Download Anxiety Disorders

‫بسم هللا الرحمن الرحيم‬
‫‪병원약사모임강의_2006_8‬‬
psycho pharmacotherapy
dr.ghasem dastjerdi
psychiatrist
병원약사모임강의_2006_8
‫اصول و مالحظات کلی درمان‬
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Diagnosis
Differential diagnosis
Drug choice
Dose
Duration
Drug _Drug interactions
Drug sideeffect
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Diagnosis
Past Treatment Response
Response in Family Members
Concurrent Medical or Psychiatric Disorders
Goals of Pharmacotherapy
• Acute Treatment
– Used to alleviate the symptoms of an actively
occurring disorder
• Continuation Treatment
– Goal: To prevent a relapse into the same
episode for which treatment began
• Maintenance Treatment
– Goal: To prevent recurrences by the ongoing
maintenance use of a medication
병원약사모임강의_2006_8
Various Reasons for Noncompliance
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Stigma of disorder
Denial of illness
Disruption of cognitive process
Side effects of medication
Slow onset of beneficial effects
Cost
병원약사모임강의_2006_8
Strategies to Increase Compliance
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Encourage active patient participation
Adequate communication
Empathetic approach/Trusting relationship
Family and community involvement and
support
• Emphasis on positive effects of medication
• Use the most simplified drug regimen
병원약사모임강의_2006_8
Classes of Psychotropics
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Antipsychotics
Antidepressants
Mood Stabilizers
Anxiolytics
Anti-Abuse
Stimulant
Cognitive enhancer
‫• آقایی ‪ 45‬ساله‪،‬کارمند‪ 85،‬کیلو گرم وزن‪ ،‬که دو هفته ای‬
‫• است به همسرش بدبین شده است‪.‬تحریک پذیری ‪،‬خود گویی و‬
‫بیخوابی دارد‪.‬‬
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Substances
Hypothyroidism
Cushing
Brain tumors
….
‫شرح حال‬
‫آزمايشات الزم‬
‫سی تی اسکن‬
‫تست کانابيس‬
‫تست متامفتامين‬
‫‪....‬‬
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‫• خانمی ‪ 35‬ساله ‪،‬دیابتیک‪،‬که از حدود هشت سال قبل دچار کم‬
‫گویی‪،‬افت عملکرد‪،‬عدم توانایی در انجام امور منزل‪،‬غمگینی و‬
‫بیخوابی گردیده است‪.‬معتقد است توسط همسایه ها کنترل‬
‫میگردد و آنها در منزلش دوربین کار گذاشته اند‪.‬‬
Drug Treatment
• Dopamine Receptor Antagonists
– Chlorpromazine (Thorazine)
– Haloperidol (Haldol)
• Dopamine and Serotonin Receptor
Antagonists
– Risperidone, Olanzapine, Aripiprazole …
– Clozapine
Dopamine Receptor Antagonist: Side
Effects
• Vegetative disorders
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decrease in blood pressure
acceleration of pulse rate
modification of myocardial activity
sweating
dry mouth
constipation
impotence
ejaculation disorders
anorgasmia
병원약사모임강의_2006_8
Dopamine Receptor Antagonist: Side
Effects
• Extrapyramidal disorders cont.
– Early dyskinesia
• Spasms of tongue, visual spasms, grimacing, gyratory and
rotatory movements of the upper extremities Neuroleptic
Parkinsonoid
• akinesia (restriction of motor movement), hypomimia (loss of
facial expression), rigor and tremor (in muscles)
– Akathisia
• Restlessness, urge to move continuously
– Tardive dyskinesia
• Involuntary chewing, smacking of lips, swallowing and rolling
movements of the tongue
• Gyratory and flailing movements of the extremities
Typical vs Atypical
• Typical (also called conventional)
antipsychotics act primarily at dopamine
receptors.
• Atypical antipsychotics are active on other
receptors as well as dopamine, and are
associated with fewer or no extrapyramidal
side-effects, an effect on negative
symptoms of schizophrenia.
