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Neurologic & Psych > EXAM 5 Anxiety Disorder Thomason > Flashcards

EXAM 5 Anxiety Disorder Thomason Flashcards

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1
Q

Which drug works the fastest but should be avoided with substance use disorder?

A

Benzos

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2
Q

What is the 1st line drug in anxiety and how is it initiated?

A

SSRIs

-start at a low dose, monitor carefully, and titrate up
if given too much it can cause activation syndrome (jitteriness)

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3
Q

A patient was treated for anxiety and got in remission, how much longer should he be in treatment?

A

12 months
for PTSD and OCS at least 2 years

-to reduce the risk of relapse

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4
Q

What does a patient often experience in the course of anxiety therapy?

A

Wax and wane of symptoms, it may get better then worse again (ex: after a stressful situation)

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5
Q

In which patient population do we use the maximum tolerated dose as fast as possible?

A

in OCD

bc that’s what it takes to address the intrusive thoughts and the compulsions that they have to complete to get rid of the anxiety from these obsessive thoughts

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6
Q

How is anxiety therapy initiated in elderly patients?

A

half the recommended dose or less to reduce side effects

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7
Q

How is anxiety therapy initiated in panic disorder patients?

A

a quarter of the recommended dose
-bc they are sensitive to serotonergic stimulation and can pushed into a panic attack easily, especially at the beginning -> ADE: jitterniness

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8
Q

When is a dose considered maintenance dose?

A

the dose that gotten them better
(try to use once daily dosing)

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9
Q

Benzos are not the drug of choice, however ho should it be started?

A

as low as possible, and as high as needed

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10
Q

How are drugs metabolized?

A

Liver
dose adjust if needed

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11
Q

When should a drug change be considered for generalized anxiety?

A

if no response after 4-6 weeks

If partial response continues for 4-6 weeks then reassess again (often it works after that)

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12
Q

When should a drug change be considered for OCD and PTSD?

A

8-12 week if no response

if there is partial response continues for 4-6 weeks then reassess again (often it works after that)

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13
Q

Which drugs may be added if there is no response?

A

Abiliify or Buspirone

but adding a drug vs switching if no response is still debated in the literature

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14
Q

Non-pharmacological treatment option

A
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15
Q

What is the first-line treatment option?

A

SSRIs in all anxiety disorders

start with a lower dose to avoid them being overstimulated

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16
Q

Which side effects are seen when starting at a dose that is too high?
!!!

A

Restlessness, jitteriness, insomnia, headache

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17
Q

Transient side effects of SSRIs
!!!

A

headache, dizziness, stomach upset (goes away in a couple of weeks)

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18
Q

Long-term side effects of SSRIs
!!!

A

weight gain
sexual dysfunction

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19
Q

How does Paroxetine have to be tapered?

A

slowly to avoid discontinuation syndrome

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20
Q

When can patients expect it to work in anxiety disorders?

A

delayed effect

-2-4 weeks
-6-8 weeks in PTSD, OCD

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21
Q

A patient with COPD, HTN, Hyperlipidemia anxiety disorder, and depression. Which SNRI should be avoided and why?

A

Venlafaxine
contraindicated in HTN

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22
Q

Side effects of SNRI

A

Duloxetine and Venlafaxine have shown good results in most anxiety disorders

-early side effects: nausea, restlessness,
insomnia and headache

-long-term: sexual dysfunction

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23
Q

Which SNRI has a significant discontinuation syndrome?

A

Venlafaxine

even if missing a dose

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24
Q

How long does it take to see the effect of SNRIs?

A

2-4 weeks

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25
Q

What is the role of TCAs?

A

Second-line - works well except for social anxiety disorder
not often seen due to side effects

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26
Q

Side effects of TCAs

A

initially increased anxiety, anticholinergic,
cardiovascular, sedation, impaired cognition, decreased seizure threshold, elevated LFTs (clomipramine)

Long-term: Weight gain, sexual dysfunction

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27
Q

Role of MAOIs

A

Last-line (treatment resistant), not often see
-work well in panic, SAD and PTSD

-in the morning and mid-day to avoid overstimulation and insomnia

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28
Q

How fast do Benzos work?

