L11 Anxiety Disorders Flashcards
anxiety disorders
- severe, excessive, persistent anxiety and irrational fears
- that impairs functioning with everyday living
- pathological
- when anxiety is out of proportion to the actual danger or threat of the situation
- persists long after original trigger disappeared (typically, more than 6 months)
- incr risks for developing cv, cerebrovascular, gi and respiratory disorders
classification of anxiety disorders, based on DSM-5, that are most amendable to drug treatment
panic disorder, GAD, SAD, OCD, PTSD
prevalence of GAD in Singapore
1.6%
prevalence of OCD in Singapore
3.6%
GAD
excessive anxiety and worries > 6 months
PD
anticipatory anxiety of recurrent panic attacks
- panic attacks are normal responses, everyone will experience
- so fearful, dare not leave the house
SAD
fear of being scrutinised or humiliated by others in public
OCD
- most common: approx 3%
- obsessional thoughts/impulses that causes anxiety
- compulsive behaviors to relieve that anxiety: but does not the thoughts and impulses
PTSD
- re-experiencing of trauma
- persistent avoidance
- increased arousal
- do not use benzodiazepines: makes pt slow and sleepy (numbing), but pt must be psychologically active (mentally alert, process emotions) to open up during therapy tx
phobias
- less amendable to medication therapy, unresponsive to SSRI (moclobemide might be useful but clincial evidence is not strong)
- fear + avoidance behaviour
- very specific triggers
fear circuit
regulated by the amygdala (helps us remember)
worry circuit
regulated by the cortico-striatal-thalamic-corticol (CSTC) loop
- ruminating the memory
pathological fear/anxiety is related to (neurotransmitter etiology)
over-activation of amygdala
- SSRI are useful: receives input from serotonergic neurons which can inhibit its outputs
GABA as an inhibitory neurotransmitter (role in etiology of AD?)
- benzodiazepines can be used for tx
medical conditions a/w anxiety
- HF
- hyperthyroidism
- dementia, delirium
- asthma, COPD
sympathomimetics
psuedoephdrine
- flu medication, can be made into meth in bulks
stimulants
amphetamines, methylphenidate, cocaine
methylxanthines
theophyllines, caffeine
thyroid hormone
levothyroxine
- over replacement
corticosteroids
prednisolone
antidepressants
ssri, tca
- esp initiation or rapid dose escalation
- incr neurotransmitters too much
dopamine agonists
levodopa
beta-adrenergic agonists
salbutamol, esp systemic/oral
- agitation
panic attack
a discrete period of intense fear/discomfort, in which >= 4 of the following sx developed abruptly and reached a peak w/in 10 mins (usually lasts no more than 20-30min)
assessment of clinical presentation: clinician-rated
Hamilton Anxiety Scale (HAM-A)
- significant anxiety = score 18-20
- response = 40-50% reduction
- recovery = score <7
(+) gold standard in RCTs
(-) 10-15mins to administer by trained rater
CBT can be used in
GAD, panic disorder, OCD, PTSD
BT used in
SAD, agoraphobia, specific phobias
no non-pharmaco therapy required for
acute stress
What is the first line tx option for PTSD?
CBT
possible pharmacotherapy for GAD
SSRIs, venlafaxine XR, pregabalin
OCD pharmacotherapy options, ranked
1st line SSRI > 2nd clomipramine > 3rd venlafaxine
all serotonergic antidepressants can be useful for LT management of AD, OCD, PTSD
SSRIs, SNRIs, clomipramine (for OCD)
serotonergic antidepressant is effective for
‘excessive worrying’ type of sx in anxiety
serotonergic antidepressant onset
at least 1-2 months
serotonergic antidepressant full response
generally 3 months
what are adjunctive benzodiazepines effective for?
- effective for physical sx of anxiety eg. muscle tension
- fast onset of action, can be within 30 mins eg. lorazepam
- aim for short term (3-4 months) of tx, prn dosing, then taper
Benzodiazepine tolerance to _____ action is more common than to _____ action?
hypnotic, anxiolytic
what types of benzo preffered in AD?
high potency (can trigger seizures, req gradual taper) - clonazepam, lorazepam (equipotent with clonazepam, 500mcg), alprazolam XR (125/250mcg, relatively toxic, only reserved for panic disorder)
which 2 benzo used in AD does not have active metabolites
- alprazolam: no major
- lorazepam: no
eg of benzo used in AD tx
alprazolam, clonazepam, diazepam, lorazepam
do not use benzodiazepines with:
- alcohol, cns depressants: incr cns depressant SE (separate them 4-6hrs apart)
- opioids: incr mortality (cns depression, avoid combi or limit doses and duration)
which benzo has the least ddi
lorazepam, not metabolised by cyp enzymes (glucuronidation)
LT goal of tx
GAD, PD, SAD, PTSD: remission of core anxiety sx, recovery of fx
OCD: complete resolution of sx is difficult to achieve, relapse rates very high with poor medication adherance
non-pharmacological mgmt is recommended in
combination to medication tx
- esp OCD, CBT + ssri or clomipramine (since pharmacotherapy alone is very difficult to achieve complete remission)
what type of antidepressants used for AD? how is it initiated and titrated? time to response? discontinuation?
all antidepressants that promote 5HT transmissions have efficacy for AD
- effective for worrying/apprehension type of sx
- initiate at very low doses, gradually titrated up to max dose range
- may take 6-12wks to respond, ocd maytake 2-3 months
- gradual taper recommended to avoid discontinuation sx ie. decr dose by 10-25% every 1-2wk
is benzo recommended for monotherapy?
no, prn
- effective for physical/somatic aspects of sx ie. muscle tension, trembling
- quick onset of effects during initial weeks
- limited duration of tx preferred
- gradual taper, avoid rebound anxiety
avoid benzo use in who?
persons with substance-use disorders
early adverse effects to pharmacotherapy
- possible incr anxiety with antidepressants during first 1-2 weeks
- nausea, headache, insomnia/sedation
- usually subsides after 2-3 weeks of continued tx (gets better as receptors downregulate)
late adverse effects to pharmacotherapy
- sexual dysfunction and weight gain are common with antidepressants
- may lead to discontinuation of tx
- impt to counsel: REVERSIBLE
serotonin syndrome
sweating, confusion, muscle twitching, hyperTN, hyperreflexia and tremors
SNRI is not effective in
OCD
