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PR3136 > Treatment of Anxiolytics > Flashcards

Treatment of Anxiolytics Flashcards

1
Q

Types of Anxiety Disorders

A

1) GAD
- Excessive anxiety & worries > 6mths

2) Panic Disorder (PD)
- Anticipatory anxiety of recurrent panic attacks

3) Social anxiety disorder (SAD)
- Fear of being scrutinised/humiliated by others in public

4) OCD
- Obsessional thoughts/impulses, followed by compulsive behaviours

5) PTSD
- Re-experiencing of trauma, persistent avoidance, increased arousal

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2
Q

What is the “fear circuit” regulated by?

A

Amygdala

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3
Q

What is the “worry circuit” regulated by?

A

Cortico-stratial-thalamic-cortical (CSTC) loop

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4
Q

Neurotransmitters involved in Anxiety disorders

A

Serotonin (5-HT):

  • Fear/anxiety due to over-activiation of amygdala
  • -> Amygdala receives input from serotonergic neurons which can inhibit its outputs

GABA:

  • Inhibitory neurotransmitter
  • Benzodiazepines potentiate GABA

Norepinephrine

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5
Q

Medical conditions associated with Anxiety

A

CVS: Congestive HF
- Hypoxia will potentiate anxiety

Endocrine: Hyperthyroidism
- Rapid irregular heartbeat, nervousness, irritability, trouble sleeping, fatigue

Neurologic: Dementia, delirium

Pulmonary: Asthma, COPD

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6
Q

Drug classes that can potentiate drug-induced Anxiety

A
  • Sympathomimetics
  • Stimulants
  • Corticosteroids
  • Antidepressants
  • Dopamine agonists
  • Beta-adrenergic agonists
  • Drug withdrawal
  • Drug intoxication
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7
Q

Clinical presentation of Panic Attack

A

Discrete period of intense fear/discomfort, sxns develop abruptly & peaks w/in 10min (usually not more than 20-30min)

> =4:

  • palpitations, pounding heart
  • sweating
  • trembling/shaking
  • sensations of SOB
  • feeling of choking
  • chest pain/discomfort
  • Nausea/ab distress
  • Dizzy, lightheaded
  • Derealization or feeling detached
  • fear of losing control/going crazy
  • fear of dying
  • numbness or tingling sensation
  • chills or hot flushes
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8
Q

Clinical presentation of GAD

A

Excessive anxiety & worry >=6mths

> =3:

  • Restlessness or feeling keyed up or on the edge
  • Easily fatigue
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (insomnia, restless unsatisfying sleep)
  • Sxns cause functional impairment
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9
Q

Clinical presentation of Panic disorder with or w/o Agoraphobia

A

1) Recurrent unexpected panic attacks
2) >= 1 of the panic attacks has been followed by >=1mth of >=1 of the following…

i) Persistent anticipatory anxiety
ii) Worry about implications of panic attacks
iii) Sig change in behaviour related to the panic attacks

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10
Q

Clinical presentation of Social Anxiety Disorder

A
  • Marked & persistent fear of >=1 social/performance situations where there is possible scrutiny by others -> Humiliating/embarrassing
  • Duration > 6mths
  • Avoid situations that are feared
  • -> Avoidance impairs functioning
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11
Q

Clinical presentation of OCD

A

Obsessions

  • recurrent & persistent thoughts/impulses/images, intrusive & inappropriate
  • recognises that obsessional thoughts are product of own mind (vs Schizoprenia)

Compulsions:

  • Repetitive behaviours/ mental acts
  • -> Acts aimed to prevent/reduce distress but not connected in realistic way, clearly excessive
  • -> Time-consuming, causes marked distress (Take >= 1hr/day), impairs functioning
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12
Q

Clinical presentation of PTSD

A
  • Person was exposed to stressor
  • Intrusion symptoms (traumatic event persistently re-experienced)
  • Avoidance (persistent effort to avoid situation)
  • Negative alterations in cognitions and mood
  • Alterations in arousal & reactivity

–> Persistence of symptoms cause distress/ functional impairment

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13
Q

Assessment of Anxiety Disorders (Clinician-rated & Clinical setting)

