2022-04-28-anxiety-psychopharmacology.md (4160B)
1 # anxiety 2 3 4 ## mostly happy and mostly functional 5 6 Define goal (which is not perfection), 7 recognize deviations, 8 and degrees of deviation 9 that warrant intervention. 10 11 General goals: 12 Stay aligned with core values, 13 participate in meaning-making activities, 14 deal with issues with minimal disruption 15 (relative to the magnitude of the issue) 16 and get back to function. 17 18 19 ## waves of anxiety 20 21 Moments that correspond w peak anxiety symptoms, 22 which make it difficult to stay aligned w core values and perform meaning-making activities. 23 24 25 ### situations 26 27 - triggers (sensual stimulus related to prior negative experience) 28 - giving a presentation 29 - taking an exam 30 - starting on a particular rotation 31 - plane flight 32 33 34 ### symptoms 35 36 - heart racing 37 - feeling of loss of control 38 - sweating 39 - inability to focus 40 - difficulty sleeping 41 - fatigue 42 43 44 ### actions 45 46 Actions that move us toward or away from 47 core values and meaning-making, 48 i.e., adaptive vs maladaptive actions. 49 50 Differentiating toward/away actions can be subtle, 51 e.g. going to get a drink with a friend could be productive or destructive. 52 53 54 ## specific disorders 55 56 Many. 57 58 Defining dx may help get a general sense of which neurotransmitters to modulate, 59 which meds and other approaches to try first. 60 61 - Panic disorder (4+ wks of panic attacks and maladaptation to them) 62 - Generalized Anxiety Disorder (3+ sx >=6mo) 63 - Social Anxiety Disorder (>=6mo) 64 - Specific Phobia (>=6mo) 65 - Neurodevelopmental disorders (e.g. ADHD dx during the pandemic - is the current situation adult-onset anxiety or unmasking latent issues?) 66 67 68 ## management 69 70 Modify the situation, symptoms, and/or actions to improve outcomes. 71 72 Define a goal and manage expectations, similar to pain mgmt. 73 Will not be able to get to 0/10 anxiety, 74 but going from 10/10 to 6/10 may allow 75 regain of meaningful function. 76 77 78 ## management of management 79 80 Most SSRIs can also be activating at first, 81 so communicate this to the patient 82 and consider a prn for peaks (benzos, buspirone). 83 84 Recognize that benzos are like afrin - 85 work like gangbusters, and fast, 86 but long-term they tend to worsen the problem. 87 Define course of treatment 88 (e.g. while we are waiting the 4-6 wks for the SSRI to fully kick in), 89 define specific situations. 90 Screen for substance use disorders 91 and family history 92 (very small percentage of people 93 will go on to develop de novo substance use disorder 94 with rx benzos). 95 96 Sexual dysfunction from any psychotropic medicine 97 does not generally get better over time, 98 consider adding buspirone >=30mg to help w this. 99 100 Stopping at <6mo is associated with higher degree of relapse, 101 so if any benefit is derived from therapy try to continue for 6mo. 102 Ideally work with a therapist to reinforce adaptive behaviors during those 6mo, 103 and afterward consider whether a taper of medicine is likely to allow the person to maintain goals. 104 105 --- 106 107 # psychopharmacology 108 109 FDA labels for drugs are general. 110 50mg of IR quetiapine, 37.5mg XR venlafaxine 111 do not map exactly onto what we usually call them 112 (second generation antipsychotic and SNRI). 113 114 ## second generation/atypical antipsychotics 115 116 ## pathways of clinical relevance 117 118 - Mesolimbic - D2 (need >=60% blockage for efficacy) 119 - Nigrostriatal - Parkinsonism, akathisia, tardive dyskinesia 120 - Mesocortical - apathy, inattention 121 - Tubuloinfundibular - galactorrhea 122 123 ## receptors "" "" 124 125 - D2 - agonism increases nausea (carbidopa-levodopa brand name chosen as marketing tactic for having less GI adverse effects "Sinemet" == "no puke") 126 - 5HT2a - antagonism: decreases EPS 127 - H1 - antagonism: sedation, decrease itching, wt gain, anxiolysis, weight gain, decreases nausea 128 - M1 - antagonism: confusion, sedation, dries, decreases nausea 129 - alpha1 - antagonism: orthostatic hypotension, sedation 130 131 Drug naming schemes reflect receptor targets. 132 133 - cloza | pine 134 - olanza | pine | H1, 5HT2a, M1, D2 (great for chemo-induced nausea, hits three relevant nausea receptors at low doses) 135 - quetia | pine | H1, 5HT2a, M1 (less D2, not quite as good for nausea, but pretty great for agitation) 136 - zipras | idone 137 - risper | idone | 5HT2a, alpha1, D2 (less weight gain, not much of a nausea medicine) 138 139 ## depression 140 141