Unit 4 Cram
Panic attacks in context of specific phobia and social phobia
-May experience a panic attack when in contact with the feared situation/thing in specific phobia -May experience a panic attack when speaking in public, which is more likely a social phobia
Tapering Benzodiazepines
***Go slowly and gradually*** -Reduction of ~ 25% of the initial dose every 2 weeks until the lowest available dose is reached2,3,4,5 OR -Decrease total daily dose by 25% the 1st week, another 25% the 2nd week, then 10% a week until discontinuation -Moderate reductions at higher doses and smaller reductions at lower doses1 -The specific dose reductions would vary as a function of patients' readiness to discontinue and the presence or absence of withdrawal symptoms -Withdrawal symptoms - rebound anxiety, restlessness, tremor, sweating, agitation, insomnia, or seizures (particularly when benzos are used > 8 weeks) -Onset of withdrawal symptoms: 1 to 2 days for benzos with short half-lives, 3 to 7 days for longer half-lives -Stabilization: Single benzodiazepine (if using >1 benzodiazepine) -Introduction of an increasing number of drug-free nights. Scheduled hypnotic use rather than prn use -Monitor for withdrawal symptoms or symptom exacerbation. If either occurs, consider maintaining th
PTSD
-certain SSRIs are approved for PTSD, but meds in general not as effective as they are for anxiety disorders-highly comorbid so many of the med tx are more effectively aimed at comorbidities such as depression, insomnia, substance abuse, and pain than at the core sx of PTSD-SSRIs often leave pt with residual sx such as sleep problems-most pts with PTSD do not take monotherapy-use benzos with caution bc they have limited efficacy and many PTD pts abuse alcohol-a1 antagonists can help prevent nightmares-exposure therapy is perhaps most effective psychotherapy-MDMA and psychotherapy combo to block reconsolidation is in testing for PTSD, so is brexpip w/ sertraline being tested
How do benzos work for anxiety?
-enhance phasic inhibition of GABA by positive allosteric modulation of post synaptic GABAa receptors in the amygdala, wereby they blunt fear-associated outputs and thereby reduce the sx of fear
What are 4 ways that trauma can occur according to the DSM?
-experiencing the threat in person -witnessing perceived threat as it occurred to others -learning that traumatic event occurred to close family member/friend -experiencing repeated aversive details of traumatic event
OCD treatment options in context of pharmacology
-placebo response rate only 5% -clinical trials support pharmacotherapy -relapse often occurs when antidepressant is stopped
How are panic attacks during phobias, PTSD, and OCD different than panic disorder?
-recurrent spontaneous attacks
Alprazalom (Xanax) dose
0.25-2 TID 0.5-3 QD
Clonazepam (Klonopin) dose
0.5-2 TID
Overview of anxiolytics with anxiety MOA Overview of anxiolytics with worry MOA
1. Fear may be caused by over activation of the amygdala 2. GABA agents like Benzos enhance phasic inhibition at postsynaptic GABA A receptors within the amygdala 3. Blocking alpha 2 delta subunit of presynaptic N and P/Q VSCCs Block excessive release of glutamate in amygdala to reduce anxiety 4. Amygdala receives input from 5HT neurons, 5HT can inhibit it's output. So SSRI/SNRIs reduce anxiety/fear by increasing 5HT in the amygdala 1. Worry is caused by over an activation of cortico-striato-thalamo-cortical circuits 2. GABA agents such as benzodiazepines may alleviate worry by enhancing their actions of inhibitory GABA interneurons with in the PFC 3. Agents that binds to the Alpha 2 delta subunits at presynaptic N and P\Q voltage sensitive calcium channels block the excessive release of glutamate in the CSTC circuits to reduce symptoms of worry 4. The pre-frontal cortex, striatum and thalamus receive input from 5HT neurons which inhibit output. So, serotonin alleviates worry by increasing serotonin in CSTC circuit
What disorders make up the trauma and stress disorders in the DSM?
1. acute stress disorder 2. adjustment disorder 3. PTSD 4. prolonged grief disorder 5. disinhibited social engagement disorder 6. reactive attachment disorder
What are the four symptom clusters of PTSD
1.intrusive memories 2. changes in physical and emotional reactions 3. negative changes in thinking 4. avoidance
Diazepam (Valium) dose
2-10 mg QID
Buspirone (Buspar) dose
5-20 TID
Dexvenlafaxine (Pristiq) dose
50-100
Fluvoxamine (Luvox) dose
50-300
What drug class is buspirone and what is it used for?
