anxiety disorders 2

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what categories are anxiety disorders classified as?: GAD
PD
OCD
PTSD
SAD
what is the 1 year and lifetime prevelance rate of anxiety disorders?: 17% and 25% respectively
what is the normal age of onset for anxiety disorders?: before age of 30
GAD: more common in men or women?: women
what is the significance of family history?: anxiety disorders are more common in those having a fam hx of anxiety and depression
co-morbidity?: common
describe some proposed pathophys for anxiety d/o: Neurochemical theory
noradrengeric model
BZD model
Serotonin model
Neoroimaging theories
increased cortical act
decreased hippocampal volume
what are some medical d/o assoicated w/ anxiety: CV: angina, CHF, MI, arrhythmia
Endrocrine/metab: hyper/hypothyroid, hypogycemia, cushings
neurologic: CNS tumors, dementia, migraines, pain, parkinson's, seizure, stroke
respiratory:asthma, COPD, pulmonary embolus, infections
psych: depression, schizo
other:anemia, lupus
what drugs and substances are associated w/ anxiety?: CNS stims: caffeine, nicotine, cocaine, methylephenidate
CNS depressant w/drawl: EtOH, BZDs, narcotic agonists
ADRs:ADs, APs, bronchodilators, OTC sympathomimetics, steroids
describe the clinical presentation of GAD: excessive anxiety and worry, occurring more days than not for at least 6 months + 3 of:
restlessness, on edge
easily fatigued
difficulty concetrating
irritability
muscle tension
sleep disturbance
sx interfere w/ fx and are not due to substance or med condition
what are the goals of therapy for GAD: reduce the severity, frequency and duration of anx sx; imrove overall fx
what is tx for mild GAD?: psychotherapy
what is tx for mod-sev GAD?: psychotherapy + pharmacotherapy
what are some non-pharm strategies for GAD: avoid caffeine, drugs of abuse, stimulants
psychotherapy: cognitive behavioral therapy, coping mechanisms, relaxation therapy
describe pharmacotherapy for GAD: acute: BZDs
long term: buspirone, venlafaxine, paroxetine, escitalopram
3rd line: TCAs
3rd/4th line: MAO-Is
BZDs possess what 4 properties?: anxiolytic, sedative, anticonvulsant, muscle relaxant
what are the advantages of using BZDs?: ease of use
relatively low toxicity
rapid onset
what are the disadvantages of using BZDs?: adverse effects
potential tolerance/dependence
what is replacing BZDs for the treatment of many anxiety conditions?: ADs
what is the MOA of BZDs?: agonists of the GABA-BZD chloride recpt complex
after a single dose of BZDs, the primary determinant of onset and duration is what?: lipophilicity
lipophilic drugs (diazepam, clorazepate) have rapid effect and short duration
less lipophilic (lorazepam, oxazepam) have slower effect but longer duration
after multiple doses of BZDs, rate and extent of accumulation is fx of what?: 1/2 life and presence of active metabolites
avoid paranteral use of what 2 BZDs?: diazepam and chlordiazepoxide
parenteral administration of which BZD provides rapid, reliable and complete absorption?: lorazepam
which BZDs are good for pts w/ hepatic dysfx and the elderly and why?: lorazepam, oxazepam and temazepam b/c they are conjugated, they do not go through hepatic metabolism
which BZD undergoes nitroreduction?: clonazepam
which BZD is long acting?: diazepam (b/c of active metabolites?)
