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Winter Therapeutics Exam #3 - Anxiety
n/a
41
Health Care
Graduate
02/08/2010

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Term
Anxiety
Definition
emotional state that causes worry, perception of danger, or feelings of threat and can lead to uncomfortable psychological and physiological symptoms
Term
Goals of Tx of Anxiety Disorders
Definition
reduce severity, frequency, & duration of anxiety symptoms;
improve pts overall functioning
Term
Nonpharm Tx for Anxiety Disorders
Definition
Avoidance of caffeine, drugs of abuse, and stimulants;
Psychotherapy;
Stress management;
Exercise
Term
Medical Conditions that cause Anxiety
Definition
angina, arrhythmias, CHF, MI, Cushing's dx, hyperthyroidism, hypoglycemia, hypokalemia, hypothyroidism, GERD, PUD, akathisia, chronic pain, seizures, Parkinsons dx, stroke, migraines, dementia, asthma, COPD, pneumonia, pulmonary embolism
Term
Medications that cause Anxiety
Definition
amphetamines, caffeine, cocaine, ephedrine, MDMA, methylphenidate, nicotine, PCP, phenylephrine, psuedoephedrine, barbiturates, benzodiazepines, EtOH, opiates, antipsychotics, TCAs, SSRIs, bupropion, albuterol, aminophylline, salmeterol, theophylline, corticosteroids, digoxin, levodopa, NSAIDs, thyroid supplements
Term
Advantages of BZDs
Definition
low cost, relatively low toxicity, easy to use, rapid onset
Term
Disadvantages of BZDs
Definition
ADRs, potential for tolerance & dependence
Term
BZDs used in tx of Anxiety Disorder
Definition
alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), oxazepam (Serax)
Term
BZDs that form active metabolites, have long half-lives
Definition
chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium)
Term
chlorazepate, diazepam
Definition
more lipophilic BZDs --> rapid anxiolytic effect, shorter duration of action, provides a "rush"
Term
lorazepam, oxazepam
Definition
BZDs that are less lipophilic --> slower anxiolytic effect --> longer duration of action;
L has reliable IM absorption
Term
lorazepam, oxazepam, temazepam
Definition
BZDs that are ONLY conjugated with NO oxidation
Term
Adverse Effects of BZDs
Definition
Common: sedation, drowsiness, ataxia, lethargy, mental confusion, motor impairment, cognitive impairment, anterograde amnesia, disorientation, slurred speech, amnesia; Rare: paradoxical agitation, decreased respiration
Term
Contraindications for Pts taking BZDs
Definition
alcohol intoxication; chronic pulmonary insufficiency; significant hepatic dx; sleep apnea; cormorbid substance use disorders
Term
BZD Withdrawal Symptoms
Definition
anxiety, insomnia, restlessness, irritability, muscle tension, seizures
Term
flumazenil (Romazicon)
Definition
BZD receptor antagonist used in tx of BZD overdose;
C/I: if TCAs used for overdose;
Will precipitate withdrawal in chronic BZD user
Term
Overdose Symptoms of BZDs
Definition
somnolence, confusion, slurred speech, respiratory depression, coma, hypotension
Term
Decreased clearance of BZDs --> Increased BZD drug levels
Definition
fluoxetine, paroxetine, fluvoxamine, itraconazole, ketoconazole, erythromycin, nefazadone
Term
Increases clearance of BZDs --> decreased BZD drug levels
Definition
carbamazepine, phenytoin, rifampin
Term
Discontinuation of BZD therapy
Definition
Related to how long pt has been on med;
"reduce gradually" --> 25% reduction in dose each wk until 50% of dose is reached, then reduce by 1/8th dose per wk
Term
buspirone (Buspar)
Definition
MoA: non-BZD anxiolytic, partial 5-HT1A receptor agonist;
Dosing:
Initial - 7.5 mg BID OR 5 mg TID, increase by 5 mg every 2-3 days;
Therapeutic - 20-30 mg/day divided
