Term
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Definition
| Emotional state caused by the perception of real or perceived danger that threatens the security of an individual |
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Term
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Definition
Physical: stomach upset, diarrhea, SOB, headache
Psychological: worrying, feelings of impending threat
-Characterized by irrational fears which significantly impair a person's social and occupational functioning |
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Term
| Factors pertaining to diagnosis and treatment |
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Definition
| -Medical disorders: anxiety can cause medical disorders, disorders can cause anxiety. Treat underlying disease first. |
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Term
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Definition
Norepinephrine: responsible for wakefulness & arousal, energy, motivation, interest, fatigue, and sustaining & focusing attention, promotes synthesis/release of serotonin, Deficiency= depressed mood, decreased conc, decreased attention, decreased info processing, and fatigue
-Serotonin: responisble for memory, emotions, wakefulness, sleep, temperature regulation, Deficiency= depressed mood, anxiety, panic, phobias, obsessions and compulsions, impulsivity
-Dopamine: plays a role in pleasure, motivation, movement, attention, cognition, Deficiency= depressed mood, psychomotor retardation, anhedonia, hypersomnia, inattention, cognitive slowing
-GABA: Major inhibitory NT in the brain responsible for regulating mood and decreasing anxieties in the over-aroused brain, slows or inhibits impulses in the mind, Deficiency= agitation, anxiety, aggression, mood swings |
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Term
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Definition
| -Hypersensitive autonomic system results in increased firing in the locus ceruleus resulting in increased NE release stimulating the sympathetic and parasympathetic nervous system |
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Term
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Definition
| -Theory proposed because the BZDs bind at the GABAa subunit and produce a rather rapid anxiolytic response by potentiating the effects of GABA |
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Term
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Definition
Anxiety is associated with abnormalities in the regulation of the 5-HT system
-5HT dysregulation can produce abnormalities in serotonin release at the 5-HT 1A/1D presynaptic autoreceptors and reuptake at the SERT site, in addition to postsynaptic binding abnormalities |
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Term
| Generalized anxiety disorder |
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Definition
Excessive worry associated with everyday situations
-Gradual course: symptoms may be present for months or years before a diagnosis is made and treatment is initiated
-Chronic course: symptoms wax and wane over time, majority of patients develop or already have anther mental disorder (Depression, substance abuse) |
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Term
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Definition
-Symptoms for >6 months
-Difficulty controlling the anxiety and worry
-At least 3 of the following: Restlessness, muscle tension, difficulty concentrating, easily tired, impaired fxn, sleep disturbances
-Constant worry causes significant distress or impairment in social, occupational, or other areas of functioning |
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Term
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Definition
-Reduce severity and duration of anxiety symptoms
-Improve overall functioning
-Improve QOL
-Long-term goal: Remission |
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Term
| Non-pharmacologic therapy: GAD |
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Definition
-Education and counseling
-Cognitive behavioral therapy (CBT)
-Patient education: limit/avoid caffein, OTC stimulants, diet pills, and alcohol, meditation/exercise, stress management |
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Term
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Definition
-Venlafaxine (Effexor)
-Duloxetine (Cymbalta)
-Escitalopram (Lexapro)
-Paroxetine (Paxil): no difference in efficacy compared with sertraline
SSRI's or SNRI's can be used as initial treatment. Above drugs are FDA approved for anxiety |
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Term
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Definition
| -BZDs, buspirone, imipramine, sertraline |
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Term
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Definition
-FDA approved BZDs: alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, lorazepam, and oxazepam): effecitve for ACUTE management of anxiety symptoms
-Long-term, patient should be managed on SSRI/SNRI |
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Term
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Definition
MOA: Serotonin 1A partial agonist
-Works best in BZD naive patients
-Dosing: 7.5mg BID, may be increased by 5mg every 2-3 days as needed
**Not given PRN**
-Minimal side effects |
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Term
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Definition
-Second or third line option due to tolerability issues
-SEs anticholinergic, cardiovascular
-Imipramine and paroxetine have shown equal efficacy
-Dosing: 50mg/day |
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Term
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Definition
Hydroxyzine: suppresses the actiivty in certain regions of subcortical area of the central nervous system. Used after SSRI/SNRI failure. May dose 25-50mg QID
Pregabalin: Binds to the alpha(2)-delta subunit of calcium channels reducing the calcium dependent release of several neurotransmitters. Not FDA approved for anxiety. Anxiolytic effects similar to lorazepam, alprazolam, and venlafaxine XR. Dosed 50mg TID
Atypical antipsychotics can be considered in refractory cases as augmentation (olanzapine, risperidone, quetiapine) |
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Term
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Definition
-Anxiety characterized by "attacks" of intense fear and discomfort
-Frequency & severity varies among individuals (also from attack to attack)
-Panic attacks may be mistaken for a medical emergency and patients may go to the ER b/c they feel they are experiencing a lie threatening condition
-Environmental features may become triggers |
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Term
