.

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9
Q

In Social anxiety disorder (SAD), what is one key specifier we must make during diagnosis?

A

Specify if the fear is performance only i.e. restricted to speaking/performing in public

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10
Q

In PTSD, what are key specifiers we must make during diagnosis?

A
  1. Dissociative symptoms

2. Delayed expression (if full diagnostic criteria not met until 6 or months post-event)

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11
Q

*What is the difference between ASD and PSTD?

A

ASD pts usually recover within 3days - 1month (< 1 month) after trauma while symptoms persisting >1 month suggest PTSD

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12
Q

What is the expected timeline of therapy for anxiety disorder patients in general?

A

Adequate trial + Good response –> at least 1 year of treatment before gradual tapering of medications
*Some may require lifelong tx

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13
Q

What is the expected timeline of therapy for OCD patients?

A

Adequate trial + Good response –> at least 1-2 years of treatment before gradual tapering of medications
*Some may require lifelong tx

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14
Q

Benzodiazepines (BZDs) should not be used in which anxiety disorder?

A

PTSD

  • associated w poorer outcomes
  • increased fear responses in pt who experience trauma and may delay recovery from said trauma
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15
Q

Role of adjunct short course (2-3wk) of BZDs or hydroxyzine in anxiety disorders?

A

Temporary relief of acute anxiety i.e. when starting antidepressants

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16
Q

Which patient group should not receive Pregabalin or BZDs for anxiety?

A

Patients with concomitant alcohol/substance abuse

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17
Q

*What are the pharmacological treatment options for GAD?

A

1st line: SSRI, SNRI, Pregabalin
2nd line: Mirtazapine, Imipramine
(SSP MI)
Note: MOH guidelines do not state place in therapy for pregabalin

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18
Q

*What are the non-pharmacological treatment options for GAD?

A 
1st line: CBT (cognitive behavioral therapy)
-Supportive/Dynamic Psychotherapy
-Meditation
-Relaxation exercise
(CSMR)
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19
Q

*What are the pharmacological treatment options for Panic Disorder?

A

1st line: SSRI or Venlafaxine
2nd line: Imipramine, Clomipramine
(SVIC)

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20
Q

*What are the non-pharmacological treatment options for Panic Disorder?

A

CBT (cognitive behavioral therapy)

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21
Q

*What are the pharmacological treatment options for SAD?

A

1st line: SSRI or Venlafaxine
2nd line: Moclobemide
(SVM)

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22
Q

*What are the non-pharmacological treatment options for SAD?

A

1st line: CBT (cognitive behavioral therapy)

Social skills training

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23
Q

*What are the pharmacological treatment options for OCD?

A 
1st line: SSRI
2nd line: Clomipramine
3rd line: Venlafaxine
(SCV)
Note: rare case of SNRI not being 1st line in anxiety disorders
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24
Q

*What are the non-pharmacological treatment options for OCD?

A

1st line: CBT (cognitive behavioral therapy)
-DBT (Dialectical Behavior Therapy)
-Surgery
(CDS)

25
Q

*What are the pharmacological treatment options for PTSD?

A

1st line: SSRI or SNRI
2nd line: Mirtazapine
3rd line: Amitriptyline, Imipramine
(SSMAI)

26
Q

*What are the non-pharmacological treatment options for PTSD?

A

1st line: CBT (cognitive behavioral therapy)
-Exposure therapy
-Eye movement desensitization and reprocessing (EMDR)
(CEE)

27
Q

What should be done if patients fail 1st line pharmacotherapy?

A

Refer to specialist for further assessment and management

28
Q

When can anxiety disorder patients expect benefit if they are on antidepressants?
Early effects: __
Improvements: __
full response: __

A

Early effects: after 2-4 wks
Improvements: generally 4-6wks
full response: may take 3 months

29
Q

What can anxiety disorder patients expect when newly started on antidepressants?

A

Transient jitteriness expected in first 1-2 w of starting

30
Q

What are general principles of pharmacotherapy when treating patients with anxiety disorder?

A
  1. Start low, go slow

2. Titrate up

31
Q

What is the difference between usage of antidepressants in anxiety disorders vs depression?

