EXAM 5 Anxiety Disorder Thomason Flashcards
Which drug works the fastest but should be avoided with substance use disorder?
Benzos
What is the 1st line drug in anxiety and how is it initiated?
SSRIs
-start at a low dose, monitor carefully, and titrate up
if given too much it can cause activation syndrome (jitteriness)
A patient was treated for anxiety and got in remission, how much longer should he be in treatment?
12 months
for PTSD and OCS at least 2 years
-to reduce the risk of relapse
What does a patient often experience in the course of anxiety therapy?
Wax and wane of symptoms, it may get better then worse again (ex: after a stressful situation)
In which patient population do we use the maximum tolerated dose as fast as possible?
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
How is anxiety therapy initiated in elderly patients?
half the recommended dose or less to reduce side effects
How is anxiety therapy initiated in panic disorder patients?
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
When is a dose considered maintenance dose?
the dose that gotten them better
(try to use once daily dosing)
Benzos are not the drug of choice, however ho should it be started?
as low as possible, and as high as needed
How are most anxiety drugs metabolized?
Liver
dose adjust if needed
When should a drug change be considered for generalized anxiety?
if no response after 4-6 weeks
If partial response continues for 4-6 weeks then reassess again (often it works after that)
When should a drug change be considered for OCD and PTSD?
8-12 week if no response
if there is partial response continues for 4-6 weeks then reassess again (often it works after that)
Which drugs may be added if there is no response?
Abilify or Buspirone
but adding a drug vs switching if no response is still debated in the literature
Non-pharmacological treatment option
What is the first-line treatment option?
SSRIs in all anxiety disorders
start with a lower dose to avoid them being overstimulated
Which side effects are seen when starting at a dose that is too high?
!!!
Restlessness, jitteriness, insomnia, headache
Transient side effects of SSRIs
!!!
headache, dizziness, stomach upset (goes away in a couple of weeks)
Long-term side effects of SSRIs
!!!
weight gain
sexual dysfunction
How does Paroxetine have to be tapered?
slowly to avoid discontinuation syndrome
When can patients expect it to work in anxiety disorders?
delayed effect
-2-4 weeks
-6-8 weeks in PTSD, OCD
A patient with COPD, HTN, Hyperlipidemia anxiety disorder, and depression. Which SNRI should be avoided and why?
Venlafaxine
contraindicated in HTN
Side effects of SNRI
Duloxetine and Venlafaxine have shown good results in most anxiety disorders
-early side effects: nausea, restlessness,
insomnia and headache
-long-term: sexual dysfunction
Which SNRI has a significant discontinuation syndrome?
Venlafaxine
even if missing a dose
How long does it take to see the effect of SNRIs?
2-4 weeks
What is the role of TCAs?
Second-line - works well except for social anxiety disorder
not often seen due to side effects
Side effects of TCAs
initially increased anxiety, anticholinergic,
cardiovascular, sedation, impaired cognition, decreased seizure threshold, elevated LFTs (clomipramine)
Long-term: Weight gain, sexual dysfunction
Role of MAOIs
Last-line (treatment-resistant), not often seen
-works well in panic disorder, SAD and PTSD
-in the morning and mid-day to avoid overstimulation and insomnia
How fast do Benzos work?
fast: 30-60 min
should not be used for more than 2 weeks
What is the consensus on the long-term use of Benzos?
Should be avoided bc of abuse, dependence and tolerance
When should Benzos be avoided?
!!!
Patients with SUD (higher chance to become dependent)
How should Benzos be prescribed PRN or schduled?
studies have shown more effective use when scheduled
Benzos in patients with depression and anxiety
Benzos make depression worse
In which of the anxiety disorders are Benzos useful?
Panic disorder
(mentioned in class)
Role of Hydroxyzine (Vistrail - FDA approved for anxiety)
used for acute anxiety as alternative for Benzos
-beneficial in treating GAD
-very sedative
-not associated with dependence
When might Hydroxyzine be useful?
acute anxiety and for sleep
Pregabalin
Not FDA approved
-effective in acute/long-term GAD and a few trials of SAD
-taper off when d/c
Side effects of Pregabalin
-dizziness, sedation, dry mouth, psychomotor impairment
(also mentioned weight gain, edema)
What is the role of Anticonvulsants?
have shown efficacy in preliminary studies for PTSD
Role of Buspirone
only in GAD
(often prescribed PRN - but it doesn’t work PRN!!!)