5HT1A agonist, used for GAD but not for other anxiety/trauma disorder subtypes. Onset of anxiolytic action is delayed similarly to delayed onset of action of SSRIs and SNRIs
Panic Disorder
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state oran anxious state . Palpitations, pounding heart, or accelerated heart rate. Sweating. Trembling or shaking. Sensations of shortness of breath or smothering. Feelings of choking. Chest pain or discomfort. Panic Disorder Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed, or faint. Chills or heat sensations. Paresthesias (numbness or tingling sensations). Derealization (feelings of unreality) or depersonalization (being detached from oneself). Fear of losing control or "going crazy." Fear of dying B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: Persistent concern or worry about additional panic attack
A 33- year- old man presents to a psychiatrist with concern about his excessive hand washing. He reports that he has a ritualistic washing routine that takes at least 20 minutes, which he performs multiple times per day for fear of contamination with infectious disease. When further interviewed, he states that he has recurrent and persistent thoughts about hand washing and risk of contamination, which he tries unsuccessfully to suppress. He reports an overwhelming sense of anxiety if he does not wash his hands or if he does not complete the "ritual". He says the behavior is "out of control". He recognizes these thoughts as functions of his own mind. He has no other symptoms. What is the likely diagnosis? A. Obsessive- compulsive disorder. B. Obsessive- compulsive personality disorder. C. Schizophrenia D. Specific phobia.
A. Obsessive- compulsive disorder.This disorder is characterized by anxiety- producing obsessions (persistent thoughts, urges, or images) or compulsions (behavior's the individual feels compelled to do repeatedly according to rigid rules). The obsessions or compulsions are time- consuming or cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
RAD & DSED
Absence of adequate caregiving during childhood is a diagnostic requirement of both RAD and DSED• Although they share a common etiology, RAD is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, while DSED is marked by disinhibition and externalizing behavior
Social anxiety disorder vs agoraphobia
Agoraphobia Often comforted by the presence of another person
Where do endocrine reactions that accompany fear occur?
HPA axis, increase cortisol and persistent activation of HPA can lead to increased rats of CAD, T2DM, stroke and hippocampal atrophy
A 20- year- old college freshman is brought to the attention of the dormitory resident assistant b/c she is not attending meals in the dining hall. The student says she feels anxious about being in the crowded kitchen and dining hall. Similarly, she has ordered all her schoolbooks online to avoid being in the bookstore b/c "it is too overwhelming". She also has not attended some of her crowded lectures. The student is able to have a good conversation in the hall of the dormitory with the resident assistant. The student denies fearing scrutiny by others. She explains that she avoids some places b/c she found that in malls or other crowded ares, she feels very worried, faints, sweaty, and dizzy. She is afraid of losing control and in being in situations where she cannot escape. What is the likely diagnosis? A. Acute stress disorder. B. Agoraphobia. C. Posttraumatic stress disorder. D. Social anxiety disorder.
B. Agoraphobia. Is characterized by fear and anxiety in two or more of the following five situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, being outside of the home alone. The individual fear or avoids these situations b/c of thoughts that escape might be difficult or help might not be available
A 30- year- old retail manager at a cosmetics store with no previous psychiatric hx finds herself experiencing distinct periods of intense anxiety two to three times per day. She is concerned b/c she has never experienced anything like this in the past. During the episodes she feels tremulous, hot, and faint, with palpitations and fear of loss of control. She denies any drug use and any recent stressors. This problem has been getting worse over the past few months and has affected her ability to function at work. She also has been losing weight and eating more. She is worried that her health has affected her appearance b/c her skin looks different, her hair is thinning, and she has swelling in her neck. What is the likely diagnosis? A. Agoraphobia. B. Anxiety disorder due to another medical condition. C. Generalized anxiety disorder. D. Social anxiety disorder (social phobia).
