Anxiety and ADHD

pathophys of GAD

increased glutamate, decreased GABA

generalized anxiety disorder

• excessive/persistent/unrealistic fear

• female, stress, FH

• neurotransmitter signal alteration, amygdala problems

• decreased serotonin

• fear that is NOT focal to specific situation

• somatic vague symptoms + psych symptoms

• first line is LIFESTYLE and CBT

• 1st line meds: SSRI, SNRI

  • benzos: alprazolam, lorazepam = bridge meds

  • buspirone: no sedation, 2-3 wk lag

social anxiety disorder

• out of porportion fear of social situations

• limbic system dysregulation

• fear of evaluation + somatic symptoms

• CBT

• antidepressants, benzos, B blockers

panic disorder

• recurrent panic attacks

• chemical imbalance

• panic attack = somatic + psych symptoms

• criteria

  • concern for future panic attacks

  • implications

  • maladaptive repsonse

SSRIs

• block serotonin reuptake, selective for SERT

• MDD, OCD, PD, PTSD, GAD, SAD

• start low and go slow

• CYP inhibitors

• sexual dysfunction, weight gain, GI problems

• serotonin syndrome if paired with MAOI

• may get worse before it gets better (give it 4-6 wks)

• increased suicide risk in pts < 25 yo

• can add pregabalin for more benefit

SNRIs

• inhibits serotonin and NE, weak inhibitor of dopamine reuptake

• GI problems, sex dysfunction, serotonin syndrome if taken with MAOIs, avoid with glaucoma

• increased suicidality in under 25 yo

• withdrawal

• gets worse before it gets better

what are the two SNRIs?

venlafaxine, duloxetine

benzodiazepines

• bind to GABA and enhances

• GAD, PD, situational anxiety

• respiratory depression, hyper/hypo, impaired cognitive and motor

• NO using opioids with it

• addiction

• dependence and withdrawal

• avoid in the elderly

short acting benzos

alprazolam

oxazepam

midozalam

less than 24 hr half life

intermediate acting banzos

lorazepam

clonazepam

12-40 hr half life

long acting benzos

diazepam

chlordiazepoxide

40-250 hr half life

why is diazepam special?

many routes: IM, IV, rectal, PO

alcohol withdrawal

buspirone

• MOA unknown, partial serotonin agonist, D2 dopamine receptor agonist

• GAD chronic

• low abuse potential

• good for geriatric

• serotonin syndrome with MAOI

• CI with renal and hepatic impairment

B adrenergic antagonist

• non selective antagonist, B 1 and 2 adrenergic receptors

• performance anxiety

• hypotension, bradycardia, wight gain, hyperlipedemia, trigger MI if abruptly stopped

• acute treatment

propanolol dosing

10-40mg PO x1, 1 hr before event

ADHD requirements for diagnosis

at least 6 symptoms for 6 mo, before 12 yo, at least 2 settings, impair function, not age appropriate

first line for ADHD? second? third?

stimulants, norepinephrine reuptake inhibitors, alpha 2 agonists

CNS stimulants

• increases dopamine in the synapse

• stimulates CNS, blocks reuptake, increases release of NE and dopamine

• growth limited first 1-3 yrs

• insomnia, appetite decrease, nausea, crying, nervous

• BBW abuse

• CI in severe heart disease

• caution with psychosis, bipolar, tourettes

• monitor height

4 CNS stimulants

methylphenidate

dextroamphetimine/amphetimine

doxmethylphenidate

lisdexanifetamine (prodrug)

norepinephrine reuptake inhibitors

• selectively inhibits NE reuptake

• no abuse!

• SE: psychosis, aggression, depression, HTN, QT long, MI, HA, ab pain, somnolence

• use with substance abuse

• BBW: suicidality in kids

norepinephrine reuptake inhibitor drug

atomoxetine

alpha 2 agonists

• stimulants alpha 2 adrenergic receptors

• combined with stimulants

• helps aggressive and explosive behavior

• decreases tics

• sedation, HA, fatigue, ab pain, hypo

alpha 2 agonists example meds

clonidine

guanficine

clonidine dosage and major side effect

TAPER 0.1mg every 3-7 days

can cause rebound HYPERTENSION

preschool treatment steps

behavioral → methylphenidate

kids 6-11 yo treatment steps

stimulant → atomoxetine → ER guanficine → ER clonidine

adults

stimulant → atomoxetine

escitalopram - use

GAD

paroxetine - use

GAD, PD, SAD, PTSD

fluoxetine - use

PD only

venlafaxine - use

GAD, PD, SAD

sertraline - use

(off label gad), PD, SAD, PTSD

duloxetine

GAD only

buspirone

GAD only