Psych Exam 2 Anxiety-Related Disorders (Waters)

definition of anxiety

· psychological, physiological, and behavioral state in animals and humans (normal)

o Caused by perceived threat to well-being or survival

o Facilities coping with adverse or unexpected situations

what are the 4 types of anxiety-related disorders?

· Generalized anxiety disorder (GAD)

· Panic disorder (PD)

· Social anxiety disorder (SAD)

· Posttraumatic stress disorder (PTSD) --> not truly an anxiety disorder

DSM-5 criteria for GAD

· Excessive anxiety and worry lasting at least 6 months and difficulty controlling the worry

· At least 3 of the following symptoms

o Feeling keyed up or on edge, unsettled

o Becoming easily exhausted

o Mind going blank, difficulty focusing

o Impatience

o Muscle tension

o Sleep disturbance, usually insomnia

· Focus of the anxiety and worry are not caused by another anxiety or psychiatric disorder

· Significant distress or functional impairment because of anxiety symptoms

· Symptoms are not caused by a substance or general medical condition

psychological and cognitive signs and symptoms of GAD

· Excessive anxiety

· Worries that are difficult to control

· Feeling keyed up or on edge

· Poor concentration or mind going blank

· Restlessness

Irritability

physical signs and symptoms of GAD

· Fatigue

· Muscle tension

Sleep disturbance

impairing signs and symptoms of GAD

· Social, occupational or other important functional areas

Poor coping skills

Hamilton Anxiety Scale (HAM-A) reduction in symptoms for remission

>70% (or score <7)

HAM-A reduction in symptoms for improved clinical response

50-70%

HAM-A reduction in symptoms for partial clinical response

25-49%

HAM-A reduction in symptoms for non-response

<25%

risk factors for GAD

-gender (females>>)

-medications, herbal products, supplements (can worsen or even cause)

-medical conditions

· Socioeconomic and ethnic factors

· Recent stressful event

· Genetics

medications, herbal products, and supplements that can worsen or cause GAD

o Caffeine

o Corticosteroids

o Bupropion

o Stimulants

o Bronchodilators

o Decongestants

o Dopamine agonists

o Thyroid hormone

o Ginseng

o St. John's wort

o Nicotine

o Yohimbe

medical conditions that can cause GAD

o Cardio vascular

o Endocrine/metabolic

o Neurologic

o Respiratory

o Menopause/estrogen deficiency

where is GAD often treated?

in the primary care setting

clinical course of GAD

o Can occur at any age (avg is 35)

o Symptoms wax and wane

o >50% of pts with GAD will have a major depressive episode

what are the first-line treatments for GAD

SSRIs and SNRI's

what are the second-line treatments for GAD

o Alternative 1st line agent

o CBT (adjunct)

o Pregabalin

o Vilazodone

o Benzodiazepine

o Buspirone

what are the third-line treatments for GAD

o Alternative 2nd line agent

o Antihistamine (hydroxyzine)

o Second-generation antipsychotic, valproate, trazodone, TCA, vortioxetine

treatment pathway for GAD

SSRIs with the most evidence for treating GAD

-paroxetine

-escitalopram

-citalopram

-setraline

SNRIs with the most evidence for terating GAD

-venlafaxine

-desvenlafaxine

antidepressant onset and titration for GAD

o 4-12 weeks for response in GAD

o Many pts won't achieve remission

o Antidepressants may initially worsen anxiety symptoms consider starting at a lower dose

what line of teratment is CBT for GAD

2nd line

CBT efficacy as a 2nd line treatment of GAD

o Most effective psychological therapy

o Identify negative thought patterns that provoke or worsen anxiety symptoms

o Can be limited by cost, time requirement, availability of trained therapists

o Pharmacotherapy has shown to be more effective than psychotherapy

what type of therapy is most effective for GAD

pharmacotherapy>> psychotherapy

what's a precaution to consider with pregabalin

there is abuse/misuse potential especially in people with a history of SUD

onset of pregabalin

rapid ~1 week

ADRs of pregabalin

-dizziness

-somnolence

-ataxia

-blurred vision

-withdrawal with abrupt discontinuation

what line of therapy are benzodiazepiens for GAD

they are 2nd line but often prescibed because they provide rapid relief (30-60 mins)

