PSYCHIATRYSt.

II Luke’s College of Medicine – William H. Quasha Memorial

Lecture: Management of Anxiety Disorders Date: September 11, 2017
Blk 3 – Lec #3 Lecturer: ChristianIrving C. Cayetano, MD, DPBP Trans Team: Team 2
3
Topic Outline 6. Buspirone (5-HT1A agonist) SSRIs and SNRIs
I. Anxiety Disorders V. Etc… o Effective anxiolytic agents
A. Classifications A. Subheading
II. 2nd Heading B. Subheading
7. Dysregulation of corticotropin-releasing factor (CRF) and
A. Subheading VI. Quiz adenocorticotropic hormone (ACTH) from the pituitary are
B. Subheading VII. Appendices implicated in the development of anxiety disorders as part of
III. 3rd Heading A. Title of Appendix 1 the HPA Axis.
IV. Etc… B. Title of Appendix 2
8. Excessive secretion of cortisol from the adrenal glands in
PPT Audio Book Transers Subhead
response to ACTH can increase anxiety symptoms.
TOPICS:
1. Management of Anxiety Disorders C. GENETIC
2. Anxiety Disorders in the Medical Setting, Focus on  Individuals with close relatives with anxiety disorders are at
Management increased risk of developing anxiety disorders
D. PSYCHOANALYTIC
I. Anxiety Disorders  Anxiety is related to unresolved unconscious conflicts or
separation from a love object
A. CLASSIFICATION  Panic disorder represents an unsuccessful attempt to defend
 The former Anxiety Disorders of DSM-IV have been against anxiety-provoking impulses
redistributed into 3 consecutive classifications in DSM-5: o Freud: When there is conflict between the id and superego
AOT1. Anxiety Disorders → ego has difficulty balancing both → anxiety.
2. Obsessive-Compulsive and Related Disorders o On the levels of conscious, pre-conscious and unconscious,
3. Trauma- and Stressor-Related Disorders there are things from the unconscious that would attempt to
Anxiety Disorders go to the pre-conscious but they are suppressed by the mind
1. Separation Anxiety Disorders
2. Selective Mutism
→ anxiety
3. Specific Phobia E. PSYCHOSOCIAL
4. Social Anxiety Disorder  Panic disorder represents a learned response of classical
5. Panic Disorder conditioning from repeated exposure to anxiety-provoking
6. Agoraphobia situations.
7. Generalized Anxiety Disorder
8. Substance/Medication-Induced Anxiety Disorder III. Generalized Anxiety Disorders
9. Anxiety Disorder Due to Another Medical Condition  How is GAD different from panic disorders?
Obsessive-Compulsive and Related Disorders • GAD is “generalized” so think “marami”
OBHTE
1. Obsessive-Compulsive Disorder • The patient will think of two or more things he/she is worrying
2. Body Dysmorphic Disorder about and can’t control those thoughts for 6 months with the
3. Hoarding Disorder ff associated symptoms (due to activation of the
4. Trichotillomania (Hair-Pulling Disorder) sympathetic nervous system/ “fight or flight” response)
5. Excoriation (Skin-Picking Disorder) o Palpitations
6. Substance/Medication-Induced Obsessive Compulsive and o Shortness of breath/Difficulty breathing
Related Disorder o Tremors
7. Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition o Vision: pupils dilate → Near vision
Trauma- and Stressor-Related Disorders o Cold, clammy extremities (blood is redistributed to the vital
1. Reactive Attachment Disorder organs)
2. Disinhibited Social Engagement Disorder o Dry mouth
3. Posttraumatic Stress Disorder o Indigestion BDZ
4. Acute Stress Disorder Benzodiazepines (BDZ) Serotogenic agents

5. Adjustment Disorders  Highly effective, response almost immediate Psychotherapy

 Generally safe (It’s difficult to overdose with BDZ)

II. Etiological Formulations  Often preferred by patients but can lead to
• Depression of CNS
A. NEURO • Dependence
 The following structures are ACTIVATED in people with anxiety: • Disinhibition
LLA 1. Limbic System
• ex. a normally shy person suddenly singing karaoke
2. Locus Coeruleus (LC) Norepinephrine • In extreme cases, a px can be violent (rare)
o Implicated in GAD, PTSD, & Panic Disorder • Deficits in memory (with chronic use)
3. Amygdala GPP
 Short-acting
o Coordinates fear behavior and the LC release
 SHORT TERM use → NOT the main medication
norepinephrine (NE)
 Usually used while waiting for the effects of SSRIs and SNRIs
(which take 2-4 weeks)
B. BIOCHEMICAL
 Valium (diazepam) is not used often in Psychiatry
1. GABA • Only for detox
o Natural inhibitory NT that reduces anxiety by binding to
 Long-acting benzodiazepenes (Clonazepam) are preferred
GABAA receptor sites (This is the reason why Clonazepam: long acting
especially if the px has trouble sleeping. Alprazolam: short acting
benzodiazepines are effective for anxiety)
 Alprazolam (Xanax) is used for daytime anxiety because it’s
o When GABA binds to GABAA receptor sites, chloride ion AlXa
mild and short-acting.
