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PR3136 CA2 > L11 Anxiety Disorders > Flashcards

L11 Anxiety Disorders Flashcards

1
Q

anxiety disorders

A
  • 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
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2
Q

classification of anxiety disorders, based on DSM-5, that are most amendable to drug treatment

A

panic disorder, GAD, SAD, OCD, PTSD

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3
Q

prevalence of GAD in Singapore

A

1.6%

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4
Q

prevalence of OCD in Singapore

A

3.6%

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5
Q

GAD

A

excessive anxiety and worries > 6 months

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6
Q

PD

A

anticipatory anxiety of recurrent panic attacks

  • panic attacks are normal responses, everyone will experience
  • so fearful, dare not leave the house
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7
Q

SAD

A

fear of being scrutinised or humiliated by others in public

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8
Q

OCD

A
  • most common: approx 3%
  • obsessional thoughts/impulses that causes anxiety
  • compulsive behaviors to relieve that anxiety: but does not the thoughts and impulses
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9
Q

PTSD

A
  • 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
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10
Q

phobias

A
  • less amendable to medication therapy, unresponsive to SSRI (moclobemide might be useful but clincial evidence is not strong)
  • fear + avoidance behaviour
  • very specific triggers
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11
Q

fear circuit

A

regulated by the amygdala (helps us remember)

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12
Q

worry circuit

A

regulated by the cortico-striatal-thalamic-corticol (CSTC) loop
- ruminating the memory

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13
Q

pathological fear/anxiety is related to (neurotransmitter etiology)

A

over-activation of amygdala

- SSRI are useful: receives input from serotonergic neurons which can inhibit its outputs

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14
Q

GABA as an inhibitory neurotransmitter (role in etiology of AD?)

A
  • benzodiazepines can be used for tx
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15
Q

medical conditions a/w anxiety

A
  • HF
  • hyperthyroidism
  • dementia, delirium
  • asthma, COPD
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16
Q

sympathomimetics

A

psuedoephdrine

- flu medication, can be made into meth in bulks

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17
Q

stimulants

A

amphetamines, methylphenidate, cocaine

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18
Q

methylxanthines

A

theophyllines, caffeine

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19
Q

thyroid hormone

A

levothyroxine

- over replacement

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20
Q

corticosteroids

A

prednisolone

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21
Q

antidepressants

A

ssri, tca

  • esp initiation or rapid dose escalation
  • incr neurotransmitters too much
22
Q

dopamine agonists

A

levodopa

23
Q

beta-adrenergic agonists

A

salbutamol, esp systemic/oral

- agitation

24
Q

panic attack

A

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)

25
Q

assessment of clinical presentation: clinician-rated

A

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

26
Q

CBT can be used in

A

GAD, panic disorder, OCD, PTSD

27
Q

BT used in

A

SAD, agoraphobia, specific phobias

28
Q

no non-pharmaco therapy required for

A

acute stress

29
Q

What is the first line tx option for PTSD?

A

CBT

30
Q

possible pharmacotherapy for GAD

A

SSRIs, venlafaxine XR, pregabalin

31
Q

OCD pharmacotherapy options, ranked

A

1st line SSRI > 2nd clomipramine > 3rd venlafaxine

32
Q

all serotonergic antidepressants can be useful for LT management of AD, OCD, PTSD

A

SSRIs, SNRIs, clomipramine (for OCD)

33
Q

serotonergic antidepressant is effective for

A

‘excessive worrying’ type of sx in anxiety

34
Q

serotonergic antidepressant onset

A

at least 1-2 months

35
Q

serotonergic antidepressant full response

A

generally 3 months

36
Q

what are adjunctive benzodiazepines effective for?

A
  • 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
37
Q

Benzodiazepine tolerance to _____ action is more common than to _____ action?

A

hypnotic, anxiolytic

38
Q

what types of benzo preffered in AD?

A 
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)
39
Q

which 2 benzo used in AD does not have active metabolites

A
  • alprazolam: no major

- lorazepam: no

40
Q

eg of benzo used in AD tx

A

alprazolam, clonazepam, diazepam, lorazepam

41
Q

do not use benzodiazepines with:

A
  • alcohol, cns depressants: incr cns depressant SE (separate them 4-6hrs apart)
  • opioids: incr mortality (cns depression, avoid combi or limit doses and duration)
42
Q

which benzo has the least ddi

A

lorazepam, not metabolised by cyp enzymes (glucuronidation)

43
Q

LT goal of tx

A

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

44
Q

non-pharmacological mgmt is recommended in

A

combination to medication tx

- esp OCD, CBT + ssri or clomipramine (since pharmacotherapy alone is very difficult to achieve complete remission)

45
Q

what type of antidepressants used for AD? how is it initiated and titrated? time to response? discontinuation?

A

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
46
Q

is benzo recommended for monotherapy?

A

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
47
Q

avoid benzo use in who?

A

persons with substance-use disorders

48
Q

early adverse effects to pharmacotherapy

A
  • 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)
49
Q

late adverse effects to pharmacotherapy

A
  • sexual dysfunction and weight gain are common with antidepressants
  • may lead to discontinuation of tx
  • impt to counsel: REVERSIBLE
50
Q

serotonin syndrome

A

sweating, confusion, muscle twitching, hyperTN, hyperreflexia and tremors

51
Q

SNRI is not effective in

A

OCD

PR3136 CA2 (5 decks)

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