Term
| 2 basic features of anxiety |
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Definition
PSYCHOLOGICAL (MENTAL)
apprehension, irritability, nervousness, worry, impending doom, fear, rumination, difficulty concentrating
PHYSIOLOGICAL (SOMATIC)
tremor, restlessness, HA, perspiration, muscle tension, palpitations, SOB |
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Term
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Definition
NT systems linked to anxiety: GABA, 5HT, NE
serotonin: dysfunction in 5HT-1A, 5HT-2A, 5HT-2C
NE:
in response to threat or fear, the locus ceruleus serves as an alarm center
activating NE release (tachycardia, tremor, sweating) and stimulating the symptathetic and parasymptathetic nervous system
the autonomic nervous system in an anxious person is hypersensitive and overreacts to stimuli |
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Term
| anxiety secondary to a medical condition |
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Definition
CARDIOVASCULAR:
angina, CHF, PE, MI
ENDOCRINE:
hyperthyroidism, hypoglycemia, folate deficiency, adrenal tumor, parathyroid disease
NEUROLOGICAL:
dementia/delirium, migraine, Parkinson's disease, seizures, stroke
RESPRIATORY:
asthma, COPD
OTHER:
anemia, lupus, premenstrual syndrome |
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Term
| DRUGS ASSOCIATED WITH ANXIETY |
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Definition
CNS STIMULANTS:
theophylline
caffeine
nicotine
albuterol
amphetamine
cocaine
pseudoephedrine
methylphenidate
CNS DEPRESSANT WITHDRAWAL:
alcohol
barbiturates
benzodiazepines
opiates
OTHERS:
fluoxetine (stimulating drug)
levodopa
aripiprazole (drug induced akathesias)
steroids
levothyroxine
prednisone |
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Term
| non Rx treatment of anxiety |
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Definition
PSYCHOTHERAPY: relaxation training, CBT, meditation
cognitive therapy: identifying negative thought patterns that may worsen anxiety and changing them to be more positive; equally efficacy to BZD treatment (GAD)
typically underused:
$$$
time requirements
limited availability of trained therapists
psychoeducation: anxiety symptoms, avoid caffeine, OTC diet pills, excessive alcohol use |
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Term
| treatment of anxiety disorders |
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Definition
ANTIDEPRESSANTS:
more effective in TREATING PSYCHOLOGICAL AND COGNITIVE SYMPTOMS (excessive worry)
treatment of co-occurring depression
NO ABUSE POTENTIAL
INITIAL SIMULATION MAY WORSEN ANXIETY
onset of action - delayed, ~2 weeks
BENZODIAZEPINES:
more effective for SOMATIC SYMPTOMS AND FOR ANTICIPATORY FEAR/AVOIDANT BEHAVIOR
RISK OF TOLERANCE AND ABUSE POTENTIAL
withdrawal symptoms: nervousness, insomnia, restlessness
onset of action: immediate |
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Term
| pregnancy category of benzodiazepines (clonazepam, alprazolam, lorazepam, diazepam, clorazepate, chlordiazepoxide, oxazepam) |
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Definition
pregnancy category D: increased risk of oral cleft
BZD are DEA schedule IV |
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Term
| 4 main pharamcologic properties of benzodiazepines |
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Definition
anxiolytic
sedative hypnotic
muscle relaxant
anticonvulsant |
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Term
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Definition
sedation
ataxia
psychomotor slowed
cognitive impairment
anterograde amnesia: short term memory loss
respiratory depression: worse when in combination with alcohol! can be lethal!
impaired coordination
slurred speech
paradoxical excitation: does the opposite of what you would expect (get more agitated, anxious); more likely in geriatrics, children, people who are developmentally delayed |
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Term
| symptoms of BZD withdrawal |
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Definition
anxiety
insomnia
restlessness
agitation/irritability
diaphoresis
nightmares
delusions/hallucinations
SEIZURES |
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Term
| BZD discontinuation syndromes |
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Definition
1) relapse = recurrence of the original anxiety symptoms that follow D/C of treatment
2) rebound = anxiety symptoms are more intense
3) withdrawal = implies a degree of physical dependence |
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Term
| to minimize BZD withdrawal, what taper schedule should be followed? |
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Definition
| ******decrease dose by 10-15% every 1-2 weeks****** |
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Term
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Definition
hepatic oxidation (through CYP3A4) and glucuronidation
EXCEPT LOT: LORAZEPAM, OXAZEPAM, AND TEMAZEPAM
are conjugated only and do not have active metabolites
considered safer in patients with liver damage!
