Anxiety & Related Disorders Flashcards
what are some drugs that may cause anxiety
steroids
dopamine agonists
stimulants
thyroid hormones
sympathomimetics
antidepressants
what are some disease states that may cause anxiety
angina
arrhythmias
hyperthyroidism
asthma
COPD
IBS
Crohn’s
PUD
what are some pathophysiology models that are hypothesized to cause anxiety disorders
noradrenergic model
GABA receptor model
serotonin model
noradrenergic model
autonomic nervous system is hypersensitive & overreactive to various stimuli
GABA receptor model
GABA has a strong inhibitory effect on 5HT, NE, DA
proposed to be lower GABA in anxiety disorders
serotonin model
dysregulation of serotonin in those with anxiety disorders
which gender is more common to have GAD
female
median age of onset for GAD
30 years
peaks in middle age
which ethnicity is more common to have GAD
european
DSM-V criteria for GAD
at least 6 months of:
-excessive anxiety or worry on most days
PLUS at least 3 of the following
-restlessness, poor concentration, easily fatigued, irritability, sleep changes, muscle tension
how long should GAD be treated
at least 12 months
nonpharmacological treatments for GAD
CBT, stress management, exercise, support groups
SSRI doses for GAD
generally need higher doses for anxiety than for depression
1st line drugs for GAD
SSRIs:
escitalopram, sertraline, fluoxetine, paroxetine, citalopram, fluvoxamine
SSRI side effects
upset stomach, appetite changes, sexual dysfunction, weight gain, GI bleed, SIADH
SNRIs
Duloxetine, venlafaxine, desvenlafaxine, levomilnacipran
SNRI side effects
increased blood pressure, nausea, constipation, sexual dysfunction
when are benzos indicated for GAD
for prn short term relief
how to dc benzos
decrease dose by 10-25% every 1-3 weeks
which benzo is more lipophilic and accumulates in tissues
diazepam
do not take benzos in combination with ___
alcohol
which populations are we cautious with benzos
history of substance use disorder
elderly (kidney/liver, fall risk, ADEs)
pregnancy & lactation
what are some antidepressants that are INEFFECTIVE in anxiety
bupropion & mirtazapine
clinical pearl when using antidepressants initially for GAD
they can initially increase anxiety. may take 2-4 weeks to see an improvement
buspirone class
5HT1 partial agonist
hydroxyzine and diphenhydramine class
H1 antagonist, useful for mild anxiety
vilazodone class and when is it used
SSRI/5HT-1a partial agonist
useful for comorbid depression
which gender more commonly has panic disorder
females
median age for panic disorder
20-24 years
peaks in young adulthood
which race/ethnicity more common for panic disorder
non-hispanic white, indigenous
DSM-V criteria for panic disorder
at least 4 symptoms of panic attack (ie palpitations, shaking, swearing, SOB, fear of dying, etc)
AND at least one month of worry about future panic attacks with maladaptive behavior changes
1st line for panic disorder
SSRIs
2nd line for panic disorder
SNRIs: venlafaxine most studied
note when dosing for panic disorder
higher doses are necessary and adequate trial duration is 6 weeks. increase dose every 1-2 weeks
other agents that may be used for panic disorder
benzos– alprazolam & clonazepam for short term use only
TCAs– imipramine & clomipramine may reduce panic attacks but side effects are bad
duration of treatment for panic disorder
at least 12 months after symptoms resolve
gender more common for SAD
females
median age for SAD
13 years, peaks in adolescence
race/ethnicity more common for SAD
indigenous
DSM-V criteria for SAD
at least 6 months of:
-marked fear about social situations
-fear of others causes avoidance out of proportion to the actual threat
first line for SAD
SSRIs
second line for SAD
SNRIs (venlafaxine)
third line for SAD
MAOIs
short term use for SAD
benzos: alprazolam & clonazepam
drug that can be used for performance-based situations in SAD
propranolol
nonpharm for SAD
CBT
treatment duration for SAD
6-12 months, adequate trial is 8-12 weeks
gender more common in OCD
females
median age for OCD
19.5 years, peaks in adolescence to young adulthood
OCD DSM-V criteria
time consuming obsessions, compulsions, or both (defined as 1 hour time consuming)
1st line for OCD
SSRIs (not citalopram/escitalopram)
adequate trial for OCD for pharm therapy
12 weeks
adequate trial in OCD for CBT
3-5 months of weekly sessions
or 3 weeks of daily sessions
1st line in OCD for SEVERE or comorbid conditions
CBT + SSRI
agents that are not first line for OCD
TCAs (clomipramine)– only after failure of 2 SSRIs (bad side effects)
3rd line would be to augment with haloperidol/SGAs
options for refractory cases of OCD
dual therapy: SSRI + clomipramine
can also try venlafaxine, mirtazapine, deep brain stimulation
treatment duration for OCD
at least 1-2 years for medicine then slow taper 10-25% decrease every 1-2 months
for therapy: should have quarterly or biannual booster CBT sessions
OCD options for pregnant/lactating patients
consider CBT
avoid clomipramine, paroxetine
OCD options for elders
avoid clomipramine
start low and go slow
OCD options for children
CBT first line
CBT+SSRI second line
if ineffective, can switch to another SSRI or clomipramine
who is more likely to develop civilian PTSD
females
what are some causes of civilian PTSD
sexual violence, interpersonal network trauma, interpersonal violence, organized violence
DSM-V criteria for PTSD
exposure to ACTUAL or THREATENED death, serious injury, etc that leads to at least one of the following: intrusive memories, dreams, flashbacks, distress
and at least one: avoidance of thoughts/feelings/convos or avoidance of external reminders
and 2 impairments in mood or cognition (ie blame, diminished interest)
and 2 evidences of arousal such as aggressive behavior, self destructive, or sleep disturbance
symptoms must occur for more than one month and cause significant distress/impairment
what are some PHYSICAL symptoms of PTSD
pain, sweating, tachycardia, hypertension, weakness, dizziness, dyspnea
what are some BEHAVIORAL symptoms of PTSD
guilt, fear, denial, depression, anxiety, social withdrawal
difference between PTSD and acute distress disorder
PTSD is for one month
acute distress disorder is for at least 2 days but less than a month
benzos for PTSD
NO
all guidelines recommend against
what can we use for nightmares in PTSD
prazosin (alpha1 antagonist)
prazosin side effects
dizziness, hypotension, orthostasis, fatigue, headache
which drug has evidence in pediatrics for PTSD
clonidine
first line for PTSD
CBT
drug options for PTSD
SSRIs: sertraline, paroxetine (fluoxetine off label)
SNRI: venlafaxine off label
adequate trial 8 weeks
less ideal options: TCAs, mirtazapine, phenelzine, mood stabilizers, antipsychotics
when to start meds for PTSD
3-4 weeks after trauma experienced
_______ reduce the 3 PTSD symptom clusters & treat comorbid anxiety/depression, reduce suicidal behaviors, with minimal side effects
SSRIs and SNRIs