A

Clinician-rated: Hamilton Anxiety Scale (HAM-A) - Gold standard

Clinical setting:
- MSE + Formal structured psychiatric review

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14
Q

Non-Pharmacological Therapy of Anxiety Disorders

A

Cognitive Behavioural Therapy (CBT)
Relaxation therapies

GAD:
+ Psychotherapy, anxiety management

OCD:
+ Exposure & Response Prevention (ERP)

PTSD:
+ Psychotherapy, counselling

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15
Q

Pharmacological Agents for GAD

A

*SSRIs
Venlafaxine XR (reserve)
Pregabalin (reserve)

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16
Q

Pharmacological Agents for Panic Disorders

A

*SSRIs

TCA

17
Q

Pharmacological Agents for Social Anxiety Disorders

A

*SSRIs

18
Q

Pharmacological Agents for OCD

A

*SSRIs
Clomipramine (2nd line)
Venlafaxine (3rd line)

Highly recommended:
CBT + SSRI/Clomipramine

19
Q

Pharmacological Agents for PTSD

A
  • SSRIs

- CBT impt 1st line too

20
Q

Dosing of Serotonergic Antidepressants

A

Starting dose: LOW

  • Transient jitteriness in initial 1-2wks
  • Consider +Benzodiazepine as adjunct

Maintenance Dose: HIGH
- Effective maintenance dosing are on the high end of the dose range

21
Q

Serotonergic Antidepressant use & place in therapy in Anxiety Disorders

A

All useful for long-term management
- SSRIs, SNRIs (except in OCD), Clomipramine (OCD)

  • Effective for “excessive worrying”
  • Onset at least 1-2mths (downregulation of autoreceptors)
  • Full response in ~3mths
  • Duration of treatment at least 1-2yrs, typically long-term
22
Q

Adjunctive Benzodiazepines in Anxiety Disorders (Therapeutic action, Dosing, tolerance & dependence, SE, Caution)

A

Therapeutic action:

  • For physical/somatic symptoms (eg. muscle tension)
  • Fast OOA (eg. Lorazepam within 30mins)

Options (High potency preferred)
- Clonazepam, Lorazepam, Alprazolam XR (for panic disorder)

Dosing: Short-term (3-4mths), PRN then taper

Side effects:
- Drowsiness, confusion, amnesia, impaired muscle co-ordination/weakness

Caution:

  • Paradoxical excitement (children & elderly especially)
  • Dependence & withdrawal symptoms

Tolerance & Dependence:

  • Tolerance in anxiolytic action not common
  • Gradual taper required
23
Q

Pregabalin for GAD (alternative when other agents fail)

A
  • GABA analogue, increases synaptic GABA
  • Also acts on voltage-gated Ca2+ channels
  • $$$
24
Q

FDA-approved Benzodiazepines for GAD

A

Lorazepam (most common, int-acting):
- PO 1-3mg/day (2-3 divided doses),
Max: 6-8mg/day
- Short DOA

Diazepam (long-acting, sedating)
- Long DOA

Alprazolam:

  • Initially PO 0.25mg TDS
  • Short DOA
25
Q

DDI of drugs used in Treatment of Anxiety Disorders

A
  • Alcohol & CNS depressants
  • MAOIs + SSRI/TCA
  • -> Serotonin syndrome

Benzodiazepines:

  • CNS depressants effect with alcohol & other CNS depressants
  • Benzodiazepines + Opioids = Increased mortality (Increase cardiopulmonary depression***)
26
Q

Long-term goals of treatment of Anxiety Disorders

A

GAD, Panic disorder, SAD, PTSD:

  • Remission of core anxiety sxs
  • Recovery of function

OCD:
- Complete resolution of sxs difficult to achieve

27
Q

Early & long-term effects of Pharmacotherapy of Anxiety Disorders

A

Early:

  • Possible increased anxiety with antidepressants during first 1-2wks
  • Nausea, HA, Insomnia/sedation usually subsides after 2-3wks

Long-term:
- Sexual dysfunction & weight gain common with antidepressants

PR3136 (14 decks)

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