Anxiety

First line drugs

100

First line treatment for GAD FDA-approved 

Duloxetine (Cymbalta), Escitalopram (Lexapro), Paroxetine (Paxil), Venlafaxine (Effexor), Alprazolam (Xanax)

Per lecture: SSRIs, SNRIs, benzodiazepines, buspirone, alpha 2 ligands (Pregabalin/Gabapentin)

200

First line treatment for Panic disorder/phobia treatment FDA-Approved

fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) Alprazolam (Xanax), Clonazepam (Klonopin)

Per Lecture: SSRIs and SNRIs as well as benzodiazepines, and alpha2 ligands

300

Social anxiety disorder first line

SSRI, SNRIs, and Alpha 2 ligands

400

OCD first line treatment FDA approved and from lecture

Clomipramine (Anafranil), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft)

Off Label – Citalopram (Celexa), Venlafaxine (Effexor), Vilazodone (Viibryd)

500

PTSD first line FDA-approved

sertraline (Zoloft) and paroxetine (Paxil)

(Effexor & Fluoxetine are considered first line treatments in the VA/DoD Clinical Practice Guideline for PTSD)

second line and augmenting

100

SECOND line treatment for GAD

TCAs, Mirtazapine, Trazadone, SPARI  (Stahls)

200

SECOND line treatment for Panic disorder/phobia treatment and augmenting meds

TCAS, Mirtazapine and Trazodone, MAOIs 

per lecture: Augmented w Buspirone (BuSpar), Alpha2 ligands (pregabalin and gabapentin)

300

Social anxiety second line

Beta blockers, benzos, MAOIs 

400

OCD second line and augmentation 

TCAs, SNRIs or MAOI

several failed SSRI trials—consider high doses of SSRI or augmentation with an atypical antipsychotic

Augmentation of an SSRI w a Benzo, lithium, or buspirone

500

PTSD second line

Buspirone (BuSpar), imipramine (Tofranil) and amitriptyline (Elavil), MAOIs & Alpha 2 ligands (per Stahl)

Caution with Benzos

adjunctive: naltrexone, mirtazapine, acamprosate, beta blickers alapha1 antagoist.

odds and ends

100

Receptors a1 and a2 review

a1 activation by NE: Turns ON SNS fight or flight 

a2 activation by NE: TURNS OFF SNS 

To REDUCE  anxiety, you would want an 

a1 antagonist AKA prazosin (Minipress) or 

an a2 agonist clonidine (Catapres)

200

Note from the book about OCD and SRIs

There is also some evidence that response to SRIs is slower in OCD than in depression; clinicians are therefore encouraged to prescribe an SRI for at least 12 weeks before deciding to switch agents or augment with another psychotropic.

NT

100

Gaba and anxiety +/-

- not enough GABA= anxiety

200

Anxiety and Serotonin? +/-

- 

Not enough serotonin may result in feeling anxious

per lecture part 2

300

how is the amount if NE related to anxiety

Can have too much OR too little and show signs of anxiety.  

Per her lecture. 

Bonus Depression + or - NE???

Depression/ NE/ -

Brain anatomy

100

Fear/panic/phobia  related brain locations 

Amygdala circuit: locus coeruleus -> amygdala, noradrenergic (NE) involvement 

Hippocampus Internal fearmonger) ->amygdala 

NTs: 5HT, GABA Glutamate, NE, voltage gated ion channels

200

Worry/obsession brain location

CSTC Pathway:

Cortico-striatal-thalamic- cortical pathway 

NTs: DA(different than fear loop), 5HT, GABA, NE, glutamate, ion channels

300

What NT lives in the Locus coeruleus and where does it project to in the brain and what are its receptors it attacthes too.

what might you see with too much activity? 

NE!! 

LC to amygdala

attatches to a1 and b1

tremmor, panic attack, autonomic arousal: sweating and +HR, nightmares

Thanks dr. Stahl

drugs

100

Benzos are ____ to GABA

Flumazenil is _____ to GABA

Benzos= agonist

Flumazenil= antagonist

200

Buspirone (Buspar) whats is its primary NT action, indication and areas of the brain it works in 

5HT- partial agonist to pre and post-synaptic 5-HT1A receptors.

Anxiety, generally as an adjunct.

Enhances serotonin in the projection to the Amygdala, PFC and the thalamus 

300

What drug would be a good choice for the treatment of PTSD related nightmares? Why?

Prazosin (Minipress)

blocks alpha 1 adrenergic receotirs to reduce noradrenergic hyperactivation 

400

What drug would be a good choice for the treatment of PTSD and SAD? Why?

Clonidine (and maybe Guanfacine)

centrally acting alpha 2 agonists, lowers NE release in the Sympathetic nuclei of the brain, and resets the body's sympathetic tone to decrease arousal state

Also ADHD in 6-17 yr olds