Tp Ii-P3 Exam 3 - Anxiety

Front 1

1a. What are the different anxiety disorders? (5)

Back 1

1. Generalized anxiety disorder (GAD
2. Social Anxiety
3. Panic Attacks
4. OCD
5. PTSD

Front 2

1a. Identify symptoms of GAD

Back 2

- A relatively constant anxiety occurring more days than not for at least 6 months.
- Sudden episodic attacks may occur
- Individual has problems controlling anxiety and worry
- Cause significant distress in daily life inc. work, relationships, and social gatherings

***Accompanied by at least 3 of the following:
1. Restlessness
2. Difficulties concentrating
3. Irritability
4. Muscle tension
5. Disturbed sleep
6. Poor coping strategies (alcohol)

Front 3

1b. Identify symptoms of Social anxiety

Back 3

- Considered a phobic disorder
- An intense and/or constant fear in social situation
- Irrational fear of being ridiculed or humiliated by others
- Exposure to situation provokes anxiety
- Person acknowledges fear is excessive (not req. in children)

***Fear severely interferes with daily life
***Symptoms may include: Blushing, muscle twitching, stuttering.

Front 4

1c. Identify symptoms of Panic attacks

Back 4

At least TWO unexpected attacks characterized w/ at least FOUR of the following symptoms which dev. abrupty & peak w/in 10mins

1. Palpitations
2. Sweating
3. Shaking
4. Chest pain/discomfort (SOB)
5. Depersonalization
6. N/GI disturbances
7. "Fear of going crazy" (loss of control)
8. Numbness/tingling
9. Chills or hot flashes

Front 5

1d. Identify symptoms of OCD
1. What is Obssession?
2. What is Compulsions?

Back 5

Presence of either obsessions or Compulsions
1. Obsession: recurrent and persisten ideas not simply about real life problems which cause anxiety
-- Contamination
-- Need for symmetry
-- Pathologic doubt
-- Religious
-- Sexual
-- Aggressive

2. Compulsions: Repetitive and intentional physical manifestations designed to reduce the anxiety
-- Cleaning
-- Arranging symmetrically
-- Counting
-- Checking
-- Hoarding

Front 6

1e. Identify symptoms of PTSD

Back 6

-- PTSD is an acute distress following a severely distressing or traumatic event.
-- Persistent symptoms of increased arousal which incl. at least TWO of the following. The disturbances occur for at least 1 month and cause sign. impairment in daily life

1. Sleep dificulties
2. Irritability/ anger outburst
3. Cognitive difficulties
4. Hypervigilance
5. Exaggerated startle response

Front 7

Subtypes & pathophysology of Social Anxiety

Back 7

1. Generalized : Involves noradrenergic system
2. Nongeneralized: Involves DA & 5HT dysfunction

Front 8

Two different types of Panic Disorder

Back 8

1. Without agoraphobie
2. With agoraphobia
- occurs in ~30% of pts w/PD
- Anxiety about being in places or situations from which escape may be difficult or embarrassing
- Situations are avoided, endured w/marked distress, or require a friend or relative

Front 9

What are some considerations when selecting tx for the different anxiety disorders? (6)

Back 9

1. Severity of symptoms
2. Comorbidity of other illnesses
3. Daily functioning
4. Availability of nonpharmacological tx
5. Drug cost
6. Compliance issues

Front 10

List the agents used to tx GAD (6)

Back 10

1. SSRIs - low risk in suicial pts. Paxil bc most seda.
2. Venlafaxine (Effexor) - FDA Indication
3. TCAs - bc of antihistiminic effects
4. Benzodiazepines
5. Buspirone (Buspar)
6. Hydroxyzine (Vistaril) - LAST line!

Front 11

3i. Compare and contrast different pharmacological agents for Generalized Anxiety Disorder (GAD)
--> Adv/disadv of using SSRIs

Back 11

1. SSRIs:

- 1st line
- Well tolerated. Effective for mixed pts. More favorable for suicidal pts due to scarcity of OD
- Start @ lower dose (to prevent serotonin surge)
- Takes longer for it to work for anxiety than depression. 8-12 wks vs 4-8wks.
- Use Paxil bc most sedating.

Front 12

3ii. Compare and contrast different pharmacological agents for Generalized Anxiety Disorder (GAD)
--> Adv/disadv of using Venlafaxine (Effexor)

Back 12

2. Venlafaxine (effexor):

- Has FDA indication for anxiety, good for mixed pts
- Works well. Low risk of suicide
- However, delayed onset, high SEs such as sexual dysfunction, N/V, weight gain.

Front 13

3iii. Compare and contrast different pharmacological agents for Generalized Anxiety Disorder (GAD)
--> Adv/disadv of using TCAs

Back 13

3. TCAs
- High Sedative properties. May be good for initial anxiety and concomittant insomnia. no early activation
- BUT cardiotoxic w/ overdose so not good for suicidal pts and very slow onset of action. More SEs (antichol), long term sedation.