B. Anxiety disorder due to another medical condition.
A 22- year- old college student presents to a MH clinic for an initial visit. She has not turned in any of her papers on time this term b/c she worries about getting poor grades, and this worry has affected her ability to concentrate. She is also very concerned about getting a job after she graduates, despite multiple meetings with a career counselor. She says that she is concerned with the sanitation at the local gym and prefers to to play recreational sports b/c she might be injured. She does not have any rituals or checking behavior's. She describes her mood as "irritable" and says that she feels "tense all the time". Her appetite has not changed, and she continues to enjoy watching movies. She denies low energy and has not had any thoughts of harming herself. She tried cocaine last year but has not used any illicit substances or alcohol recently. What is the likely diagnosis?A. Adjustment disorder.B. Generalized
B. Generalized anxiety disorder.This disorder involves excessive anxiety and worry about a number of things that persists for a minimum of 6 months. The behavior is not due to a medical condition or substance.
Concerned parents bring a 33- year- old man to the psychiatrist. He appears to be his stated age, with erythematous face and holding his reddened and chapped hands away from his body. He takes a few minutes to adjust into the seat. He appears very embarrassed during the evaluation as he shares his story. He describes being very concerned about getting sick from the germs in the environment. This concern translates into frequent hand washing and showering. He explains that he has a particular ritual for these grooming procedures and that if he feels that he made a mistake, he has to repeat the whole procedure from the start. He specks approximately 5 hours per day on his grooming rituals. He also shares that things in his room have to be in a particular order; otherwise, he feels very uncomfortable and thus spends significant time readjusting these items. Moreover, when driving, he frequently worries that the ran over
B. Obsessive- compulsive disorder.This disorder is characterized by anxiety- producing obsessions (persistent thoughts, urges, or images) or compulsions (behavior's the individual feels compelled to do repeatedly according to rigid rules). The obsessions or compulsions are time- consuming or cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
A 37- year- old single mother divorced her husband about 8 months ago and has custody of their two daughters. She went back to work full time "to make ends meet". About 2 moths ago, while at work, she began to feel extremely anxious. Within a few minutes, she had heart palpitations and difficulty breathing and almost fainted. Her coworkers rushed her to the hospital. A thorough medical workup was performed and no underlying medical cause was identified. Within 1 week, she had another attack at the local grocery store and felt embarrassed b/c she has to lie down on the floor for about 10 minutes while she was surrounded by the store's concerned customers until the symptoms subsided. She has had two other "freak outs" in different situations. She has constant concern that the problem will "happen again". She has been skipping meetings at work to avoid embarrassment in front of her coworkers in case she "goes crazy" aga
B. Panic disorder. This disorder is characterized by a pattern of recurrent panic attacks accompanied by persistent worry or behavioral change. Anxiety symptoms and functional impairments are independent of the actual panic attack. Panic attacks are uncued/ spontaneous. At least once of the attacks has been followed by 1 month (or more) of once (or more) of the following:* persistent concern about having additional attacks.* worry about the implications of the attack or its consequences (e.g losing control, having a heart attack, "going crazy")* a significant change in behavior related to the attacksThe panic attacks are not due to the direct physiological effects of a drug or a medical condition. The panic attacks are not better accounted for by another mental disorder.
A 3- year- old girls in a park attempts to sit on the lap of a homeless person. She is pulled away by her mother who recently has been out of town. While the mother was away, the girl had been under the care of the grandmother who spent little time with the girl. The girl does not respond to the affection shown to her by her mother or grandmother. The girl is indiscriminately affectionate with strangers. She has no evidence of motor abnormalities and has met all developmental milestones appropriately. What is the likely diagnosis? A. Autism spectrum disorder. B. Mental retardation. C. Reactive attachment disorder. D. Rett syndrome.
C. Reactive attachment disorder. This disorder is characterized as a disruption in a child's normal attachment behavior. It is the result of grossly negligent parenting and maltreatment. The child exhibits a pattern of inhibited, emotionally withdrawn behavior toward adult caregivers. There is minimal social and emotional responsiveness to others, episodes of unexplained irritability, sadness or fearfulness with adult caregivers. The onset must have been before age 5. Developmentally the child should be at least 9 months old.
A plastic surgeon refers a 22- year- old hairdresser with no known hx of mental illness to a psychiatrist. She underwent facial reconstruction and other surgeries after a disfiguring fire at her salon. When she was seen at a 1- year follow- up appointment, the exam room mirror alarmed her. She said that she "felt apart from" her body and was markedly distressed. She described the sensation as disabling b/c it occurs often at work. However, she is not able to clearly characterize her symptoms, aside from feeling "outside" herself. Aside from emotional distress from her symptoms, she has intact reality testing ability. What is the likely diagnosis?