N-desmethyldiazepam (DMDZ) is an active metabolite of diazepam with a t1/2 of 20-100 hours |
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Term
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Definition
oxazepam
t1/2 = 5-14 hours
no accumulation
severe withdrawal symptoms if D/C abruptly |
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Term
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Definition
alprazolam, lorazepam, clonazepam
alprazolam and lorazepam t1/2 = 10-20 hours, BID-TID dosing
clonazepam t1/2 = ~40 hours = QD dosing |
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Term
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Definition
diazepam, clorazepate, chlordiazepoxide
have metabolites that accumulate
LESS SEVERE WITHDRAWAL SYMPTOMS
daily dosing
avoid in elderly |
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Term
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Definition
high lipophilicity (onset 30-60 minutes)
diazepam, clorazepate, alprazolam
absorbed rapidaly and distributed quickly
increased abuse potential
moderate lipophilicity:
chlordiazepoxide, lorazepam, clonazepam, temazepam
low lipophilicity:
oxazepam
absorbed slowly |
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Term
| criteria for generalized anxiety disorder |
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Definition
A.
excessive anxiety and worry occurring more days than not for > or equal to 6 months about a # of events or activities
B.
difficult to control the worry
C.
anxiety or worry is associated with > or equal to 3 of the following symptoms:
restlessness
easily fatigued
difficulty concentrating
irritability
muscle tension
sleep disturbances
D.
anxiety and worry not caused by another psychiatric illness (depression, mania, schizophrenia)
E.
CONSTANT WORRY CAUSING SIGNIFICANT DISTRESS AND IMPAIRMENT IN SOCIAL OR OCCUPATIONAL FUNCTION
F.
excessive worry and anxiety not caused by substance abuse or general medical condition |
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Term
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Definition
| antidepressants (SSRIs) and CBT |
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Term
| general dosing guidelines for GAD |
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Definition
START LOW AND GO SLOW
initially patient's anxiety may worsen due to increased availability of 5HT in the neuronal synapse
Ex) Venlafaxine XR 37.5 mg q am pc, inc by 37.5-75 mg q wk to goal dose of 100-225 mg/d
Ex) Paroxetine 10 mg/d x 1 wk, then inc to 20-40 mg/d
response is gradual over 8-12 weeks
continue treatment for at least 6-12 months |
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Term
| additional options for GAD treatment |
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Definition
BZDs, buspirone, beta blockers
BZDs: 1st line when rapid onset is essential and substance abuse is not an issue (limit use to 2-6 weeks); added to lessen initial anxiety of starting an SSRI
buspirone:
5HT1A partial agonist
onset: 2-4 weeks
NO PRN USE
taken with food = increased bioavailability
ADRs: jitteriness, dizzy, nausea, HA |
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Term
| drug interactions with buspirone |
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Definition
buspirone is a CYP3A4 substrate
3A4 inhibitors increase buspirone levels:
fluoxetine
fluvoxamine
erythromycin
clarithromycin
azole antifungals
grapefruit juice
protease inhibitors
3A4 inducers decrease buspirone levels:
rifampin decreases buspirone levels by 10-fold |
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Term
| patient counseling with buspirone |
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Definition
benefits: lack of sedative effects of BZDs, no abuse potential, safer in overdose
must be taken QD, no prn use
takes several weeks to see effects
no abuse potential
dose not affect sexual function
given with food significantly increases bioavailability |
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Term
| criteria for obsessive compulsive disorder |
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Definition
A.
either obsessions or compulsions are present
obsessions = recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inapproprate and that cause marked anxiety or distress
compulsions = repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently, arranging) aimed at prevention or reducing distress
B.
the person has recognized that the obsessions or compulsions are excessive or unreasonable
C.
the obsessions or compulsions cause marked distress, are time consuming (> 1 hours/day), or impair occupational/social functioning
D.
