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AC- CNS lectures > Management of anxiety disorder 1.2.1 (Anxiolytics & Hypnotics) > Flashcards

Management of anxiety disorder 1.2.1 (Anxiolytics & Hypnotics) Flashcards

1
Q

What are the general principles of management?

A

Step 1: Confirm diagnosis

  • hx assessment
  • physical examination to exclude underlying medical cause
  • identify features to define specific anxiety disorder (&/or co-existing psychiatric disorders)

Step 2: Identify and address factors that may exacerbate the disorder

  • Psychological factors
  • Lifestyle factors

Step 3: Initiate therapy

  • Psychoeducation
  • Psychological treatments
  • Pharmacological management
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2
Q

Why do anxiety disorders require ongoing management?

A

Anxiety disorders are usually relapsing and chronic and require ongoing treatment

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3
Q

How do we avoid exacerbating anxiety disorders?

A
  • avoiding exacerbating agents such as…
    • financial difficulties
    • relationship difficulties
    • elcohol, nicotine
    • illicit drug use
    • excessive caffeine intake
    • excessive work
    • inadequate sleep
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4
Q

What is the most appropriate psychological intervention for treatment of anxiety?

A
  • psychological treatments
  • includes CBT, exposure therapy & lots of others
  • self help therapies online–> e therapy
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5
Q

What is a 1st line intervention for anxiety? What does it do?

A
  • CBT
  • focuses on changing maladaptive thinking patterns and behaviour
  • based on two key principles
    • Cognitions may control feelings and behaviour
    • Behaviours may affect thought patterns and emotions
  • 12-20 weekly sessins
    • individual or group therapy or self directed formats
    • follow up booster sessions after 3 or 6 months useful
  • Benzos can interfere with effectiveness of CBT
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6
Q

What is exposure therapy? What anxiety conditions is it useful for?

A
  • based on the principle of respondent conditioning
  • useful for PTSD, OCD, specific phobias
  • when people are fearful of something they often avoid what they fear however in the long term this can make fears worse
  • exposure therapy= face fears & challenge them in a controlled way
  • can be done using virtual reality
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7
Q

What is E-therapy for?

A
  • Generally CBT-based treatment approach
  • Can be as effective as face-to-face therapies
  • Mood gym
  • Mindsport courses
  • E-couch programmes
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8
Q

For pharmacotherapy for anxiety- used when psychological interventions are ineffective or not available

A) What is first line?

B) What is used in exceptional circumstances?

C) What are other drugs used in anxiety?

A

A) SSRIs (for all anxiety disorders) + SNRIs for some disorders

B) Benzodiazepines

C) TCAs, MAOIs, Buspirone, Anticonvulsants, Anttipsychotics, Beta-blockers

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9
Q

What drugs are used for GAD, general anxiety disorder?

A
  • escitalopram, SSRI
  • paroxetine, SSRI
  • venlafaxine, SNRI
  • duloxetine, SSRI
  • imipramine
  • busprirone
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10
Q

What drugs are used for SAD, social anxiety disorder?

A
  • escitalopram, SSRI
  • paroxetine, SSRI
  • sertraline, SSRI
  • venlafaxine, SNRI
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11
Q

What drugs are used for panic disorder?

A
  • SSRI or venlafaxine
  • clomipramine or imipramine
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12
Q

What drugs are used for specific phobias?

A
  • no ongoing pharmacotherapy recommended
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13
Q

What drugs are used for OCD, obsessive compulsive disorder?

A
  • Citalopram, SSRI
  • escitalopram, SSRI
  • fluoxetine, SSRI
  • fluvoxamine, SSRI
  • paroxetine, SSRI
  • sertraline, SSRI
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14
Q

What drugs are used for PTSD?

A
  • fluoxetine, SSRI
  • paroxetine, SSRI
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15
Q

What are some common adverse effects for SSRIs?

A
  • nausea, diarrhoea
  • agitation
  • insomnia, drowsiness
  • tremor
  • dry mouth
  • dizziness
  • headache
  • sweating
  • weakness
  • anxiety
  • sexual dysfunction
  • rhinitis,
  • myalgia
  • rash
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16
Q

What are some considerations with SSRIs?

A
  • taper over several weeks to avoid withdrawal effects when ceasing
  • Drug interactions: Several are potent inhibitors of CYP enzymes
  • QT interval prolongation effects
  • Risk of serotonin toxicity with other serotonergic drugs
  • Effects on platelet aggregation → ↑ risk of bleeding n Risk of hyponatraemia
17
Q

How to dose SSRIs in patients who have anxiety? What is seen when starting SSRIS? What is the onset of action?

A
  • Start patients on half the minimum strength tablet available –> continue at that dose for a few days to a week until patient feels confident enough to increase dose
  • Increased anxiety when starting SSRIs
  • Onset of action is slower for anxiety (4-6 weeks)
18
Q

How do benzodiazepines (BDZs) work?

A
  • potentiate the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic, sedative, hypnotic, muscle relaxant and antiepileptic effects
19
Q

Which BZDs are used for the following and why:

A) For anxiety

B) For insomnia

C) For controlled drugs

A

A) Diazepam, lorazepam, oxazepam

  • rapid onset of action and long half life –> less withdrawal symptoms

B) Temazepam

  • >rapid onset of action but short half life

C) Alprazolam

Flunitrazepam

20
Q

What are the indications for BZDs? Provide THREE answers

A
  • Can provide rapid symptomatic relief
  • Reserved for short-term (2 to 4 weeks) use or intermittent use as part of a broader treatment plan
  • (up to 2 weeks) to manage agitation or insomnia when starting antidepressants
21
Q

What to consider when prescribing BZD?