C. Depersonalization/ derealization disorder.This disorder is characterized by episodes of Depersonalization (I.e sense of being detached from one's body or mental processes) and/ or derealization (feelings of unreality or being detached from the environment) while reality testing remains intact.
A primary care physician refers a 60- year- old Cambodian man to a psychiatrist to rule out a psychotic disorder. The man was previously given a diagnosis of Schizophrenia b/c he "hears voices". He has been prescribed a large dose of an antipsychotic medication, which he talked daily, with very little symptom relief. He states that the medicine helps him sleep. The psychiatrist learns that the man is a survivor of the Cambodian genocide of the 1970s who survived torture under the Khmer Rouge regime, witnessed executions, and endured forced labor in Communist Cambodia. The man reports that subsequent to the extremes of traumatic experience he sustained, he has had chronic symptoms of anxiety with panic attacks. He also reports a concern of "thinking too much". When asked to clarify what he means, he describes ruminating, worried thoughts about his past traumas. He reports severe insomnia and nightmares about Cambodia
C. Posttraumatic stress disorder. This disorder is defined as exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: directly experiencing a traumatic event, witnessing the event that occurred to others, learning that the traumatic event occurred to a close family member or close friend, experiencing repeated or extreme exposure to aversive details of the traumatic events. The symptoms have occurred for over a 1- month period. The individual has increased arousal and avoids internal and external stimuli that are reminiscent of the trauma. There are specific criteria for children 6 years and younger.
A young man comes to the clinic. He is a 26- year- old veteran who previously was involved in combat in the Middle East, where he was exposed to a few explosions. Since he returned about 4 months ago, he has had difficulty sleeping and has experienced frequent nightmares. He has avoided going out, b/c any loud noise startles him, disturbed him significantly, and brings back memories of the explosions. He sees himself as a failure and believes that he was not strong enough to tolerate combat. When his friends have approached him, their comments and jokes irritate him, and he isolates himself more. He has not been able to concentrate well and failed to pass the online courses he has been taking for his college degree. His mother has become increasingly concerned and encouraged him to come to the clinic. What is the likely diagnosis? A. Acute stress disorder. B. Adjustment disorder. C. Posttraumatic stress disorder. D.
C. Posttraumatic stress disorder. This disorder is defined as exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: directly experiencing a traumatic event, witnessing the event that occurred to others, learning that the traumatic event occurred to a close family member or close friend, experiencing repeated or extreme exposure to aversive details of the traumatic events. The symptoms have occurred for over a 1- month period. The individual has increased arousal and avoids internal and external stimuli that are reminiscent of the trauma. There are specific criteria for children 6 years and younger.
A young girl is in second grade. Last year her parental grandfather died from cancer. Since then her parents have become increasingly concerned about her. Last week a babysitter said that the girl sat staring at the front door almost the entire night, waiting for her parents to return from their date night. Their daughter keeps asking to say home from schoo. She pleads for her mother to stay home with her, stating, "I don no wan you to drive to work. What if you get in an accident? Just stay home with me." Before she goes to bed at night, she complains of headaches, which only seem to subside if she sleeps in her parent's room. They have stopped allowing her to sleep in their room, but some mornings they find her sleeping in the hallway right outside their bedroom door. She refuses to attend sleepovers with friends b/c she always feels "sick" while she is there. What is the likely diagnosis? A. Major depressive diso
C. Separation anxiety disorder. This disorder is distinguished by developmentally inappropriate excessive anxiety around separation from significant others (parents or spouse). Features include clinically significant (e.g severe distress or impairment of function) symptoms of anxiety; unrealistic worries about the safety of loved ones; reluctance to fall asleep without being near the primary attachment figure; excessive distress, such as tantrums, when separation is imminent; nightmares with separation- related themes; and homesickness, such as a desire to return home or make contact with the significant others. In addition, physical and somatic symptoms, such as dizziness, lightheadedness, headaches, names, stomachache, cramps, vomiting, muscle aches, or palpitations, may be present and problematic. In children and adolescents the symptoms must be present for at least 4 weeks and in adults 6 months. Symptoms cause significant impairment and distress.
