W01 - PSYCH: Anxiety Disorders; Psychopharmacology Flashcards
To define the symptoms of anxiety disorders.
brought on by perception of a threat that may or may not be present
Psychological arousal
Autonomic Arousal
Muscle Tension
Hyperventilation
Sleep Disturbance
Anxiety Disorders
- particular stimulants or generalised anxiety
- F>M, but cultural and alcohol factors
Phobic Disorders
Anxiety Disorders
Obsessive Compulsive Disorders
PTSD
Phobic Disorders
Core symptoms of GAD but specific and particular stimuli
- phobic avoidance
- Sufferer also experiences anxiety if there is a perceived threat of encountering the feared object or situation “anticipatory anxiety”
*Phobic
* Social = tremor and blushing pre-dominant
* Agoraphobic
Anxiety Disorders
+ Fear-related disorders
OCD
intrusive, egodistonic (unwanted and unpleasant)
= result in compulsion = physical action or mental effort as a result of the obsession
*M=F
* aetiology = 5HT receptor and functionning
PTSD
associated with stress
*F>M (USA)
* Vulnerability factors; genetic susceptibility
*delayed/protracted reaction to stressor or exceptional severity
*Hyperarousal
Re-experiencing phenomena
Avoidance of reminders
Mgmt of Phobic Disorders
Social Phobia mgmt
> Cognitive Behavioural Therapy
> Education and advice
> Medication SSRI antidepressants
Mgmt of OCD
> education and planning; involving close contacts
> Serotonergic: SSRI Fluoxetine,
Clomipramine
> CBT: exposure and response prevention, examination and weakening convictions
Mgmt of PTSD
> screening of survivors at 1mos
> watchful waiting, review
trauma-focussed CBT
eye movement desensitisation reprocessing
sedatives (risk of dependence)
Models of Stress
Balance between processing perceived threat and perceived ability to cope
= problem focussed coping
= emotion focussed coping
*yerkes dodson curve = bell curve of stressXperformance
DDx of Anxiety Disorders
1) Psychiatric Conditions
Depression
Schizophrenia
Dementia
Substance Misuse
2) Physical Conditions
Thyrotoxicosis
Phaeochromoctoma
Hypoglycaemia
Asthma and or Arrhythmias
Generalised Anxiety Disorder
“In general terms GAD for instance is caused by a stressor acting on a personality predisposed to the disorder by a combination of genetic factors and environmental influences in childhood.”
- pretty common, F>M
Mgmt of GAD
> Counselling
Clear Plan of Management
Explanation and education
Advice re caffeine, alcohol, exercise etc.
> Relaxation training
Group or individual
DVDs, tapes or clinician led
Medication
!Sedatives have high risk dependency
>Antidepressants SSRI or TCA
> Cognitive Behavioural Therapy
Mgmt with Antidepressants
- selection based on response hx, sfx, coexisting conditions
- 2-4w delay before improvement
indications: uni/bipolar, organic, anxiety: OCD, social, PTSD
Medication
(1) SSRI
(2) SNRI
SSRIs
tx for anxiety and depressive symptoms
serotinergic
sfx: GI upset, sexual dysf., anxiety, restlessness, nervousness, insomnia, fatigue/sedation, dizziness
little cardiotox in overdose
- discontinuation syndrome = agitation, GI uspset, disequilibrium, dysphoria
> FLUOXETINE
Activation syndrome and deactivation syndrome
activation = ⇧serotonin = GI, anxiety, panic and agitation
2-10d; warn pt.!
discontinuation = agitation, GI uspset, disequilibrium, dysphoria
* more common w/ shorter half life drugs
Fluoxetine
*SSRI
- long half-life thus ⇩discontinuation syndrome; but can build up
- initially activating thus good for energy levels
- good for pt with noncompliance issues
- inapp for hepatic pt.
Sertaline
*SSRI
- weak P450 = good inpolypharmacy
- short half life = low build up risk
- less sedating
- full stomach req for max absorption
- GI adverse reaction risk
TCAs
- effective family but significant sfx profile
antihistaminic, cholinergic, adrenergic
lethal overdose
Long QT syndrome
- secondary TCA metabolites, sfx less severe as 3º TCA
- tertiary TCAs cross-react w/ other receptors = more sfx
> Amitriptyline
Desipramine
MAOIs
- irreversibe binding and increase of NE, dop, serotonin
- indicated in resistant depresseion
*SFX: ortho hypoT, wt gain, dry mouth, sedation, sexual dysf., sleep disturbance
!cheese reaction = tyramine-rich foods precipitate hypertensive crisis
- cheese
-cured meats
- pickled fermented foods
- high salt sauces
- alcoholic beverages
!serotonin syndrome: ⇧serotonin = GI, tachy, hyperpyrexia
- 2w break before switching to MAOI from SSRI except for fluoxetine = 5w break dt long half life
> Selegiline
Isocarboxazid
Phenelzine
SNRIs
- inhibit serotonin and NA uptake like TCA but without poor sfx profile
- depression, anxiety, NEUROPATHIC PAIN
> Venlafexine
Duloxetine
Venlafexine
*SNRI
*minimal drug interactions
*short half-life = fast renal clearance thus good for renal pt and geris
- increase in diastolic BP
- GI sfx
- bad discontinuation syndrome thus TAPER
*QT - sexual dysf.