A

fast: 30-60 min

should not be used for more than 2 weeks

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29
Q

What is the consensus on the long-term use of Benzos?

A

Should be avoided bc of abuse, dependence and tolerance

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30
Q

When should Benzos be avoided?
!!!

A

Patients with SUD (higher chance to become dependent)

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31
Q

How should Benzos be prescribed PRN or schduled?

A

studies have shown more effective use when scheduled

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32
Q

Benzos in patients with depression and anxiety

A

Benzos make anxiety worse

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33
Q

In which of the anxiety disorders are Benzos useful?

A

Panic disorder
(mentioned)

34
Q

Role of Hydroxyzine (Vistrail - FDA approved for anxiety)

A

used for acute anxiety as alternative for Benzos
-beneficial in treating GAD

-very sedative
-not associated with dependence

35
Q

When might Hydroxyzine be useful?

A

acute anxiety and for sleep

36
Q

Pregabalin

A

Not FDA approved
-effective in acute/long-term GAD and a few trials of SAD
-taper off when d/c

37
Q

Side effects of Pregabalin

A

-dizziness, sedation, dry mouth, psychomotor impairment

(also mentioned weight gain, edema)

38
Q

What is the role of Anticonvulsants?

A

have shown efficacy in preliminary studies for PTSD

39
Q

Role of Buspirone

A

only in GAD
(often prescribed PRN - but it doesn’t work PRN!!!)
-no sedation or dependence
-but less effective

40
Q

ADE of Buspirone

A

does work on 5-HT: nausea headache
also: dizziness, jitteriness, dysphoria (initial)

41
Q

When does Buspirone start working?

A

1-2 weeks -> full effects over several weeks

start with 5 mg TID (or BID), titrate up to a max of 60 mg/day

42
Q

Role of Quitepine

A

monotherapy in GAD

43
Q

Adjunctives

A

Abilify

44
Q

Role of ß blockers

A
  • reduce autonomic anxiety symptoms: tremors, blushing, palpitations
    -no efficacy in any of the anxiety disorders based on studies
    -used in non-generalized SAD: before a speech or an exam
45
Q

Identifying the anxiety disorder

A

-fear of anxiety symptoms: panic disorder
-embarrassment in social interactions: SAD
-social situations, multiple worries: GAD

46
Q

Drugs causing anxiety

A

-Caffeine, Theoyphiylline, nicotine
-Stimulants: Ketamine, amphetamines, cocaine, methamphetamine
-CNS depression withdrawal: stopped alcohol, opioids, benzo cold turkey
-Psychotropic medications
-starting a new antidepressant
-some cardiovascular meds
-heavy metals, toxins
-prednisone

47
Q

Disease states causing anxiety

A

-Hyperthyroidism (they can’t sit still)
-Asthma, COPD: cant breath -> anxiety
-Vitamin B12 deficiency
-Lupus
-Depression

48
Q

Diagnostic criteria GAD

A

-having excessive anxiety and worry occurring more days than not for at least 6 months, multiple activities (school, work)

-difficulty in controlling worry
-3 or more of the following 6 symptoms:– Restlessness or fee

49
Q

Diagnostic criteria Panic Disorder

A

at least 2 unexpected panic attacks with at least 4 of the symptoms:
-Cardiac, sweating, shaking
-SOB or choking, nausea,
dizziness, depersonalization
-fear of loss of control, fear of dying
-paresthesias (feeling of tingling, numbness, needles) chills or hot flashes
THEN 1 of the following for 1 month

-Persistent concern about having another attack
-Worry about the consequences of the attack
-Significant change in behavior because of the attack
-May occur with or without agoraphobia

50
Q

What is Agoraphobia?

