Manage ANXIETY Flashcards
Definition of GAD
Excessive anxiety and worries >6 months
Main Biological mechanism of anxiety disorders
Neurochemical deregulation such as:
- NE increased in locus coeruleus of brain
- 5HT, GABA, and others
Distinguish between the five different type of anxiety disorders
- GAD: Excessive anxiety and worry for ≥ 6months,
- PD: RECURRENT, UNEXPECTED panic attacks
- SAD: Fear/anxiety or avoidance of social/perf situation ≥6 months. Person fears humiliation/embarrassment in their act
- OCD: Recurrent and persistent thoughts/actions that are intrusive
- PTSD: Exposure to traumatic events with involuntary thoughts after occurrence for ≥1 month
- ASD: same as PTSD, but 3d-1month after trauma
POP-SG
Goals and Duration of therapy in Anxiety disorder
Goals:
- Remission of sx
- Return to pre-morbid functioning
Duration: ≥1 year, some may need lifelong tx
(note: OCD: 1-2y tx)
Common first line pharmaco therapy among ALL anxiety disorders
SSRI
First line options for all the different anxiety disorders (aside from SSRI)
- GAD: SNRI, Pregabalin
- PD: Venlafaxine
- SAD: Venlafaxine
- OCD: NIL (only ssri)
- PTSD: SNRI
Second line options for all the different anxiety disorders
- GAD: Mirtazapine, Imipramine
- PD: Clomi, Imi (TCA)
- SAD: Moclobemide (MAOI)
- OCD: Clomipramine (TCA)
- PTSD: Mirtazapine
What if patients fail first-line Pco tx for anxiety disorders?
Refer to specialist for further assessment and management
State the most common non-pco tx for anxiety disorders
CBT (Cognitive behavioural therapy)
Name the non-pco tx unique to SAD
Social skills training
Name the non-pco tx unique to OCD
DBT (Dialectical Behavioural Therapy)
List the non-pco txs unique to PTSD
- Exposure therapy
2. Eye movement desensitisation and reprocessing (EMDR)
What is expected in patients who are only initiated with ADs (antidepressants) for anxiety disorders? Are there any ways to help with this?
Transient jitteriness in first 1-2 weeks
- Adjunct BZD PRN
General rule for dosing ADs in anxiety
Start low, go slow, titrate up
What are some differences between the usage of ADs in anxiety VS ADs in depression?
- Anxiety: Higher range of maintenance dose (E.g. prozac 60-80mg for anxiety instead of 20-60mg for depression)
- Anxiety: ADs usually take 3 months for full response (instead of 1 month for depression)
Onset of different therapeutic effects of ADs in anxiety disorders
- Early anxiolytic effect: 2-4 weeks
- Improvements: 4-6 weeks
- Full response: up to 3 months
BZD are indicated for the short-term relief of severe anxiety EXCEPT which anxiety disorder?
PTSD
Purpose of BZD in anxiety?
Short-term relief of SEVERE anxiety, useful for the PHYSICAL sx
Caution with use of BZD?
Use short term to reduce risk of dependence
How to minimise risk of BZD misuse, dependence and withdrawal?
- Taper dose
- 25% per week till half of original dose
- Then 1/8 every 4-7d
OR - Switch to LONGER HALF-LIFE BZD (diazepam) at EQUIVALENT daily dose, then taper gradually
AND - Avoid Rx BZD to patients with co-morbid alc/substance abuse
What are some other Tx options and their purpose in Anxiety disorders?
- Pregabalin: GAD. Rq renal adjustment CrCL < 60
- Buspirone: ONLY FOR GAD. Delayed onset (2 wk)
- Hydroxyzine: Anxiolytic from its sedative properties (tolerance in 2 weeks)
- Propranolol: taken BEFORE anxiety-provoking situation
- SGA: used by specialists as augmentation
Name the main drug interactions of BZD and ADs in terms of CYP enzymes
- BZD: 3A4 (except lorazepam)
2. ADs: 2D6, 3A4
Presentation of serotonin syndrome and how to avoid?
Presents as clinical TRIAD:
- Mental status changes
- Autonomic hyperactivity
- Neuromuscular abnormalities
To avoid: Avoid multiple HT-agents/buspirone with MAOI
Monitoring parameters for Anxiety?
- Sx diary:
- E.g. characteristics of anxiety episodes, any suicidal/homicidal thoughts, frequency, duration, triggers, etc. - ADR of pharmacotherapy
- E.g. Insomnia/Drowsiness from ADs
- E.g. Ataxia in BZD
- E.g. suicide in ≤24yo on ADs