precautions to know for benzodiazepine use in GAD

o Long term use is not recommended due to dependence and withdrawal symptoms

§ Withdrawal can occur after taking it for 4-6 weeks

§ Rebound anxiety

what is rebound anxiety

immediate, transient return of anxiety symptoms with increased anxiety compared to baseline when stopping consistent use of a benzodiazepine

rules for benzodiazepines

o May initiate benzos when starting an antidepressant for GAD until antidepressant begins to take effect (limit 2-3 weeks) or for treatment-resistant GAD

o Avoid if history of SUD

o Not effective for depression and may worsen depression/PTSD with long-term use

BZDs and depression

not effective and may worsen depression/PTSD with long-term use

which benzos are misused the most and why

diazepam because they have a rapid onset of action

adverse CNS effects of benzodiazepines

· Drowsiness, sedation

· Psychomotor impairment--> falls

· Disorientation, confusion

· Depression

· Irritability

Memory impairment

abuse, dependence, and withdrawal effects with benzodiazpeines

· High potential for abuse (CIV) especially if history of SUD

· Withdrawal symptoms

· Anxiety

· Insomnia

· Restlessness

· Muscle tension

· Irritability

Seizures (high dose, long duration of therapy, concurrent use with meds that lower seizure threshold)

abuse and benzodiazepines, who should you be cautious about giving these to?

people with a history of SUD because they have high abuse potential

what schedule are benzos?

CIV

which benzodiazepines are safe in patients with hepatic impairment?

· lorazepam, oxazepam, temazepam (LOT)

which drugs have additive CNS and respiratory depression when used with benzos?

alcohol and opioids

which drugs cause a decrease in concentraion of benzodiazepines

-phenytoin

-carbamazepine

-phenobarbital

which durgs cause an increase in concentration of benzodiazepines

CYP3A4 inhibitors (like fluoxetine)

may need to decrease the dose with these

what is the goal of benzo discontinuation

avoid withdrawal symptoms including seizures

tapering off of benzodiazepines

· Reduce dose by 25% per week until 50% of dose is reached

o Then reduce dose by 1/8 every 4-7 days

>8 weeks of BZD therapy, what is the optimal taper duration?

2-3 weeks

>6 months of BZD therapy, what is the optimal taper duration?

4-8 weeks

>1 year of BZD therapy, what is the optimal taper duration?

2-4 months

switchign meds in anxiety disorders, what should you do first if 1 first-line doesn't work?

o First try an alternative 1st-line med before switching to 2nd line

what line of teratment is busprione in GAd

2nd line

buspar generic name

buspirone

lyrica generic name

pregabalin

onset of buspirone in GAD

o Onset may take 2 weeks but full effect may take 4-6 weeks

long-term efficacy of busprione

inconsistent evidence of long-term efficacy

busprione is less likley to be effective if the patient has used ___ within the last ___

if they have used benzos within the last month

ADRs of busprione

dizziness, nausea, headache

initial dose of busprione

7.5mg BID

what patients is buspirone not recommended in?

hepatic or renal impairment

hydroxyzine brand names

atarax and vistaril

what line of treatment is hydroxyzine for GAD

3rd line

when can hydroxyzine be taken?

Symptomatic (prn) relief of anxiety or scheduled

ADRs of hydroxyzine

anticholineric and antihistamine effects including sedation

treatment duration for GAD

· Duration: >/=12 months after treatment response

· Gradually taper off of dose

panic disorder criteria

· recurrent unexpected panic attacks with >/= 1 attack followed by at least 1 month of more than 1 of the following

o Constant concern about having another attack

o Being anxious about the implications of the attack or its consequences

o Maladaptive behavior changes to avoid having panic attack

panic attack vs panic disorder

if you have one panic attack it doesn't necessarily mean you have panic disorder

agoraphobia criteria

· fear or anxiety in >/=2 of the following situations

o Public transportation

o Open spaces

o Enclosed places

o Crowds or standing in line

o Outside of home alone

phsychological symptoms of a panic attack

-depersonalization

-derealization

-fear or losing control, going crazy, dying

physical symptoms of panic attacks

o Abdominal distress, nausea

o Chest pain, palpitations, tachycardia

o Chills, hot flashes, sweating

o Dizziness, light-headedness

o Feeling of choking

o Shortness of breath

o Trembling or shaking

risk factors for panic disorder

o Gender (female more likely)

o Medications, herbal products, supplements (same as GAD)