Antipsychotics (Neuroleptics)
• Typical Neuroleptics
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High potency (Haldol)
Medium potency (Stelazine)
Low potency (Thorazine)
Depot/Decanoate (Prolixin-D or
Haldol-D/LA)
• Atypical Neuroleptics
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Clozaril (Clozapine)
Risperidol Pisperidone)
Zyprexa (Olanzapine)
Seroquel (Quetiapine)
Geodon (Ziprasidone)
병원약사모임강의_2006_8
Neuroleptics: Indications
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Schizophrenic disorders
Mania
Acute Psychotic reactions
Mood d/o with psychotic symptoms
Delirium/dementia
병원약사모임강의_2006_8
‫• آقایی ‪ 50‬ساله ‪،‬کشاورز‪ 85،‬کیلو گرم وزن‪،‬با سابقه بیماری‬
‫قلبی و زخم معده که مصرف داروهای مربوطه را دارد با‬
‫عالیم افسردگی‪،‬نا امیدی‪،‬بیخوابی‪،‬کاهش میل جنسی‪،‬کاهش‬
‫تمرکز‪،‬کاهش انرژی مراجعه کرده است‪.‬‬
Depression: Who Needs Meds?
• Depressed mood with
neurovegetative
symptoms > 4 weeks
• Previous episodes
• Severe, disabling, or
presence of Sx
Increase
• Comorbid anxiety d/o
• Psychotic symptoms
• Family history of
suicide
Antidepressant Classes
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TCA (Elavil)
MAOI (Nardil)
– Monoamine oxidase inhibitors
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Selective Reuptake Inhibitors
– SSRI (Prozac)
– SDRI (Wellbutrin)
– SNRI (Effexor)
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Serotonin Modulators
– Desyrel
– Remeron
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Serotonin & Norepinehrine
Reuptake Inhibitor
– Cymbalta (2004)
dr.dastjerdi
dr.dastjerdi
Pre- and Postsynaptic Active Agents
15– Sedation, weight ↑
Mirtazapine
30
(Remeron)
Dopamine Reuptake Inhibitor
200– Insomnia/agitation, GI distress
Bupropion
400
(Wellbutrin)
Mixed Action Agents
100– Drowsiness, insomnia/agitation,
Amoxapine
600 CA, weight ↑, OSH,
(Asendin)
anticholinergica
Clomipramine 75– Drowsiness, weight ↑
300
(Anafranil)
150– Drowsiness, OSH, CA, GI
Trazodone
600 distress, weight ↑
(Desyrel)
No sexual dysfunction.
Twice-a-day dosing with
sustained release. No sexual
dysfunction or weight gain.
Movement disorders may occur.
Dose titration is needed.
Dose titration is needed.
Priapism is possible.
dr.dastjerdi
TCA-Common Side Effects
• Weight gain
• Anticholinergic
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Dry mouth, cavities
Blurred vision
constipation
Urinary retention
Tachycardia
• Sedation, fatigue
• Tremor, dizziness
• Impotence
TCA-Efficacy
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Depression
Anxiety
Panic
OCD (Anafranil Only)
PTSD
Bulimia
Chronic Pain
Headaches
Depression: SSRIs
• Other treatments
– Biploar I disorder, dysthymic disorder, eating
disorders, panic disorders, obsessivecompulsive, and borderline personality disorder.
– Prozac has been used for: Anxiety, panic
attacks, phobias, obsessive compulsivenss,
anorexia and bulimia, seasonal affective
disorder, obesity, PMS, chronic pain.
Depression: Commonly Used SSRIs
• Side Effects
– mostly involved the central nervous system and the
gastrointestinal system
– sexual dysfunction(delayed ejaculation)
– some adverse symptoms can disappear or lessen with time.
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Fluoxetine (Prozac, Lilly) (Selective for 5-HT)
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
R-Fluoxetine (Mirror of Prozac, 2003)
Duloxetene (Cymbalta, 2004)
병원약사모임강의_2006_8
SSRI-Efficacy
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Depression
Panic
OCD
PTSD
Social Phobia
Bulimia
PMS, BDD
Chronic Pain
SSRI-Common Side Effects
• Insomnia, headache
• Nausea, anorexia
– Diarrhea
– Constipation (Paxil)
• Sexual dysfunction
– Decreased libido
– Anorgasmia
• Nervousness, tremor
– Myoclonus
– Teeth-clenching
Wellbutrin- Special Factors
• Pro:
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No sexual dysfunction
No weight gain
Smoking Cessation
Preference in Bipolar
depression?
