Treatment of Anxiety

What medical conditions can be associated with anxiety symptoms?

-CVD: angina, arrythmias, CHF, hypertension, MI

-Endocrine and metabolic: hyperthyroidism, hypothyroidism, diabetes.

-GI: IBS, Chron’s, ulcerative colitis

-Neurologic: migraine , seizures, stroke, neoplasms, poor pain control

What can be drug induced anxiety?

-happens with the use of CNS stimulating medications ( dose dependent)

-onset is usually rapid after the initiation/change in dose of medication.

What are medications that can cause anxiety?

amphetamines

appetite suppressions

asthma medications

caffeine

nasal decongestants

steroids

CNS depressants

What is generalized Anxiety Disorder?

patient has excessive anxiety and worry about a number of events or activities for a period > 6 months

-patient has difficulty controlling the worry.

-patient has at least 3 of the following symptoms:

• restlessness or feeling keyed up or on the edge

• easily fatigued

• difficulty concentrating

• irritability

• muscle tension

• sleep disturbances

-patient has clinically significantly distress or impairment

What are some psychic symptoms of generalized anxiety disorder?

-worry

-sense of dread

-irritability

-restlessness

-difficulty concentrating

What are some somatic symptoms of generalized anxiety disorder?

-muscle pains and aches

-dry mouth

-sweating

-dizziness

-tachycardia

-dyspnea

-nausea/diarrhea

-frequent urination

What are panic attacks?

-and abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.

A person is considered to have a panic attack after presenting with > 4 of the following somatic and cognitive symptoms:

palpitations/tachycardia

sweating

trembling/shaking

sensation of SOB

feelings of choking

chest pain or discomfort

nausea

feeling dizzy/faint

chills/heat sensations

numbness/tingling

derealization

depersonalization

fear of losing control

fear of dying

What is panic disorder?

-patient has recurrent unexpected panic attacks.

-At least one of the attacks has been followed by 1 month or more of one or both of the following:

• persistent concern or worry about additional panic attacks or their consequences

• a significant maladaptive change in behavior related to the attacks

What is social anxiety disorder?

-marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.

Signs and symptoms of Social Anxiety Disorder:

-the social situations almost provoke fear or anxiety

-social situations are avoided or endured with intense fear

-fear or anxiety is out of proportion to the actual threat posed by the social situation

-fear, anxiety, or avoidance is persistent, typically lasting at least 6 months

-the fear , anxiety, or avoidance causes clinically significant distress or impairment

-some have performance only SAD

-fears and anxiety associated with SAD are confined to social situations; patients are typically symptoms-free when alone

-usually begins in teenage years and can greatly interfere with development of social skills and achievement of full academic and career potentials

-Very high risk of comorbidity and suicide attempts

What is OCD?

-obsessions: is the thought

• recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbances, as intrusive and unwanted and in the most individuals caused marked anxiety or distress

• examples:

  • contamination, pathological doubt, somatic , order/symmetry, sexual, aggressive

-compulsions: is the action

• are repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rigid rules.

• Examples:

  • cleaning , hoarding, counting, repeating words

How do you diagnosis OCD?

-diagnosis requires the presence of obsessions, compulsion or both.

-the obsessions or compulsions are time-consuming ( > 1 hr/day) or cause clinically significant distress or impairment

What is PTSD?

-exposure to actual or threatened death, serious injury or sexual violence via either:

• directly experiencing the trauma

• witnessing the trauma occurred to a close family member/friend

  • experiencing repeated or extreme exposure to aversive details of the trauma

How do you diagnosed PTSD?

-diagnosing requires symptoms from 4 clusters:

• intrusion of symptoms: distressing, memories, nightmares, flashbacks

• avoidance symptoms: avoidance of memories, thoughts, or feelings about the trauma, avoidance of external reminders

• Cognition and mood symptoms: inability to recall and important aspect of the trauma, exaggerated negative beliefs, negative emotional state, anhedonia, feelings of detachment

• Arousal and reactivity symptoms: irritability, anger outburst, self destructive behavior, hypervigilance, exaggerated startle reflex

-duration of disturbance is more than 1 month

-causes clinically significant distress o impairment

Different conditions that may cause anxiety:

-situational anxiety: normal response to a stressful situation

-medical conditions: such as thyroid, MI, CHF, IBS, COPD

-psychiatric disorders: anxiety may be a symptom of an underlying psychiatric disorder

-substance-induce: CNS stimulant use or CNS depressant withdrawal

What is the prognosis of anxiety disorders?