A
  • Always check for a history of problem alcohol or drug use
  • Be wary of prescribing to unfamiliar patients, especially if asking for a particular drug by name (may indicate drug-seeking behaviour)
  • Carefully discuss the potential for addiction with the patient
  • Avoid using short-acting drugs as they are the most highly addictive
  • Only prescribe small quantities of medication at a time
  • Use only as short-term treatment
  • Ensure regular review of the patient and continuity of care.
22
Q

Which BZD used for GAD?

A
  • diazepam
  • 2mg to 5mg as a single dose repeated up to twice daily
  • Short term measure only during a crisis for severe or disabling anxiety
  • Up to 2 weeks treatment then reduce dose to zero by 6 weeks
  • Long term use only in rare instances where other therapies have failed.
23
Q

Which BZD used for SAD?

A
  • A short-acting BDZ can be used just before a performance in instances of specific performance anxiety
  • alprazolam
  • However, side effects may inhibit the performance
24
Q

What conditions is there evidence of benefit/no benefit in for the use of BDZs?

A
  • benzodiazepines have evidence of benefit in GAD, SAD and panic disorder, but not OCD or PSTD
25
Q

What are the common ADV of BZDs?

A
  • drowsiness
  • over-sedation
  • light-headedness
  • hypersalivation
  • ataxia
  • slurred speech
  • dependence
  • effects on vision
26
Q

What are the symptoms of BZD withdrawal syndrome?

A
  • Anxiety
  • insomnia
  • irritability
  • myoclonic jerks
  • palpitations
  • sensory disturbances
  • occasionally seizures
27
Q

How to do dose reduction for BZDs? What are the peak effects at weak 2 of withdrawal?

A
  • Dose reduction at a rate of 15% per week is usually tolerated
  • Titrate dose decrease depending on symptoms
  • Higher dose preparations – stabilise on equivalent dose (ddd) of diazepam before reducing dose (not > 80mg/day)
  • e.g. 5mg of diazepam = 0.5 mg of alaprozalam
  • May need to withdraw in inpatient setting
  • Peak effects at week 2- anxiety, panic, insomnia, muscle spasms, vomitting, diarrhoea, seizures
28
Q

For other drugs used for anxiety, when should TCAS be avoided?

A
  • need to be avoided with any patient at risk of suicide or those with underlying cardiac disease
  • Second line after SSRIs (prolong QT interval and increase arrythmias)
  • Cardiotoxicity in overdosage
  • Efficacious but more side effects than SSRIs – anticholinergic effects, hypotension and weight gain
  • Sedation can sometimes be useful in anxiety disorders
  • doses of TCA’s for treating panic are often higher than those for depression
29
Q

MAOIs used for anxiety…

A
  • occasionally used by specialists in social phobia following failure of SSRIs
  • phenelzine also used rarely in PTSD
  • phenelzine → tyramine interactions, less interactions with moclobemide
30
Q

When may mirtazapine be used for anxiety? Side effects?

A
  • option in PTSD
  • less N, V and sexual dysfunction than SSRIs but more weight gain and sedation
31
Q

Which antipsychotics are used for anxiety? Why are they used?

A
  • risperidone, quetiapine, olanzapine- SGA, atypical
  • evidence limited and side effect risk is high
  • most evidence of effect in OCD when used in combination with an SSRI
  • olanzapine with SSRI has been used for PTSD and social phobia
32
Q

When may buspirone used for anxiety? MOA and when is it appropriate to use?

A
  • Partial agonist of serotonin 5HT1A receptors
  • Not currently available but may be obtained as an SAS drug
  • May be preferable to BDZs for management of GAD in patients with a history of substance misuse – less potential for dependence
  • May take 2 weeks for optimal benefit
  • Avoid use with MAOIs = increases BP
  • avoid eating graepfruit
  • causes drowsiness
33
Q

When is pregabalin used for anxiety? What is the MOA? ADV?

A
  • GAD
  • pre-synaptic inhibitor of the release of excitatory neurotransmitters
  • somnolence, nausea, dizziness, dry mouth
  • expensive
  • no rebound anxiety when discontinued but need to withdraw slowly to avoid precipitating a seizure
34
Q

When are beta blockers used for anxiety? Which patient is it not appropriate in?

A
  • used for physical symptoms (manifestations of sympathetic overactivity) including tremor, palpitations and sweating which can be distressing and unpleasant
  • does not relieve the mental aspects of social phobia
  • little evidence to support their use even in SAD
  • avoid use in patients with asthma, severe peripheral vascular disease and some patients with heart failure
  • caution in patients with diabetes
35
Q

What are some complementary medicines that can be used for anxiety?

A

Kava Kava may cause liver failure = not recommended

St John’s Wort for depression

Passionflower* GAD

Inositol* panic disorder & OCD

Valerian root

Melatonin

Omega-3-fatty acids

5-Adenosyl-L-Methionine

36
Q

When to consider an antidepressant for anxiety disorder?

A
  • consider an antidepressant for those who do not respond to non-drug therapy, selecting on the basis of evidence of efficacy in the diagnosed anxiety disorder

AC- CNS lectures (28 decks)

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