Chapter 2: Practical Psychopharmacology-Schwartz

Question 1

Clinical Diagnosis

Answer 1

1. Convention exists where if the anxiety disorder was premorbid to the depressive disorder, then the patient carries two diagnosis; depression and anxiety.
2. If the MDD is premorbid and the anxiety only occurs while depressed, then the patient just carries the MDD diagnosis and anxiety falls under this.

Question 2

Panic disorder (p.35)

Answer 2

1. People with PD do not experience generalized worrying
2. Not triggered solely by social situations or reminders of traumatic events
3. Do experience abrupt, intense physical anxiety without a clear trigger
4. Recurrent and unexpected panic attacks.
5. Often no rhyme or reason to initial onset of panic attacks.

Question 3

Prescriber treatment guidelines (general guidelines)

Answer 3

1. SSRI are preferred as first interventions
2. SNRIs are then considered.
3. THen can weigh using a benzo, sedative (xanax). TCA, MAOI

Question 4

GAD prescribing

Answer 4

1. Buspar only if no depression exists
2. SSRI low dose and titrate to approved minimum dose
   a. After a few weeks if there is full remission, continue for several months
   b. then a slow discontinuation can be considered.
3. If GAD is severe or recurrent, then continue SSRI longer term
4. If no response to SSRI at low dose, then move to middle dose for a few weeks
   a. if no response, then move to full dose for several weeks
   b. if no response, then is a therapeutic failure.
5. If buspar and an SSRI fail to fully treat the patient, then try SNRI
6. If still no response, then consider combination or switch to monotherapy with greater side effects

Question 5

GAD genetics

Answer 5

1. 30% of symptom development might be attributed to genetic loading.

Question 6

Neuroanatomy (p. 52)

Answer 6

1. Frontal cortex- serves to control and contain our basic drives and impulses; more evolved brain area
2. Limbic system- more primitive area responsible for basic drives and impulses.
   a. anterior cingulates and insular cortex are the highest level of processing in this system.
   b. ACC in IC integrate sensory, affective, and cognitive components of pain while processing information regarding the internal bodily state.
   c. hippocampus manages the HPA stress response
3. Dance Analogy- back and forth communication of frontal cortex and limbic system
   a. normal function- frontal cortex analyzes the threat and with mild to moderate stressors it can interrupt fight or flight limbic signals to prevent inappropriate anxiety.
   i. if th threat is severe then fight/flight reaction occurs.
   b. when DSM anxiety develops- the amygdala can be too aggressive or hyperactive and lead to panic attacks. The cortical system may be too weak to override.

Manage/prevent anxiety (cortical top down processing):

4. Dorsolateral prefrontal cortex (DLPFC)- executive functioning and complex planning.
5. Ventromedial prefrontal cortex (VMPFC)- higher level emotional experience processing.
6. Orbitofrontal cortex (OFC)- impulse control, response prevention

Promote anxiety (limbic drive processing):

7. Anterior cingulate cortex (ACC)- allows vigilance, concentration, and monitoring of internal states.
8. Insular cortex (IC) - allows integration of sensory information.
9. Hippocampus (HC)- Interacts with the HPA, regulates stress response, stores visceral and protective memory for fast reflexive responses to threats.
10. Amygdala (AM)- allows visceral, stimulus-driven fear, aggression, defensive behavior, and fight/flight.

Question 7

Functional neuroanatomy of anxiety disorder (p. 54)

Answer 7

1. PD- increased activity in AM, HC, ACC; lowed activity in DLPFC.
2. SAD- increased activity in AM; lowered activity in ACC and DLPFC.
3. GAD- increased activity in AM, ACC, and IC; increased activity in VLPFC.
4. PTSD- increased activity in the AM, ACC, and VMPFC; lowered activity in caudate.

Question 8

Ten families of medications for anxiety disorders (p. 54)