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Block 3 PSYCH Exam -- Anxiety Disorders (#13 - 14)


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Autonomic symptoms of anxiety
Inc. BP, HR, RR, muscle tension

Inc. levels of Epi, NE, GH, Cortisol, Prolactin
BDZs mechanism of action
Positive allosteric modulators of GABA
General effects of BDZs (5)
Muscle relaxant
BDZ-receptor antagonist
Block effects of BDZs

Used to reverse anesthesia and in cases of OD
BZ-1 Receptor location & effect

BZ-2 Receptor locations & effect
Hippocampus, Striatum, SC

Muscle relaxant
Zolpidem (Ambien)
BZ-1 selective agonist

Causes sedation
NO disruption of normal REM sleep pattern
This is especially dangerous when mixed with BDZs
BDZs that are reliably absorbed IM (2)
BDZ w/ the shortest half-life and thus most amnestic effect
Lorazepam key points
Given acutely to agitated pts.

Helps combat EPS from antipsychotics

NOTE: when given in combos, sedative effects are synergistic
Flurazepam key points
LONG half-life
Good for middle insomnia

NOTE: can cause some daytime sedation
Triazolam key points
SHORT half-life
Better for initial insomnia

Rarely assoc. w/ amnesia or behavior changes
Side effect of ALL BDZs except Zolpidem
Suppression of REM sleep and stages 3 and 4
BDZ side effects (4)
Mild cognitive impairment
Greater rate of falls (elderly)
When is it good to use BDZs that don't have active metabolites?

Which BDZs don't have them?
In liver disease

Lorazepam, Oxazepam, Temazepam
Risk factors for BDZ dependence (5)
History of alcohol dependence
Potency of medication
Duration of treatment
Rapidity of onset of CNS effects
Agents with shorter-effects
Most reasonable BDZs for routine use (2)
What are beta-blockers good for treating (2)?
Performance anxiety

NOTE: LESS effective for cognitive symptoms
(ie worry, expectation)
What is clonidine used to treat (2)?
Autonomic arousal in opiate withdrawal

MILDLY effective in anxiety disorders
(NOT 1st choice)
What part of the brain do SSRIs enhance 5HT activity in?
ALL areas of the brain
Generalized Anxiety Disorder requires 3 or more of the following
Restlessness (feeling "keyed up")
Being easily fatigued
Difficulty concentrating ("mind going blank")
Muscle tension
Sleep disturbance
Behaviorist theory about anxiety
Anxiety is a conditioned behavior
Psychoanalytic theory on anxiety
Sign of some unconscious conflict

"Signal anxiety" is a sign that repression is failing
Cognitive behavioral theory on anxiety
Pt. is anxious due to characteristic cognitive distortions
Characteristics common to BOTH depression and anxiety (5)
Heightened automatic info. processing
Maladaptive Schemas
Reduced capacity for problem solving
Drug of choice for Generalized Anxiety Disorder
Buspirone or SSRI

NOTE: TCAs and venlafaxine will also work
NOTE: BDZs used to be DOC
Panic attack
Discrete period of intense fear or discomfort
4 or more symptoms from the list
Develop abruptly, reach a peak WITHIN 10 MINUTES
Within what time do panic attacks reach their peak?
Panic Disorder
Recurrent unexpected Panic Attacks

At least one of the attacks followed by 1 or more of:

Persistent concern about additional attacks
Worry about the implications
Significant change in behavior
Most common comorbid condition w/ Panic Disorder
Major Depressive Disorder (50-65%)

Comorbidity has poorer prognosis
Prevalence of other comorbid anxiety disorders
Social phobia (15-30%)
OCD (10%)
GAD (25%)
Most common age of onset for Panic Disorder
Mid 20s
Is Panic Disorder more common in men or women?
Women (2-3x)
% of panic disorder pts. who attempt suicide

Compared to 8% with MDD
Ablation of what in animals blocks the fear response?
Locus Ceruleus
These triggers true Panic Attacks in panic pts. but NOT in normals (2)
Sodium lactate infusion
NOTE: does NOT cross BBB

