Term
| What is the epidemiology and pathophysiology of anxiety disorders? |
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Definition
- Prevalence ~ 3-5% (GAD 3.1%, SAD 6.8%, PD 2.7%)
- Onset during early adult hood < 30, ~50% have agoraphobia
- Females > Males
- Genetic Link
- Co-morbidities: Depression, IBS, Pulmonary Disease, Sleep Disorder, Substance Abuse (social impairment)
- Genetic component, chromosomal identifications, No association with serotonin polymorph, Animal models show 5HT1A associations
- Neuro-circuitry in the amygdala, is the emotional center, controls fear, arousal
- Hormonal Influence --> steroid hormones, corticotropin releasing hormone, and cortisol levels may be changed |
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Term
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Definition
- Discrete period of intense fear or discomfort
- Sx reach peak at ~10 minutes
- Happens abruptly, may have trigger
- Body now sensitized to environment as Amygdala fires up the fight or flight |
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Term
| What is the difference between panic attack and panic disorder? |
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Definition
Attack - Episode of sudden intense fear in absence of danger
Disorder - Unexpected panic attack followed by persistent concern about having another attack. Recurrent. After at least 1 panic attack sx become exponential, constantly worrying. May progress to agoraphobia. Complications include depression, ETOH abuse, frequent ED abuse, Suicide |
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Term
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Definition
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Term
| What are the symptoms of a panic attack? |
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Definition
Psychological
Depersonalization - Stepping outside of your body
Derealization - Feels like you're in a dream, something is off
Fear of losing control, going crazy, dying
Physical
Diarrhea, Nausea, Chest pain, SOB, Sweating, Dizziness, light-headedness, tachycardia, trembling, shaking, paresthesis, fear of choking |
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Term
| What are the goals of anti-anxiety therapy? |
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Definition
| Acute Phase - Limit number and intensity of panic attacks (4 weeks with benzos, 12 weeks with antidepressants). Relieve anticipatory anxiety. Alleviate panic-related phobias (Agoraphobia). Improve quality of life. Overall goal is full remission |
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Term
| What are the non-pharmacologic options for anxiety? |
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Definition
Lifestyle modifications - Relaxation techniques, limit stimulant use
Cognitive Behavioral Therapy - Cognitive restructuring, exposure therapy |
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Term
| What are the pharmacologic options for anxiety? |
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Definition
Antidepressants - SSRI, Venlafaxine, TCA
Benzodiazepines
MAOI - Phenelzine
Other agents |
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Term
| Name the antidepressants and their dosing as used for anxiety |
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Definition
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Generic
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Brand
|
Initial Dose (mg)
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Dose Range (mg)
|
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Citalopram
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Celexa
|
10
|
20-60
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Escitalopram
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Lexapro
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5
|
10-20
|
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Fluoxetine
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Prozac
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5
|
20-80
|
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Fluvoxamine
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Luvox
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25
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150-300
|
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Paroxetine
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Paxil
Paxil CR
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10
12.5
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20-60
25-75 (CR)
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Sertraline
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Zoloft
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25
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50-200
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Term
| What are the TCA's and SNRI's used for anxiety.....as well as their dosing? |
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Definition
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Generic
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Brand
|
Initial Dose
|
Dose Range
|
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SNRI
|
|
|
|
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Venlafaxine
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Effexor
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37.5-75
|
75-225
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Desvenlafaxine
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Pristiq
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50
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50-400
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Duloxetine
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Cymbalta
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30
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30-90
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TCA
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|
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Imipramine
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Tofranil
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10
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75-250
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Term
| What are the Benzodiazepines used for anxiety.....as well as their dosing? |
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Definition
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Generic
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Brand
|
Initial Dose (mg)
|
Frequency
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Dose Range
|
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Alprazolam
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Xanax
Xanax XR
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0.25-0.5
0.5-3
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3-4 times daily
Once if XR
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4-10
1-10
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Clonazepam
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Klonopin
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0.125-0.25
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1-2 times daily
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1-4
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Diazepam
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Valium
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2-10
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1-2 times daily
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5-40
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Lorazepam
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Ativan
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0.5-2
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2-3 times daily
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1-8
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Term
| What are some adjunctive treatment options in anxiety therapy? |
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Definition
- Nefazodone
- Gabapentin
- Pregabalin
- Lamotrigine
- Levetiracetam
- Carbamazepine
- Buspirone
- Antipsychotics
- Phenelzine |
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Term
| What are some general rules for antidepressant anxiety treatment? |
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Definition
- Start lowest dose and titrate to therapeutic dose in 10-20 days
- Higher doses than in MDD, see effects in 4-6 weeks
- Document failure only after taking max dose for 8-12 weeks |
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Term
| What is the efficacy and dosing of SSRI's in anxiety? |
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Definition
- 75% efficacy
- Delayed response: initial improvement in 4 weeks, may take up to 12 weeks
- Initial low dose anxiogenic effects include jitteriness, restlessness, agitation |
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Term
| What is the efficacy and dosing of TCA's and SNRI's in anxiety therapy? |
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Definition
Venlafaxine - recently accepted option
Imipramine - Extensive data
Duloxetine/Desvenlafaxine/Despiramine/Clomipramine - limited data
- All patients should be offered CBT and pharmacotherapy
- Adjunctive agents reserved for refractory patients |
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Term
| What are some considerations in benzodiazepine anxiety therapy? |
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Definition
- Rapid onset of action
- Well tolerated
- Limited tolerance?