| Clinical course: Panic disorders |
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Definition
-Panic attacks unexpected or situational
-Chronic disease: symptoms wax & wane
-Complication: agoraphobia |
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Term
| DSM-IV-TR criteria: Panic Disorders |
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Definition
-A discrete period of intense fear of discomfort, developing abruptly and intensifying quickly. Attacks last 20-30 minutes
-Palpitaions, sweating, trembling, feeling of choking, chest pain, nausea, dizziness, derealization or depersonalization, fear of losing control, parathesias, chills or hot flashes
-Panic disorder: More than 2 unexpected panic attacks, at least one of the attacks has been follwed by at least 1 of the following for a duration of > 1 month: Anticipatory anxiety or phobic avoidance |
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Term
| Non-pharmacologic therapy: Panic disorders |
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Definition
-CBT: applied relaxation, exposure through imagery, panic management, etc
-Exercise
-Patient education: Avoid substances which trigger attacks |
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Term
| Pharmacologic therapy: Panic disorders |
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Definition
First line: SSRIs & effexor. Doses are typically started at half the typical starting dose of antidepressants and titration is slow to avoid anxiety
Second-line drugs: TCAs (decrease frequency of panic attacks)
Last line: MAOIs |
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Term
| Summary of panic disorder |
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Definition
Therapeutic efficacy should be evaluated only after an adequate drug trial and altered if there is no response after about 6-8 weeks of therapy. Treat for about 12-24 months if there is a response. Taper medication over 4-6 months to reduce relapse risk
-BZDs should only be used acutely and if anxiety is severe may see increased doses |
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Term
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Definition
A chronic long-term illness requiring extended therapy
-Intense irrational fear of being negatively evaluated or scrutinized in at least one social or performance situation
-Patients may also experience panic attacks |
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Term
| DSM-IV-TR crieria - Social anxiety disorder |
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Definition
-Marked and persistent fear of one or more social or performance situations where the person is exposed to unfamiliar peopleor possible scrutny by others and the person fears humiliation or embarrassment
-Exposure to the feared event provokes an immediate anxiety response
-The person realizes the fear is excessive
-Avoidance of the situation or situation is endured with intense anxiety or distress
-Symptoms significantly interfere with normal activities or cause marked distress
-Symptoms can NOT be due to drug substance, medical disorder, or a different psych disorder |
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Term
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Definition
-Exposure to feared situations
-Social skills training
-Applied relaxation therapy
-CBT |
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Term
| Pharacologic Therapy: SAD |
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Definition
first Line: Escitalopram, fluvoxamine
Second Line: Citalopram, clonazepam (Dose: 0.25mg/day may increase as tolerated), Beta blockers (**used PRN to control autonomic response to stress, PROPRANOLOL 10-40mg 1-2 hours prior to event, give test dose to assess tolerability) |
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Term
| Alternative therapy for SAD |
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Definition
-Buspirone
-Phenelzine (alternative treatment for resistant SAD)
-Pregabalin or gabapentin (may consider trying around last line option for unresponsive patients)
-Mirtazapine- efficacy is sparse |
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Term
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Definition
-SSRIs/SNRIs are first line agents
-Therapy should be continued for at least 8-12 weeks at maximum dosage before non-response is determined
-Treatment should be continued for at least 12 months after improvement in symptoms is seen (associated with better long term outcomes such as decrease risk of relapse0
-Medication should be tapered slowly to prevent relapse once it is decided to discontinue treatment
-Propranolol or clonazepam may be used prn for performance anxiety 1-2 hours before event |
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Term
| Post-traumatic stress disorder |
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Definition
-Anxiety associated with trauma: military combat, violent personal attack, kidnapping, taken hostage, terrorist attack, torture, incarceration, natural disasters, severe car accidents, etc
-Exposure to trauma and the intensity of the response increase the risk of PTSD
-Duration and severity of stressor are most critical factors affecting development of PTSD |
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Term
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Definition
-Presentation is not predictable because symptoms are related to the duration and intensity of the trauma, the presence of other psychiatric disorders, and how the patient deals with trauma
-Approximately 20% of PTSD pts attempt suicide |
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Term
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Definition
-Exposure to traumatic event that was perceived as life threatening or likely to cause serious harm to self or others
-Symptoms from each of these 3 clusters must be present for at least one month:
1. Reexperiencing: memories, dreams, flashbacks, hallucination, illusions, psych or phys distress
2. Avoidance of: thoughts, feelings, conversations, activities, places, people, do not remember pars of trauma, feel detached
3. Increased arousal: sleep disturbances, irritability, difficulty concentrating, hypervigilance |
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Term
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Definition
-Short term: decrease in symptoms (intrusive reexperiencing, avoidance, and hyper-arousal), improvements in disability, other psych disorders, and QOL
-Long term: remission |
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Term
| Pharmacologic therapy: SAD |
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Definition
-First line therapy: SSRIs (sertraline, paroxetine). SSRIs treat symptoms in all 3 clusters.