CO2 Inhalation
NOTE: lactate is metabolized into CO2
False Suffocation theory
Pts. have overly sensitive chemoreceptors

Mild increase in CO2 triggers a smothering sensation
Treatment of Panic Attacks
Education and support
Cognitive techniques

BDZs can be used acutely (usually not monotherapy)

SSRIs or TCAs can be used for prophylaxis
("Start low, go slow")
Treatments for Phobic Disorders (3)
BDZs for acute anxiety or panic

Beta-blockers for specific phobias or performance anxiety

SSRIs and MAO-Is for worry in Generalized Social Phobia
Main criteria for PTSD (4)
Exposure to traumatic event
Persistent re-experiencing of traumatic event
Avoidance of stimuli assoc. w/ event and numbing of responsiveness
Persistent symptoms of increased arousal
In children, recollections of a traumatic event may present as this
Repetitive play in which themes of the trauma are expressed
% of people exposed to traumatic stressor that get Acute Stress Disorder
% of people who get Acute Stress Disorder that develop PTSD

SO, of those who have traumatic stressor, 25% get PTSD
% of women who report childhood sexual abuse
Learned Helplessness
Similar to PTSD

Responds to TCAs
With chronic stress, what happens to cortisol system?
Cortisol system responsiveness DECLINES
Type of treatment required for PTSD
Multimodal (psychotherapy + meds)

Meds alone are not especially helpful
Effects of TCAs and MAO-Is in PTSD treatment
Treat mood and anxiety symptoms
Treat hypervigilance
Treat re-experiencing phenomena

MUCH LESS effect on withdrawal and numbing
Effects of clonidine, naltrexone, and propranolol in PTSD treatment
Similar results to TCAs/MAO-Is
Effects of Li and Carbamazepine in PTSD treatment
Help only w/ anger outbursts
Effects of BDZs in PTSD treatment
May help w/ anxiety
(Use w/ caution)

LITTLE EFFECT on numbing/re-experiencing
Effects of SSRIs in PTSD treatment
Treat depression and anxiety
Treat re-experiencing and numbing

BUT, many pts. can't tolerate SSRI side effects
(esp. anxiety)
Link between Tourette's and OCD
5% of OCD pts. have Tourette's
2/3 of Tourette's pts. have OCD
Is psychoanalysis effective for OCD?
OCD responds preferentially to what types of drugs?

BUT, up to 40% of pts. don't respond
Addition of D2-blocker helps
Functional neuroimaging in OCD shows what?
INCREASED activity in:

Orbitofrontal lobes
Caudate nucleus
Anterior cingulate gyrus

Pts. w/ OCD appear to have TOO MUCH executive function
OCD pts. have loss of volume in what part of their brains?
Caudate nucleus

This could be involved in feedback loop that relates to Tourette's
What effect do cocaine/stimulants have in OCD?
Worsen the behaviors
Can bring out motor tics in Tourette's
How do atypical anti-psychotics effect OCD?
They can make it worse

They further increase DA activity in the frontal lobe
Associated w/
Strep infection
In PANDAS, what does an initial negative swab test mean?

Pt. should be retested in 72 hours
How is PANDAS treated?
10 day course of antibiotics

OCD symptoms dissipate in about 14 days
Treatment for OCD
SSRIs (60% response rate)
-- Higher doses/trial than with depression
-- Effect is via downregulation of receptors

Behavior Therapy

Neurosurgery (90% response rate)
What happens in OCD when you stop SSRI treatment?
Symptoms return
The fear circuit centers on what?
The Amygdala
The pleasure circuit centers on what?
The nucleus accumbens
Shortest 1/2 life
Short duration of effect
Good for INITIAL insomnia
Long half life
Slow onset of effects

Can aid in smoothly detoxifying a pt. from BDZs
Rapid onset of effects
Short duration of effect

Great risk of addiction

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