channels open, resulting in reduced firing of neurons,
producing a calming effect.  Lorazepam is not available in the Philippines due to its use as a
2. Benzodiazepines date-rape drug (side effects of amnesia)
o potentiate the effectiveness of GABA by binding to specific  Amnesia is a common side-effect of BDZ when taken with
Anxiolytic
sites on the GABAA receptor complex alcohol BDZ+Alcohol=Amnesia
3. Serotonin (5-HT) and NE SSRI, SNRI, Atypical Antidepressants
4. Epinephrine  Highly effective, first line choice
Anxiety o Released in the “fight or flight” response. Anxiety  SSRIs are usually the 1st choice
5. Caffeine, IV lactate, Yohimbine, CO2 1. Escitalopram, Duloxetine, and Venlafaxine
o Stimulate the release of NE o FDA approved
▪ Resulting in panic attacks in persons with Panic DO ☺ FDA approved drugs for GAD will be asked in the exam!!
o Escitalopram (Lexapro) – SSRI
o Duloxetine (Cymbalta) – SNRI
By Caseñas and Chua | Checked by Capinpin o Venlafaxine (Effexor) –SNRI
EsLa
DuloCym
VenEff
 PSYCHIATRY II| Lec 3 | Management of Anxiety Disorders | V. 1

2. Bupropion Despite being an anxiolytic 3. TCAs

o can increase anxiety, especially in patients not first • Considered first-line Not FDA approved for panic disorder
stabilized on an SSRI/SNRI • Imipramine & Clomipramine are effective for the treatment
▪ In general, antidepressants + BDZ are used in of panic disorder (but not FDA approved for this indication).
combination to avoid such side-effects • However, TCA side effects, drug interactions, and potential
3. Alpha1-andrenergic antagonists (Prozacin) lethality combined with alcohol may limit their usefulness.
o Can be effective for somatic anxiety 4. MAOIs Better pa rin ang SSRI
4. Alpha2-andrenergic antagonists (Clonidine) Effective pero with • Likely the most effective agents for the treatment of panic
o Can be effective for somatic anxiety adverse side effects
disorder
5. Beta-andrenergic antagonists (Propanolol)
• But adverse side effects and potentially serious drug and food
o Can be effective for somatic anxiety
interaction limit their usefulness.
6. Hydroxyzine (Iterax) HyIte
Panic-Focused CBT & Exposure Therapy
o antihistamine
 Effective treatments for panic disorder
o Can be effective for some patients with GAD
Psychotherapies  Individuals with panic disorder tend to focus on bodily
1. CBT Cognitive behavioral therapy sensations that signal the onset of the next panic attack.
o can be highly effective, especially when combined with • They are taught to recognize the point before the onset of the
medications next panic attack, so they can take the medication beforehand
o likely considered the non-pharmacological treatment of “Panic Control Treatment”
choice  Typically requiring approximately 12 sessions of CBT
2. Individual (insight-oriented, supportive) and Dynamic  Involves cognitive restructuring, breathing techniques, & bodily
(analytical) therapies sensation awareness
o can be effective  Assure px that he/she is healthy and that what she is
o Supportive: reassurance and comfort experiencing is just anxiety since most pxs go to the ER with a
o Insight-oriented: uncovering unconscious conflicts and fear of dying or fear of losing control.
identifying ego strengths
o Dynamic: increase anxiety tolerance V. Specific Phobia
 Very rare since most people just avoid the cause of their phobia
IV. Panic Disorder  BDZ (not FDA approved) and CBT can be effective treatments,
Not FDA approved for specific phobia
 What’s the difference between panic disorder and GAD? especially when combined.