A

-Anxiety about being in a situation where escape
is difficult, or help is unavailable when having a panic attack (anxiety about having the anxiety attack)

examples:
-open spaces
-trains, tunnels, bridges, crowded rooms

51
Q

Pharmacological Treatment of Panic Disorder

A

1st: SSRI
2nd: TCA: Imipramine, clomipramine, Benzos
3rd (treatment-resistant): phenelzine (MAOI)

52
Q

Disadvantages of Alprazolam

A

-high risk for dependence

-short-half-life: strong high, effects wear off after a few hours -> patient feels anxious again and has to take another dose (interdose rebound anxiety leading to dependence after a few weeks)

53
Q

Which Benzos are lipophilic?

A

Diazepam
Alprazolam
clorazepate

very lipophilic -> gets into the brain fast but leaves the brain fast, diazepam sticks around in the fat tissue

54
Q

Benzos with slow onset

A

less euphoric
-chlordiazepoxide (Librium) -> alcohol use disorder
-clonazepam
-oxazepam

55
Q

Long-half-life and slow onset Benzos

A

less euphoric
-chlordiazepoxide (Librium) -> use in alcohol use disorder
-clonazepam
-diazepam (BUT quick onset)

56
Q

Short half-life

A

oxazepam
alprazolam
lorazepam

dose multiple times a day

57
Q

Which benzos are useful in patients with liver disease or cirrhosis or the elderly?
!!!

A

LOT: they undergo Glucuronide conjugation (Phase II metabolism) and don’t need oxidation in the liver

Lorazepam - anxiety
Oxazepam - better for anxiety
Temazepam - is used for sleep

58
Q

A patient on long-term Benzos is started on Carbamezapime. What may happen?

A

DDI with a CYP inducer -> Benzo level drop -> withdrawal symptoms

DDI with CYP inhibitors like fluoxetine or erythromycin will increase Benzo levels

59
Q

When should Benzos be stopped and when do we usually see full dependence?

A

stop after 1 month -> taper OFF

-full dependence after 3-4 months due to downregulation of endogenous GABA (by the time they stop they don’t produce enough of natural GABA?)

60
Q

What happens if the benzo is stopped abruptly?

A

Withdrawal symptoms
-rebound anxiety (anxiety that feels worse than the initial one) !!!
-insomnia, jitteriness
-muscle aches, ataxia (poor muscle control)
-depression
-blurred vision

-can be lethal due to status epileptics and seizure

highest risk for misuse: Alprazolam, lorazepam, and diazepam

61
Q

When to expect withdrawal symptoms

A

quicker with short-acting like alprazolam (may be on the next day)

-may switch alprazolam to a longer-acting Benzo LIKE clonazepam (same potency but easier to taper)

takes longer with long-half-life benzos

62
Q

How to taper Benzos
!!!!

A

-> 8 weeks: taper over 2-3 weeks
-> 6 months: taper over 4-8 weeks
-> 1 year: taper over 2-4 months (or even 6 months)

-reduce by 25% every week until you get t o50% of the dose -> then reduce by 1/8 every 4-7 days

63
Q

Diagnostic criteria SAD

A

-fear of one or more social or performance situations involving exposure to unfamiliar people
or possible scrutiny by others, or the fear of acting in a way that would be humiliating

-exposure to the fear situation causes anxiety
-The patient know that the fear is unreasonable

64
Q

Treatment for SAD

A

Cognitive Behavioral therapy + pharmacologic treatment works best

-CBT: Change negative thoughts patterns, Repeated exposure to feared situations, Social skills training, improvement within 6-12 weeks

-SSRI, 2nd line: Imipramine or clonazepam

65
Q

Diagnostic criteria for OCD

Obsession

A

Obsession
-thoughts, impulses or images that are
intrusive and unwanted (not due to worries about daily life) -> causing anxiety

-product of the patient’s mind

-patients try to suppress the thoughts or images by applying other thoughts or actions

66
Q

Diagnostic criteria for OCD
Compulsive

A

feeling the need to perform repetitive behaviors in response to an obsession (thoughts, impulses)

-WHY? -> The behaviour helps to reduce distress or to prevent something bad (in their mind - someone dies) from happening

-patients understands that the behaviour is unreasonable (kids don’t understand it)