A

Effective maintenance doses of AD for anxiety disorders tends to be on the higher end of dose range
- e.g. fluoxetine 60-80mg/day, sertraline 150-200mg/day

32
Q 
What kind of side effects do TCAs exhibit?
Amitriptyline → Nortriptyline
Imipramine → Desipramine
Dothiepin (Dosulepin)
Clomipramine
A
  1. α-adrenergic blockade: CVS (tachycardia, orthostatic hypotension, heart block)
  2. Antihistaminic: sedation/ weight gain
  3. Anticholinergic: dry mouth /constipation /blurred vision / urinary retention
  4. Serotonergic: sexual dysfunction
33
Q

How do MAOIs i.e. Moclobemide work?

A

Reversible inhibition of MAO-A

Increase: NE, dopamine, 5-HT

34
Q

What kind of side effects/interactions do MAOIs exhibit?

Moclobemide

A 
Postural hypotension
Restlessness and insomnia
Cheese reaction
Serotonin syndrome
(PRCS)
35
Q

When can anxiety disorder patients expect benefit when taking BZDs?

A

30 - 60minutes

36
Q

What are the BZDs of choice for anxiety?

A

Alprazolam
Bromazepam
Diazepam
Lorazepam

37
Q

Dose of Lorazepam for short course PRN?

A

PO 1-3mg/day (in 2-3 divided doses)

Max: 6mg/day

38
Q

What are the BZDs of choice for panic disorder?

A

Clonazepam/Alprazolam

39
Q

Dose of Alprazolam for short course PRN?

A

Initially PO 0.25-0.5g BD-TDS

Max: 4-6mg/day

40
Q

Dose of Diazepam for short course PRN?

A

PO 2-10mg BD-QDS

41
Q

Dose of Clonazepam for short course PRN?

A

Initially PO 0.5mg BD

Max: 4mg/day

42
Q

Dose of Bromazepam for short course PRN?

A

PO 1.5-3g up to TDS

43
Q

Most BZDs that undergo hepatic oxidation are metabolized by __ except for __.

A
  1. CYP3A4

2. Lorazepam

44
Q

*Key counselling pointers for BZDs?

A
  1. Drowsiness, avoid operating vehicles (tolerance expected)
  2. Avoid alcohol
  3. Withdrawals if abrupt discontinuation after long term use
  4. Sx relief only
    (DAWS)
45
Q

If a patient has been on BZDs long term, how should BZDs be discontinued without causing withdrawal symptoms?

A

gradual dose reduction of 25% q weekly till half of

original dose –> then reduce by 1/8th q 4-7days

46
Q

Propranolol is contraindicated in __.

A

patients with asthma (may cause bronchospasm)

47
Q

Propranolol dose for anxiety is 10-20mg (initially). It should be taken __.

A

30-60min prior to anxiety provoking situation

48
Q

Smoking is an example of a potent __ inducer/inhibitor.

A

1A2 inducer

49
Q

Fluvoxamine is an example of a potent __ inducer/inhibitor.

A

1A2 inhibitor

50
Q

Rifampicin is an example of a potent __ inducer/inhibitor.

A

2C19 and 3A4 inducer

51
Q

Fluoxetine is an example of a potent __ inducer/inhibitor.

A

2D6 inhibitor

52
Q

Paroxetine is an example of a potent __ inducer/inhibitor.

A

2D6 inhibitor

53
Q

Bupropion is an example of a potent __ inducer/inhibitor.

A

2D6 inhibitor

54
Q

Phenytoin is an example of a potent __ inducer/inhibitor.

A

3A4 inducer

55
Q

Carbamazepine is an example of a potent __ inducer/inhibitor.

A

3A4 inducer

56
Q

Nefazodone is an example of a potent __ inducer/inhibitor.

A

3A4 inhibitor

57
Q

Serotonin syndrome commonly presents as a triad of __.

A
  1. Mental status changes
  2. Autonomic hyperactivity
  3. Neuromuscular abnormalities
    (MAN)
58
Q

*Key monitoring strategy for anxiety patients is __ and __.

A
  1. keeping a symptom diary

2. Monitor for ADRs of pharmacotherapy

59
Q

The use of opioids and __ may cause profound CNS depression, possibly leading to death.

A

BZDs

Psychiatric Pharmacotherapy (5 decks)

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