• Panic disorder is more extreme.  CBT should also include exposure therapy Similar from earlier
 What’s the difference between panic attacks and panic disorder? • Gradual desensitization through increased exposure to
the stimuli
• Panic disorder
1. Duration • Some institutions even use virtual reality
2. Recurrence • A px with fear of heights can be asked to imagine that
3. Anticipatory anxiety he/she is on a skyscraper
o When a patient can anticipate when a panic attack will  Propranolol can reduce somatic anxiety symptoms.
occur, so he/she will avoid going out from fear of having  Behavioral Therapy involves 3 components:
ESP 1. Exposure – the patient undergoes exposure to the phobic
another attack.
 Recommended somatic treatments for panic disorder include 4 stimuli either gradually or totally (flooding)
classes of medications: 2. Systematic Desensitization – patient taught relaxation
SBTM 1. SSRIs techniques to be applied while mentally visualizing the phobic
2. High potency BDZs agent
3. TCAs 3. Participant Modelling – the treating therapist personally
4. MAOIs demonstrates that the object or situation is not dangerous
 Medications can reduce the frequency and intensity of panic
attacks but may not, without CBT, ameliorate anticipatory VI. Social Anxiety Disorder
anxiety or agoraphobia Kaya, medication (BDZ+Antidepressant) plus CBT  Medications especially when combined with CBT and CBGT
• Only CBT is affective for anticipatory anxiety or agoraphobia can be very effective treatments.
 Somatic treatments may take up to 10-12 weeks to become  SSRI: first-line treatment choice for generalized forms of social anxiety
optimally effective. disorder
Instead of Fluoxetine
 Hyperventilation can induce a panic attack secondary to a  Fluvoxamine, Paroxetine, Sertraline, and Venlafaxine are
decrease in blood CO2. FDA approved. FPSV Not FDA approved for social anxiety disorder
• Tx: breathe deeply into a paper bag, increasing PCO2.  MAOIs (particularly phenelzine) may provide the most
 Buspirone, Beta-blockers and Bupropion are NOT effective effective treatment (not FDA approved) but have potentially
treatments for Panic Disorder. Mga Bs di maganda dangerous drug and food interaction
 Medications are often continued for at least 1 year, and possibly  BDZs can be helpful on an immediate-need basis but have
indefinitely. multiple side effects, including the potential for drowsiness.
Medications  Propranolol 20-40mg taken 30 mins before a performance or a
1. SSRIs, SNRIs, Atypical Antidepressants test can effectively improve “performance (test) anxiety”
• Fluoxetine, Paroxetine, Sertraline, Venlafaxine are FDA
approvedFPSV VII. Obsessive-Compulsive Disorder SSRI
• Higher doses than those used to treat depression are often  A combination of a potent serotonergic agent and CBT is
required considered the most effective treatment.
• An expected initial worsening of anxiety symptoms at the  Potent 5-HT reuptake inhibitors (SSRIs; clomipramine) are
initiation of therapy may necessitate starting at a lower dose considered 1st line medications. TCA
then combining the medication with BDZ  The Behavioral component consists of Exposure & Response
• AE: weight gain (rituals) Prevention.
• SSRI & clomipramine more effective than BDZ, MAOI, other TCAs • Exposure is more helpful in reducing obsessions. EO-RC
TCA
2. High Potency BDZ • Response prevention more helpful in reducing compulsions.
• Alprazolam & Clonazepam are FDA approved  Treatment should be individualized.
• The benefit of almost immediate symptom relief is unique to  8-12 weeks or longer may be required for optimal response to
BDZs (most rapid onset of action) Pero sinabi kanina, genally safe medications and higher dosages than used for depression or
• The potential for abuse and for side effects should always GAD.
be considered prior to initiating treatment with BDZs
• Combining a BDZ and an SSRI can be especially effective. Page 2 of 6
 Fluoxetine 40-60mg
Smaller dose Fluvoxamine 150-300mg
Paroxetine 40mg Higher dose
Sertraline 100-200mg
Clomipramine 150-250mg
Smaller dose means more potent
 Targeted daily doses are as follows: Paroxetine 40mg,
Fluoxetine 40-60mg, Fluvoxamine 150-300mg, Sertraline
100-200mg and Clomipramine 150-250mg.