-chronic in nature but symptoms tend to wax and wane

-frequent comorbidity with depressive disorders, substance use disorders, and other anxiety disorders

-hospitalization is infrequent, but anxiety disorders cause decreased quality of life and impaired functioning.

BZDs used for anxiety disorders:

-alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, lorazepam, oxazepam

Which anxiety disorder do you not use BZDs in?

-PTSD or OCD

These anxiety disorders have established efficacy of use of BZDs:

-Generalized anxiety disorder

-Panic Disorder

-Social anxiety disorder

Which BZDs are good for people with hepatotoxicity because they are liver friendly?

-lorazepam and oxazepam ( they skip phase I and go straight to phase II metabolism)

These BZDs are long acting, cause less severe withdrawal, but can accumulate and cause daytime sedation:

-diazepam

-chlordiazepoxide

-clorazepate

These BZDs are used for anxiety disorders but they are faster acting and have increased risk of withdrawal:

-alprazolam

-clonazepam

What can impair the oxidation of BZDs?

-aging

-liver disease

-drug interactions

BZDs side effects:

-CNS effects:

• sedation

• fatigue

• difficulty concentrating, memory problems

• ataxia

• psychomotor slowing

• falls

• paradoxical excitement ( especially in elderly)

• respiratory depression

Medications that can decrease BZDs concentractions:

-carbamazepine

-rifampin

-smoking

Medications that can increase the BZD levels:

-cimetidine

-erythromycin

-fluoxetine

-isoniazid

Medications if taking with any BZD can increase the CNS depression effects:

-antihistamines

-antidepressants

-barbiturates

-ethanol

-opiates

What dosage of BZD is needed to treat panic disorders?

-higher dosage of BZDs

BZDs dosing strategy to treat anxiety:

-start at low doses in divided schedule

-titrate every 2-4 days according to anxiolytics, side effects, max dose recommended

What are withdrawal symptoms of BZDs?

-frequent:

• anxiety , insomnia, irritability, muscle aches

-common:

• nausea, depression, ataxia, fatigue

-rare:

• seizures, psychosis, delirium

True/False: withdrawal is more likely to occur and be severe in cases involving higher dosages and/or longer durations of therapy

-True

How can you reduce the risk of withdrawal with BZDs?

-discontinue BZDs gradually , by 1/8 to ¼ of the total daily dose every 1-2 weeks

-rate should be individualized to the patient

-first half of taper is generally easier and quicker than the last half of taper.

-total taper should take 2-4 months.

This medication is the only drug used in monotherapy for generalized anxiety disorder:

-buspirone

What are some adverse effects of buspirone?

-no significant sedation, no cognitive impairment or psychomotor difficulties

-no sexual dysfunction

-can cause nausea, dizziness, and headache

Dosing for Buspirone:

-given twice a day - three times a day

-initial dosage is 15 mg/day

-can be titrated upward by 5 mg/day every 2-3 days

-maximal dose: 60 mg/day

Does buspirone cause withdrawal or abuse?

-not seen

What is the first line medications for generalized anxiety disorder?

-antidepressants

Antidepressants in GAD:

-are 1st line and treatment of choice of chronic anxiety

-paroxetine, escitalopram, venlafaxine XR, and duloxetine are FDA approved treatments

-TCas are limited use

-Mirtazapine can be used

When do antidepressants work to show efficacy in anxiety?

-takes 2-4 weeks to see maximal effectiveness

When medications are used as bridge therapy to help treat generalized anxiety disorder?

-BZDs

What is the use of BZDs in generalized anxiety disorder?

-helps to reduce somatic symptoms more than psychic symptoms

-patients have a decrease in symptoms within hours to days

-used as bridge therapy , which is short term for 2-6 weeks therapy for acute anxiety effects during initiation of antidepressant treatment

What is used second line to help treat generalized anxiety disorder?

-Buspirone

What is the use of buspirone in generalized anxiety disorder?

-2nd line to treat generalized anxiety disorder

-more effective in treating psychic symptoms of anxiety than BZDs

True/False: Buspirone must be given routinely and not prn for treatment of generalized anxiety disorder

-True

How long does it take buspirone to work in the treatment of generalized anxiety disorder?