-no sedation or dependence
-but less effective
ADE of Buspirone
does work on 5-HT: nausea, headache
also: dizziness, jitteriness, dysphoria (initial)
When does Buspirone start working?
1-2 weeks -> full effects over several weeks
start with 5 mg TID (or BID), titrate up to a max of 60 mg/day
Role of Quitepine
monotherapy in GAD
Adjunctives
Abilify
Role of ß blockers
- 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
Identifying the anxiety disorder
-fear of anxiety symptoms: panic disorder
-embarrassment in social interactions: SAD
-social situations, multiple worries: GAD
Drugs causing anxiety
-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
Disease states causing anxiety
-Hyperthyroidism (they can’t sit still)
-Asthma, COPD: cant breath -> anxiety
-Vitamin B12 deficiency
-Lupus
-Depression
Diagnostic criteria GAD
-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 feeling keyed up and on edge
-Easily fatigued
-Difficulty concentrating, or mind going blank
-Irritability
-Sleep disturbance (difficulty falling asleep or staying asleep, or restless, unsatisfying sleep)
Diagnostic criteria Panic Disorder
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
What is Agoraphobia?
-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
Pharmacological Treatment of Panic Disorder
1st: SSRI
2nd: TCA: Imipramine, clomipramine, Benzos
3rd (treatment-resistant): phenelzine (MAOI)
Disadvantages of Alprazolam
-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)
Which Benzos are lipophilic?
Diazepam
Alprazolam
clorazepate
very lipophilic -> gets into the brain fast but leaves the brain fast, diazepam sticks around in the fat tissue
Benzos with slow onset
less euphoric
-chlordiazepoxide (Librium) -> alcohol use disorder
-clonazepam
-oxazepam
Long-half-life and slow onset Benzos
less euphoric
-chlordiazepoxide (Librium) -> use in alcohol use disorder
-clonazepam
-diazepam (BUT quick onset)
Short half-life
oxazepam
alprazolam
lorazepam
dose multiple times a day
Which benzos are useful in patients with liver disease or cirrhosis or the elderly?
!!!
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
A patient on long-term Benzos is started on Carbamezapime. What may happen?
DDI with a CYP inducer -> Benzo level drop -> withdrawal symptoms
DDI with CYP inhibitors like fluoxetine or erythromycin will increase Benzo levels
When should Benzos be stopped and when do we usually see full dependence?
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?)
What happens if the benzo is stopped abruptly?
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
When to expect withdrawal symptoms
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
How to taper Benzos
!!!!
-> 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 to 50% of the dose -> then reduce by 1/8 every 4-7 days
Diagnostic criteria SAD
-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
Non-pharm + Pharm Treatment for SAD
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
Diagnostic criteria for OCD
Obsession
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
Diagnostic criteria for OCD
Compulsive
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)
Comorbidities that come with OCD
-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)
Treatment OCD
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)
Treatment course in OCD
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
Stressors in PTSD
exposed to a traumatic event
- experienced, witnessed, or been confronted with threatened death or serious injury, or sexual violence
- response involved intense fear, helplessness, or horror
->in kids: agitated or disorganized behavior
Other criteria for PTSD
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
How is PTSD diagonsoed?
having symptoms of B, C, and D for more than one month
Subtypes of PTSD
-Acute: symptom duration of < 3 months
-Chronic: symptom duration of >3 months
-delayed onset: symptoms start after 6 months
Treatment PTSD
-1st line: SSRI or SNRI (Venlafaxine), Prazosin for combat-related PTSD (soldier)
-TCAs: amitriptyline, imipramine, Mirtazepine, Nefazodone, Lamotrigine
Prazosin
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
Treating specific symptoms of PTSD
Hyperarousal, flashbacks, impulsivity
Antiadrenergic: Prozasin
Treating specific symptoms of PTSD
-Startle (scare, shock) response, nightmares
-Psychosis or flashbacks with hallucinations, dissociation
Anticonvulsants for startle
Antipsychotics for psychosis and hallucinations
Nightmares: Anticonvulsatns or Cyproheptadine
Treating specific symptoms of PTSD
irritability, mood swings
Lithium
Which drug should be avoided in PTSD?
!!!
Benzos
patients may get benzos prescribed when having a panic attack and going to the ER -> prescriber thinks
it calms them down
!!!!!
Which drugs are acceptable/not acceptable in pregnancy?
Anxiety disorder
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
Children with anxiety disorder
-start with psychological therapy
-SSRI: fluoxetine -> watch for suicidal ideation and behaviors that make them harm themselves
-look for activation syndrome
Elder with anxiety disorder
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