 Medications should be continued for a minimum of 1 year, and
possibly indefinitely (same with panic disorders)
 Psychoanalysis, Cognitive Therapy, Buspirone, noradrenergic
antidepressants, and BDZs are NOT considered effective
Pero it was mentioned earlier na
OCD treatments.
CBT is combined with medications
Somatic Therapies Citalopram
Fluoxetine also
 Fluvoxamine, Paroxetine, Sertraline, and Venlafaxine are
FDA approved for the treatment of OCD and are considered the
1st line treatment. FFPSC
 Citalopram, Mirtazapine, Venlafaxine and Duloxetine can
also be effective (not FDA approved).
 Clomipramine
• A tertiary-amine TCA & a potent 5-HT reuptake inhibitor FDA
approved for treatment of OCD.
• Significantly more effective than other TCAs and equal to or
more efficacious than MAOIs or SSRIs.
 MAOIs
• Very effective, but an adverse side effect profile and
dangerous drug/food interactions limit their usefulness
• Not FDA approved for this indication
 ECT Electroconvulsive therapy
• Used when treatments with medications, CBT, & a
combination of medications + CBT have failed
• Deep brain stimulation and vagus nerve stimulation are
showing promise as less invasive treatments Anterior
Anterior capsulotomy
 Psychosurgery Tractotomy
Limbic leucotomy
• Includes anterior cingulotomy, tractotomy, anterior
capsulotomy, and limbic leucotomy
• For severely incapacitating (intractable) OCD in patients who
remain unresponsive after trials of all available treatments
Non-Somatic Therapies
 CBT
• Considered 1st line treatment
• Very effective treatment, alone or in combination with
medications
• Basic tenet is exposure-response prevention
VIII. Post-Traumatic Stress Disorder
 Because of the complex nature of PTSD, treatment is usually
empirical and often based on ameliorating target symptoms
 No uniform treatment approach
Medications
 Antidepressants can be useful for treating depression, anxiety,
intrusive symptoms and avoidant symptoms:
 SSRIs – 1st line treatment for PTSD
 Sertraline and Paroxetine are FDA approved but other SSRIs
PS
have been shown to be effective as well (Fluoxetine,
Fluvoxamine, Citalopram)
 SNRIs and AtypANs (Mirtazapine, Nefazodone, & Trazodone)
MNT
can be very effective, with an early benefit of improved sleep.
 TCAs (especially Amitrptyline and Imipramine but NOT
Desipramine) are effective as monotherapies (not FDA
Not FDA
approved approved) BUT can be dangerous if combined with alcohol or
for PTSD
overdosed,
 MAOI Phenelzine (NOT FDA approved) has demonstrated
robust response with a reduction in avoidant and intrusive
symptoms and an enhanced response to psychotherapy.
Because of its side-effects, it is reserved for treatment-
resistant PTSD.
 BDZs are generally NOT recommended CDLTG
 Mood Stabilizers (carbamazepine, divalproex, lamotrigine,
topiramate, gabapentin) can be helpful to control flashbacks,
nightmares, impulsive behaviors, and intrusive thoughts, but
have not been widely studied.
 Antipsychotic Medications – helpful on a short-term basis to
treat more intense and problematic symptoms (hyperarousal,
hypervigilance, dissociative symptoms, aggression, re-
experiencing traumatic events)
NON-PHARMACOLOGIC TREATMENTS
 CBT
 Individual psychotherapy, hypnosis, psychodynamic
psychotherapy
 Group therapy
Family/marital therapy
By Gip & Bianca | Checked by I was too tired to change this part
BDZ not effective
OCD
PTSD
IX. Acute Stress Disorder
 What’s the difference between acute stress disorder and PTSD?
• Duration (siyempre mas acute si acute stress disorder diba?)
 There are no FDA-approved somatic treatments available for
Acute Stress Disorder.
 Treatment is targeted to symptom relief (insomnia, anxiety,
hypervigilance, depression).
 Psychological debriefing can be very helpful to reduce
symptoms and possibly to prevent development of PTSD.
X. Adjustment Disorder
 Characterized by an emotional response to a stressful event
 Stressful event triggers signs and symptoms within 3 months
with a response that is more than expected
Ex. Px who commits suicide after her boyfriend broke up with
her  #sadlyf
Treatment
 Psychotherapy remains the treatment of choice. Individual
psychotherapy offers the opportunity to explore the meaning of
the stressor to the patient so that earlier traumas can be worked
through.