4 categories of OCD
Contamination • Most common • Obsession of contamination, followed by washing or compulsive avoidance of contaminated object Pathological Doubt • Obsession of doubt, followed by a compulsion of checking Intrusive Thoughts • Intrusive obsessional thoughts without a compulsion Symmetry • Need for symmetry or precision, which can lead to a compulsion of slowness
A mother brings her 15- year- old daughter to a psychiatrist's office. The mother says that for the past year, her daughter has not said a word to her teachers. With her family members or friends, however, she is very talkative and engaging, without any speech impairments or language abnormalities. The mother notes that her daughter met all developmental milestones appropriately and reached puberty at age 14. She never had to repeat a grade in school, although her grades this year are faltering b/c she does not speak in class. She is otherwise attentive and does well on homework. The mother denies any impulsive behavior. The pt does not speak to the psychiatrist when addressed, but shakes her head no when asked if she has experienced any hallucinations, mood disturbances, or traumatic episodes in her past. She sits patiently in her chair, smiling, without any fidgeting or unusual movements. What is the likely diagnos
D. Selective mutism. This disorder is identified by a persistent failure to speak in certain situations with a demonstrated ability to talk as evidenced by doing so in other situations. Selective mutism last a minimum of 1 month and cannot be evident only in the first month of school. This diagnosis is not given if it is apparent that the individual's failure to speak has its roots in a lack of familiarity of or comfort with the language. Selective mutism is slightly more common in females.
A 28- year- old woman seeks psychiatric consultation. She explains that 10 years ago, she had a panic attack while presenting her project at the high school science fair. Since then she has developed an intense fear of being embarrassed or humiliated in a public venue. She is constantly worried that others are scrutinizing her. She is very self- conscious and afraid that she will have heart palpitations, trembling, or stuttering or that her mind will go blank. She refuses to go on dates and is not being considered for a new job b/c she declined the interview. She is tired of living such an isolated life. What is the likely diagnosis? A. Avoidant personality disorder. B. Obsessive- compulsive disorder. C. Panic disorder. D. Social anxiety disorder (social phobia).
D. Social anxiety disorder (social phobia). This disorder is characterized by fear of embarrassing oneself in social situations or feeling foolish. Avoidance behavior is often evident and the condition is not due to a medical situation or substance. The disorder typically lasts for more than 6 months.
A 40- year- old woman says she is "very anxious about public speaking", to the point of having episodes that resemble panic attacks when she faces speaking before even small groups of familiar coworkers. Her division chief expects that employees will present at conferences before he will promote them. She is not only unable to give presentations to large audiences but also avoids most social events related to her work. She feels as if she is "acting like an idiot" when she is with colleagues, especially her work supervisors. The anticipation of a meeting with her boss can cause her to worry and lose sleep for days. She does not have anxiety in other contexts. What is the likely diagnosis? A. Generalized anxiety disorder. B. Major depressive disorder. C. Obsessive- compulsive personality disorder. D. Social anxiety disorder.
D. Social anxiety disorder. This disorder is characterized by far of embarrassing oneself in social situations or feeling foolish. Avoidance behavior is often evident and the condition is not due to a medical situation or substance. The disorder typically lasts for more than 6 months.
A 41- year- old man reports to the psychiatrist that he is afraid of dentists. He has a hx of extreme anxiety upon entering a dental office, to the point that he feels dizzy and nauseated. He becomes excessively anxious in the waiting room and has a very difficult time completing visits. He is so fearful about dentists that he reports he cannot take his own children to their dentist b/c he has "anxiety attacks" in the office. Rather, he insists that his wife take the children. His aversion to the dentists has led to his missing regular appointments for more than 6 years. He plans to go soon, only b/c he has severe tooth pain and believes he may need a root canal. He does not have anxiety in other contexts. What is the likely diagnosis? A. Adjustment disorder with anxiety. B. Generalized anxiety disorder. C. Posttraumatic stress disorder. D. Specific phobia.
D. Specific phobia.
man brings his 36- year- old wife to a new primary care doctor b/c she has lost patches of her hair recently. He notes that her last doctor sent her to a dermatologist, who felt that an underlying skin condition was unlikely. In a private exam room without her husband present, she says that she secretly pulls out her hair in clumps to relieve tension. The act of pulling her hair brings her relief. She denies changes in mood, sleep, concentration,, or energy level. What is the likely diagnosis? A. Generalized anxiety disorder. B. Major depressive disorder. C. Tic disorder. D. Trichotillomania
D. Trichotillomania(Hair - pulling disorder) This disorder involves compulsive hair pulling that leads to significant hair loss. There is increased tension before hair pulling and pleasure or relief when pulling the hair out. The individual makes repeated attempts to decrease or stop the hair pulling. This behavior is not the result of a medical condition or another mental condition. This condition is more common in women and the average age of onset is 13 year of age.
