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Neuro Quiz 8 > Treatment of Anxiety Disorder > Flashcards

Treatment of Anxiety Disorder Flashcards

1
Q

DSM-5 Criteria for Generalized Anxiety Disorder

A
  1. The symptoms occur for at least 6 months.
  2. The patient finds it difficult to control worry.
  3. Must have three or more of the following symptoms (however, only 1 symptom is required in children)
    a. Restless or feeling on edge most of the time
    b. Easily fatigued
    c. Having difficulty concentrating
    d. Experiencing irritability most of the time
    e. Experiencing muscle tension most of the time
    f. Having sleep disturbances
  4. Other medical conditions, psychiatric illnesses, and substance abuse have been excluded
  5. Worrying causes significant distress and impairment in daily function (This is the main factor that separates “normal worrying” from GAD)
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2
Q

Non-Pharm Treatment of Anxiety

A 
Cognitive Behavioral Therapy
Stress management
Meditation
Regular exercise routine
Reduce or avoid caffeine, nicotine and other stimulants
Reduce or avoid alcohol
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3
Q

Pharmacological Treatment of Anxiety

A

First line and cornerstone = antidepressants

BZD (only short term and if needed for acute treatment)

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4
Q

Steps to Treating Generalized Anxiety Disorder (GAD)

A
  1. Consider psychotherapy initially or during
  2. Acute management: BZD and taper in 4-6 weeks
  3. Chronic Management
  4. Combination therapy (SSRI, SNRI, mirtazapine, TCA)
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5
Q

Chronic Management Options

A

No response: switch to a different SSRI or SNRI
Partial response: Keep the current antidepressant and add a 2nd generation antipsychotic (quetiapine), BZD, Anthistamine (hydroxyzine) or buspirone

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6
Q

Duration of therapy for GAD?

A

At least 12 months

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7
Q

Panic Disorder

A

Spontaneous panic attacks followed by a fear of having another panic attack
Last 20-30 minutes
Develop agoraphobia
Impair daily and occupational function

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8
Q

Define agoraphobia

A

Fear of crowded spaces or enclosed public places

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9
Q

DSM5 for Panic Disorder

A
  1. Patient meets both (a) and (b):
    a. Has recurrent unexpected panic attacks
    b. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
    i. Persistent concern about having additional attacks
    ii. Worrying about the consequences of the attack
    iii. A change in behavior related to the attacks
  2. May be associated with or without agoraphobia
  3. The panic attacks are not due to the direct effects of a substance, another medical condition or another mental disorder.
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10
Q

DSM5 for Panic Attack

A
  1. A period of intense fear or discomfort in which at least 4 of the following symptoms develop abruptly and reach a peak within 10 minutes:
    a. a. Chest pain
    b. Chills or hot flashes
    c. Choking feeling
    d. Derealization or depersonalization
    e. Fear of dying
    f. Fear of losing control
    g. Lightheaded
    h. Nausea or upset stomach
    i. Paresthesias
    j. Shaking
    k. SOB or sensation of smothering
    l. Sweating
    m. Tachycardia
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11
Q

Pharmacotherapy of Panic Disorder

A

Antidepressants are cornerstone and first line (SSRI or SNRI)
BZD: if needed for acute; only until antidepressant has started working (4-6 weeks)

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12
Q

Treatment of Panic Disorder

A
  1. Psychotherapy
  2. Acute Management with BZDs
  3. Chronic Management
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13
Q

Chronic management for panic disorder

A

1st: SSRI or Venlafaxine
2nd: Switch to another
3rd: Switch to another above or imipramine
4th: Add a BZD, gabapentin, 2nd generation antipsychotic

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14
Q

Panic disorder therapy duration:

A

12-24 months

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15
Q

PTSD DSM5

A
  1. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
    a. Directly experiencing the traumatic event
    b. Witnessing, in person, the event as it occurred to others
    c. Learning that the traumatic event occurred to a close family member or close friend
    d. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
  2. Has at least (1) of the following REEXPERIENCING symptoms:
  3. Has at least (1) of the following AVOIDANCE symptoms:
  4. Has at least (2) of the following NUMBING symptoms:
  5. Has at least (2) of the following INCREASED AROUSAL symptoms:
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16
Q
  1. Has at least (1) of the following REEXPERIENCING symptoms:
A
  1. Flashbacks, intrusive thoughts
  2. Dreams
  3. Sense of reliving the experience, illusions, hallucinations, dissociative flashbacks
  4. Psychological distress at exposure or cues that symbolize ore resemble
  5. Physiological reactivity on exposure or cues that symbolize or resemble
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17
Q
  1. Has at least (1) of the following AVOIDANCE symptoms:
A

a. Puts effort to avoid thoughts, feelings, or conversations associated with the trauma
b. Avoids activities, places, or people that arouse recollections of the trauma

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18
Q
  1. Has at least (2) of the following NUMBING symptoms:
A

a. Unable to recall an important aspect of the trauma
b. Decreased interest in activities
c. Feelings of detachment from others
d. Restricted affect
e. Sense of foreshortened future
f. Persistent negative emotional state (e.g., fear, horror, anger, guilt, shame)
g. Persistent, distorted cognitions about the cause of consequences of the traumatic event that lead the individual to blame himself or others

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19
Q
  1. Has at least (2) of the following INCREASED AROUSAL symptoms:
A

a. Difficulty falling or staying asleep
b. Irritability or outbursts of anger
c. Difficulty concentrating
d. Hypervigilance
e. Exaggerated startle response
f. Reckless or self-destructive behavior

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20
Q

Symptoms of PTSD:

A

More than 1 month and are clinically significant distress or impairment within their social, work or other areas of functionality

21
Q

Treatment Approach to PTSD

A

1st: SSRI or venlafaxine
2nd: Try another
3rd: Mirtazapine or TCA
Additionally: augmentation agents for sleep, flashbacks, irritability paranoia
NO BZDS IN PTSD!!!