-Alternatives: Venalfaxine XR, not FDA indicated (hyper-arousal symptom cluster was not shown to improve)
-MAOIs Phenelzine has shown efficacy in reducing re-experiencing, intrusion, and avoidance. Last line treatment
-TCAs: may consider imipramine or amitriptyline if other options fail
Augmentation: atypical antipsychotics, prazosin (alpha-1 adrenergic antagonist)
**AVOID BENZO USE, worsening of symptoms**
Consider trazodone if insomnia is an issue |
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Term
| Obsessive compulsive disorder |
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Definition
-A disorder characterized by obsessions and compulsions
-Most common obsessions include thoughts of contamination, repeated doubts about not performing an action or hurting someone b/c of an action, orderliness
-Patient try to neutralize obsessions with compulsions
-OCD patients experience intrusive thoughts (specific phrases, images, numbers
-Excessive reassurance seeking
-Repetitive behaviors/rituals
-Distorted idea of risk, and excessive feelings of guilt and self-doubt |
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Term
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Definition
-Approx avg of 17 years before treatment
-Onset earlier in men than women
-Chronic in nature
-Stress induces and exacerbates symptoms
-Screening tool: Yale-Brown obsessive compulsive scale |
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Term
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Definition
-Obsessions: recurrent and persistent ideas or thoughts that are experienced as intrusive and senseless.
-Compulsions: repetitive and intentional behaviors or mental acts performed in response to the obsessions or according to rigid rules
-The person realizes the obsession and compulsions are excessive/unreasonable
-The O/Cs are time consuming (>1hr/day), cause distress, and interfere with daily functioning |
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Term
| Pharmacologic therapy: OCD |
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Definition
First line: SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline
Dosing: higher doses for longer durations are associated with the best outcomes and greatest relief of symptoms
-12 week trial is necessary before trying an alternative agent (response may take 6-8 weeks, maximal response @ 20 weeks)
-Treat for at least a year before considering a taper
Fluoxetine 80mg-120mg
Fluvoxmine 300mg-450mg
Paroxetine 60mg-100mg
Sertraline 225mg
**First dose is usually maximum, second dose is OCD max |
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Term
| Second line therapy for OCD |
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Definition
-Clomipramine: TCA drug of choice after 2 or 3 SSRIs fail
-Alternative options: venlafaxine, lithium, mirtazapine
-Augmentation: monotherapy may not adequately control symptoms, antipsychotics |
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Term
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Definition
-Anxiolytic and hypnotic effects
-BZDs potentiate the inhibitory effect of GABA leading to decreased anxiety
-Dosing: PRN vs scheduled, longer half-life agents are preferred, use only half adult daily dose for elderly pts, AVOID use in pregnancy and lactation |
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Term
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Definition
-Issues: rebound anxiety, recurrence/relapse, tolerance (risk with shorter half-life agents
Dependence: a person's normal functioning is compromised bc there is a psychological need for the drug
Abuse: persistent or sporadic and implies the use of the drug is not consistent (risk increases with higher potency BZDs)
Symptoms of BZD withdrawal
Frequent symptoms: anxiety, insomnia, irritability
Common symptoms: nausea, depression, ataxia, blurred vision, diaphoresis
Rare symptoms: psychosis, seizures, delirium
*Taper dose to avoid withdrawal |
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Term
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Definition
Anxiety is a disorder which necessitates nonpharmacologic, and pharm therapy to prevent negative outcomes and to increase a person's quality of living
-SSRIs are first line agents for all types of anxiety
-BZDs should not be initiated if anxiety is not severe enough to cause impairment during daily activities |
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