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85 Cards in this Set
- Front
- Back
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Components of anxiety
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1. Psychological - Mental features such as worry, fear, tension
2. Somatic - Physical features such as sweating, tachycardia, rapid breathing |
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Anxiety disorders are more common for (males / females)
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females
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Anxiety disorders are correlated with (3)
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-Family history of
-Depression -Substance-abuse |
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Aproximately ___ % of the population have AD, and approximately ___% of them get treated for it
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25%
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The area of the brain known as _____ is though to regulate anxiety and emotion
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locus ceruleus
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Neurotransmitter systems such as ___, ___, ___, ___, ___, and ___ are affected in AD
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GABA
serotonin norepinephrine cholecystokinin glutamine |
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Areas of the brain affected in anxiety disorders are:
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Locus ceruleus, limbic system, prefrontal cortex
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What are the classes of anxiety disorders? (6)
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1. Phobic disorders
2. Panic disorders 3. Agoraphobia without a history of panic disorder 4. OCD 5. Posttraumatic stress disorder (PTSD) 6. Generalized anxiety disorder |
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Definition of phobic disorder
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Intense, persistent, irrational fear that interferes with normal functioning.
Management is usually by avoidance. eg. public speaking |
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Types of phobic disorder
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1. Social phobia - Fear of embarrassing themselves in public
2. Specific phobia - eg. Animals, situations, blood, environmental |
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Definition of panic disorder
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Spontaneous, unexpected, discreet episodes of extreme anxiety lasting less than 30 minutes.
Followed by anxiety of having more attacks. |
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Definition of panic attack
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Having an overwhelming sense of doom, fear of dying, losing control
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What are the two subdivisions of panic disorders?
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1. With agoraphobia
2. Without agoraphobia |
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Definition of obsessive-compulsive disorder
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Syndrome of recurrent and persistent obsessions and or compulsions.
The mind thinking about these unwanted acts, then doing repetitive rituals to counteract that. |
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Definition of obsessions
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Recurrent, persistent ideas, thoughts or impulse
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Definition of compulsions
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Repetitive, purposeful behavior
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Posttraumatic stress disorder - duration of acute versus chronic
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Acute: less than 3 months
Chronic: greater than 3 months |
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Acute stress disorder - duration
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2 days to 4 weeks
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Definition of post traumatic stress disorder
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A pathological reaction to a psychological traumatic experience.
It is of sufficient magnitude to evoke distress in almost everyone. Symptoms involve recurrent experiences of the trauma. Consists of intrusive thoughts, images, and nightmares |
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PTSD is usually associated with ___ and ___
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Depression and substance abuse
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Generalized anxiety disorder definition
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Persistent, excessive anxiety and worry(always unhappy and low mood).
Not associated with any stimulants. Duration is greater than six months. Comorbidity with another anxiety disorder is common. |
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Things you check at baseline workup in order to rule out AD (3)
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1. Medical illness - Such uncontrolled pain or hypo/hyperthyroidism
2. Drug-induced: for example thyroid medication, CNS depressant withdrawal 3. Other primary psychiatric disorders: such as stimulant abuse, depression |
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Nonpharmacologic strategies to treat anxiety disorder (2)
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1. Psychotherapy - Therapies to make sure the patient knows what is real or not, use logic to put fear in perspective
2. Behavioral therapy - Patients are brought into prolonged contact with stressor agent -Meditation and aromatherapy can be useful adjunct therapies |
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Benzodiazepines – use in anxiety disorder – Indication
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– Not first-line
– All are equally efficacious – Used as an adjunct therapy in addition to other antianxiety meds – Best to manage the somatic symptoms – Use for GAD, social phobia, panic attacks |
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Benzodiazepines – use in anxiety disorder – how to use
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– Use lowest effective dose (LED)
– Use for 2 to 4 weeks maximum – Can be used on a PRN basis while waiting for other anti-anxiety meds to take effect – Be careful of rebound anxiety when stopping the medication |
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Benzodiazepines – use in anxiety disorder – contraindications
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– Not for use in early trimester of pregnancy due to cleft palate risk. Late trimester as well due to withdrawal and hypertonia.