what side effects are associated w/ BZDs?: sedation, drowsiness, ataxia, lethargy, mental confusion, motor/cog impairment, disorientation, slurred speech, anterograde amnesia; rarely: paradoxical agitation, depressed respiration (usually when mixed w/ EtOH or TCAs)
what are some contraindications to BZD use?: alcohol intox, chronic pulmonary insufficiency, significant hep dx, sleep apnea, comorbid substance use d/o
what drug inx is of concern w/ BZDs?: EtOH - additive CNS depression
who is at greatest risk for abusing BZDs?: pharmacy students:)
individuals w/ h/o drug abuse
most commonly abused are alprazolam and diazepam
how long does it usually take for physical dependence to develop when taking BZDs?: 3 weeks
what are the w/drawl sx associated w/ BZDs?: anxiety, insomnia, seizure, muscle tension (opposite of drugs effects)
describe the difference in w/drawl sx for short t1/2 and long t1/2 BZDs?: short = intense sx, appear w/in 1-2 days
long = less intense, appear in 3-8 days
which effects of BZDs does tolerance develop to?: sedative, anticonvulsant, muscle relaxant
no tolerance to anxiolytic effect
describe a possible tapering strategy for d/c BZD therapy: 25% dose reduction per week until 50% of dose is reached, then decrease by 1/8 of dose each week
if on short acting, switch to long
true or false? tapering will eliminate w/drawl sx for BZDs?: False
what is second line therapy for GAD?: buspirone
describe the MOA of buspirone: 5-HT1a partial agonist
nonBZD anxiolytic lacking sed hyp, muscle relax, anticonvulsant properties
what are the advantages of using buspirone for tx of GAD: no abuse potential
no sedation or impairment of motor activity
what are the disadvantages of using buspirone?: long onset of effect
no cross tolerance to BZDs
previous BZD users may not feel they respond as well
how long does it take to see the effects of buspirone?: 1 month
what are the side effects of buspirone?: dizziness, nausea, HA
describe some drug inx w/ buspirone: CYP inhib increase drug levels
CYP inducers decrease
other serotonergic drugs may cause serotonin syndrome
describe the clinical presentation of panic disorder (PD): begins as a series of panic attacks; attacks followed by 1 month persistent concern about having another
pts seek medical assistance for "medical problems"
pts develop agoraphobia
avoid specific situation where they feel an attack may occur
describe a panick attack: discrete period of intense fear that develops and ends abruptly and has at least 4 of the following:
palpitations, sweating, shaking, SOB, choking, CP, nausea, dizziness, depersonalization, fear of losing control/going crazy, fear of dying, numbness, chills/hot flashes
what are the treatment goals for PD?: reduce/eliminate attacks
reduce duration/intensity of attacks
reduce/elim anticipation
prevent phobic avoidance
improve social/occupational fx
what are some non-pharm tx for PD?: avoid caffeine, DOAs and stims
psychotherapy: CBT - focus on correction of maladaptive thoughts and behaviors
what is first line treatment for PD?: SSRIs (start at 1/4 to 1/2 recommended starting dose)
how long does it take to see antipanic effects when using SSRIs for PD?: 4-6 weeks, up to 12 weeks
when are BZDs used as first line for PD?: pts requiring rapid relief of anticipitory anx and pts unable to tolerate SSRIs
how long does it take to see antipanic effects when using BZDs for PD?: 1 week
which two BZDs are commonly used in treating PD?: alprazolam and clonazepam
what agents besides SSRIs and BZDs may be used to tx PD?: venlafaxine
TCAs (imipramine, clomipramine)
MAO-Is
how long does it take to see antipanic effects when using TCAs for PD?: 4 weeks, up to 12 weeks
in which pts should tx for PD not be d/c'd: pts having:
severe panic d/o
h/o severe relapse
high levels of current stress
define obsessions: recurrent and persistant thought, impulses, or images that are intrusive, inappropriate and cause anxiety
not excessive worries about real life probs
attempts are made to ignore
recognized that they are product of person's own mind
define compulsions: repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession
aimed at preventing or reducing distress
what is recommended tx for mild OCD: psychotherapy
exposure tx
response prevention
what is recommended 1st line tx for mod/severe OCD? 2nd line?: SSRIs
clomipramine (after 2-3 failed SSRIs)
how long until improvements are seen in OCD sx?: 4-10 weeks
what other agents besides SSRIs and clomipramine may be used to tx OCD?: ondansetron
venlafaxine
what tx may be used to aumgment tx for OCD? (severe cases): atypical APs
risperidone, olanzapine, quetiapine
what are the four criteria for PTSD?: exposure to traumatic event
the event is re-experienced
persisten avoidance of stimuli associated w/ event
persistant sx of increased arousal
duration lasts more than one month
what are non-pharm recommendations for PTSD?: psychotherapy:
anxiety management
CBT
exposure therapy
what agents are 1st line in treating PTSD?: SSRIs
how long does is take to see a response in treating PTSD w/ SSRIs?: 8 weeks
PT MUST BE COMPLIANT!!!
what agents are used 2nd line in treating PTSD?: venlafaxine, mirtazapine
besides SSRIs and venlafaxine/mirtazapine, what other agents are used to treat PTSD?: trazadone/nefazodone
TCAs
Mood stabilizers
Antiadrengerics
Buspirone
APs
may require combo of drugs from ALL classes to control severe pts!
describe the clinical presentation of social anxiety disorder (SAD): fear of social/performance situations
exposure to situation provokes anxiety
person recognized that fear is excessive/unreasonable
situations are avoided or endured w/ intense anxiety
what are some non-pharm tx for SAD: CBT
exposure therapy
social skills training
what agents are first line in treating SAD?: SSRIs
how long does it take to see a response in treating SAD w/ SSRIs?: 4-8 weeks
what other agents besides SSRIs are used to treat SAD?: venlafaxine
BZDs
MAO-Is
propranolol
what agent is used for SAD prior to performance situations?: propranolol taken prn 1-2 hours before presentation/performance
MUST DO A TEST DOSE! pt may pass out

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