T2 EX6 L2 (ANXIETY PT. 1) (JOHNSON)

3 major anxiety disorders?

GAD

Social anxiety disorder (SAD)

Panic disorder (PD)

2 major stress disorders?

OCD

Post-traumatic stress disorder

Role of amygdala in anxiety disorders?

Emotional memory and processing fear

Overactivity in area worsens anxiety

Role of prefrontal cortex in anxiety disorders?

Decision making, personality development and higher order thinking

When dysfunctional will be unable to control anxiety

Role of hippocampus in anxiety disorders?

Episodic memory and recall

Chronic stress and anxiety can lead to affecting memory and emotional regulation

Serotonin levels ___________ in anxiety (increased, decreased?)

decreased

Norepinephrine levels __________ in anxiety (increased, decreased?)

increased

GABA levels ___________ in anxiety (increased, decreased?)

decreased

Dopamine levels ___________ in anxiety (increased, decreased?)

Dysregulated (all over the place, nice try bub)

DSM-5 criteria for diagnosis of GAD

Excessive anxiety and worry almost daily for 6 months or more, about numerous events or activities

Anxiety and worry associated with at least 3 of the following:

Restlessness

Being easily fatigued

Difficulty concentrating or mind going blank

Irritability

Muscle tension

Sleep disturbance

Screening tools used to assess anxiety severity? (three)

GAD-7

HAM-A

Beck anxiety inventory (BAI)

First line pharmacological treatment of GAD generally... (per BAP, NICE, etc.)

CBT first line

SSRI, SNRI,

BZD short-term

TCA

Potentially pregabalin, quetiapine

Second line pharmacological treatment of GAD generally... (per BAP, NICE, etc.)

Try sum u havent tried yet

World Fed says TCAs and BZDs are second-line

Third-line pharmacological treatment of GAD generally... (per BAP, NICE, etc.)

BZD if unresponsive to SSRI/SNRI

Mix in some CBT with pharmcotherapy

Pregabalin?

World Fed says buspar, augment with SGA (risp, olan)

What symptoms does CBT target? (three)

Intolerance of uncertainty

Poor problem solving

Worry helps deal with problems

Strongest evidence for treating GAD has been seen with... (four)

SSRIs

SNRIs

Pregabalin

Some SGAs

T/F: Imipramine shows great efficacy in treatment of GAD but is considered second line.

True

When do we like BZDs for GAD?

BZDs for acute relief, and for treatment of resistant cases in the absence of use

Things to consider when selecting treatment for a patient with GAD? (seven)

1. Patient age

2. Previous response to treatment

3. Risks

4. Potential for overdose

5. Tolerability

6. Patient preference

7. Cost

About how long are BZDs recommended for acute management of GAD?

1-2 wks

What agents do we employ for chronic management of GAD?

SSRIs - paroxetine, escitalopram

SNRIs - venlafaxine, duloxetine

Others - buspirone, hydroxyzine

How do we approach Klonopin dosing in elderly with GAD?

Decrease usual dose by 50%

Applies to hepatic impairment as well

How do we approach Valium dosing in hepatic impairment?

Dec. usual dose by 50%

Which two screening tools for GAD are patient rated? Which of the three we use is clinician rated?

GAD-7, BAI self-rated

HAM-A, clinician rated

T/F: Omeprazole increases conc. of diazepam and prolongs t1/2.

True

Valproic acid, probenecid affect lorazepam levels how?

Decrease clearance, inc. levels

Three BZD of choice in elderly?

Lorazepam

Oxazepam

Temazepam

T/F: BZD use should not exceed six months, and be tapered upon discontinuation.

True

T/F: Take venlafaxine w/ food.

True

T/F: Venlafaxine has dose-dependent increase in blood pressure (>300 mg).

True

T/F: Upon SNRI initiation, anxiety may worse before it improves.

True

How long until SNRI effects for GAD are seen?

4 wks

Symptoms of antidepressant discontinuation syndrome? (seven)

GI upset

Light-headedness

Headache

Flu-like symptoms

Sweating

Electric/shock-like sensations

Tremor

+ more

How does antidepressant discontinuation syndrome happen?

Begins 1-3 days after abrupt D/C of a serotonergic drug, and may last 1-2 weeks

How do we avoid antidepressant discontinuation syndrome?

Taper down gradually over time buddy duh

MOA buspirone?

5-HT1A partial agonist (presynaptic)

Side effects associated with buspirone? (six)

Confusion

Dizziness

Excitement

Hostility

Blurred vision

Nervousness

Buspirone place in GAD therapy?

Second line

Hydroxyzine place in GAD therapy?

First line

For how long is hydroxyzine therapy considered effective?

12 wks

T/F: Hydroxyzine contraindicated in conditions where anticholinergic effect would worsen disease.

