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Clinical Management of Anxiety Disorders Flashcards

1
Q

For evaluation of any anxiety disorder, we should…

A

Gather history + review all systems
Rule out anxiety disorders due to other medical conditions or substance use
Suicidal ideation or intention

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2
Q

Classes of medications that are used for anxiety include…

A

Serotonergic agents
Gabapentin/pregabalin
Benzodiazepines
Beta-blockers
Alpha-1 adrenergic antagonist

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3
Q

Goals of therapy for an acute episode of GAD include the following…

These can really be applied to any anxiety disorder

A

Decrease severity + duration of anxiety symptoms
Improve overall function

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4
Q

Long-term goals of therapy for GAD include…

These can really be applied to any anxiety disorder

A

Reach remission - minimal/no anxiety symptoms, no functional impairment, improval of QoL
Treat co-morbid conditions
Minimize AE’s from pharmacotherapy

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5
Q

Benefits of psychotherapy for GAD is that…

A

It is least invasive and safest

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6
Q

Treatment plan of pharmacotherapy depends on…

A

Severity and chronicity of symptoms
Age
Medication history
Comorbid medical/psychiatric conditions

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7
Q

Elimination of contributing factors for GAD include…

A

Reducing/avoiding alcohol, caffeine
Avoidance of stimulants and medications that may induce anxiety

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8
Q

Non-pharm treatment that has the most evidence is…

A

Psychotherapy +/- counselling

CBT = most effective
But overall underused due to cost, time requirements, limited professionals

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9
Q

Other aspects of non-pharm treatment besides psychotherapy include…

A

Exercise
Relaxation techniques
Biofeedback

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10
Q

1st line drugs for GAD treatment include…

A

SSRI - escitalopram, paroxetine, sertraline
SNRI - duloxetine, venlafaxine
Pregabalin

Most studies done, and given approved indication in guidelines

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11
Q

2nd line treatment options for GAD include…

A

BZD’s with short-term use
Bupropion
Buspirone
Hydroxyzine

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12
Q

Can the other SSRI’s be used in GAD?

A

Yes, others are often used in practice. Paroxetine, escitalopram, and sertraline were the ones specifically studied in GAD

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13
Q

Imipramine (TCA) and trazodone are ____ compared to placebo for GAD, but ____

A

More effective compared to placebo, but less tolerable

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14
Q

Open label trials have showed that mirtazpine can be ____ for GAD

A

Effective; low evidence compared to others, but used a lot in practice

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15
Q

Bupropion has been shown to have similar efficacy to escitalopram for GAD, however…

A

Can exacerbate anxiety

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16
Q

BZD’s are most often used for acute anxiety; long-term use is not recommended due to…

A

Physiological/psychological dependence

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17
Q

BZD’s are not effective for…

What kind of symptoms?

A

Depressive symptoms, and may worsen depression

CNS depressant

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18
Q

While pregabalin is 1st line for GAD, it is especially effective when a patient experiences anxiety and ____