– Secreted in breastmilk – Not for use in elderly due to fall risk |
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Rapid onset benzodiazepines (3)
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– Diazepam
– Alprazolam – Lorazepam |
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Benzodiazepines – use an anxiety disorder – How to taper
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– 10 to 15% every week, 5 to 10% every few days
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Benzodiazepines – use in anxiety disorder – Patient education
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– Anticipated length of therapy is 2 to 4 weeks
– Drug interaction with alcohol – Emphasize adjunctive therapy only – No dose adjustment unless advised |
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Antidepressants – use in anxiety disorder – How to use
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– First line of treatment
– All classes can be used (Except buproprion as it is stimulatory) |
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Antidepressants – use in anxiety disorder – Advantages over benzodiazepines
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– Better for the psychological component
– Can treat comorbidities, anxiety and depression – No dependency and less risk in substance-abuse – Safer to use in pregnancy |
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Antidepressants – use an anxiety disorder – disadvantages over benzodiazepines
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– Onset is 2 to 4 weeks
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Panic disorders – best therapy is ___
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Behavior therapy
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Hyperstimulation syndrome – Definition
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Exacerbation of panic, makes anxiety disorder worse at first due to initial effects of antidepressant medication
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Antidepressants – use in panic disorders - Tricyclics - Dose, time to effect
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– Imipramine and Clomipramine
– 150-300 mg – Start at lowest dose to decrease stimulation effect – Response may take 5 to 10 weeks |
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Antidepressants – use in panic disorders - MAOI - Dose, time to effect
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– Phenelzine: 45-90 mg/day
– Response may take 5 to 10 weeks – Added concern because of Tyramine diet – Start at lowest dose to decrease stimulation effect |
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Recommended to use ___ (short/long) half-life benzodiazepine for elderly
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Short half-life
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Diazepam is a ___ (short/long) half-life benzodiazepine
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Long half-life (100hr)
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Side effects of SSRIs - (In order of frequency)
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- Nausea
- Somnolence - Insomnia - Diarrhea - Consitipation - Dry mouth - Headache - Dizziness - Anxiety - Agitation - Anorexia - Tremor - Sweating |
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Side effects of Benzodiazepines – (in order of frequency)
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- Drowsiness (tolerance develops)
- Dizziness - Decrease in concentration - Anterograde amnesia |
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Side effects of TCAs
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- CNS effects (Agitation on the initiation of therapy, confusion, drowsiness, headache, tremors, seizures)
- Anticholinergic effects (Dry mouth, blurred vision, constipation) - Cardiovascular effects (Increase in heart rate, Arrhythmias, Orthostatic hypotension) - Anorgasmia |
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In anxiety disorder – benzodiazepine naïve patients can use ___.
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- Buspirone (Buspar)
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Buspirone - Use in AD - What is the class, and expected onset of action
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- Serotonin agonist
- Onset in 1 week, max effects 6 weeks - BZD naive patients only |
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Buspirone - Use in AD - Advantages over benzodiazepines
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– Less sedation and cognitive impairment
– No dependence issues – Does not interact with CNS depressants – Can be used for substance abuse disorders |
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Buspirone - Use in AD - Disadvantages over benzodiazepines
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– Inconsistent reports of efficacy
– May take 2 to 4 weeks for effect (not a PRN drug) |
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Buspirone - SE
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– Nausea
– Headed – Dizziness – Restlessness (non-sedating) |
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With OCD, ___ may require even higher than normal doses in order to be effective
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Antidepressants
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Within the benzodiazepine class, ___ is considered the most potent and has severe withdrawal
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Alprazolam
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___ (drug class) has the least benefit for OCD and post dramatic stress disorder
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Benzodiazepines
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___ (drug) is used for performance anxiety. What is the usual dose?
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Propranolol. 10-40mg BID.
10-80mg 30-90 min prior to task. |
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___ is an antihistamine that can be used for anxiety disorder. Give dosing and SE.
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– Hydroxyzine
– Drowsiness, sedation, headache, anticholinergic effects, decrease in cognition – 25-50mg TID |
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___ is an investigational drug that can be used for anxiety disorder.