 No studies have assessed the efficacy of pharmacological
interventions but it may be reasonable to use medications to
treat specific symptoms.
cingulotomy
XI. Body Dysmorphic Disorder
 Characterized by a preoccupation with an imagined defect in
appearance that causes significant distress or impairment
Treatment
 Surgical, Dermatological, Dental, and other Medical
Procedures – unsuccessful
 MOAI, TCA – reported to be successful
 Fluoxetine & Clomipramine – reduce symptoms in at least
50% of patients
 SSRI + (Clomipramine OR Buspirone OR Lithium OR
Methylphenidate OR Antipsychotics)
XII. Hoarding Disorder
 Characterized by acquiring and not discarding things that are
deemed to be of little or no value, resulting in excessive clutter
of living spaces.
Treatment
 Difficult to treat
 In one study, only 18% of patients responded to medication and
CBT.
 SSRI treatment – mixed results
 CBT – most effective.
• Training in decision-making and categorizing.
XIII. Hair-Pulling Disorder (Trichotillomania)
 Chronic disorder characterized by repetitive hair pulling, leading
to a variable hair loss that may be visible to others.
Treatment
 NO CONSENSUS
 Treatment usually involves psychiatrists and dermatologists
in a joint endeavor.
 SSRI – Initial reports showed efficacy
 Other: Fluvoxamine, Citalopram, Venlafaxine, Naltrexone
and Lithium
XIV. Excoriation (Skin-Picking) Disorder
 Characterized by the compulsive and repetitive picking of the
skin
Treatment
 Difficult to Treat
 There is support for the use of SSRIs (Fluoxetine)
 Other: Naltrexone, Lamotrigine
 Habit reversal and CBT
Page 3 of 6
PSYCHIATRY II| Lec 3 | Management of Anxiety Disorders | V. 1
XV. Medical Conditions for Differential Dx with Anxiety  Look for:
Illness • Insomnia
• Alcohol, caffeine use
Table 1. Medical Conditions for Differential Diagnoses with Anxiety • Adverse effects of medications
Illnesses • Medical conditions
Respiratory Cardiovascular Endocrine o Delirium
Asthma Angina Pectoris Hyperadrenalism o Depression
Chronic Congestive Heart Hyperthyroidism o Pain
Obstructive Failure o Metabolic States
Pulmonary o Withdrawal from alcohol, nicotine, opiods
Disease
(COPD) C. MANAGEMENT
Sleep Apnea Dysrhythmias Hypothyroidism  Supportive counseling
 Complementary therapies
Metabolic Neurological Behavioral  Pharmacotherapy
Hypoglycemia Post-concussion Substance abuse –  Combinations are best
syndrome stimulants
Porphyria Seizures Alcohol/Benzodiazepine XIX. Supportive Counseling
withdrawal  Weave into routine care
Sydenham’s Treatment effects: • Include family when possible
chorea inhalers,  Improve understanding
antihypertensives  Create a different perspective
 Identify strengths, coping strategies
XVI. Psychological Intervention  Re-establish self-worth
Cognitive Behavioral Therapy  Develop new coping strategies
 Demonstrated to be highly effective  Educate about modifiable factors
 Anxiety viewed as an emotional signal or an “alarm reaction”  Consult, refer to experts
 Treatment program needs intervention to “take away the
danger” from the medical illness XX. Complementary therapies
 PSYCHOEDUCATION
 Muscle relaxation
 Massage
XVII. Case Example  Guided imagery
 58 year old female  Hypnosis
 History of 2 Myocardial Infarctions  Meditation
 Cardiac defibrillator was implanted to control for arrhythmias  Aromatherapy
(had activated for 2 occasions)  Avoid caffeine, alcohol
 Due to fear of triggering the defibrillator, patient had become  Treat insomnia
housebound except for MD appointments
 Became hypervigilant over cardiac symptoms XXI. Acute Anxiety
Psychological Treatment: A. BENZODIAZIPINES
 exploring the nature of her cardiac symptoms and using her own – ideal for short-term management
experience to help differentiate between cardiac-onset versus • Anxiolytics, muscle relaxants, amnestics, antiepileptics