Duloxetine
- SNRI
- beneficial for physical symptoms for depression
- less BP sfx than venlafexine
- drug-interactions
- bad LT compliance
Vortioxetine
- SNRI
- less GI sfx, BP sfx
*expensive!!!
Mirtazapine
- novel antidepress.
- serotinergic, may augment SSRI
+ hypnotic at lower doses 2º to antihistaminic effects - !increases cholesterol, wt gain
- very sedating
Tx-Resistant Depression
> SSRI / SNRI + Mirtazepine
+Lithium
+ or antipsychotic
> ECT
Prophylactic Tx of Depression
1st episode = requires 6mos post remission
2nd episode = requires 1yr post remission
3rd epiisode = lifelong
*risks of relapse
Indications of mood stabilisers
bipolar, cyclothymia, schizoaffective
*lithium
* anticonvulsants
* antipsych.
Lithium
- reduces suicide rate
- LT prophylaxis in mana and depressive episodes
- +ve outcome = +ve FH response, pure mania (Bip. I), mania followed by depp.
! UE & TSH monitoring = steady state after 5d. then 3mos check, and then 6mos
= goal between 0.6-1.2
Lithium Sfx
GI, diarrhea
- thyroid abn = polyuria/dypsia
- leukocytosis
- hair loss, acne
- reduced seizure threshold, cognitive slowing
!lithium toxicity!
Valproic acid
- effective in mania, not as. much in deppr; better tolerated than lithium
- pt +ve. predictors
- rapid cycliing
- comorbd substance issues
- comorbid anxiety disorders
- baseline liver function tests, prego, FBC
!folic acid reduction = neral tube defect
valproic acid sfx
platelet dysfunction
GI sfx
wt gain
sedation, tremor
hair loss
*LFT increase, but not of concern unless triples+
Why avoid valproic acid in child bearing women
Risk of neural tube defect secondary to folic acid reduction
Acute mania mgmt
> olanzapine
quetiapine
risperidone.
If you’re taking an antidepressant when the mania or hypomania starts, your doctor or nurse may advise you to stop taking the antidepressant.
!agranulocytosis;
+mood stab: lithium
+ or mood stab: Na valporate (CI in young child bearing)
Carbamezepine = acute mania and mania prophylaxis
- basline liver function tests, FBC, ECG
- follow up and adjust at 1mos
* for rapid cyclers and mixed patients
Carbamezepine sfx
Rash most common
GI sfx
sedation, dizzy
AV conduction delays
D-D interactions
Lamotrigine
- anticonvulsants and neuropathic pain with baselines
- if stopped for 5d must restart initiation dose pattern
Lamotrigine sfx
GI sfx
sedation, dizzy
*toxic epidermal necrolysis
* SJS
*blood dyscrasias
*d-d= and valproic acid, sertaline can increase lamotrigine levels
Antipsychotics
for: schizophrenia, schizoaffective, bipolar, or when augementing agent in resistant disorders
- dopamine receptor antagonists
(1) high risk to extrapyramidal sfx= high binding
(2) high cardiotox. and ACh sfx = low binding dt receptor cross-interaction
(3) atypical serotonin-dop. antag. =
1
> Fluphenazine
> Haloperidol
> Pimozide
2
> risperidone
> chlorpromazine
> Thioridazine
3
What is the most significant projections in the brain concerned in psychoticsymptoms and patients
mesocortical
What is the most significant projections in the brain concerned in positive symptoms (hallucinations and dleusions etc.) in patients
mesolimbic
Risperidone
- atypical but acts like a typical at higher doses
- increased extrapyramidal sfx
- most. likely to induce hyperprolactinemia
- best profile for existing hyperlipidemia
- wt gain and sedation
- ci: hypotension, extrapyramidal akathisia
Olanzapine
- atypical antipsychotic
- hypercholesterolemia + etc., +wt gain
- hyperprolactinemia risk
- abn LFTs
Quetiapine
- atypical antipsych
- most likely to cause orthostatic hypotension
- abn LFT
- wt gain, but lesser risk
- hypercholesterolemia etc
Aripiprazole
- atypical antipsyc
*1st line?
*partial D2 agonist
* nil wt gain, QT prolong, low sedation
* but significant D-D interactions thus dosing required in polypharm.
Clozapine
- reserved for treatment resistant but very effective despite sfx profile
- agranulocytosis = thus persistent monitoring
- increased risk of seizures
- !sedation, wt gain, abn LFTs, hypercholesterolemia etc
Significance of insight and link to relapse
Commonest psychotic symptom is lack of insight = greatest reason for non-compliance = relapse
- third episode = reduced functionning, lower IQ, negative symptoms
Most significant antipsychotic adverse effects
tarditive dyskinesia = involuntary muscle movements, may not resolve with cessation
*neuroleptic malignant syndrome = PSYCHIATRIC EMERGENCY, muscle. rigidity, fever,mental status, autonomic instability, deragend bloods
*extrapyramidal side effects:acute dystonia, parkinson syndrome, akathisia
mgmt of extrapyramidal syndrome
> anticholinergics: benztropine etc.
> dopamine facilitators: amantadine
> betablockers (akathisia)
> benzodiazepines (akathisia)
!ACh d-d interactions
Significance of akathisia
increased risk for suicide!
> BB
benzodiazepines
Anxiolytics
- used in tandem with SSRIs/SNRIs in GAD
> Buspirone - serotonin agonist, nil sedation, 2w acting
benzodiazapines - insomnia in anxiety disorders, used in withdrawal but significant sfx profile