• Con:
– Poor anxiolytic; not antipanic
– Seizure issue
병원약사모임강의_2006_8
Effexor- Special Factors
• Pro:
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Energizing
Rapid onset
Severe depression
Anti-panic?
No weight gain
• Con:
– Hypertension issue
병원약사모임강의_2006_8
Remeron-Special Factors
• Pro:
– Sleep enhancing at 15
mg.
– limited sexual
dysfunction
– Anti-nausea
– IBS improved?
– Chronic pain
– Anxiolytic; anti-panic
• Con:
– Weight gain
SSRI: Other Indications
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Anxiety/Panic
Bulimia Nervosa
PMDD
OCD-Spectrum
Impulse Control
Clip
Eating Disorders
• Bulimia Nervosa
– SSRI
– All antidepressants
• Anorexia Nervosa
– SSRI
Impulse Control: SSRI-Responsive?
• Kleptomania
• Trichotillomania
• “Compulsive” D/O
– Paraphilias
– Pyromania
– Gambling
Chronic Pain States
• TCA
– Toxicity/Intolerance
– Alcohol synergism
• Alternatives
– Remeron*
– SSRI
• Potential Advantages
– Safe & Well-tolerated
• *Preserve sleep architecture
Insomnia
• Trazodone
– Males: priapism
– Safe, not abusable, cheap
• Remeron
– 15 mg dose
– Safe
• TCA
– Low dose
– Toxicity issues
병원약사모임강의_2006_8
‫• دختر خانمی ‪ 19‬ساله با خلق افسرده‪،‬پرخوابی‪،‬کندی قابل‬
‫مالحظه سایکوموتور‪،‬ناامیدی‪،‬اقدام به خودکشی‪،‬احساس‬
‫گناه و افکار مرتبط با مرگ مراجعه نموده است‪.‬‬
‫• وی سال قبل در بهار دچار بیخوابی ‪،‬پرحرفی‪،‬خلق‬
‫باال‪،‬احساس انرژی‪،‬افزایش میل جنسی و افزایش فعالیت‬
‫سایکوموتور گردیده بوده است که با درمان دارویی خوب‬
‫شده است‪.‬‬
Mood Stabilizers
• Used for “Bipolar” or “Manic-Depressive”
to regulate mood
• Lithium (naturally occurring mineral)
• Carbamazepine (Tegretol)
• Valporic Acid (anticonvulsant)
• Topamax
• Lamotrigine
Mood Stabilizers
• Mood Stabilizers are commonly listed as
Anti-Convulsants because of their calming
effect and action dealing with seizures.
• They have lately become very effective in
treating such things as Bipolar Disorder,
Depression, or Anxeity Disorders.
Mood stabilizer-Side effect
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Depend on specific drug
Li: Thyroid, kidney S/E
Carbamazepine: blood cell
Valproic acid: weight
Topamax/lamotrigine: skin eruption
‫• آقایی ‪ 40‬ساله‪،‬کارگر معدن‪ ،‬چند ماهی است که از حمالتی‬
‫از اضطراب‪،‬طپش قلب‪،‬احساس تنگی نفس و احساس از‬
‫دست دادن کنترل خویش شاکی است‪.‬وی سابقه چندین ساله‬
‫وسواس شستشوهم دارد‪.‬‬
Anxiety
• That first date, an important job interview, the big
speech, a critical test . . . times when most people
feel a little anxious. Sweaty palms and
"butterflies" in the stomach during challenging
situations are normal.
• Anxiety disorders, however, are medical illnesses
that differ dramatically from normal feelings of
nervousness. The symptoms of these disorders
often occur without warning and make the simplest
of life’s routines sources of nearly unbearable
discomfort.
Anxiety Disorders: Differentiation
Disorder
Core Fear
Common Triggers
OCD
Obsession
Obsession or “Tension”
Panic Disorder
Dying
Crowds, bridges, etc.