A

Neuropathic pain

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19
Q

MOA of buspirone is…

A

5-HT 1A partial agonist

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20
Q

Onset of effect for buspirone is…

A

Delayed; 2 weeks or longer

Not useful for acute anxiety

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21
Q

Buspirone efficacy is…

A

Inconsistent for long term use - not commonly used

Only indicated for GAD or to potentiate AD’s

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22
Q

MOA of hydroxyzine is…

A

5-HT2 and H1 antagonist

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23
Q

Hydroxyzine is uncommonly used in clinical practice because…

A

Lack of tolerability - anticholinergic, sedation

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24
Q

Second generation antipsychotics have anxiolytic effect that is mediated via…

A

5-HT 1A

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25
Second generation antipsychotics are 3rd line for GAD due to...
AE's and limited evidence | Usually used as augmenting agents
26
In terms of GAD treatment timeframe, onset of symptom relief (for SSRI/SNRI) is usually... | What should we do if no response?
2-4 weeks ## Footnote No response in 2 weeks, increase dose No response in 4 weeks, unlikely to respond; potentially augment
27
Maximal response for GAD treatment (for SSRI/SNRI) takes about...
12 weeks
28
Treatment duration for GAD is usually....
12-24 months ## Footnote However, 60% patients don't achieve remission and may require longer tx
29
MOA of BZD's is...
Binding to BZD receptors on GABA neuron Increases frequency of opening of chloride channels, by increasing binding affinity for GABA Shift in chloride ions results in hyperpolarization (less excitable state) and stabilization
30
BZD's role in GAD is to...
Provide rapid initial relief of anxiety symptoms
31
BZD effects on anxiety may not be significantly different from placebo after...
4-6 weeks of treatment ## Footnote **However, some refractory patients may need long-term BZD treatment**
32
BZD's are primarily effective for relieving ____ rather than ____
Somatic symptoms, rather than the key features characteristic of GAD
33
BZD's commonly used in GAD include...
Alprazolam, bromazepam, lorazepam, diazepam, clonazepam
34
Short half life BZD's include...
Alprazolam Bromazepam Lorazepam ## Footnote Alprazolam: 12-15h Bromzepam: 8-30h Lorazepam: 10-20h
35
Long half-life BZD's include...
Clonazepam Diazepam
36
BZD's with faster onset of 20-60 minutes include...
Clonazepam Diazepam Lorazepam
37
BZD's with a slower onset of 1-2 hours include...
Alprazolam Bromazepam
38
Common AE's with BZD include | CNS depressant, GABA blocker
Sedation Psychomotor impairment Dizziness, ataxia, lightheadedness ## Footnote Paradoxical response can occur (agitation, irritability, confusion); variability in how people respond to BZD
39
More serious AE's with BZD's include...
Memory impairment Depression, confusion, hallucinations **Respiratory depression**
40
Patients may develop ____ to anxiolytic effects of BZD's, which may necessitate...
Tolerance; may necessitate dosage increases with chronic use
41
Risk of BZD dependence increases with...
Higher dose +/- longer use History of AUD, SUD, or personality disorders
42
A benefit of long-acting BZD's is...
Less risk of withdrawal, good choice for tapering
43
A disadvantage of using long-acting BZD's is...
More daytime sedation
44
A benefit of short-acting BZD's is...
Better hypnotic and sedative properties
45
Disadvantages of short-acting BZD's include...
More rebound anxiety Inter-dose withdrawal Anterograde amnesia (memory impairment)
46
These BZD drugs are preferred in elderly + liver dysfunction, due to...
Lorazepam, oxazepam, temazepam; no active metabolites ## Footnote LOT drugs
47
Withdrawal symptoms of BZD's include... | Think of excess stimulation
**Seizures** Rebound anxiety, sweating N/V Agitation, insomnia, tremors + twitching Increased heart rate
48
Onset of BZD withdrawal usually starts within ____ after the BZD is stopped
1-2 days
49
Withdrawal symptoms from BZD can be avoided by...
Tapering ## Footnote SLOW is ok; too fast of a taper = withdrawal symptoms common
50
BZD's should be precautioned with the following medical conditions...
Sleep apnea, COPD, CNS depression, pregnancy Substance use history | Due to BZD AE's; respiratory depression ## Footnote Pregnancy - possible teratogen, can precipitate withdrawal in newborns
51
BZD's need to be cautioned with other drugs, such as...
Alcohol, opioids, barbiturates Clozapine Significant sedation, profound respiratory depression, coma, death
52
A BZD antidote is ____, and it reverses...
Flumazenil; reverses hypnotic-sedative effect of BZD
53
Flumazenil clinical usage is limited, due to risk of...
Causing seizures in BZD dependant patients ## Footnote Can be used in emergency settings, where respiratory support is available
54
Initial treatment of panic disorder is with...
Medication or psychotherapy | Evidence doesn't support superiority of either, or for combination ## Footnote Augment with CBT if ongoing symptoms despite pharm
