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65 Cards in this Set

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1 Year prevalence rate for Anxiety disorders
17%
Lifetime prevalence rate for Anxiety disorders
25%
What is the typical onset for Anxiety disorders?
Before age 30
Anxiety disorders are more common in which sex?
Women
Cardiovascular conditions associated with Anxiety disorders
Angina, CHF, MI, arrythmias
Endocrine/Metabolic disorders associated with Anxiety
Hyper/Hypothyroidism, hypoglycemia, cushing's disease
Neurologic disorders associated with anxiety
CNS tumors, Dementia, migraines, pain, parkinsons, seizures, stroke
Respiratory disorders associated with anxiety
Asthma, COPD, pulmonary embolus, infections
Other disorders associated with anxiety
Anemia, lupus
Drugs associated with anxiety
CNS stimulants, Antidepressants, Antipsychotics, steroids, CNS depressant withdrawal
Describe DSM Diagnostic Criteria for Generalized Anxiety Disorder (GAD)
1. Excessive anxiety and worry, ocurring more days than not for at least 6 months.
2.Person cannot control worry
3.Anxiety and worry associated with 3 or more of the following (Restlessness, feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance).
4.Anxiety and worry not caused by some other illness
5.Cosntant worry causing disruption of life
6.Not caused by drug or medical condition
Tx for Mild GAD
Psychotherapy
Tx for Moderate-Severe GAD
Psychotherapy + Pharmacotherapy
Describe Non-pharm Tx for GAD
Avoid caffeine, DOA and stimulants.
Psychotherapy (Cognitive behavioral therapy)
Change maladaptive behaviors by substituting coping mechanisms
Applied relaxation therapy (focuses on excessive worry and muscle tension)
Pharmacotherapy overview for Acute GAD
BZDs
Pharmacotherapy overview for long term GAD
Buspirone
Venlafaxine
Paroxetine
Escitalopram
Other options Tx wise for Long-term GAD
TCA's 3rd line
MAOIs - 3rd or 4th line
What is the role of TCA's in treatment of long-term GAD?
3rd line alternative
What is the role of MAOIs in the treatment of long term GAD?
3rd or 4th line alternative
What therapeutic properties do BZDs possess?
Anxiolytic
Sedative
Anticonvulsant
Muscle Relaxant
Advantages to BZD use in GAD
Ease of use
Low toxicity
Rapid onset
Disadvantages of BZD use in GAD
ADR
Potential for tolerance and or dependence (Actually pretty low)
What is the primary determinant of a BZDs onset and duration?
Lipophilicity
__________ and ________ are the most lipophilic and therefore have the most rapid anxiolytic effect but a shorter duration.
Clorazepate and diazepam
Agents that have a ____________ lipophilicity tend to have the fastest onset and shorter duration.
Higher
____________ and ___________ are less lipophilic BZDs therefore have a slower onset and a longer duration.
Lorazepam and oxazepam
Parenteral administration should be avoided with which BZDs?
Diazepam and Chloridazepoxide
Which BZD is metabolized in the gastric juice to an active metabolite that is completely absorbed?
Clorazepate
LOT
Lorazepam, oxazepam and Temazepam
Which BZDs undergo conjugation only and therefore can be used in elderly patients and those with hepatic dyfunction
LOT
Lorazepam, Oxazepam and Temazepam
Clonazepam undergoes which type of metabolism?
Nitroreduction
Common BZD ADR's
Sedation, drowsiness, ataxia, lethargy, mental confusion, motor and cognitive impairment, disorientation, slurred speech, amnesia.
Rare BZD ADR's
Paradoxical agitation (Triazolam), depressed respiration
BZD Contraindications (6)
1.Alcohol
2.Chronic pulmonary insufficiency (Relative)
3.Significant hepatic disease (USE LOT)
4.Sleep apnea (Relative)
5.Comorbid substance use disorders
Which BZDs are most commonly abused?
Alprazolam and Diazepam
How long does it take for individuals to become dependent typically to a BZD?
3 weeks or longer of scheduled use
BZD Withdrawal symptoms
Anxiety, insomnia, muscle tension, seizures
Tolerance develops to which effects of BZDS
Sedative/Hypnotic
Muscle relaxant
Anti-convulsant
NOT ANXIOLYTIC though
If you are attempting to D/C a BZD in a patient who has been taking a short-acting agent, what strategie may help with the tapering?
Switch to a long acting agent
In the treatment of GAD, Buspirone typically is considered what line of treatment?
Second
Describe effects and characteristics of Buspirone
Non-BZD anxiolytic without sedative-hypnotic, muscle relaxant and anticonvulsant properties
Advantages of Buspirone
No abuse
No sedation or impairment of motor activity
Disadvantages of Buspirone
Long onset of effect!!!!
No cross tolerance with BZDs
Previous users of BZDs will not feel they respond as well
Buspirone MOA
5-HT1a partial agonist
Onset of effect for Buspirone
Long- a month
ADR of Buspirone
Dizziness, Nausea, Headaches
Drug interactions for Buspirone
3A4 inhibitors: Verapamil, diltiazem, itraconazole, erythomycin increase levels
Rifampin - Decrease levels
Serotonergic meds - Serotonin syndrome
Describe Panic Disorder
Begins as a series of panic attacks, then concern about having another, then they seek medical help due to fear of other medical problems. Patients often develop agoraphobia secondary to panic attacks
What is agoraphobia?
Fear of being in an inescapable situation
NonPharm for Panic Disorder
Psychotherapy-CBT
Avoid caffeine, DOA and stimulants
1st line Tx for Panic Disorder
SSRIs
What is the dosing concept for SSRI's in the treatment of panic disorder?
Go 1/4 to 1/2 normal starting dose to prevent ADR of anxiety from becoming an issue.
BZDs: Role in therapy for panic disorder
Used 1st line in patients requiring rapid relief of anticipatory anxiety and patients who cannot tolerate antidepressants.
Commonly used BZDs for Panic disorder
Alprazolam 0.25-0.5mg TID
Panic dose: 4-10mg daily in divided doses
OR
Clonazepam 0.25mg BID
Panic: 3-6mg in divided dose
What other agents may be used in the treatment of Panic disorder
Venlafaxine, TCAs, MAOis
Which TCAs MAY be used in the treatment of panic disorder?
Imipramine and Clomipramine
Recommended Tx for Mild OCD
Nonpharmacologic therapy only
Psychotherapy (Exposure therapy or response prevention)
Recommended Tx for Moderate to severe symptoms
Pharmacologic
1st line OCD agents
SSRIs
2nd line OCD agents
Clomipramine (After 2-3 failed SSRIs)
What are some non 1st or 2nd line agents that may be used for OCD
Odansetron or Venlafaxine
OCD Augmentation strategies
Risperdal
Olanzapine
Seroquel
Nonpharmacologic therapy for PTSD
Psycho: Anxiety management, CBT, Exposure therapy
Pharmacotherapy for PTSD
1st line: SSRIs
2nd line: Venlafaxine, mirtazapine
1st line agents for SAD
SSRIs (4-8 week onset)