Anxiety Disorders Flashcards
*Under the DSM-5 criteria, how might a patient with Generalized anxiety disorder (GAD) present?
Excessive anxiety and worries >6m
*Under the DSM-5 criteria, how might a patient with Panic disorder (PD) present?
Anticipatory anxiety of recurrent panic attacks
*Under the DSM-5 criteria, how might a patient with Social anxiety disorder (SAD) present?
Fear of being scrutinized or humiliated in public
*Under the DSM-5 criteria, how might a patient with Obsessive compulsive disorder (OCD) present?
Obsessional thoughts/impulses that causes anxiety
+/- compulsive behaviors to relieve anxiety
*Under the DSM-5 criteria, how might a patient with Acute stress disorder (ASD)/ Post traumatic stress disorder (PTSD) present?
Re-experiencing, persistent avoidance, negative cognitions and ↑ arousal after exposure to trauma
What are some medical illnesses that can contribute to symptoms similar to anxiety disorders?
Cardiovascular diseases
Hypothyroidism
Electrolyte imbalances
What are some drugs associated with anxiety symptoms?
Herbs, Antidepressants, illicit substances and Anti-hypertensives
(HAIA)
Before diagnosing anxiety disorders, it is important to exclude: __
Medical disorders, drug induced causes or Other mental disorders.
In Social anxiety disorder (SAD), what is one key specifier we must make during diagnosis?
Specify if the fear is performance only i.e. restricted to speaking/performing in public
In PTSD, what are key specifiers we must make during diagnosis?
- Dissociative symptoms
2. Delayed expression (if full diagnostic criteria not met until 6 or months post-event)
*What is the difference between ASD and PSTD?
ASD pts usually recover within 3days - 1month (< 1 month) after trauma while symptoms persisting >1 month suggest PTSD
What is the expected timeline of therapy for anxiety disorder patients in general?
Adequate trial + Good response –> at least 1 year of treatment before gradual tapering of medications
*Some may require lifelong tx
What is the expected timeline of therapy for OCD patients?
Adequate trial + Good response –> at least 1-2 years of treatment before gradual tapering of medications
*Some may require lifelong tx
Benzodiazepines (BZDs) should not be used in which anxiety disorder?
PTSD
- associated w poorer outcomes
- increased fear responses in pt who experience trauma and may delay recovery from said trauma
Role of adjunct short course (2-3wk) of BZDs or hydroxyzine in anxiety disorders?
Temporary relief of acute anxiety i.e. when starting antidepressants
Which patient group should not receive Pregabalin or BZDs for anxiety?
Patients with concomitant alcohol/substance abuse
*What are the pharmacological treatment options for GAD?
1st line: SSRI, SNRI, Pregabalin
2nd line: Mirtazapine, Imipramine
(SSP MI)
Note: MOH guidelines do not state place in therapy for pregabalin
*What are the non-pharmacological treatment options for GAD?
1st line: CBT (cognitive behavioral therapy) -Supportive/Dynamic Psychotherapy -Meditation -Relaxation exercise (CSMR)
*What are the pharmacological treatment options for Panic Disorder?
1st line: SSRI or Venlafaxine
2nd line: Imipramine, Clomipramine
(SVIC)
*What are the non-pharmacological treatment options for Panic Disorder?
CBT (cognitive behavioral therapy)
*What are the pharmacological treatment options for SAD?
1st line: SSRI or Venlafaxine
2nd line: Moclobemide
(SVM)
*What are the non-pharmacological treatment options for SAD?
1st line: CBT (cognitive behavioral therapy)
Social skills training
*What are the pharmacological treatment options for OCD?
1st line: SSRI 2nd line: Clomipramine 3rd line: Venlafaxine (SCV) Note: rare case of SNRI not being 1st line in anxiety disorders
*What are the non-pharmacological treatment options for OCD?
1st line: CBT (cognitive behavioral therapy)
-DBT (Dialectical Behavior Therapy)
-Surgery
(CDS)
*What are the pharmacological treatment options for PTSD?
1st line: SSRI or SNRI
2nd line: Mirtazapine
3rd line: Amitriptyline, Imipramine
(SSMAI)
*What are the non-pharmacological treatment options for PTSD?
