1. Goals of therapy for GAD
    Manage acute sx-by reducing frequency, duration and severity of anxiety and improve overall fxn.

    Long term - remission with minimal or no anxiety sx, no fxnal impairment and increased QOL
  2. First line drugs for GAD
    • Duloxetine
    • Escitalopram
    • Paroxetine
    • Venlafaxine XR
  3. Second line drugs for GAD
    • BZDs
    • Buspirone
    • Imipramine
    • Sertraline
  4. Alternatives for GAD
    • Hydroxyzine
    • Pregabalin
  5. First line drugs for Panic Disorder
    • SSRIs
    • Venlafaxine XR
  6. Second line drugs for Panic disorder
    • Alprazolam
    • Clomipramine
    • Clonazepam
    • Imipramine
  7. Alternative drug(s) for panic disorder
  8. First line durgs for social anxiety disorder
    • Escitalopram
    • Fluvoxamine
    • Paroxetine
    • Sertraline
    • Venlafaxine XR
  9. Second line drugs for Social Anxiety Disorder
    • Citalopram
    • Clonazepam
  10. Alternative drugs for social anxiety disorder
    • Buspirone
    • Gabapentin
    • Mirtazapine
    • Phenelzine
    • Pregabalin
  11. DOC for acute management of anxiety symptoms
  12. Alprazolam dosage range for anxiety disorders
  13. Chlordiazepoxide dosage range for anxiety disorders
  14. Clonazepam dosage range for anxiety disorders
  15. Clorazepate dosage range for anxiety disorders
  16. Diazepam dosage range for anxiety disorders
  17. lorazepam dosage range for anxiety disorders
  18. oxazepam dosage range for anxiety disorders
  19. Duloxetine dosage range for GAD
  20. Escitalopram dosage range for GAD
  21. Imipramine dosage range for GAD
  22. Paroxetine dosage range for GAD
  23. Venlafaxine dosage range for GAD
  24. Buspirone dosage range for GAD
  25. Hydroxyzine dosage range for GAD
  26. Pregabalin dosage range for GAD
  27. At dosages less than 225mg/day this drug functions more like an SSRI
  28. MOA of venlafaxine
    Potent inhibitor of 5HT and NE reuptake (SNRI) and a moderate effect of DA uptake
  29. Common side effects of venlafaxine
    • nausea(37%)
    • vomiting(6%)
    • insomnia
    • dry mouth
    • somnolence

    ADRs are a fxn of dose

    Increases SDBP is higher at >300mg/day and this dose is not recommended
  30. Second line option for GAD and alternate option for pts with substance abuse history
    May be more effective in treating psychic sx rather than somatic
  31. MOA of buspirone
    Inhibit 5hT1A and 5HT2 receptors
  32. Side effects of buspirone
    • Fewer than BZDs
    • Dizziness (12%)
    • Drowsiness (10%)
    • Nervousness (9%)
    • Uneasiness
    • HA
    • --common at doses > 20mg/day
    • ETOH and buspirone in combo does not impair performance
  33. Fear of being in a place or situation where fleeing or obtaining help might be difficult. Patients befin to avoid these places or experience severe anxiety
  34. Risk factors for Panic Disorder
    • Genetic component - First degree relative dx will have greater likelihood and twins
    • Women 2x greater than men
    • Rate of recurrence after remission is higher in women
    • Agoraphobia can occur at anytime but often develops within first year
  35. Intrusive and recurrent thoughts
  36. Ritualistic behavior
  37. CBT is as effective as pharmacotherapy for this disorder
    panic disorder
  38. First line therapy for OCD
    • SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline FDA approved)
    • Clomipramine
  39. Scales for OCD
    Y-BOCS (Yale-Brwwon Obsessive Compulsive Scale)
  40. Essential characteristics of GAD
    • Persistent excessive worry accompanied by symtoms suggestive of CNS arousal (irritability, muscle tension, insomnia, restlessness, sweating)
    • Intensity, duration or frequency of worry exceeds what is warrented by the event
    • Theme or types of worry may change over time
  41. GAD Rating Scales
    • HAM-A - Hamilton Rating Scale for Anxiety
    • SAS - Zung Self-rating anxiety scale
    • State-Trait Anxiety inventory - patient rated
  42. Only TCA efficacious for OCD
  43. Adverse effects of clomipramine
    • Anticholinergic
    • Cardiovascular
    • Weight gain is common
    • Increased seizure risk (doses >250mg/day)
  44. Alternative pharmacotherapy for nonresponders in OCD
  45. These drugs may increase clomipramine levels and may be used to augment therapy
    • Fluvoxamine
    • Paroxetine
    • Fluoxetine
    • --May increase clomipramine levels
    • Pts >40 should receive EKG
    • Monitor BP and Pulse
  46. Types of PTSD
    • Acute (<3months)
    • Chronic (>3months)
    • Delayed onset (>6 months between onset of sx and traumatic event)
  47. Name the three clusters of PTSD sx
    • Re-experiencing
    • Avoidance
    • Increased arousal
    • --Pt should have sx from each
  48. Pharmacotherapy as monotherapy is usually not beneficial for this disorder
    PTSD - up to 70% of pts have response to pharm and nonpharmacologic therapy
  49. Adults with mild acute PTSD should receive what type of therapy?
  50. Adults with mild chronic, severe acute and severe chronic PTSD should receive what type of therapy?
    psychotherapy or combo of psychotherapy and pharmacotherapy
  51. These drugs have FDA approval for PTSD
    • sertraline
    • paroxetine
  52. These drugs should be reserved for patients who fail treatment with other medications
    • MAOIs
    • Mirtazepine
    • Venlafaxine XR
  53. Alternative treatments for PTSD
    • Anticonvulsants/Mood Stabilizers - rec if co-morbid bipolar disorder. May reduce irritabilty and impulse control
    • Gabapentin - may be useful in pts with co-morbid chronic pain
    • Anti-adrenergic agents (clonidine, guanfacine, propranolol) - may reduce arousal, re-experiencing behaviors and dissociative sx
    • SGAs - unclear (2nd line)
  54. As effective as CBT for treatment resistant SAD
    MAOI (phenelzine)
  55. Second line therapy for SAD
    • BZDs (clonazepam most studied)
    • Best candidates - low risk for abuse with low risk for abuse who need acute relief or have falied other tx
  56. Reduce perfomance related anxiety
    • Beta-blockers
    • Propranolol - 10-80mg/day
    • Atenolol - 25-100mg/day
  57. Last line therapy for SAD
    • Gabapentin
    • Side effects - dizziness and dry mouth
    • Dose range - 900-3600mg/day in three divided doses
Card Set
Generalized Anxiety Disorders