-
what medications can cause anxiety
- sympathomimetic agents--decongestants, beta agonist inhalers
- stimulants--caffeine, amphetamines, cocaine
- antipsych meds--abilify
- cannabis
- etoh--cns depresseant
- hypnotic agents
- steroids --prednisone
-
what are three types of PTSD severity?
- PERSISTENT RE EXPERIENCING >1 psychossis like distressing recollections of even, recurrent nightmares, flashbacks panic attacks, sweating
- PERSISTENT INCREASED AROUSAL >2 difficulty falling/staying asleep, irritability or outburts of anger, difficuluty concentrating, hypervigilance, exaggerated startle response
- PERSISTENT AVOIDANCE>3 avoids thoughts, feelings, conversations, avoids activities, palces or ppl that arouse recollections, inability to recall important aspects of trauma, markely diminished interest in ativity
-
What is first line then second line treatment for PTSD?
- FIRST LINE
- sertraline
- paraoxiteine--reexperiencing avoidance, numbess, and hyperarousal symptoms
- SECOND LINE
- TCAs-- desipramine, nortriptylie, imipramine, doxepin
- MONOAMINE OXIDASE INHIBITORS-- phhenylzine, tranylcypromine, isocarboxazid
-
what is augmentations for first line treatment for PTSD
- ANTICONVULSANTS--for reexperienceing, arousal--divalproex, carbamazepine, topiramate, lamotrigene
- ALPHA 2 ADRENERGIC AGONST/BETA BLOCKERS--to target reexperiencing (severe nightmares)--clonidine, propranolol, pindolol
- SECOND GENERATION ANTIPSYCHOTICS--target psychosis/avoidance or fist line treatment resistance--olanzapine, quetiapine, risperidone, ziprazidone, ariprazole
-
what is pharmacotherpay timeline for PTSD
- SSRI at target dose for 8 weeks 1-2 years
- Violence/nightmares--add mood stabilizer/clonidine
- OR
- psychosis--add antipsychotic agent
- Step 3--unapproved agents (TCAs and mAOIs) assess for sub abuse/avoid benzos
- antidpressent combos and consider adding divalproex or antipsychotics
-
what disease states should benzos be avoided?/cautioned?
- AVOIDED
- PTSD
- OCD
- CAUTIONED
- panic disorder
- generalized ax
-
what are concners iwht benzos
- psych dependence
- physical dependence
- rebound vs breakthrough ax
- withdrawal symptoms
- recurrent ax
-
what affects onset of action of benzos
what affects duration of action
- lipophilicity--onset
- metabolis--duration--ALL PHASE 1(oxidative metabolism) increased duration of affects bc activit metabolites
- except for LOT = phase 2--good for hepatic dysfunction or geriatric
-
what are side effets of benzos
- sedation, confusion anterograde amnesia
- cognitive imparieement --not due to sedation--visual spatial, attention, time preformed tasks
- psychomotor impairment
- behavioral disinhibition
- respiratory depression, rarely alone
- ethanold additive CNS/respiratory effects
- psycholoical and or physical dependence
-
what benzos for
- useful for acute anxiety or intial adjunct
- duration 4-6 months after 100% recovery
- TAPER ALL MEDS OVER 3-4 month period
- patient tolerabilyt/withdrawal
- benzo taper 10-25% reductions q 2 wekes
- switch to a benzo diazepine with longer t1/2
-
what are drug interactions with benzos
- Ethanol/CNS sedative
- alprazolom cyp 3a4
- --erythormycin
- fluvosamine/fluoxetine
- ketoconazole
- carbamazepine
- divalproex sodium--inhibit phase II
- cigs
- enzyme inducers
- BC pills
-
what re obsessiosn
- recurrent persistent thoughts impuleses or images
- thoughts, images or impulsess that are excessive worries
- attempts to ignore/suprres or to neutralize the obsessions
- recognsised that the obsessions are irrational
-
what are compulsions
- insistent, repetitive intrusive and unwatned urges to perform an act
- act is contrary to hte persons conscoius wishes or standards
- behaviors are metnal acts are aimed at preventing or reducting distress or preventing some dreaded event or situation
- marked anxiety results from failure to perform the compusions
-
what is first line treatment for OCD
- CBT or SSRI
- Sertraline
- paroxetine
- fluoxetine
- fluvoxamine
-
what is second line for OCD
- velafaxine
- TCAs--clomipramine
- benzos--not recommended
- antipsychotics--use wiht caution
-
how do you go about treating OCD
- select antidepressent--target dose 4-5 weeks
- increase to max dose by 4-9 weeks from start
- OR increase to max dose earlier than 6 weeks
- swith to another approved agent--repeat
- swithc to unapproved agent or augmenation
- response--continue same dose for 8-12 weeks
- DURATION--first epidsode 1-2 yars or 3-4 mild relapse, or 2-4 severe relapse LT>5 years
-
what is wrong with generalized anxiety disorders
- extremely chornic in nature-->10 years
- economic burden
- excessive ax or worry for ?6 months regardina number of activities
- difficult to control the worry
-
DX generalized ax
- ?3 symptoms
- restlessness or feeling keyed up easily fatigued
- poor concentration mind going blank
- irritability
- muscle tension sleep disturbance
-
What are first line treatments for GAD
- SSRI--paroxetine, escitalopram
- SNRI--venlafaxine ex, duloxetine
-
what are second line treatments for GAD
Alprazoloam, buspirone, TCAs
-
what are risks/se benefits and prescribing info for buspirone
- SE--NVheadaches, insomnia, resltessness, sweating, serotonin syndrome
- Benefits-no tolerance/dependency
- delayed onset 4-6 weeks
- no muscle relaxant or anticonvulsive or sedation
- better efficiacy in benzo naive pt
- 5 mg TID, titrate by 5-10 mg q 4-7d 15-60 mg dividided TID
-
Treatment regimen for GAD
- 1--FDA approved antidepressant for 1 year and/or acute relief BZ for 4-6 weeks
- 2--switch to another approved agent
- 3--repeat step 2 before using unapproved agents (SSRI, TCA, HYDROXYZINE)
- 4--add short term bz for somatic symptoms or propranlolol for autonoimc symptoms in specific situations
-
what are characteristics of panic attacks/dz?
- CHARACTERISTICS--
- attacks last 20-30 min
- onset variable teens-30s Women ?men
- increase risk 4-7 x if 1st degree relative has
- period of intense fear or discomfort develop aburbtly>=4symptoms:
- palpitations, racing heart, sweating, trenbling or shaking, feeling of choking, chest pain or discomfort, nausea or ab distress, dizziness, unsteady lightheadedness, faint, derealization or depersonalization, fear of losin control or goin crazy, fear of dying, parethesias, chills or hot flashes
-
what is treatments for panic disorder/social phobia
- FIRST LINE--SSRI--
- sertraline, paroxetine, fluoxetine--panic disorder
- SNRI--venlafaxine
- SECOND LINE
- benzos, TCAs imipramine
- THIRD LINE
- MAOI--phenelzine
-
what is treatment regimen for panic disorder/social phobia
- 1--start approved antidepressant--use low start dose, target dose for 8-12 weeks OR acute relief bz x 1-2 wks
- 2--switch to another approved agent
- 3--repeat step 3 before using unapproved agents (TCAs and MAOis)
- 4-- add bez or antidpressant combo
|
|