anxiety-onset symptoms • Contraindicated in elderly (amnesia, high risk for falls)
• If well-localized pain, it’s most probably due to anxiety • Choose based on half-life (t½)
 Further, the defibrillator was reframed from an agent of harm • Never use more than one at a time
(unpredictable, aversive event) to an agent of protection • Taper slowly Short acting BZD
given to elderly
(facilitating and protecting normal cardiac rhythm) • Short Acting: Alprazolam, Lorazepam, Oxazepam, ALOTT
 increasing the understanding of the medical illness was a Tamazepam, Triazolam
primary intervention for the patient o More rebound anxiety effects & withdrawal reactions
o Better sedative/hypnotic;
XVIII. Key Points o Preferred over long acting in elderly (less accumulation) &
in patient with lever disorders (easier metabolized)
A. PATHOPHYSIOLOGY
• Long Acting: Chlordiazepoxide, Clonazepam,
 Maladaptive neurotransmitter-based response to stimuli, Clorazepate, Diazepam, Flurazepam
CCCDF
involving: o Less rebound symptoms;
• Norepinephrine NSG o Better choice when tapering off BZDs
• Serotonin (Clonazepam/Diazepam)
• GABA o Withdrawal may be delayed 1-2 wk; Given bedtime
 Modest genetic component o Bedtime dose option for hypnotic & anxiolysis Treats insomnia
 Anxiety can be generated by o Caution in patients with:
• Symptoms ▪ Severe respiratory disease (COPD or asthma)
o Hypoxia HPS ▪ Sleep apnea
o Pain ▪ Myasthenia gravis
CD-LA-OT-Mgt
o Sepsis  Longer t½ - sustained effect, may accumulate
• Adverse reactions • Clonazepam 30 – 40 hr
o Akathisia movement disorder characterized by a feeling of inner
restlessness and a compelling need to be in constant motion • Diazepam 20 – 54 hr
o Medication withdrawal  Shorter t½
B. ASSESSMENT • Lorazepam ≈ 12 hr (ideal)
 Detailed interview • Alprazolam ≈ 11.2 hr (risk of rebound)
• “Do you worry a lot?”  Very short t½ (risk of rebound is high)
• “Are you often fearful?” • Oxazepam 2.8 – 8.6 hr
• “Do you feel anxious?” • Triazolam 1.5 – 5.5 hr
 Tools  Ideal for procedures
• Hospital Anxiety and Depression Scale (HADS) • Midazolam 1.8 – 6.4 hr
• Profile of Mood States  Alternatives:
• Gabapentin
• Trazodone
Page 4 of 6
PSYCHIATRY II| Lec 3 | Management of Anxiety Disorders | V. 1
b. Citalopram d. Alprazolam

5. RJ’s grandmother has anxiety. She often lies wide awake at

B. Chronic Anxiety night and can go for 2 days without sleeping. RJ read your
psych trans and saw that long-acting benzodiazepenes like
 The major disadvantage of the 5-HT/NE anxiolytics is delayed
Clonazepam are given for pxs with trouble sleeping. Should
onset of therapeutic action (usually 2-4 weeks)
you prescribe Clonazepam?
 In patients with severe anxiety, this limitation poses a
management problem
Answers:
 Benzodiazepine medication may become clinically necessary
1. B. Px should not combine TCA and BDZ with alcohol since it
 Start simultaneously can cause symptoms of amnesia.
BS • Benzodiazepine
2. A. Kookie had symptoms of GAD. Alprazolam (Xanax) is a mild
• SSRI As mentioned earlier, long acting
and short-acting BDZ indicated for daytime anxiety. Not C
BZD is better for tapering off
 Taper benzodiazepine once SSRI effective in 4 – 6 weeks because we should never use more than one BDZ at a time.
 Consult a psychiatrist if therapy ineffective All other choices are long-acting BDZs.
 SSRIs 3. A. Jay has agoraphobia. Only CBT is effective for anticipatory
PCE • Paroxetine anxiety CBT trains Px with decision-making. Psychosurgery is
• Citalopram only for severely incapacitating OCD or in Px who remain
• Escitalopram unresponsive even after all available treatments.
4. C. Chimchim has test/performance anxiety. Propranolol 20-
A. SSRIs 40mg taken 30 mins before a performance or a test will
 Latency 2-4 weeks effectively improve anxiety.