-may take up to 4-6 weeks to see optimal results

This medication is given in generalized anxiety disorder to help with physical symptoms ( tremor and tachycardia):

-propranolol

What are considerations in making a medication selection for treatment of generalized anxiety disorder?

-need for rapid relief

-comorbidities

-past/present substance abuse

-adverse effect profile

-potential drug interactions

-medication cost

How long does it take for BZDs to work to help treat panic disorder?

-takes 1-2 weeks to work

What are the BZDs that are FDA approved medications to treat panic disorder?

-alprazolam

-clonazepam

What medication is 2nd line expect in severe cases to treat panic disorder?

-BZDs

What is considered 1st line therapy to treat panic disorders?

-antidepressants

Which antidepressants are FDA approved to treat panic disorder?

-paroxetine

-sertraline

-fluoxetine

-venlafaxine XR

How long does it take antidepressants to work in order to treat panic disorders?

-4-6 weeks

What are the advantages of antidepressants vs. BZDs in treatment of panic disorders?

-no abuse potential

-antidepressant efficacy as well as antipanic efficacy

What are the disadvantages of antidepressants vs. BZDs in treatment of panic disorder?

-slower onset of response

-initial hyperstimuatory effects

What medications are ineffective in treatment of panic disorder?

-buspirone

-bupropion

-trazadone

When are combination drugs used to treat panic disorder?

-treatment resistance

Which TCAs are used in panic disorder?

-imipramine and clomipramine

Which medication is 2nd line to treat social anxiety disorders?

BZDs

Which BZDs are used in social anxiety disorders?

-alprazolam and clonazepam

How long does it take for BZDs to work in social anxiety disorer?

-within 2 weeks

Which antidepressants are FDA approved to treat social anxiety disorder?

-sertraline

-fluvoxamine

-paroxetine

-venlafaxine XR

How long does it take antidepressants to work to help with social anxiety disorder?

-12 weeks

This class of medications are used to help with performance anxiety seen with social anxiety disorder:

-beta blockers:

• propranolol: 10-80 mg

• atenolol: 25-50 mg

• can be giving 1-2 hours before performance activity

What are other medications used in social anxiety disorder?

-bupropion

-pregabalin

-gabapentin

-tiagabine

-levetiracetam

Which medication is not effective in social anxiety disorder?

-TCAs

What are the FDA approved treatments for OCD?

-clomipramine

-fluoxetine

-sertraline

-paroxetine

-fluvoxamine

When can you used clomipramine to help with OCD?

-after 2-3 failed trials of SSRIs

What are second line medications for OCD?

-venlafaxine and mirtazapine

What medications can be used as augmentation strategies to treat OCD?

-SGAs (risperidone, olanzapine, quetiapine)

-Pindolol

-Clonazepam

-Lithium

-Buspirone

If you decide to use SSRIs + clomipramine, what must you look out for:

-serontonin syndrome

How long does it take to see a response from medication therapy used to treat OCD?

-3-4 weeks, but adequate trial is considered 8-12 weeks max

Treatment goals of PTSD:

-reduce core symptoms: intrusion, avoidance, cognition/mood, arousal/reactivity

-reduced comorbid symptoms

-improve quality of life

-improve overall functioning

1st line treatment for PTSD

-antidepressants

What SSRIs are FDA approved to treat PTSD?

-sertraline and paroxetine

TCAs in PTSD treatment:

-found to be effective

-concerns with adverse effects and risk for overdose

What medications can be used as augmentation to treat PTSD?

-antiadrenergic:

• used for nightmares, sleep disturbances

• Prazosin, Clonidine

-Anticonvulsants:

• used for irritability , impulsivity, anger, aggression

• Valproic acid, Carbamazepine, Lamotrigine, Topiramate, Gabapentin

-SGAs:

• used for dissociative symptoms and sleep disturbances

True/False: PTSD has high substance abuse comorbidity

-True

How long does it take pharmacotherapy to work for PTSD treatment?

-improvement may be noted in the first two weeks

-improvement continues over about 8-12 weeks

How long should a person continue therapy for anxiety disorders?

-they should take medication for 12 months, and then gradual attempt discontinuation phase

-some patients may require many years of therapy

Patient counseling points for BZDs:

can cause sedation: caution while driving

possibility of withdrawal if abruptly discontinued

do not take with alcohol or other CNS depressants

Patient counseling for buspirone and antidepressants:

-do not use PRN.

-Used as regularly scheduled

-may take several weeks before beneficial effects are seen

-may make anxiety worse before it gets better.