True

Side effects associated with hydroxyzine?

Anticholinergic

MOA of hydroxyzine?

H1 receptor antagonist, 5-HT2 receptor antagonist

Place in GAD therapy for pregabalin?

First-line (in one guideline I guess)

T/F: Lyrica effective in the short-term treatment of GAD.

True

Describe a panic attack

A distinct period of intense fear or discomfort when 4 or more symptoms developed suddenly and achieve a peak within 10 minutes

MAAAANy symptoms, dont worry about this bro

SOB, choking, chest pain, trembling, fear of dying, fear of going crazy, etc. are just some

DSM-5 criteria for diagnosis of panic disorder (PD)?

Recurrent unexpected panic attacks with at least one of the attacks being followed by a month or longer of at least 1 of the following

Constant concern about another attack

Being anxious about implications of attack

Maladaptive changes in behavior designed to avoid having panic attacks

Panic attacks are not caused by the direct effects of a substance, another psychiatric disorder, or medical condition

Screening tools (2, clinician rated) for PD?

Panic Disorder Severity Scale (PDSS)

PRIME-MD

First line for treatment of PD is generally... (per BAP, NICE, World Fed)

Get some CBTs done

SSRIs, SNRIs

BZDs

TCAs

Second line for treatment of PD is generally... (per BAP, NICE, World Fed)

Try sum new if after 3 months no dice

TCAs here too, mostly second-line due to adverse effects

BZDs too per World Fed

Third line treatment of PD is generally...

All over the place

some say SGAs, some say group CBT? some say lithium + clomipramine, etc

T/F: All SSRIs work in PD, but only fluoxetine and sertraline are FDA approved.

True

Role of Effexor XR in PD therapy?

FDA approved for short and long term treatment of PD

When can we start trying MAOIs in PD?

Only when other depressants have not been working

Mirtazapine role in PD therapy?

Only really used when patients have comorbid insomnia

Most-used BZDs in PD?

Klonopin

Xanax

T/F: BZDs should not be used as monotherapy in patients with a history of depression

True, why not just add an antidepressant if its gonna help both

T/F: Avoid BZDs in patients with a substance or alcohol use disorder.

True

When used as monotherapy, when can full benefit of BZDs be seen?

4-6 weeks

Acute therapy phase of PD is typically how long?

1-3 months

During acute therapy phase of PD, when do we know we need to alter therapy?

No response after 6-8 weeks at maximally tolerated dose

T/F: Patients who respond to PD therapy should continue medication at the full dosage for at least 1 year; if residual symptoms continue, the medication should be continued or titrated.

True

Talk to me bout transcranial magnetic stimulation (TMS)?

Promising non-invasive treatment for panic disorder

Magnetic pulses at a higher frequency over a shorter period

Deep TMS goes deep

DSM-5 Criteria for diagnosis of SAD?

Marked fear or anxiety about 1 or more social situations where the individual is exposed to possible scrutiny by others (eating or drinking)

Individual fears that showing anxiety symptoms or acting in a way that will be negatively evaluated

Social situations typically provoke anxiety or fear

Social situations are avoided or endured with anxiety or intense fear

Anxiety or fear is out of proportion to the actual threat posed by the social situation and to the sociocultural context

Screening tools for SAD? (two, one self and one clinician rated)

SPAI (self)

LSAS (clinician)

How long should CBT last for (at least) in SAD therapy?

12 wks

First-line treatment for SAD is generally... (per BAP, NICE, World Fed)

SSRIs goated

SNRIs pretty good

Second-line treatment for SAD is generally... (per BAP, NICE, World Fed)

Try sum else, like venlafaxine

Klonopin pretty accepted here too

Third-line treatment for SAD is generally... (per BAP, NICE, World Fed)

Augment with buspar, add phenelzine, citalopram, gabapentin

T/F: Paroxetine and sertraline FDA approved for SAD.

True

When do we use propranolol for SAD?

Nongeneralized performance-related SAD

like if you were scared because you had to sing in a concert

When do we know we need to increase a dose in SAD?

If no/not adequate response to 4 weeks of therapy

How long should pharmacotherapy be continued in SAD?

1 year or longer to prevent relapse

Ashley is a 26-year-old grad student who presents to your clinic with a chief complaint of "my heart is about to jump out of my chest." While shopping at Whole Foods, she developed sudden onset of racing heart, shortness of breath, tingling in hands and feet, and a fear of dying. The symptoms came on suddenly "out of the blue." The feeling was so intense that she had to leave the cart full of groceries in the store and drive straight to the mental health clinic.

