anxiety disorders - dr krysiak

2 hours --> 10 questions

_______ disorders are the most commonly occurring psychiatric disorders

a. depression

b. anxiety

c. substance abuse

b,

what drugs can cause increased anxiety in a dose-dependent manner?

CNS stimulants

list common medical symptoms associated with anxiety symptoms

• cardiovascular

  • angina

  • arrhythmias

  • CHF

  • HTN

  • IHD

  • MI

• endocrine and metabolic

  • cushing’s

  • diabetes

  • hyperthyroidism

• neurologic

  • migraine

  • seizures

  • stroke

• respiratory

  • asthma

  • COPD

  • PE

  • pneumonia

checkpoint

which of the following medical conditions is most likely to mimic symptoms of anxiety and should be ruled out during the diagnostic workup?

a. osteoarthritis

b. hypothyroidism

c. hyperthyroidism

d. chronic kidney disease

c.

what is the noradrenergic model?

hypersensitivity of the autonomic nervous system

basically release of NE in response to threat/fear

anxiolytics would block this

what is the GABA receptor model?

benzos enhance the inhibitory effects of GABA —> neuronal excitability is reduced

what are characteristic features of all anxiety disorders?

anxiety and avoidance behavior

OR

fear and worry

describe generalized anxiety disorder (GAD)

gradual onset with avg. age of 21 years

exacerbated or precipitated in later life by severe psychologic stressors

CHRONIC

GAD

persistent symptoms for at least __________

a. 6 months

b. 12 months

c. 4 weeks

d. 3 months

a.

GAD

anxiety or apprehensive expectation is accompanied by at least three psychologic or physiologic sympoms:

• restlessness or feeling keyed up or on edge

• being easily fatigued

• difficulty concentrating or mind going blank

• irritability

• muscle tension

• sleep disturbances

T/F in generalized anxiety disorder, the anxiety and worry CANNOT be confined to features of another psychiatric illness (panic attacks, being embarrassed in public)

TRUE

list psychological and cognitive symptoms of GAD

• excessive anxiety

• worries that are difficult to control

• feeling keyed up or on edge

• poor concentration or mind going blank

list physical symptoms of GAD

• restlessness

• fatigue

• muscle tension

• sleep disturbance

• irritability

list impairment symptoms of GAD

• social, occupational, or other important functional areas

• poor coping skills

what is the ACUTE goal of GAD treatment?

reduce severity and duration of anxiety symptoms

what is the LONG TERM goal of GAD treatment

remission with minimal or no anxiety symptoms

no functional impairment

increased QOL

what are the 2 parts of the patient-oriented treatment plan for GAD

psychotherapy + drug therapy

antianxiety meds indicated for pts experiencing symptoms severe enough to cause functional disability

what is the most effective psychotherapy for GAD?

CBT

list nonpharm tx options for GAD

• psychoeducation

• short-term counseling

• stress management

• psychotherapy — CBT

• meditation

• exercise

list first line drugs for GAD

• antidepressants

  • paroxetine

  • duloxetine

  • escitalopram

  • venlafaxine XR

what drug is considered for GAD when patients fail to respond to SSRIs or venlafaxine?

imipramine

list monitoring parameters for GAD pharmacotherapy

once every 1-2 weeks until stable, then monthly

how long should pharmacotherapy for GAD be continued following an adequate trial and good response?

a. at least 1-3 months

b. at least one year

c. 6-8 weeks

d. 2-4 weeks

b.

what agents are second line for GAD?

BENZOS

• alprazolam

• chlordiazepoxide

• clonazepam

• clorazepate

• diazepam

• lorazepam

• oxazepam

Buspirone (Buspar)

what agents are most frequently prescribed for the ACUTE treatment of anxiety, are NOT recommended to use LONG-TERM because of dependence, and are NOT effective for depressive symptoms?

BENZOS

should we use benzos in pts with substance abuse disorders?

HELL NAHHHHH

idk if we need to know

what benzos are lipophilic —> absorbed rapidly and distributed quickly in the CNS? (SATA)

a. diazepam

b. clorazepate

c. lorazepam

d. oxazepam

a. b.

idk if we need to know

what benzos are NOT lipophilic —> slower absorption and onset of effect? (SATA)

a. diazepam

b. clorazepate

c. lorazepam

d. oxazepam

c. d.

benzos go under 2 metabolic processes: hepatic oxidation by _______ and glucuronide conjugation

a. CYP2D6

b. CYP2C9

c. CYP3A4

d. CYP1A2

c.

what benzo has the highest potential for impairment of memory and recall?

a. alprazolam

b. chlordiazepoxide

c. clonazepam

d. lorazepam

a.

T/F tolerance to benzos develops to the sedative, muscle relaxant, and anticonvulsant activities, BUT NOT anxiolytic and antipanic attacks

TRUE

dosage adjustments of benzos for GAD should occur how often?

what is an adequate trial?

dosage adjustments: weekly

adequate trial: 3-4 weeks at max dose

what is the recommended duration of therapy with benzos for acute anxiety?

a. at least 1-3 months

b. at least one year

c. 6-8 weeks

d. 2-4 weeks

d.

which second line agent for GAD is effective for psychic symptoms of anxiety, but is NOT useful when needing immediate anxiolytic relief?

a. benzos

b. buspirone (buspar)

b.

what is a reason for poor adherence with buspirone (buspar) for GAD?

dosed 2-3 times/day

_______ increase levels of buspirone (buspar)

a. CYP3A4 inducers

b. CYP2D6 inducers

c. CYP2D6 inhibitors

d. CYP3A4 inhibitors

d.

______ may increase blood pressure and cause hypertensive crisis when taken with MAOI

buspirone (buspar)

when do we see full therapeutic benefit from buspirone for GAD?

a. 4-6 weeks

b. one year

c. 6-8 weeks

d. 2-4 weeks

a.

how often should patients be monitored initally with GAD?

every 2 weeks

T/F initial pharmacotherapy with an SSRI will NOT lead to remission of GAD

TRUE

checkpoint

which neurotransmitter is the primary inhibitory regulator in the CNS and is targeted by benzos?

a. serotonin

b. dopamine

c. norepinephrine

d. GABA

d.

checkpoint

which of the following medications is considered first-line for the treatment of generalized anxiety disorder (GAD)?

a. alprazolam

b. buspirone

c. duloxetine

d. hydroxyzine

c.

how does panic disorder begin?

what is it followed by?

begins as a series of unexpected panic attacks involving an intense, terrifying fear similar to that caused by life-threatening danger

followed by at least 1 month of persistent concern about having another panic attack, worry about possible consequences, or a significant behavioral change related to attacks

about 70% of patients with panic disorder may develop __________

agoraphobia: anxiety about being in places or situations in which escape might be difficult or where help might not be available in the event of a panic attack

basically patients avoid specific situations where they think a panic attack will happen

list the diagnostic criteria for PD

discrete period of intense fear or discomfort, in which ≥ 4 of he following symptoms developed abruptly and reached a peak within 10 minutes

• palpitations, pounding heart or incr. heart rate

• sweating

• trembling or shakine

• sensations or SOB

• feeling of choking

• chest pain/discomfort

• nausea or abdominal distress

• feeling dizzy, unsteady or faint

• derealization or depersonalization

• fear of losing control

• fear of dying

• paresthesias

• chills or hot flushes

T/F after pharmacotherapy for PD, less than 50% of patients have occasional panic attacks

FALSE - over 50% of patients have occasional panic attacks