Agoraphobia
Being Trapped
Open spaces, crowds
GAD
Everything
Anything stressful
Social Phobia
Public
Embarrassment
Public speaking,
Performance anxiety
PTSD
Recurrence of
Traumatic Event
Trauma-related places
or experiences
Anxiolytics
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Antidepressants
Benzodiazepines
Buspirone
Antihistamines
– over-rated
– tolerance develops
fast
• Neuroleptics
Anxiety Pharmacotherapy
Disorder
GAD
Panic D/O
Social Phobia
OCD
PTSD
Acute/Situational
Buspirone or BZD
BZD + AD
BZD or b-blocker
SSRI
BZD
BZD=benzodiazepine
AD=antidepressant
GAD=generalized anxiety disorder
OCD=obsessive-compulsive disorder
PTSD=post-traumatic stress disorder
병원약사모임강의_2006_8
Chronic
AD
AD
AD
same
AD
Benzodiazepines
• Short-term use or
situational anxiety
• Tolerability
• Cognitive effects
• Enhanced effects
– gender
– age
– alcohol
병원약사모임강의_2006_8
Common Benzos: Dosing
Generic
Brand Name
Starting Dose
Usual Dose
Alprazolam
Xanax
.25-.5 TID
0.75-4.0
Clonazepam
Klonopin
0.5-1.0 BID
0.5-4.0
Lorazepam
Ativan
0.5-1.0 TID
2.0-6.0
Oxazepam
Serax
15-30 TID
30-120
Chlordiazepoxide
Librium
5-25 TID
15-100
Zolpidem
Ambien
2-5 TID
5-10
Gabapentin
Neurontin
2-5 TID
5-10
병원약사모임강의_2006_8
Benzodiazepine Side Effects
• Behavioral Disinhibition
– hostility, aggressiveness, rage reactions
– paroxysmal excitement, irritability
• Psychomotor Impairment
– synergistic effects with ETOH
• Cognitive Impairment
– impaired visuospatial ability & sustained attention tasks
• Withdrawal Phenomena
– flu-like symptoms (mild), psychotic s(x)s or seizures (severe
병원약사모임강의_2006_8
Miscellaneous
• Sexual dysfunction
– Yohimbine
• Commonly used but major side effects: Elevated blood pressure and
heart rate, nausea, vomiting, sweating, urinary frequency – Recent 2003
Studies show no effect on sexual performance.
– Sildenafil Citrate (Viagra) (2001)
• Originally developed to tx cardiovascular disease.
• Side Effects: Combination with nitroglycerin might cause death (severe
hypotension). Blurred vision, blue vision, temp color blindness, breast
enlargement, priaprism. 1 study showed 40% of men with heart disease
using Viagra with ED had a serious reaction.
– Vardenafil (Levitra) (2003)
Newly released by Bayer/SmithGlaxoKline for the tx of ED (similar side
effect), similar effectiveness (80%)—more potent.
병원약사모임강의_2006_8
ADHD
• 3 to 6% of school
population
• Treatment
– Ritalin (methylphenidate)
– Adderall (Dexedrine &
Amphetamine)
• from the amphetamine
family
– Atomoxetine
– No clinical proof one is
better than the other
(Dulcan, 1986)
병원약사모임강의_2006_8
Methylphenidate (MPH)
• Stimulates many mental functions by blocking
dopamine transporter
(i.e.re-uptake blockade at synapse)
병원약사모임강의_2006_8
Methylphenidate (MPH)
• Stimulates many mental functions by blocking dopamine
transporter (i.e.re-uptake blockade at synapse)
• Not addictive in ADHD treatment
• Sustained release preparations popular
병원약사모임강의_2006_8
Methylphenidate (MPH)
• Appetite decrease
• Onset insomnia
• Growth problems infrequent with immediate release
(Ritalin, Equasym), unknown frequency with sustained
release preparations (Concerta XL, Equasym XL)
병원약사모임강의_2006_8
Atomoxetine
• non-stimulant (?) ADHD treatment
• blocks norepinephrine transporter,
especially in frontal lobes
• no insomnia though some reduced weight
gain with growth in first 12 months of use
• likely to be non-controlled
병원약사모임강의_2006_8
Risperidone
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reduces aggressive behaviour and rage
reduces tics
looks useful in PDDs
weight gain a problem
병원약사모임강의_2006_8
‫• خانمی ‪ 24‬ساله‪،‬مطلقه‪،‬به علت پرخاشگری ارجاع شده‬
‫است‪.‬در شرح حال مصرف سیگار و تریاک داشته و‬
‫نوسانات خلقی‪،‬عدم توفیق تحصیلی‪،‬چند بار اقدام به خود‬
‫کشی‪،‬و یکبار فرار از منزل برای چند روز داشته است‪.‬‬