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30 Cards in this Set
- Front
- Back
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This is an uncomfortable feeling of fear or apprehension, often accompanied by vague physical feelings. Can be daily, under specific circumstances, mild, intense, acute and chronic.
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Anxiety
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What are three types of anxiety disorders that you will use drugs to treat?
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Panic disorder with agoraphobia
Generalized anxiety disorder Post traumatic stress disorder |
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Development of emotional and/or behavioral symptoms within 3 months after an identifiable stressor. Symptoms are usually sleep disturbances, depressed mood, eating changes, worry and/or jitteriness. Typically last less than six months after the end of the stressor. Stressors may be chronic such as terminal illness or pain due to caretaking responsibilities of a loved one (e.g. spouse of an Alzheimer's patient).
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Adjustment disorder
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20-90% of patients with panic disorder also have?
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depression
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40% of patients with generalized anxiety disorder have comorbid?
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depression
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Use for tx of acute anxiety symptoms
Anxiolytic, muscle relaxant, anticonvulsant and sedative-hypnotic effects lead to many FDA indications Same mechanism of action (MOA) Bind to BZD site on GABAA receptor Differ in pharmacokinetic (PK) properties Absorption/Distribution Lipophilicity Metabolism Though all hepatically metabolized, route and inactive vs active metabolites Excretion Half life and duration of action |
Benzodiazepines
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What are the adverse effects of benzodiazepines?
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Sedation, Cognitive impairment, Ataxia/incoordination, respiratory depression, anterograde amnesia, paradoxical agitation.
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What are the seven types of BZD?
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Halcion triazolam
Klonopin clonazepam Xanax alprazoplam Ativan lorazepam Valium diazepam Serax oxazepam Librium chlordiazepoxide |
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Excessive anxiety and worry more days than not for at least 6 months
Anxiety is difficult to control Anxiety and worry are associated with three or more of the following Restlessness or feeling keyed up Easily fatigued Difficulty concentrating Irritability Muscle tension Difficulty falling or staying asleep |
Generalized Anxiety Disorder GAD
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Lifetime prevalence of 5%
Higher rates of cardiovascular disease and irritable bowel syndrome Females > Males Frequently seen in primary care manifest with Headaches, palpitations, sweating and GI disturbances (primarily diarrhea) |
Generalized Anxiety Disorder GAD
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What are the treatment options for GAD?
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SSRIs
Duloxetine Venlafaxine Buspirone Benzodiazepines TCAs Nefazodone, mirtazapine Atypical antipsychotics |
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Antidepressants for GAD
Dosing is similar to that used in depression All take 2-6 weeks to work All potentially could worsen anxiety during the first week. |
Venlafaxine
SSRIs Duloxetine Imipramine |
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MOA: 5HT1A partial agonist (also has affinity for D2 receptors in the brain)
Advantages: Almost as effective as benzos for GAD No sedation, cognitive impairment, respiratory depression, dependence or withdrawal Lacks abuse potential Disadvantages: Onset of effect ~2 weeks, but can take 6 weeks for full effect (similar to the antidepressants) |
Buspirone (Buspar) for GAD
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BZD used for GAD should follow what guidelines?
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Low potency
Can be high potency if dose is low Long acting Short acting agents require too many doses and result in troughs of efficacy |
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British Association of Psychopharmacology (2005)
Guidelines for TX GAD? |
Acute
SSRIs, TCAs, benzos Prophylaxis SSRIs, venlafaxine(SNRI), buspirone |
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NICE (2007) Guidelines for TX GAD?
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SSRIs for 12 weeks then switch to another for at least 6 mos.
Benzos for no more than 4 weeks Venlafaxine (SNRI) second line (dose 75mg or less) |
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Period of intense fear in which 4 of the following symptoms develop abruptly and reached a peak within 10 minutes:
Palpitations Sweating Trembling Shortness of breath or smothering Feeling of choking Chest pain Nausea Dizzy or lightheadedness Fear of losing control Fear of dying Paresthesias Chills or hot flushes |
Panic Attacks
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At least one of the attacks has been followed by 1 month of one of the following
Persistent concern about having additional attacks Worry about the implication of the attack Significant change in behavior related to the attacks |
Panic Disorder
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What is first line treatment for panic disorder?
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Potent antidepressants at high doses.
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What are the rules to follow when using an antidepressant to use as prophylaxis against panic attacks?
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Need to start low and increase dose slowly
SSRIs can precipitate a panic attack if initially dosed too high. Goal dose is at high end of dosing range. Important to treat for at least 8 weeks (and probably 12). 50% of patients will achieve a full response. 80% will be considered responders and derive some benefit on intensity and frequency of attacks. |
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These are useful for acute attacks of panic disorder. High potency, short acting agents are the most useful.
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BZDs - Alprazolam, Lorazepam
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What is a common treatment pan for panic disorder, ie. for prophylaxis and acute?
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SSRI daily for prophylaxis
Benzo prn for acute attacks |
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The person has been exposed to a traumatic event which involved actual or threatened death or serious injury. The persons response was with intense fear, helplessness or horror.
The patient experiences 3 of the following Subjective sense of emotional detachment Reduction in the awareness of the persons surroundings Derealization Depersonalization Dissociative amnesia The event is reexperienced via nightmares or flashbacks The person avoids events that arouse recollections of the event Marked symptoms of increased arousal or anxiety The symptoms occur within 4 weeks of the event |
Acute stress disorder
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Criteria A: The person has been exposed to a traumatic event and the response to the event was intense fear, helplessness, or horror.
Criteria B: The event is reexperienced Criteria C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness Criteria D: Persistent symptoms of increased arousal |
Post Traumatic Stress Disorder
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What is the major difference between acute stress disorder and post traumatic stress disorder?
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Time course of symptoms relative to traumatic event is the difference between ASD and PTSD
In ASD, symptoms occur within 4 weeks of traumatic event In PTSD, symptoms occur at least 4 weeks after traumatic event |
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What is the TX for ASD and PTSD?
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Group therapy is critical for this population.
Medications are only symptom therapy. It is important to avoid benzos in this population, however, sometimes it is necessary. |
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What pharmacotherapy is used for ASD and PTSD?
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Primarily the SSRIs
Venlafaxine Nefazodone Anticonvulsants Atypical antipsychotics Beneficial for flashbacks, agitation and perhaps nightmares Prazosin (alpha 1 receptor antagonist) for reduction of nightmares. Start at 1mg qhs and titrate up. Average dose in clinical trials is 10mg. |
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not strong enough for panic attacks, considered only for anxiety symptoms.
gabapentin, tiagabine, pregabalin, topiramate. Studied and shown effective but not as effective as the serotonergic agents. |
Antiepileptics
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Other Anxiolytic Medication
Not recommended as monotherapy but as an adjunct to SSRIs. |
Atypical antipsychotics (5-HT2 blockade)
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Other Anxiolytic Medication
a 1st generation antihistamine an effective sedative, hypnotic, and tranquilizer |
Hydroxyzine
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