Max = 60 mg/day
Onset: 1-2 wks, takes 4-6 wks for full benefit;
ADRs:
dizziness, nausea, HA
Drug Interactions:
risk of serotonin syndrome
rifampin decreases effects of drug
verapamil, diltiazem, itraconazole, erythromycin increases effects of drug;
Term
Advantages of using buspirone (Buspar)
Definition
no abuse potential; little/no sedation or impairment of motor activity; safe in overdose
Term
Disadvantages of buspirone (Buspar)
Definition
long onset of effect; previous BZD users may not feel they respond well to drug; NOT for PRN use
Term
Generalized Anxiety Disorder Diagnostic Criteria
Definition
1) excessive anxiety & worry occurring for at least 6 months on most days;
2) Pt has difficulty controlling the worry;
3) Anxiety & worry, associated with 3 of following: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
4) Anxiety & worry not confined to another psychiatric illness
5) constant worrying that interferes with social or occupational functioning;
6) NOT caused by a drug, substancec, or medical condition
Term
Nonpharm Tx for GAD
Definition
avoid caffeine, drugs of abuse, & stimulants; Psychotherapy --> cognitive behavioral therapy; Applied relaxation therapy; Change maladaptive behaviors by substituting with other coping mechanisms
Term
Pharm Tx for GAD
Definition
should be used for moderate-severe GAD only;
1st line option - SSRIs:
paroxetine 20 mg daily
escitalopram 10 mg/day
1st line option - SNRIs
duloxetine 30 mg daily x 1 wk then increase to 30 mg BID
venlafaxine 37.5-75 mg/day
2nd or 3rd line options:
TCAs, buspirone, BZDs ('bridge therapy' for time lapse of SSRI full effect)
Term
Panic Disorder (PD) Diagnostic Criteria
Definition
begins as series of panic attacks followed by at least 1 month of peristent concern about having another panic attack; often seek med assistance for what they believe to be a medical problem; may develop agoraphobia 2ndary to panic attacks; may avoid specific situations where they feel a panic attack may occur;
Requires at 4 of following the develop abruptly and reaches a peak within 10 min:
palpitations, sweating, shaking, sensations of shortness of breath, feelings of choking, chest pain, nausea, dizziness, depersonalization, fear of losing control, fear of dying, numbness, chills or hot flashes
Term
Goals of Tx of PD
Definition
reduce # or eliminate panic attacks; reduce duration & intensity of panic attacks; reduce or eliminate anticipatory anxiety; prevent phobic avoidance; improve social & occupational functioning
Term
Nonpharm Tx of PD
Definition
avoid caffeine, drugs of abuse, and stimulants;
psychotherapy - CBT that focuses on correction of pt's maladaptive behaviors & thoughts
Term
Pharmacotherapy of PD
Definition
SSRIs - mainstay:
start at 1/4-1/2 recommended starting dose;
sertraline 25 mg/day, paroxetine 10 mg/day IR or 12.5 mg/day CR, fluoxetine 10 mg/day
Others:
venlafaxine 37.5 mg/day
Selected BZDs - 1st line in pts requiring RAPID relief of anticipatory anxiety & those unable to tolerate antidepressants:
alprazolam - initial: 0.25-0.5 mg TIX, antipanic: 4-10 mg daily (divided doses)
clonazepam - initial: 0.25 mg BID, antipanic: 3-6 mg daily (divided doses)
Also may try TCAs (last line):
Imipramine - initial: 10 mg HS, antipanic: 150-300 mg qHS
Clomipramine - initial: 25 mg qHS, antipanic: 25-150 mg qHS
Other agents: MAO-Is, nefazodone, mirtazepine, atypical antipsychotics
Term
Obsessive Compulsive Disorder (OCD) Diagnostic Criteria
Definition
A. Obsessions:
1) recurrent & persistent thoughts, impulses, or images that are intrusive, inappropriate, & cause marked anxiety
2) thoughts, impulses, or images are not simply excessive worries about real-life problems