6. No. Long-acting BDZs help with sedation BUT If elderly, is
 Well tolerated
contraindicated in elderly since it can cause amnesia. Elderly
 Once-daily dosing
pxs also can’t metabolize it properly so they may sleep for
 Start with lower doses in advanced illness, titrate to therapeutic several days at a time.
dose
 Check for medication interactions
☺ SUMMARY ☺
 Considered the first-choice medications for most anxiety
disorders PLEASE READ ME!
 Although there is no evidence of differential anxiolytic benefit
✓ Non-somatic/ Non-pharmacological treatment of choice for
within the SSRI class, subtle intra-class differences in
ALL ANXIETY DISORDERS – CBT
pharmacokinetic profile can guide prescribing choices
✓ Treatment of choice for GAD – SSRIs
 Some of the SSRIs (fluoxetine, paroxetine, and fluvoxamine)
may inhibit some P450 drug-metabolizing liver enzymes FFP ✓ Most effective for the treatment of panic disorder – MAOIs
 Potential for drug-drug interactions in the medically co-morbid (but adverse effects limit their use)
patient on multiple medications ✓ Most effective treatment for OCD – potent serotonergic agent
 Sertraline and citalopram appear less likely to affect P450 + CBT
isoenzymes SC ✓ Somatic treatment of choice for OCD – Clomipramine
 May therefore be more useful for the anxious patient on multiple ✓ 1st line treatment for PTSD – SSRIs
medications ✓ For Panic disorder & OCD, meds should be taken for ≥ 1 year
 No direct effect on cardiac function in routine dose or in ✓ Potency: Alprazolam > Valium > Diazepam AVD
overdose ✓ Potency (for OCD): Paroxetine > Fluoxetine > Sertraline >
PFSF
 Important advantage over tricyclics, and MAOIs Fluvoxamine
 Generally safe for anxiety patients with ongoing cardiac disease _________________________________________________
✓ Immediate relief of symptoms/ Acute anxiety – BDZ
B. SNRIs X EXCEPT OCD! ( NOT managed with BDZ)
 Venlafaxine – important option for patients with GAD ✓ Chronic anxiety – BDZ + SSRI (then taper BDZ)
 Capacity to produce a remission state in treatment-resistant ✓ Test anxiety – Propranolol
group ✓ Px with GAD and allergies – Hydroxyzine (Iterax)
 Safety and side-effect profile are comparable to the SSRIs ✓ Px with GAD and insomnia – Clonazepam – Long-acting BDZ)
 Tendency to produce mild hypertensive effects (10-15 X EXCEPT in elderly Px!
mmHg increments in systolic BP) in some patients ✓ Px with daytime anxiety – Alprazolam (Xanax) – short-acting
BDZ
Quiz ✓ Px with PTSD and insomnia – Mirtazapine, Nefazodone,
Trazodone
1. What should you remind patients to do when taking TCA and ✓ Px with multipleFDA APPROVED
medications DRUGS
– Sertraline, Citalopram
BDZs? Generalized Anxiety Panic Disorder
a. Take it before meals c. Take it during daytime Disorder
b. Don’t take it with alcohol Escitalopram (Lexapro) Fluoxetine
Duloxetine (Cymbalta) Paroxetine
2. Kookie experiences palpitations and DOB during the day Venlafaxine (Effexor) Sertraline
accompanied by dry mouth, cold extremities and tremors, Venlafaxine (Effexor)
which of the ff BDZs can be given? Social Anxiety Disorder & PTSD
a. Alprazolam c. Diazepam + Alprazolam OCD FPSV
b. Clonazepam d. Chlordiazepoxide (same lang sa panic disorder
except for Fluvoxamine)
3. Jay always avoids public places or parties since they make Fluvoxamine Sertraline
him panic and feel trapped and helpless. How do we manage Paroxetine Paroxetine
Jay? Sertraline
a. CBT c. Sedation Venlafaxine
b. Psychosurgery d. Antihistamines OCD FFPSC
Fluvoxamine
Fluoxetine
4. Chimchim has a thesis defense in front of a panel in a few Paroxetine
days and needs help for controlling his anxiety. Which of the Sertraline
Citalopram
ff should be given?
a. Sertraline c. Propanolol

By Gip & Bianca | Checked by I was too tired to change this part Page 5 of 6