the content of the obessions or compulsions not restricted to another Axis I diagnosis, substance abuse, or medical condition |
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Term
| criteria for PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) |
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Definition
mechanism unclear:
children with strep infections may develop antibodies which attack the CNS and produce OCD symptoms
course: symptoms wax and wane, worsening with future infections
associated symptoms: separation anxiety, nighttime fears, bedtime rituals, cognitive deficits, oppositional behavior, motoric hyperactivity
diagnostic criteria:
presence of OCD and/or tic disorder
ONSET BETWEEN 3 YO AND PUBERTY
ABRUPT SYMPTOMS onset and/or episodic course of symptom severity
GABHS infection
associated neurologic abnormalities |
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Term
| 1st line treatment for OCD |
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Definition
SSRIs and behavioral therapy
5HT selectivity is essential for response to OCD!
usually reduce ~50% of symptoms (psychotherapy is very important)
response to treatment is often gradual and delayed, max response takes 12-26 weeks
target symptoms do NOT worsen before they improve |
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Term
| common SSRI doses for OCD treatment |
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Definition
higher doses
fluoxetine: 20-80 mg q AM
sertraline: 50-200 mg daily with food
fluvoxamine: 150-200 mg q HS or BID
starting dose is the same as for depression
maintenance dose may be higher
DON'T have to start low and go slow with OCD treatment |
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Term
| 2nd line treatments for OCD |
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Definition
TCAs
antipsychotics (for comorbid tics)
clomipramine (TCA): 150-250 mg/day
MAX 250 MG DUE TO SEIZURE RISK |
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Term
| why are desimpramine and nortriptyline ineffective for OCD treatment? |
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Definition
secondary amines TCAs have more NE activity
tertiary amines are more effective for OCD b/c of higher 5HT activity |
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Term
| criteria for panic disorder |
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Definition
A.
presence of at least 2 UNEXPECTED panic attacks
B.
at least 1 of the attacks has been followed by at least 1 month of PERSISTENT CONCERN ABOUT HAVING ANOTHER ATTACK or significant change in behavior b/c of the attack
C.
attacks not due to direct physiological effects of substance abuse or medical condition
D.
attacks not better accoundted for by another mental disorder (social phobia, specific phobia, OCD, PTSD)
E.
presence or absence of agoraphobia (1/3 of patients) - marked fear of being alone or being in public places from which escape might be difficult so person avoids such situations (malls, grocery stores, elevators, driving) |
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Term
| criteria for a panic attack |
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Definition
discrete period of intense fear or discomfort with > or equal to 4 of 13 symptoms developing abruptly.
symptoms peak in 10 MINUTES (last 10-30 minutes)
palpitations
sweating
trembling
SOB
feelings of choking
chest pain
nausea
dizziness
depersonalization
fear of losing control
fear of dying
numbness or tingling sensations
chills or hot flashes |
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Term
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Definition
cause: dysregulated firing in the locus ceruleus and hyperresponsiveness of the NE system
caffeine, alcohol, nicotine, cannabis, amphetamines, cocaine - all may trigger a panic attack
medical conditions: hyperthyroidism, seizure d/o, cardiac arrhythmias
situationally bound panic attacks are more characteristic of specific phobias or SAD
nocturnal panic attacks almost always = panic disorder |
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Term
| 1st line treatment for panic disorder |
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Definition
CBT, exposure treatment, relaxation treatment
SSRIs and BZDs
SSRIs decrease frequency of panic attacks, anticipatory anxiety, and depression
SSRIs take 4-6 weeks for efficacy
BZDs allow for more rapid relief (1 week) - give on schedule and NOT prn to prevent attacks
panic disorder patients have increased BZD withdrawal = taper slowly over 4-9 months (clonazepam preferred due to moderate half life) |
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Term
| dosing of SSRIs for panic disorder treatment |
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Definition
START LOW AND GO SLOW
people with panic disorder are VERY SENSITIVE TO DOSE CHANGES |
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Term
| 2nd line treatments for panic disorder |
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Definition
TCAs and MAOIs
TCAs (imipramine and clomipramine) - very effective but increase risk for ACh side effects and cardiac effects |
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Term
| criteria for post traumatic stress disorder |
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Definition
A.
person witnessed or experienced event involving death or serious injury OR was confronted with actual or threatened death and person's response involved intense fear, helplessness, or horror
B.