OCD vs hoarding disorder
Display some of the classic symptoms of OCD such asrecurring intrusive thoughts or compulsive rituals• Symptoms of hoarding worsen with time, rituals are not fixed, andobsessions about dirt or contamination are absent.• Patients with OCD have better insight• Hoarding behavior is seldom repetitive and is not viewed as intrusiveor distressing to the person who is hoarding• Hoarding disorder tends to be less responsive to classic treatments forOCD (exposure therapy, CBT, SSRIs
FDA approved SSRIs for OCD
Fluoxetine Fluvoxamine Paroxetine Sertraline -often need higher doses -best outcome when combines with CBT
FDA Approved Meds for Social Anxiety Disorder
Fluvoxamine Paroxetine Sertraline Venlafaxine
MOA of GABA with benzos
GABA increases frequency of opening the chloride channel but only to a limited extent. Combining GABA with benzos increases the frequency of opening inhibitor channels, but not to increase amount of chloride across individual chloride channels or to increase the duration of channel opening, rather just for more inhibition of the neuron. Alone benzos don't have any effect, but when GABA is simultaneously binding to its sites this increases the frequency of the chloride channels opening.
MOA of benzos in anxiety
GABA is the principal inhibitor NT in the brain and reduces the activity of many neurons including in the amygdala and CSTC loops. Works on the amygdala and in the PFC within CSTC loops to relieve anxiety. It does this by enhancing phasic inhibition at postsynaptic GABA A receptors within the amygdala to reduce fear outputs, thus reducing fear. Does the same thing with worry loops be enhancing actions of inhibitory interneurons in the CSTC circuits, in order to reduce worry.
How is anxiety of GAD different than of panic disorder?
In GAD, the anxiety emerges and dissipates more slowly than ina panic attack
Rumination of MDD vs OCD
MDD: thoughts are mood-congruent and not considered intrusive or distressing -- not linked to compulsions like in OCD
Most important risk factors in PTSD
Most important risk factors are the severity, duration, and proximity ofa person's exposure to the actual trauma
anxiety neurotransmitters
NE, serotonin, GABA
OCPD vs OCD
OCD: intrusive thoughts, images, or urges; repetitive behavior performed in response to the intrusions OCPD: enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control
what regions are predominantly involved in development of anxiety?
PFC amygdala hippocampus HPA
FDA Approved Meds for PTSD
Paroxetine 20mg Sertraline 25 mg
Serotonin and Anxiety
Serotonin is a key NT that innervates the amygdala and CSTC circuits (PFC, striatum, and thalamus)Can regulate sx of both fear and worrySSRIs can be helpful social anxiety, GAD, panic disorder, PTSD, and OCD
Therapy in OCD
Principal strategies are exposure and response prevention• Desensitization, thought stopping, flooding, implosion therapy, andaversive conditioning
standard pharmacotherapy approach in OCD
SSRI or clomipramine
Panic Disorder Meds
SSRI's paroxetine-sedative=calming, but wt gain Citalopram, escitalopram, fluvoxamine, and sertraline are next best tolerated -SSRI's can be activating: start low, go slow (esp. fluoxetine)
Clomipramine
TCA OCD
What is in charge of remembering the various stimuli associated with a given fearful situation? How?
The amygdala- it does this by increasing efficiency of neurotransmission at glutamate synapses in the lateral amygdala. As sensory input about those stimuli comes in from the amygdala or sensory cortex its relayed to the central amygdala where fear conditioning also improves the efficiency of neurotransmission at another glutamate synapse. Both synapses are restructured and permanent learning is embedded into this circuit by an NMDA receptors triggering the long term effects where each time sensory input is received from the sensory cortex or thalamus, a fear response is triggered as output from the amygdala when there is similar input that was received during the trauma event. Input to the lateral amygdala is regulated by the pre-frontal cortex specifically the ventromedial pre-frontal cortex and by the hippocampus. If the VMPFC cannot suppress that fear response at the amygdala fear conditioning continues. The hippocampus remember is the context of the trauma and makes sure fear is triggered when fearful stimulus or anything similar is it in countered. Most medications for anxiety work by decreasing the fear output from the amygdala. This means these medications are not cures since the underlying neuronal learning is still malfunctioning.