67
Q

Comorbidities that come with OCD

A

-Depression (75%)
-other anxiety disorders
-Tics (Tourette)
-PANDAS (pediatric autoimmune neuropsychiatric
disorders) happens with a Strep infection (goes away after antibiotic therapy)

-OCD spectrum disorder
-Somatoform disorders (body dysmorphic disorder, they see them selves bigger or skinnier)
-eating disorder
-impulse control disorder (nail biting)

68
Q

Treatment OCD

A

Cognitive Behavioral Therapy + pharmacologic treatment works best

-CBT: Exposure therapy (goal is to not respond to the exposure)
-Neurosurgery
-deep brain stimulation

-SSRI,
2nd line (after 2 SSRIs failed: Clomipramine (TCA) - as effective as SSRIs but less tolerable
3rd: IV Clomipramine, or SSRI + antipsychotic (haloperiodol, quetiapine, olanzapine, risperidone)

69
Q

Treatment course in OCD

A

improvement in 4-6 weeks or 10-12 weeks
-may titrate up more rapidly in OCD

-after response, patients should stay on the meds for 1-2y
-when D/C: taper reducing by 25% every 2 months

-life.long prophylaxis if they had 2-4 severe relapses or 3-4 mild relapses

70
Q

Stressors in PTSD

A

exposed to a traumatic event

  1. experienced, witnessed, or been confronted with threatened death or serious injury, or sexual violence
  2. response involved intense fear, helplessness, or horror
    ->in kids: agitated or disorganized behavior
71
Q

Other criteria for PTSD

A

Criterion B: intrusive recollection (PTSD after a stressor, now it comes back to the mind over and over, dreams)
Criterion C: avoidance
Criterion D: negative alterations in mood or cognitions
Criterion D: hyper-arousal
Criterion E: duration

72
Q

How is PTSD diagonsoed?

A

having symptoms of B, C, and D for more than one month

73
Q

Subtypes of PTSD

A

-Acute: symptom duration of < 3 months

-Chronic: symptom duration of >3 months

-delayed onset: symptoms start after 6 months

74
Q

Treatment PTSD

A

-1st line: SSRI or SNRI (Venlafaxine), Prazosin for combat-related PTSD (soldier)

-TCAs: amitriptyline, imipramine, Mirtazepine, Nefazodone, Lamotrigine

75
Q

Prazosin

A

alpha-1 antagonist (actually a BP med)

-with the first dose patients should be in bed, they may pass out when taken while they are standing

76
Q

Treating specific symptoms of PTSD
Hyperarousal, flashbacks, impulsivity

A

Antiadrenergic: Prozasin

77
Q

Treating specific symptoms of PTSD

-Startle (scare, shock) response, nightmares
-Psychosis or flashbacks with hallucinations, dissociation

A

Anticonvulsants for startle

Antipsychotics for psychosis and hallucinations

Nightmares: Anticonvulsatns or Cyproheptadine

78
Q

Treating specific symptoms of PTSD

irritability, mood swings

A

Lithium

79
Q

Which drug should be avoided in PTSD?
!!!

A

Benzos

patients may get prescribed in patients who are having a panic attack and going to the ER -> prescriber think it calms them down
!!!!!

80
Q

Which drugs are acceptable/not acceptable in pregnancy?

Anxiety disorder

A

SSRIs are fine - except paroxetine !!!

avoid Benzos - bc of the risk of withdrawal of the baby after being born

breastfeeding -> Sertraline is the drug of choice, avoid fluoxetine bc it makes babies irritable

81
Q

Children with anxiety disorder

A

-start with psychological therapy
-SSRI: fluoxetine -> watch for suicidal ideation and behaviors that make them harm themselves
-look for activation syndrome

82
Q

Elder with anxiety disorder

A

avoid anticholinergics: TCAs, Paroxetine

-risk for EPS (caution with antipsychotics), orthostasis (prazosin), EKG changes

-paradoxical reactions to benzodiazepines-more anxious instead of calming (also in kids)

Drugs that showed an effect
-Citalopram
-Escitalopram
-Venlafaxine: caution: should be avoided in HTN and it is hard to taper

Neurologic & Psych (36 decks)

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