- If used > 6 weeks, antidepressant add-on yields no benefits
- P450 substrate (Alprazolam, Clonazapam, Diazepam, Lorazepam)
- Taper over 4-6 months to end treatment, take multiple variables into consideration
- In overdose use Flumazenil --> initially 0.2mg IV then 0.3mg IV 30 seconds later, 0.5mg IV every minute up to 3mg? Caution as this may precipitate withdrawal |
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Term
| What is the algorithm for initial treatment of multiple anxiety disorders? |
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Definition
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Term
| What is the algorithm for acute follow-up treatment of multiple anxiety disorders? |
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Definition
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Term
| What are the substrates for major anxiety treatments? |
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Definition
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2D6
|
3A4,5,7
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Imipramine
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Alprazolam
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Fluoxetine
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Diazepam-3OH
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Paroxetine
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Buspirone
|
|
Duloxetine
|
|
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Fluvoxamine
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|
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Venlafaxine
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|
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Term
| What are the liver enzyme inhibitors for major anxiety treatments? |
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Definition
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2D6
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3A4,5,7
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Bupropion
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Indinavir, Nelfinavir, Ritonavir
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Fluoxetine, Paroxetine
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Clarithromycin, Erythromycin
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Quinidine
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Itraconazole, ketoconazole
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Duloxetine
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Nefazodone
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|
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Grapefruit Juice
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|
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Verapamil, Diltiazem
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|
|
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Term
| What are the liver enzyme inducers for major anxiety treatments? |
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Definition
|
2D6
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3A4,5,7
|
|
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Carbamazepine
|
|
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Phenobarbital
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|
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Phenytoin
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Pioglitazone
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|
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Rifabutin
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|
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Rifampin
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St. John's wort
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Term
| What is generalized anxiety disorder? |
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Definition
- Persistent symptoms for most days at least 6 months of the year.
- Unrealistic or excessive anxiety and worry about a number of activities
- Gradual onset with the average age of 21, but most in teens or 35-45 |
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Term
| What are the psychological and cognitive symptoms of GAD? |
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Definition
- Excessive anxiety
- Worries that are difficult to control
- Feeling keyed up or on the edge
- Poor concentration or mind going blank
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Term
| What are the physical symptoms of GAD? |
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Definition
- Palpitations, pounding heart
- Restlessness
- Fatigue
- Muscle tension
- Sleep disturbance
- Irritability |
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Term
| What or how does GAD impair someone's life? |
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Definition
| Social, occupational, or other important functional areas, poor coping abilities |
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Term
| What is the treatment of GAD? |
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Definition
- Psychotherapy is first line with meds indicated when sx produce functional disability
- Lifestyle mods: avoid caffeine, stimulants, diet pills, ETOH |
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Term
| What is social anxiety disorder? |
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Definition
- Chronic long-term illness
- Same intense, irrational, persistent fear but now it is focused on a social or performace situation
- Fear of embarassment leads to avoidance of situations
- Typically in teens, fear of seeking treatment, typically curable |
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Term
|
Definition
Fears - being scrutinized by others, embarassed, humiliated
Feared Situations - Speaking or addressing a group of people/strangers
Physical Symptoms - Blushing, butterflies in stomach, diarrhea, sweating, trembling, tachycardia |
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Term
| What are the treatments of SAD? |
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Definition
- CBT and pharmacotherapy are effective
- CBT and pharmaco equal in acute treatment, Medication is often first line due to CBT accessibility (or lack of?)
- Sertraline is FDA approved, paroxetine, escitalopram and venlafaxine are also used
- Duration of treatment with meds predict response (5-12 months)
- TCA's not effective |
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