3) attempts are made to ignore or suppress thoughts, impulses, or images
4) it is recognized the obessions are a product of person's own mind

Compulsions:
1) repetitive behaviors that person feels driven to perform in response to an obsession
2) behaviors are aimed at preventing or reducing distress

B. Person has recognized that obsessions or compulsions are excessive or unreasonable
C. Obsessions or compulsions cause marked distress, are time consuming, or significantly interfere with person's occupational or social functioning
D) disturbance is not due to direct physiological effects of a substance or a general medical condition
Term
Nonpharm Tx of OCD
Definition
recommended for mild OCD; Psychotherapy - exposure therapy, response prevention
Term
Pharmacotherapy for OCD
Definition
recommended for pts w/ moderate-severe OCD; gradual improvement seen in 4-10 wks; pts need higher doses of antidepressants;
1st line - SSRIs:
fluoxetine 20 mg/day (max = 80 mg/day), paroxetine 20 mg/day, sertraline 50 mg daily (max = 200 mg/day), fluvoxamine 50 mg/day IR, 100 mg/day ER;
2nd line agent: Clomipramine - selected after failing 2-3 SSRIs;
Augmentation: SSRI + risperidone, olanzapine, quetiapine, venlafaxine;
*NO BZDs - NO EFFICACY to tx OCD*
Term
Post Traumatic Stress Disorder (PTSD) Diagnostic Criteria
Definition
A) exposure to a traumatic event - witnessed event involving actual or threatened death or serious injury, person's response involved intense fear, helplessness, or horror;
B) tramautic event is persistently experienced in 1 or more of following: recurrent & intrusive distressing recollections, recurrent distressing dreams, acting or feeling as if traumatic event was recurring;
C) Persistent Avoidance of stimuli associated with trauma
D) Persistent symptoms of increased arousal
E) duration of disturbance is more than 1 month
F) Disturbance causes clinically significant distress or impairment in social or occupational functioning
Term
Goals of Tx of PTSD
Definition
reduction in core symptoms; improvement in disability & QOL; long-term remission
Term
Nonpharm Tx for PTSD
Definition
anxiety management; CBT; exposure therapy
Term
Pharm Therapy for PTSD
Definition
1st line - SSRIs (takes up to 8 wks for response):
sertraline - 25 mg/day, increase to 50 mg/day after 1 wk, increase to 200 mg/day MAX
paroxetine - 20 mg/day
2nd line agent - mirtazapine
Other agents used:
venlafaxine
antiadrenergic: prazosin 1-4 mg daily --> decreases nightmares, sleep disturbances, also trazadone, nefazadone;
TCAs
mood stabilizers
buspirone
antipsychotics
Term
Social Anxiety Disorder (SAD) Diagnostic Criteria
Definition
marked, persistent fear of 1 or more social or performance situations; exposure provokes anxiety; fear is excessive or unreasonable; situations are avoided or endured with intense anxiety; it interferes with occupational or social functioning; it is NOT caused by drugs, a substance, or medical condition
Term
Nonpharm Tx of SAD
Definition
CBT; exposure therapy; social skills training
Term
Pharm Tx for SAD
Definition
1st line - SSRIs:
onset - 4-8 wks
sertraline 25 mg/day, increase up to 50 mg/day after 1 wk (MAX = 200 mg/day)
fluvoxamine 100 mg/day
paroxetine 20 mg/day
Others:
venlafaxine 75 mg daily
BZDs
MAO-Is
Propanolol prn 1-2 hrs before presentation or performance
Term
Kava
Definition
alternative herbal product;
MoA: increases GABA
ADRs: GI upset, HA, dizziness, drowsiness, dry mouth, allergic skin rxns, INCREASED LFTs
Drug interactions: CNS depressants
Dosing: 100 mg TID (70 mg lactones)
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