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- Pregabalin (Lyrica)
- 150-600mg daily |
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___ therapy is the best for OCD
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Behavior
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OCD - Pharmacological Tx choices
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- TCAs and all the SSRIs
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____ (drug) is the best TCA to use for OCD
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Clomipramine
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The etiology of OCD involves ___ dysregulation
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Serotonin
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Treatment of OCD involves ___ (higher/lower) doses and a duration of ___ weeks
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- higher
- 10-12 weeks |
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Preferred treatment of phobias involves ___ therapy
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Behavioral
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Paroxetine has an indication for ___ phobias
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Social
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Pharmacological treatment of phobias can include ____(classes)
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-SSRIs, Benzodiazepines and MAO-I
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Insomnia is considered chronic if you can't sleep for ___ weeks
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3 weeks
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Insomnia can present in these ways (4)
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1. Difficulty falling asleep
2. Difficulty staying asleep 3. Early morning awakening 4. Combination of above |
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Sleep disorders - Non pharmacological Tx
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- Use bedroom for sleep and sex only
- Wind down before bed - Exercise - Don't exercise or eat large meals before bed - Avoid/Limit naps - Avoid caffeine |
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Sleep disorders - Non-prescription Drugs & Dosing (3)
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- Diphenhydramine: 50-100mg hs
- Tryptophan: 500-1000mg - Melatonin: 1-3mg |
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Sleep disorders - Rx Treatment types
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-BZD
-Zoplicone(Imovane) -Chloral Hydrate -Others are TCAs(amitryptyline), Trazodone, Methotrimeprazine |
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Sleep disorders - BZD use is recommended to be used for a maximum of ___ weeks
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4 weeks
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Sleeping disorders - BZD that is effective for daytime anxiety as well
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Clonazepam(Rivotril): 0.5mg-1mg HS
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Sleeping disorders - Good BZD choices (3)
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-Temazepam (Restoril): 15-30mg HS
-Oxazepam (Serax): 15-30mg HS -Lorazepam (Ativan): 0.5-1mg HS (med rapid onset 30-60min) |
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Sleeping disorders - Flurazepam is not recommended due to ___
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Accumulation leading to hangover symptoms, confusion and impairment
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Sleeping disorders - Triazolam is not recommended due to ___
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-Behavioral changes
-Retrograde amnesia -Withdrawal symptoms -Rebound insomnia -DIs |
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Zoplicone(Imovane) is a good choice for sleep disorders - Dosing and SE
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Dose: 5 - 7.5mg HS
-Dry mouth -Bitter taste -Residual sedation |
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Chloral hydrate (Noctec) for sleep disorders..
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is not recommended.
Fatal in doses >4g. Regular doses 500mg-1g HS. |
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Trazodone (Desyrel) for sleep disorders..
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-Antidepressant
-Good for antidepressant induced insomnia -50-100mg HS |
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Methotrimeprazine (Nozinan) for sleep disorders..
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-Antipsychotic
-Non-addictive sedative, be careful of EPS -5-10mg HS -25-50mg HS |
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Narcolepsy - Clinical Presentation (3)
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-Cataplexy(70-80%) - sudden loss of muscle tone
-Sleep paralysis(25-50%) - associated with nacolepsy -Hypnagogic sleep(20-50%) - vivid dreams |
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Narcolepsy - Non-pharmacologic Treatment
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-Psychoeducation for patient and family
-Scheduling daytime naps -Support groups |
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Narcolepsy - Daytime sleepiness - Pharmacological Treatment
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-Methylphenidate: 2.5 - 5mg BID
-Modafinil: 200 - 500mg OD or BID |
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___(drug class) can suppress REM sleep and can cause REM rebound(when stop drug get constant dreaming)
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TCAs
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Sleep apnea is associated with ___ and ___
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Obesity and HTN
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A complication of sleep apnea is ____ retention leading to possible ____ issues
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CO2 / MI
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Two classes of sleep apnea
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- Central (10%)
- Obstructive (90%) |
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Central sleep apnea - definition
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Brain does not send the proper signals to the muscles that control your breathing, causing breathing to stop during sleep
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Obstructive sleep apnea - Non pharmacologic treatment
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-Avoid CNS depressants / sedatives / alcohol
-Lose weight -Prevent sleeping on the back |
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Obstructive sleep apnea - Treatment options
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-CPAP: ~5mmHg, lifelong
-Surgical: removal of enlarged tonsils, tracheostomy, uvulopalatopharyngoplasty, suture of soft palate |
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Central sleep apnea - Treatment options
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-CPAP
-Nasal mechanical ventiation Drug: -Medroxyprogesterone 5 - 10mg -Protripyline 10mg -Acetazolamide (carbonic anhydrase inhibitor) 250mg-1g per day |