traumatic event is persistently RE-EXPERIENCED (dreams, nightmares, flashbacks, recurrent thoughts)
C.
persistent AVOIDANCE of stimuli associated with the trauma
D.
persistent symptoms of INCREASED AROUSAL (insomnia, irritability, anger outbursts, hypervigilance)
E.
duration of disturbance > 1 month
F.
disturbance caused significant distress or impairment to patient's social, occupational functioning
3 CARDINAL SYMPTOMS = RE-EXPERIENCE, AVOIDANCE, AND INCREASED AROUSAL |
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Term
| criteria for acute stress disorder |
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Definition
symptoms last < 1 month but > 2 days
less severe form of PTSD |
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Term
| causes of PTSD and those at increased risk |
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Definition
stress-induced hyperactivity of central NE systems believed to lead to generalized anxiety and autonomic hyperarrousal
most exposed to traumatic event do not develop PTSD
those at increased risk:
experienced assaultive violence and more chronic trauma
experiencing dissociative symptoms soon after trauma
childhood sexual or physical abuse
history of depressive or anxiety disorders
HIGHEST RATE OF ALCOHOL AND SUBSTANCE ABUSE
suicide risk very high |
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Term
| 1st line treatment for PTSD |
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Definition
CBT and SSRIs
improvement in 1st 2 weeks include: sleep disturbances, nightmares, irritability
good treatment response more likely to occur if treatment begun within 1st month after trauma
adjunctive trazodone 25-50 mg hs for insomnia
continue treatment 6-12 months (acute cases); 12-24 months (chronic cases)
BENZODIAZEPINES ARE NOT USED IN PTSD: abuse potential is too high |
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Term
| typical dosing of SSRIs for PTSD |
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Definition
START LOW AND GO SLOW
PTSD patients are hypersensitive to dose changes
response is very gradual over 8-12 weeks |
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Term
| 2nd line treatment for PTSD |
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Definition
mood stabilizers (lithium, valproate, CBZ)
effective for explosiveness, irritability, hyperarrousal, impulsivity, and sleep disturbances
atypical antipsychotics for psychotic symptoms and sleep
alpha-1 antagonists (prazosin) may help decrease nightmares
TCAs should be avoided due to increased risk of suicide
BZDs ineffective and increased abuse potential |
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Term
| criteria for social anxiety disorder |
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Definition
A.
marked persistent fear or > or equal to 1 social or performance situations in which patient is exposed to unfamiliar people or FEARS THEY WILL BE HUMILIATED OR EMBARRASSED
B.
exposure to feared social situation provokes anxiety
C.
patient recognizes that the fear is excessive or unreasonable
D.
the feared social/performance situation is avoided
E.
the AVOIDANCE interferes with the person's social or occupational functioning
F.
in patients < 18 yo duration is at least 6 months
G.
not caused by substance abuse or medical condition |
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Term
| 1st line treatment for SAD |
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Definition
CBT, SSRI, beta blockers
beta blockers decrease peripheral autonomic symptoms of anxiety but not effective in treatment of generalized SAD
decreased tremors, sweating, blushing
propranolol 10-80 mg given 1-2 hours before performance
ADRs - bradycardia and hypotension |
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Term
| usual dosing for SSRIs used for SAD |
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Definition
patients can usually tolerate standard starting doses of SSRIs
Ex) paroxetine 20-60 mg/day
allow 8-10 weeks for adequate response
continue treatment for at least 12 months |
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Term
| 2nd or 3rd line treatment for SAD |
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Definition
BZDs and MAOIs
BZDs may reduce the effectiveness of exposure treatment
MAOIs (phenelzine) very effective |
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Term
| anxiety disorder treatment summary |
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Definition
GAD
1st line = SSRI, BZD, buspirone
2nd line = TCA, beta blocker
2nd/3rd line = MAOI
OCD
1st line = SSRI
2nd line = TCA, AP
PD
1st line = SSRI, BZD
2nd line = TCA
2nd/3rd line = MAOI
PTSD
1st line = SSRI
2nd line = AP, mood stabilizer
SAD
1st line = SSRI, beta blocker
2nd line = BZD
2nd/3rd line = MAOI |
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