o Environmental triggers

o Stressful life events

o Smoking

o Genetics (1st degree relative)

clinical course of PD

o Frequency of panic attacks may wax and wane in response to stressors

§ Most pts need long-term treatment

o 1/3 of pts achieve remission

o 1/5 of patients have chronic PD

what factors can predict chronic panic disorder

§ Long duration of illness

§ Severe agoraphobia

§ Comorbid personality, mood, or other anxiety disorders

§ Excessive sensitivity to physical symptoms

PD

panic disorder

first-line treatment for PD

· psychotherapy (CBT, exposure therapy) AND/OR medications (SSRI’s or venlafaxine)

o SSRI’s are equal efficacy- significant improvement in panic severity, anticipatory anxiety, agoraphobia, disability, and quality of life

o Pts may be hypersensitive to ADRs at initiation of treatment

2nd line treatment for PD

o Alt first-line agents

o Benzos for residual anxiety of rapid symptom control (if no SUD history)

o TCA’s- used if SSRI’s or venlafaxine is ineffective, but they have more side effects

o Exercise

when should benzos not be used as monotherapy

if pt has comorbid depression

which benzos are most commonly prescribed for PD?

alprazolam and clonazepam

third-line treatment of PD

o Alt 2nd-line agent

o Phenelzine (MAOI)

treatment goals of PD

o Reduce frequency and severity of panic attacks

o Reduce anticipatory anxiety, fear-driven avoidance, and impaired functioning

onset of antidepressant efficacy in PD

3-4 weeks (may be >6 months for full remission)

onset of BZD efficacy in PD

reduce acute anxiety within hours but may take. 4-6 weeks for full benefit as a monotherapy

duration of PD acute phase of therapy

1-4 months --> change treatment if no response after 12 weeks at max tolerated dose

duration of PD maintenance phase of therapy

continue for 12 months after treatment response

duration of PD discontinuation phase of therapy

depends on pt but taper over 4-6 months to avoid relapse

DSM-5 criteria for social anxiety disorder

· Significant anxiety/fear about at least 1 social situation where individual is exposed to possible scrutiny by others

· Fears they will display anxiety symptoms or act in a way that will be negatively assessed

· Social situations cause anxiety or fear

· Social situations are avoided or experienced with anxiety/fear

· Anxiety/fear > actual threat posed by the social situation

· Anxiety/fear/avoidance persists for >/= 6 months

· Symptoms cause impairment or distress

· Symptoms not caused by substance

· Symptoms> what would be expected from comorbid medical conditions

what must be specified about social anxiety disorder according to DSM-5 criteria?

must specify if it's performance-only social anxiety

fears of social anxiety disorder

- Scrutinized by others

- Embarrassment

Humiliation

feared situtations of social anxiety disorder

- Public speaking

- Eating/drinking in front of others

- Interacting with authority figures

- Talking with strangers

Use of public restrooms

physical symptoms of social anxiety

- Blushing

- "butterflies"

- Diarrhea

- Sweating

- Tachycardia

trembling

risk factors for social anxiety

· psych comorbidity

· genetics ( 1st-degree relative)

· familial factors (parental overcontrol)

· early childhood anxiety disorders

· life stressors

onset vs treatment of social anxiety

onset is usually 14-16 years old but treatment is delayed by about 10 years

comorbid conditions with social anxiety

anxiety, depression, SUD

pathophysiology of performance-only subtyoe of social anxiety

NE syetm dysfunction

SAD

social anxiety disorder

pathophysiology of general SAD

o decreased D2 receptor binding

o low DA metabolite levels--> higher incidence of SAD in Parkinson's pts and during antipsychotic treatment

o hypersensitive 5-HT2 receptors

first-line treatment of SAD

o CBT

o SSRI’s

§ Improve anxiety, avoidance, and disability

o Venlafaxine

which SNRIs are first-line for SAD

venlafaxine only

which SSRIs are first-line for SAD

paroxetine, sertraline, escitalopram, fluvoxamine

2nd-line treatment of SAD

o Alt 1st line agent

o Pregabalin

o Mirtazapine

o Gabapentin

efficacy of benzos/ antipsychotics in SAD

little evidence to support augmentation with benzos or antipsychotics but may be an option in pts with partial response

treatment options for performance-related SAD

beta blockers- propanolol and atenolol

what do beta blockers do in performance-related SAD pts

decrease tremor palpitations and blushing