22
Q

Augmentation Agents

A 
#1: Prazosin (hypervigilance and nightmares)
#2: Olanzapine, risperidone, quetiapine (paranoia and flashbacks)
23
Q

Treatment duration for PTSD

A

At least 12 months

24
Q

DSM5 for OCD

A
  1. Presence of obsessions, compulsions, or both:
    a. Obsessions are defined by the following (MUST present with BOTH):
    i. Recurrent or persistent thoughts, impulses, or images that are intrusive and inappropriate and that cause marked anxiety or distress
    ii. Attempts are made to ignore or suppress the thoughts, impulses, or images or to eliminate them
    b. Compulsions are defined by the following (MUST present with BOTH):
    i. Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession
    ii. The behaviors or mental acts are not pleasurable and are designed to prevent discomfort or the occurrence of a dreaded event that is unknown
  2. Cause marked distress, are time consuming, or significantly interfere with the person’s normal routine, occupational functioning, or usual social activities.
  3. If another psychiatric disorder is present, the content of the obsessions or compulsions is not restricted to it.
  4. The disturbance is not due to the direct physiologic effects of a substance or a medical condition.
25
Q

Treatment Guide for OCD

A

1st: SSRI, if one doesn’t work try another (symptomatic reduction can take 6-12 weeks)
2nd: After 2 fails with SSRIs, change to clomipramine
3rd: Combo SSRI + antipsychotic OR clomipramine

26
Q

OCD Treatment duration

A

Once they respond, treat for 1-2 years

Most patients will require life long therapy

27
Q

Alprazolam

A 
Xanax
High lipophilicity
Half-life 12-15 hours
Oxidative pathway
No active metabolite
28
Q

Chlordiazepoxide

A 
Librium
Low Lipophilicity
Half-life 5-30 hours
Oxidation pathway
Yes active metabolite
29
Q

**Diazepam

A 
Valium
High lipophilicity
Half-life 20-80 hours
Oxidation
Yes active metabolite
30
Q

**Lorazepam

A 
Ativan
Low lipophilicity
Half-life 10-20 hours
Conjugation
No active metabolite
31
Q

**Oxazepam

A 
Serax
Low lipophilicity
Half-life 5-20 hours
Conjugation
No active metabolite
32
Q

**Clonazepam

A 
Klonopin
Low lipophilicity
Half-life 30-40 hours
Nitroreduction
No active metabolite
33
Q

Increased lipophilicity =

A

Rapidly absorbed and quickly distributed

Slower absorption and slower onset

34
Q

Decreased lipophilicity =

A

Slower absorption and slower onset

35
Q

Elderly and Hepatic impairment patients

A

Fewer side effects with agents metabolized by conjugation not oxidation (lorazepam and oxazepam)

36
Q

BZD Adverse Effects

A

CNS/respiratory depression
Abuse potential
Anterograde amnesia
Memory impairment

37
Q

BZD Withdrawal

A

Gradually taper
Decrease dose by 25% per week until 50% dose is reached
Then decrease dose by 1/8 every 4-7 days

38
Q

BZD Withdrawal Length

A

Less than 8 weeks: taper for at least 2 weeks
Greater than 8 weeks but less than 6 months: taper for 2-3 weeks
Greater than 6 months but less than a year: taper for 1-2 months
Greater than 1 year: taper for 2-4 months

39
Q

BZD Drug Interactions

A

Alcohol and CNS depressants

Metabolized by 3A4 and 1A2 (chlordiazepoxide and diazepam only)

40
Q

BZD Dosing

A

Start low and taper up (weekly increases)

Duration: 2-6 weeks for acute

41
Q

Venlafaxine Indications

A

SNRI
GAD
SAD
Panic Disorder

42
Q

Duloxetine Indications

A

SNRI

GAD

43
Q

Fluoxetine Indications

A

SSRI

OCD and panic disorder

44
Q

Paroxetine Indications

A 
SSRI
GAD
SAD
OCD
Panic disorder
PTSD
45
Q

Fluvoxamine Indication

A

SSRI

OCD

46
Q

Sertraline Indications

A 
SSRI
OCD
SAD
Panic Disorder
PTSD
47
Q

Escitalopram Indications

A

SSRI

GAD

48
Q

Buspirone MOA, benefits, use, treatment

A

5HT1A agonists
Does not cause sedation, motor impairment or drug dependency
2nd line for GAD
Takes 3-4 weeks before max benefit seen (NOT ACUTE)

49
Q

Buspirone Drug Interactions

A

Meds that increase CNS serotonin levels (serotonin syndrome)

Metabolized by 3A4

Neuro Quiz 8 (4 decks)

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