Anxiety

What is the lifetime prevalence of anxiety related disorders in adults ages 18-64?

33%

What is the median age of onset of GAD?

31 years

Which psychiatric comorbidities occur most frequently with anxiety disorders?

- depression

- alcohol and substance use disorders

- other anxiety disorders

What causes anxiety?

environmental factors, genetic factors, adverse life events

What are some factors that increase risk for anxiety?

- female

- loneliness

- adverse parenting

- chronic somatic illness

What is the essential feature of GAD?

excessive anxiety or worry involving multiple events or activities occurring more days than not for at least 6 months

Symptoms of GAD

- restlessness

- easily fatigued

- poor concentration or mind going blank

- irritability

- muscle tension

- insomnia or unsatisfying sleep

What psychiatric disorders may contribute to anxiety symptoms?

- mood disorders

- hypochondrias

- personality disorders

- alcohol or substance use

- alcohol or substance withdrawal

What neurologic disorders may contribute to anxiety symptoms?

- stroke

- seizure disorders

- dementia

- migraine

- encephalitis

- vestibular dysfunction

What cardiovascular disorders may contribute to anxiety symptoms?

- angina

- arrhythmias

- congestive HF

- mitral valve prolapse

- MI

What chronic pain conditions may contribute to anxiety symptoms?

- neuropathic and nociceptive pain

- fibromyalgia

- radicular and arthritic pain

What endocrine/metabolic disorders may contribute to anxiety symptoms?

- hypo/hyper thyroidism

- hypoglycemia

- Cushing/Addison disease

- pheochromocytoma

- hyperadrenocorticism

- hyponatremia

- hyperkalemia

- vitamin B12 deficiency

What respiratory disorders may contribute to anxiety symptoms?

- asthma

- COPD

- pulmonary embolism

- pneumonia

- hyperventilation

What medications are associated with anxiety symptoms?

- anticonvulsants

- antidepressants

- antihypertensives

- antimicrobials

- antiparkinson drugs

- bronchodilators

- corticosteroids

- decongestants

- herbals

- NSAIDs

- stimulants

- thyroid hormones

- toxicity

- withdrawal of CNS depressants

What are the goals of therapy for GAD?

reduce severity and duration of anxiety symptoms and restore overall functioning

Long term goal for GAD

achieve and maintain remission

Non-pharm therapies for GAD

- exercise

- stress management

- psychosocial therapies

- avoid things that could potentiate anxiety

Why are antidepressants the drugs of choice for GAD?

- tolerable side effects

- no risk for dependency

- efficacy in common comorbid conditions

Which symptoms of anxiety do antidepressants reduce?

cognitive (worry and apprehension)

What is the onset of anti anxiety effect with antidepressants?

2-4 weeks

1st line antidepressants for GAD

SSRIs or SNRIs

If 1st line for GAD fails -->

switch to another SSRI or SNRI

If second try at SSRI/SNRI fails for GAD -->

switch to a different agent:

1. SSRI/SNRI

2. imipramine

3. buspirone

4. pregabalin

Which SSRIs are used in the management of GAD?

- citalopram

- escitalopram

- fluoxetine

- fluvoxamine

- paroxetine

- sertraline

Which SNRIs are used in the management of GAD?

- venlafaxine

- desvenlafaxine

- duloxetine

Which TCAs are used in the management of GAD?

imipramine

Other agents used in the management of GAD

- buspirone

- hydroxyzine

- pregabalin

- gabapentin

- quetiapine

How long should BZDs be used in GAD treatment?

short term --> 2-3 weeks

Which symptoms of anxiety are BZDs more effective for?

somatic symptoms

What are the disadvantages of BZDs?

- risk for withdrawal

- potential interdose rebound anxiety

- risk for abuse and dependence

MOA: BZDs

enhance the action of GABA at the GABAa receptor

Which BZDs are preferred for pts with reduced hepatic function secondary to aging or disease?

lorazepam and oxazepam (bypass hepatic oxidation)

What are common s/e of BZDs?

- CNS depressant effects (drowsiness, sedation, psychomotor impairment, ataxia)

- Cognitive effects (poor recall, confusion, irritability, anterograde amnesia)

MOA: gabapentinoids

Blocks Ca2+ channel which decreases glutamate release

Pregabalin efficacy for GAD

favorable efficacy in acute and chronic treatment of GAD

Gabapentin efficacy for GAD

mixed evidence supporting efficacy in GAD

Gabapentinoid examples

pregabalin, gabapentin

MOA: buspirone

5-HT1a partial agonist (reduces presynaptic 5-HT firing)

How does buspirone differ from BZDs?

no abuse potential, withdrawal symptoms, or potentiate alcohol and sedative hypnotic effects

Onset of action of buspirone

gradual --> 2 weeks

A/E: buspirone

dizziness, drowsiness, nausea, HA