Upon interview, she reveals that this has happened 4 times in the past2 months. She states that the fear of having another of these attack sis affecting her job performance and relationship with family. Based on clinical presentation, the patient most likely meets DSM-5 criteria for which of the following anxiety disorders?

a. GAD

b. SAD

c. PD

d. OCD

C. PD

Based on the diagnosis made (PD, no comorbidities, no DDIs, no preference revealed) what is the best medication to initiate for Ashley current condition in your office?

A. Mirtazapine 15mg PO qhs

B. Alprazolam 0.5mg PO daily PRN

C. Refer Ashley to CBT

D. Fluoxetine 20 mg PO daily + Buspirone 10mg PO twice daily

B. Alprazolam 0.5 mg PO daily PRN

A - may be appropriate with insomnia, CBT

C - Not gonna solve any problems on its own

D - not recommended to augment with buspar until 3rd line

What are 3 symptoms that must be present for a diagnosis for GAD?

Difficulty concentrating, mind blanks

Irritability

Restlessness

Easily fatigued

Muscle tension

What SSRIs are FDA approved for GAD? (two)

Paroxetine, escitalopram

What is the most common self rated tool used in GAD screening?

GAD-7

DSM-5 diagnostic criteria for PTSD?

Exposure to a traumatic event, followed by..

Occurrence of intrusive symptoms (dissociative, recurrent dream)

At least ONE avoidance symptom (avoiding activities, thoughts, memories)

At least TWO changes in cognitions and emotions (trouble with recall, negative feeling about self or others)

At least TWO hyperarousal symptoms (easily startled, irritable, self-destructive)

Last for at least 1 mth

Impair social functioning

Not be caused by another medical condition or the use of a substance

Panic attacks last how long, peak when?

Peak at 10 minutes, last around 30-45 minutes

Jacob has been bullied and pushed on the ground everyday since 4th grade because he wears clothes that don't fit him. Sometimes he has cuts and bruises from falling on the ground. He tells his parents he doesn't want to go to school or socialize anymore.

Does this meet criteria for a PTSD "Traumatic Event"?

No, I don't think this qualifies as threatened death, serious injury, sexual violation

Still not cool, sorry Jacob bro

Acute stress reaction post-traumatic event is defined as...

Symptoms persist 0-2 days after the event

Acute stress disorder post-traumatic event is defined as...

Symptoms 2-30 days after event

Acute PTSD post-traumatic event is defined as...

Symptoms 1-3 mths after event

How do we define chronic PTSD?

Symptoms >3 mths after traumatic event meeting DSM-5 criteria

Samantha was at school when an earthquake erupted. Several classmates were injured during the disaster. A month later she moved from her apartment by the railroad tracks due to increased panic attacks Does this meet criteria for a PTSD "Traumatic Event"?

Yea it does cause she witnessed many of her classmates get injured, there was a reality of death or serious harm, and she has since taken drastic measures to avoid triggers

Rebecca was in the army for many years. Her unit was never in combat, but over the course of 2 years, she saw several other women in her unit sexually assaulted or threatened during deployments to Afghanistan. Does this meet criteria for a PTSD "Traumatic Event"?

Yea definitely, witnessing sexual violation counts toward the criteria

PTSD screening tools?

PC-PTSD

PTSD checklist (PCL-5)

CAPS-5 (clinician administered, gold standard)

What are our main PTSD treatment drugs? (three, with MODERATE evidence)

Sertraline

Paroxetine

Venlafaxine

What drug can we use for PTSD associated nightmares?

Prazosin

T/F: Trauma-focused CBT and EMDR are absolute first line for PTSD, followed by SSRI.

True

T/F: TCAs should be avoided if possible in patients with past suicide attempts.

True

Typical initial dose for paroxetine in PTSD?

20 mg

Typical initial dose for sertraline in PTSD?

50 mg daily

Max dose paroxetine for PTSD in adult patient <65?

50 mg

Max dose sertraline for PTSD in adult patient <65?

200 mg

Dosage adjustment for paroxetine with CrCl <30 or hepatic impairment of any severity?

Max 40 mg dose

Dose adjustment for sertraline in hepatic impairment?

Dec. dose by 50%

T/F: BZDs good for PTSD.

Not really bro no evidence

Blessica is a 30-year-old veteran who presents to your clinic with a history of PTSD, HTN, and Insomnia. She will begin CBT with a therapist in your clinic but would also like to start medication.

What is the most appropriate initial pharmacologic treatment for Blessica's post-traumatic stress disorder?

A. Sertraline 50 mg PO daily

B. Venlafaxine 150 mg PO daily

C. Imipramine 75 mg PO qhs

D. Fluoxetine 20 mg PO daily + olanzapine 5 mg PO qhs

A. Sertraline 50 mg PO daily

B - not a bad option maybe but not on our big 3

C - TCA not really in there for PTSD, may work in theory but not on the list

D - whats goin on here even