55
1st line pharmacotherapy for panic disorder includes...
SSRI's SNRI's - venlafaxine, duloxetine
56
2nd line pharmacotherapy for panic disorder includes...
TCA's - similar efficacy to SSRI/SNRI, but less well tolerated Augment with SGA or BZD depending on comorbidity
57
If a patient has not responded to anything else in panic disorder, we can try...
Phenelzine
58
These are the most studied TCA's for panic disorder...
Clomipramine Imipramine
59
BZD's are not an effective strategy to treat an acute panic attack because...
Onset of BZD will typically occur after the panic attack
60
BZD's may be helpful in panic disorder, if a patient... | Circumstance?
Knows their triggers - can take one to help prevent occurrence of panic attack
61
BZD may also be helpful in panic disorder if an individual is starting an antidepressant and...
Needs help with residual anxiety symptoms that are physical ## Footnote NOT treating underlying mood/anxiety disorder
62
Most patients with panic disorder are ____ to medication AE's, which can lead to...
Hypersensitive; lead to activation (early worsening of anxiety, agitation, irritability) ## Footnote Therefore, start low and titrate slow
63
Acute treatment duration with panic disorder is about... | We should alter treatment if no response in...
1-3 months | Alter treatment if no response after 6-8 weeks
64
Maintenance treatment duration with panic disorder is usually ____, however...
12 months; but if residual symptoms continue, continue treatment | Longer than 12 months is very common
65
If we want to discontinue pharmacotherapy for panic disorder, we need to consider some factors such as...
Duration of stability Presence of psychosocial stressors Patient's motivation to stop treatment
66
If we are discontinuing pharmacotherapy for panic disorder, we should taper over ____ to...
4-6 months, to reduce the risk of relapse
67
Important non-pharm treatment for SAD includes...
CBT | Is a 1st line option
68
1st line pharmacotherapy for SAD includes...
SSRI's (escitalopram, fluvoxamine, paroxetine, sertraline) Venlafaxine Pregabalin
69
Venlafaxine for SAD is shown to be effective, specifically for patients who...
Fail to respond to SSRI's
70
For performace related SAD, this could be given...
Propranolol 10-80mg Atenolol 25-50mg 1-2 hours before performance | Consider CI's for beta-blockers
71
Onset of symptom relief using pharmacotherapy for SAD is usually...
6 to 8 weeks | Venlafaxine is sometimes as early as week 3
72
Pharmacotherapy treatment duration for SAD is usually...
1 year or longer, after response is attained
73
If a patient wants to discontinue pharmacotherapy for SAD, tapering usually needs to be done for ____
3-4 months | Relapse common after discontinuation
74
Key non-pharm treatment for PTSD is...
Trauma-focused psychotherapy ## Footnote Reorganization of traumatic memory into an inactive, consolidated memory
75
1st line pharmacotherapy for PTSD includes...
SSRI's - Fluoxetine, paroxetine, sertraline Venlafaxine
76
For trauma-related nightmares in PTSD, this is 1st line pharmacotherapy...
Prazosin
77
Benzodiazepines in PTSD are...
Contraindicated - lack of efficacy, and likely to worsen severity and outcomes ## Footnote Interfere with memory consolidation process, and not helping with underlying symptoms
78
Mean doses of prazosin are usually...
Men: 15-16mg/night Women: 7mg/night ## Footnote A lot of people are usually not on this high dose, so would be ineffective. Mean dose for daytime is lower; men: 4mg, women: 1.7mg
79
Onset of symptom relief with pharmacotherapy in PTSD is usually...
2-8 weeks
80
Maximal response with pharmacotherapy in PTSD is usually achieved within...
12+ weeks
81
Treatment with pharmacotherapy for PTSD is usually ____, but... | Duration?
12-24 months, but most patients are on lifelong treatment unless they undergo intensive CBT
82
Non-pharmacological 1st line treatment for OCD is...
CBT
83
1st line pharmacotherapy for OCD includes...
SSRI's Venlafaxine Aripiprazole, risperidone for adjunctive treatment
84
If an OCD patient gets little/no response to 1st line treatment, they should try...
An alternate SSRI, or venlafaxine if not tried yet
85
For OCD, if 2 SSRI's fail, this drug is recommended...
Clomipramine (TCA) ## Footnote Equally/slightly more efficacious than SSRI, but less tolerable and more DI's
86
Augmentation for OCD pharmacotherapy should be considered in patients...
With a partial response to 1st line treatment (40% decrease in OCD rating scale)
87
Something that may really help OCD patients is to...
Keep a symptom diary - data + content of obsessions and compulsions, and time spent in carrying out compulsion
88
Onset of symptom relief with pharmacotherapy for OCD is usually...
2-4 weeks
89
Maximal response with pharmacotherapy for OCD is usually obtained within...
10-12 weeks
90
Treatment duration of pharmacotherapy in OCD is...
1-2 years, but experts recommend indefinite treatment for most patients ## Footnote Relapse rates are extremely high

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