anxiety

mostly happy and mostly functional

Define goal (which is not perfection), recognize deviations, and degrees of deviation that warrant intervention.

General goals: Stay aligned with core values, participate in meaning-making activities, deal with issues with minimal disruption (relative to the magnitude of the issue) and get back to function.

waves of anxiety

Moments that correspond w peak anxiety symptoms, which make it difficult to stay aligned w core values and perform meaning-making activities.

situations

• triggers (sensual stimulus related to prior negative experience)
• giving a presentation
• taking an exam
• starting on a particular rotation
• plane flight

symptoms

• heart racing
• feeling of loss of control
• sweating
• inability to focus
• difficulty sleeping
• fatigue

actions

Actions that move us toward or away from core values and meaning-making, i.e., adaptive vs maladaptive actions.

Differentiating toward/away actions can be subtle, e.g. going to get a drink with a friend could be productive or destructive.

specific disorders

Many.

Defining dx may help get a general sense of which neurotransmitters to modulate, which meds and other approaches to try first.

• Panic disorder (4+ wks of panic attacks and maladaptation to them)
• Generalized Anxiety Disorder (3+ sx >=6mo)
• Social Anxiety Disorder (>=6mo)
• Specific Phobia (>=6mo)
• Neurodevelopmental disorders (e.g. ADHD dx during the pandemic - is the current situation adult-onset anxiety or unmasking latent issues?)

management

Modify the situation, symptoms, and/or actions to improve outcomes.

Define a goal and manage expectations, similar to pain mgmt. Will not be able to get to 0/10 anxiety, but going from 10/10 to 6/10 may allow regain of meaningful function.

management of management

Most SSRIs can also be activating at first, so communicate this to the patient and consider a prn for peaks (benzos, buspirone).

Recognize that benzos are like afrin - work like gangbusters, and fast, but long-term they tend to worsen the problem. Define course of treatment (e.g. while we are waiting the 4-6 wks for the SSRI to fully kick in), define specific situations. Screen for substance use disorders and family history (very small percentage of people will go on to develop de novo substance use disorder with rx benzos).

Sexual dysfunction from any psychotropic medicine does not generally get better over time, consider adding buspirone >=30mg to help w this.

Stopping at <6mo is associated with higher degree of relapse, so if any benefit is derived from therapy try to continue for 6mo. Ideally work with a therapist to reinforce adaptive behaviors during those 6mo, and afterward consider whether a taper of medicine is likely to allow the person to maintain goals.

psychopharmacology

FDA labels for drugs are general. 50mg of IR quetiapine, 37.5mg XR venlafaxine do not map exactly onto what we usually call them (second generation antipsychotic and SNRI).

second generation/atypical antipsychotics

pathways of clinical relevance

• Mesolimbic - D2 (need >=60% blockage for efficacy)
• Nigrostriatal - Parkinsonism, akathisia, tardive dyskinesia
• Mesocortical - apathy, inattention
• Tubuloinfundibular - galactorrhea

receptors “” “”

• D2 - agonism increases nausea (carbidopa-levodopa brand name chosen as marketing tactic for having less GI adverse effects “Sinemet” == “no puke”)
• 5HT2a - antagonism: decreases EPS
• H1 - antagonism: sedation, decrease itching, wt gain, anxiolysis, weight gain, decreases nausea
• M1 - antagonism: confusion, sedation, dries, decreases nausea
• alpha1 - antagonism: orthostatic hypotension, sedation

Drug naming schemes reflect receptor targets.

• cloza | pine
• olanza | pine | H1, 5HT2a, M1, D2 (great for chemo-induced nausea, hits three relevant nausea receptors at low doses)
• quetia | pine | H1, 5HT2a, M1 (less D2, not quite as good for nausea, but pretty great for agitation)
• zipras | idone
• risper | idone | 5HT2a, alpha1, D2 (less weight gain, not much of a nausea medicine)

depression