Front 14

3iv. Compare and contrast different pharmacological agents for Generalized Anxiety Disorder (GAD)
--> MOA of Benzodiazepines
--> Adv/disadv of using Benzodiazepines

Back 14

4. Benzodiazepines --> NOT PRN

--> MOA: Bind to benzo (GABA A) receptors on post-synaptic GABA neuron, which opens chloride channels and hyper polarizes neuronal membranes (facilitating GABA). Metabolized to active cmpnds, careful with alcoholism or liver dz.

--> Rapid onset, initial insomnia, can use combo with SSRI/SNRI/TCA, prevents initial increase in anxiety
-Disadv: side effects, cognitive impairment (mostly in elderly),dizziness, hepatic complications, not good for mixed pts.
-LOTe: lorazapam, oxazepam, temazapam, bypass CYP450 issues. Good for patients with lots of other meds or hepatic Issues

**If Benzo is not as effective, just change med, don't increase dose. Sometimes start with SSRI to contradict stimulatory effect.

Front 15

3v. Compare and contrast different pharmacological agents for Generalized Anxiety Disorder (GAD)
--> Adv/disadv of using Buspirone (Buspar)

Back 15

5. Buspirone (Buspar)
5HT1A partial agonist/ Increases DA transmission

- Very limited abuse potential, no cognitive impairment, low suicidal risk, low SE profile
- Long onset (4-6 wks), not for severely ill pts, no panic disorder or OCD, need high doses,
- Must be scheduled, NOT PRN
- if a benzo didn’t work, it’s likely that Buspar will not work either

Front 16

3vi. Compare and contrast different pharmacological agents for Generalized Anxiety Disorder (GAD)
--> Adv/disadv of using Hydroxyzine (Vistaril)

Back 16

Hydroxyzine (Vistaril)
H1 blocker; anticholinergic

Last line! high anticholinergic properties

Front 17

3b. Agents used to tx Social Anxiety
(7)

Back 17

1. SSRIs
2. Venlafaxine (Effexor)
3. Benzodiazepines --> PRN only!
4. Buspirone (Buspar)
5. Beta Blockers
6. Gabapentin (Neurontin)
7. MAOIs --> LAST LINE!

Front 18

3b. Compare and contrast different pharmacological agents for Social Anxiety

Back 18

1. SSRIs: low suicide risk, good efficacy
2. Venlafaxine: Low abuse potential. But initial increase in anxiety.
3. Benzodiazepines: Only for anticipated environmental stressors --> PRN
4. Buspirone: SCHEDULED not PRN
5. Beta Blockers:
ADV: Propanolol 10-20mg, Atenolol 25mg, reduce peipheral manifestations of anxiety (sweating, tachy, tremor) - use test dose. Disadv: orthostasis, not used in severe cases
6. Gabapentin (Neurontin)
7. MAOIs (Phenylzine) last line! for refractory pts. quicker onset but tyramine interaction with foods, DIs, serotonin syndrome.

Front 19

Summary Panic Disorder sx & tx

Back 19

2 attacks with: palpitations, sweating, shaking, SOB, N, numbness, chills or hot flashes
Sudden onset lasting about 10mins May pass out and go to ER.

TX: SSRI, TCA, MAOI, BZD

Front 20

Summary GAD sx & tx

Back 20

Restlessness, difficulty concentraing, irritability, muscle tension, sleep, decision-making. (At least 3)

TX:
1. SSRI (not prozac or zoloft bc activating)
2. Venlafaxine (Effexor)
3. TCAs
4. Benzos: Lorazepam (Ativan), Oxazepam (Serax), Temazepam (Restoril)
5. Buspirone (Buspar) --> 5HT1A partial agonist, increases DA transmission, use in mild-mod cases. NOT FOR SEVERE CASES
6. Hydroxyzine (Vistaril) LAST LINE.

Front 21

Summary Social anxiety sx & tx

Back 21

Blushing, muscle twitch, stuttering, N/V in social situations
High risk: young, single, and poor

TX:
1. SSRIs, 2. Venlafaxine --> scheduled doses
3. BZDs --> PRN (give test dose)
4. Buspirone --> scheduled
5. BB- low dose, give test dose
6. Gabapentin
7. MAOIs --> Last line!

Front 22

Summary OCD sx & tx

Back 22

Obsessed w/: contamination, symmetry, religion, etc.
Compulsive about: cleaning, checking, arranging, counting, hoarding. May take >1hr/day

pts will have smaller pituitary gland --> coritsol --> anxiety.
high cortisol: depressive. Low cortisol: aggressive

TX:
SSRIs- high doses, try 2 b4 swtiching to TCA
TCA- high doses
Combo of SSRI and ??

Front 23

Summary PTSD sx & tx

--> which class of drugs are completely inaffective in PTSD?

Back 23

PTSD --> Benzos completely inaffective!

Acute distress after: rape, hurricane, war, death --> nightmares, panic episodes, etc.

TX:
SSRIs - first line!, TCAs, MAOIS, anticonvulsants, antipsychotics if seeing hallucinations (risperdal)