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what is anxiety disorders
unhealthy level of anxiety which becomes excessive or irrational and becomes a disabling disorder
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risk factors for anxiety disorders
- FH
- stressfull life event
- decreased communication with friends/family
- poor diet
- lack of exercise
- alcohol, amphetamines, caffeine, cocaine
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Types of anxiety disorders
- GAD
- PD (social anxiety disorder)
- Phobias
- OCD
- PTSD
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pts with GAD are also likely to have what
- panic disorder
- dysthmia
- bipolar I dsorder
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panic disorder is strongly associated with what disorder
bipolar I disorder
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causes of differential diagnosis of anxiety disorder
- hyperglycemia
- hyperthyroidism
- electrolyte abnormalities
- arryhythmias
- angina
- pseudoephedrine
- trauma
- alcohol
- nicotine
- BZD withdrawal
- excessive caffeine intake
- substance abuse
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what is GAD
anxiety over unidentified cause or "everything"
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diagnosis of GAD
- sx must be present most days for 6 mths
- three or more of the symptoms
- rule out substance abuse
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symptoms of GAD
- easily fatigued
- sleep problems
- trouble concentrating
- restlessness
- irritability
- muscle tension
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what is cognitive behavioral thinking (CBT)
a psychotherapeutic approach that aims to solve problems
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what is CBT effective for
anxiety disorders
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what does CBT identify
it identifies distorted patterns of thinking which leads to feelings and behavior
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what does CBT teach
it teaches the pt how to change distorted thoughts (behaviors)
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diazepam
valium (very fast)
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chlorazepate
tranxene (fast)
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parenteral BZDs
- Diazepam (valium)
- Lorazepam (ativan)
- Chlordiazepoxide (librium)
- midazolam (versed)
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BZDs used for elderly and pts with liver disease
lorazepam (ativan), oxazepam (serax), temazepam (restoril)
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ADEs of BZDs
- sedation
- feeling of tiredness
- drowsiness
- difficulty concentrating
- anterograde amnesia
- delayed reaction
- balance impairment
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FDA SSRIs approved for the treatment of GAD
- escitalopram (lexapro)
- paroxetine (paxil)
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how do you want to implement the SSRI medication
start low, go slow to minimize ADE
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how much can SSRIs overlap with BZDs
over a 2-4 week course
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how long does it take for adequate trial when given SSRI
8-12 weeks
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which SNRIs are FDA approved to treat GAD
duloxetine (cymbalta) and venlafaxine (effexor)
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facts about Buspirone for the treatment of GAD
- slow onset of action (2-4 wks)
- well tolerated
- no sexual dysfunction
- safe in OD
- not a controlled substance
- less effective in pts with hx of BZD treatment
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mirtazapine has a low incidence of what as an ADE
low incidence of anxiety
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what are the non SSRI antidepressants
- Mirtazapine (remeron)
- nefazodone
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diagnosis of panic disorder
- must have at least 2 panic attacks
- must present with 4 symptoms
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physical symptoms of panic disorder
- abdominal pain
- chest pain/discomfort
- chills
- dizziness
- hot flashes
- nausea
- sweating
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SSRIs used to treat Panic disorder
- fluoxetine (prozac)
- paroxetine (paxil)
- sertraline (zoloft)
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SNRIs used to treat panic disorders
venlafaxine (effexor)
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how are BZDs used in panic disorders
- -to alleviate short term panic attacks
- -initiate activation while pts become stable on long term treatments
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which BZDs may be preferred in panic disorders
clonazepam (klonopin) due to long DOA
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other drugs that have been used in the treatment of panic disorders
- nefazodone
- mirtazapine (remeron)
- valproic acid (depakote)
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sx of SAD
- blushing
- trembling
- butterflies
- sweating
- increased heart rate
- phobic avoidance
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first line for treating SAD
SSRIs
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which SSRIs are FDA approved to treat SAD
- Venlafaxine
- paroxetine
- sertraline
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second line treatment for SAD
BZDs- usually PRN
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which drug is used as augmentation with other therapies to treat SAD
gabapentin (neurontin)
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what are B-blockers used for in treating SAD
used to decrease physical symptoms of anxiety (tremor, flushing, tachycardia)
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how are MAOIs used in SAD treatment
used for treatment resistant patients
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5 subtypes of phobia
- animal
- natural environment
- blood-injection
- situation
- others
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antidepressants should not be used to treat which disorder
phobias (only responsive to behavioral therapy)
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what is PTSD
traumatic disorder that occurs following exposure to a traumatic event
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symptoms of PTSD
- re-experiencing traumatic event
- reduced responsiveness
- hyperarousal
- increased symptoms of arousal
- marked avoidance of usual activities
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diagnosing PTSD
- precipitating traumatic event
- Sx must significantly disrupt normal activities
- must last for more than one month
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first line agent for PTSD
SSRI
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first line SSRIs used to treat PTSD
- sertraline (zoloft)
- paroxetine (paxil)
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second line for treatment of PTSD
TCAs
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how long is the treatment of PTSD
minimum of 12 weeks
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how are BZDs used in treating PTSD
- for treating Sx of:
- anxiety
- irritablilty
- insomnia
- *does not reduce core Sx
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what medications do you consider if SSRI is not working when treating PTSD
- nefazodone
- trazodone
- venlafaxine
- mirtazapine
- buproprion
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which drug is used for augmentation in the management of nightmares
prazosin
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which drug has the ability to reduce stress and emotional arousal in PTSD
propranolol
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how long should therapy be maintained for the treatment of PTSD
minimum of 1 year, 2 years with residual sx
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First line for OCD
CBT and/or SSRI
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which first line agents are used for the treatment of OCD
- fluoxetine
- fluvoxamine (faverin, luvox)
- paroxetine
- sertraline
- venlafaxine (effexor)- SNRI
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what drug can be used as second line to treat OCD
Clomipramine
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how many times must an SSRI be tried before trying clomipramine
2-3 times
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