Explain the mechanism of fear conditioning
When someone has a Trumatic experience the sensory input goes to the amygdala where it combines with input from the VMPFC and hippo campus so that a fear response can be generated or suppressed. For a fear response, the amygdala remembers the stimuli associated with that experience by increasing glutamate so that on future exposures with similar stimuli a fear response occurs. If the VMPFC doesn't give input to suppress the response then fear conditioning continues.
FDA approved for PTSD
paroxetine sertraline
Alpha 2 delta ligands as anxiolytics MOA
These are gabapentin and pregabalin:- they bind to alpha 2 delta subunits of presynaptic N and P/Q VSCCs to block the release of glutamate when neurotransmission is excessive in the amygdala to cause fear and in the CSTC circuits to cause worry. So these bind to overly active VSCCs to reduce fear and worry.
Avoidance in specific phobias vs OCD
phobia: feared object is much more circumscribed and don't involve rituals
Which of the following is considered a culture- specific symptoms of panic attacks? a. shortness of breath b. headaches c. heat sensation d. fear of going crazy
b. headaches
Hoarding prognosis
difficult to treat CBT difficult d/t poor insight, low motivation, and resistance
Key difference in acute stress disorder and PTSD
duration of symptoms Acute Stress disorder: 3 days - 1 month PTSD: longer than 1 month
if a drug is highly lipophilic what does this mean less lipophilic?
enters brain quickly, but disappears into fat quickly slower effect, more sustained relief, less intense effect
benzo tapering
expect anxiety, insomnia, resistance better success rate if combo with therapy
FDA approved for OCD in peds
fluoxetine fluvoxamine sertraline
which antidepressants are most likely to cause problems with CYTP450
fluoxetine fluvoxemine paroxetine
FDA approved for OCD
fluoxetine, paroxetine, sertraline, fluvoxamine
Difference between panic disorder and GAD?
in GAD, malfunctioning in the amygdala and CSTC worry loops may be hypothetically persistent and unremitting, yet not severe VS in panic disorder, malfunctioning may be intermittent but catastrophic in an unexpected manor
hydorxyzine
lot of FDA approvals histamine receptor agonist dry mouth, tremor no taper
What meds are approved for Social Anxiety Disorder in peds
nothing-have to use off label
in body dysmorphic disorder, the obsessions and compulsions are limited toconcerns about physical appearance; and in trichotillomania (hair-pullingdisorder), the compulsive behavior is limited to hair pulling in the absence ofobsessions. Hoarding disorder symptoms focus exclusively on the persistentdifficulty discarding or parting with possessions, marked distress associatedwith discarding items, and excessive accumulation of objects.
other obsession disorders vs OCD
which med is prescribed for performance anxiety
propranolol -somatic symptoms
Where are autonomic outputs of fear (inc BP and HR) regulated?
reciprocal connections between the amygdala and locus coeruleus
How are the recurrent thoughts, avoidant behaviors, and repetitive requests for reassurance in anxiety disorders different from those of OCD?
recurrent thoughts in GAD: about real-life concerns OCD: not real-life concerns and content is odd, irrational, or seemingly magic -- often linked to a compulsion
First line medication for PTSD
sSRI
benzos treat what other than anxiety
seizures, alcohol withdrawal, TD
FDA approved for PTSD
sertraline and paroxetine
Recurrent thoughts in social anxiety disorder vs OCD
social anxiety disorder: feared situation is limited to social interactions -avoidance or reassurance seeking is focused on reducing this social fear
Paroxetine (Paxil) dose
start @ 10-20 Range 20-6-
sertraline (Zoloft) dose
start @ 25-50 Range 50-200 half dose for kids
Panic Attack Time Frames
symptoms over 10 min lasts 20-30 min not more than an hour -have anxiety about next attack
Where are traumatic memories stored?
the hippocampus, which can activate the amygdala causing it to activate other brain regions and generate a fear response.
Where is is affect or feeling of fear regulated?
via reciprocal connections the amygdala shares with the orbitofrontal cortex and anterior cingulate cortex