1st line: CBT (cognitive behavioral therapy)
-Exposure therapy
-Eye movement desensitization and reprocessing (EMDR)
(CEE)
What should be done if patients fail 1st line pharmacotherapy?
Refer to specialist for further assessment and management
When can anxiety disorder patients expect benefit if they are on antidepressants?
Early effects: __
Improvements: __
full response: __
Early effects: after 2-4 wks
Improvements: generally 4-6wks
full response: may take 3 months
What can anxiety disorder patients expect when newly started on antidepressants?
Transient jitteriness expected in first 1-2 w of starting
What are general principles of pharmacotherapy when treating patients with anxiety disorder?
- Start low, go slow
2. Titrate up
What is the difference between usage of antidepressants in anxiety disorders vs depression?
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
What kind of side effects do TCAs exhibit? Amitriptyline → Nortriptyline Imipramine → Desipramine Dothiepin (Dosulepin) Clomipramine
- α-adrenergic blockade: CVS (tachycardia, orthostatic hypotension, heart block)
- Antihistaminic: sedation/ weight gain
- Anticholinergic: dry mouth /constipation /blurred vision / urinary retention
- Serotonergic: sexual dysfunction
How do MAOIs i.e. Moclobemide work?
Reversible inhibition of MAO-A
Increase: NE, dopamine, 5-HT
What kind of side effects/interactions do MAOIs exhibit?
Moclobemide
Postural hypotension Restlessness and insomnia Cheese reaction Serotonin syndrome (PRCS)
When can anxiety disorder patients expect benefit when taking BZDs?
30 - 60minutes
What are the BZDs of choice for anxiety?
Alprazolam
Bromazepam
Diazepam
Lorazepam
Dose of Lorazepam for short course PRN?
PO 1-3mg/day (in 2-3 divided doses)
Max: 6mg/day
What are the BZDs of choice for panic disorder?
Clonazepam/Alprazolam
Dose of Alprazolam for short course PRN?
Initially PO 0.25-0.5g BD-TDS
Max: 4-6mg/day
Dose of Diazepam for short course PRN?
PO 2-10mg BD-QDS
Dose of Clonazepam for short course PRN?
Initially PO 0.5mg BD
Max: 4mg/day
Dose of Bromazepam for short course PRN?
PO 1.5-3g up to TDS
Most BZDs that undergo hepatic oxidation are metabolized by __ except for __.
- CYP3A4
2. Lorazepam
*Key counselling pointers for BZDs?
- Drowsiness, avoid operating vehicles (tolerance expected)
- Avoid alcohol
- Withdrawals if abrupt discontinuation after long term use
- Sx relief only
(DAWS)
If a patient has been on BZDs long term, how should BZDs be discontinued without causing withdrawal symptoms?
gradual dose reduction of 25% q weekly till half of
original dose –> then reduce by 1/8th q 4-7days
Propranolol is contraindicated in __.
patients with asthma (may cause bronchospasm)
Propranolol dose for anxiety is 10-20mg (initially). It should be taken __.
30-60min prior to anxiety provoking situation
Smoking is an example of a potent __ inducer/inhibitor.
1A2 inducer
Fluvoxamine is an example of a potent __ inducer/inhibitor.
1A2 inhibitor
Rifampicin is an example of a potent __ inducer/inhibitor.
2C19 and 3A4 inducer
Fluoxetine is an example of a potent __ inducer/inhibitor.
2D6 inhibitor
Paroxetine is an example of a potent __ inducer/inhibitor.
2D6 inhibitor
Bupropion is an example of a potent __ inducer/inhibitor.
2D6 inhibitor
Phenytoin is an example of a potent __ inducer/inhibitor.
3A4 inducer
Carbamazepine is an example of a potent __ inducer/inhibitor.
3A4 inducer
Nefazodone is an example of a potent __ inducer/inhibitor.
3A4 inhibitor
Serotonin syndrome commonly presents as a triad of __.
- Mental status changes
- Autonomic hyperactivity
- Neuromuscular abnormalities
(MAN)
*Key monitoring strategy for anxiety patients is __ and __.
- keeping a symptom diary
2. Monitor for ADRs of pharmacotherapy
The use of opioids and __ may cause profound CNS depression, possibly leading to death.
BZDs
