Study Guide: Medications for Anxiety disorders, OCD, trauma (A+ Guide)
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Course
NURSING 6506
Institution
University Of Manitoba (UManitoba
)
Study Guide: Medications for Anxiety disorders, OCD, trauma
1. Regarding OCD: (lecture, podcast & Stahl)
a. What is the first-line treatment for OCD?
o First line treatment is CBT and Exposure Therapy for mild to moderate OCD
o High doses of SSRIs
o clomipramine.
b. Which SSRIs are most effec...
Study Guide: Medications for Anxiety disorders, OCD, trauma
1
1. Regarding OCD: (lecture, podcast & Stahl)
a. What is the first-line treatment for OCD?
o First line treatment is CBT and Exposure Therapy for mild to moderate OCD
o High doses of SSRIs
o clomipramine.
b. Which SSRIs are most effective in OCD?
All SSRI are considered the same in term of effectiveness. Clomipramine may be more effective, but this has
not been confirmed based on placebo studies. Clomipramine is 2nd line.
c. How effective are SSRIs for OCD?
About 40-60% of ppl see improvement. Of those, 20-40% see reductions in sx’s
d. How is dosing of SSRIs different for OCD than for depression?
Tend to dose on higher end of SSRI’s when compared to dosing MDD(ocd dosed ~120 mg ).
Higher doses can decrease tolerability (↑SE). Max tolerable dose trial ~ 6 weeks -- Takes 12 weeks for max
plateau improvement
e. What is the role of clomipramine in the treatment of OCD?
Clomipramine (TCA) is FDA approved but 2nd line for OCD due to higher SE and higher risk of higher.
Better for use in comorbid OCD and depression. Clomipramine 1st line for PAD
f. What is the role of antipsychotics in symptoms of OCD?
Antipsychotics used to augment therapy. AP proved effective in reducing symptoms in conjunction with
clomipramine or SSRI.
o FGA(haloperidol)l in augmentation to Fluvoxamine/ssris = effective reduced obsessions but
poor tolerability (EPS).
o SGA = effective with less SE. ↓ Y-BOCs after 12w. Risperidone & aripiprazole best studied.
Quetiapine evidence as well.
g. What other medications are used in OCD?
SNRI’S, AP, Li+, CBT, exposure therapy, deep brain stimulation (DBS), transcranial magnetic stimulation
(TMS)
⤷Per stahl– augment with Lithium, buspirone, and maybeeee BZD
, Study Guide: Medications for Anxiety disorders, OCD, trauma
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⤷SNRI(venlafaxine) effective – 2nd line
⤷ MAOIs can be used second line.
⤷treatment resistant(TxR)- after failing multiple high dose SSRI trials, augment with AP
h. How can we reliably assess OCD symptoms during treatment, to ensure our treatments are working?
Monitoring Y-BOC scores*. Monitoring the effectiveness of OCD treatments involves use of standardized
assessment tools such as like the Y-BOCS. This tools quantitatively measures sx changes and feedback,
experiences, and SE from medications.
Total score base on both obsessions and compulsions:
Mild 8-15; Moderate= 16-23; Severe = 24-31; Extreme OCD = 32-40. * Please see end of
document for YBOCS scale.
2. Explain which medical conditions and other medications can contribute or cause a patient’s
anxiety symptoms. (This isn’t in your reading – think through what you have learned already in
school, work, etc. Think critically and look up if you need to – what differentials would you want
to rule out?)
Medical conditions that contribute/cause a patient’s anxiety symptoms can be endocrine, cardiovascular,
neurological, metabolic, nutritional, sleep related, or substance use related in origin.
Endocrine- hyperthyroidism and hypothyroidism, hormone imbalances Anx’ sx’s
o Pheochromocytoma - PA sx’x like sweating, increases HR, tremors, SOB, pale skin.
Cardiovascular- arrhythmias, CHF, MI can present palpitations and chest discomfort(angina) feeling of
Anx’ or PA –
o
Respiratory - RR conditions can cause SOB and chest tightness, leading to feelings of anxiety
Neurological- MS, parkinsonism, epilepsy can cause anxiety or anxiety related to sx’s of condition
Metabolic- Conditions like diabetes and hypercalcemia can impact mood and cognitive function and
cause anxiety
Nutritional- low vitamin and mineral levels of may contribute to increased anxiety
Substance use – use or withdrawal of substances (ex: caffeine, ETOH, nicotine) and illicit substances (ex:
meth, cocaine) can cause significant anxiety symptoms.
Medications that contribute/cause a patient’s anxiety can be stimulants, steroids, beta agonist(CV and RR
meds), and withdrawal from meds.
Stimulants: ex) amphetamines (ADHD), caffeine, weight loss drugs, and decongestants- anxiousness
Corticosteroids that work inflammatory conditions can cause psychological side effects such as anxiety
Steroids, thyroid, and hormones: high or large change in dose can lead issues of hyperthyroidism and
hormone imbalance, which can include significant psychological side effects, such as anxiety.
Beta agonist (ex: albuterol, epinephrine) can cause tremors, increase HR, palpitations, nervousness,
, Study Guide: Medications for Anxiety disorders, OCD, trauma
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resembling anxiety.
Antidepressants such as SSRI an SNRI can cause increased anxiety
Abrupt withdrawal from drugs can cause rebound sx’s such as anxiety
To rule out- Obtain EKG if pt. mentions palpitations, inc HR, or chest pain. Order CBC, TSH (serum
thyrotropin), BMP, UA, and a U tox. And general physical screening if they present/state numerous physical
complaints.
3. Which receptors do benzodiazepines target? (Be specific! - Chapter 6 in Stahl)
Benzodiazepine-sensitive target 2 β-units , 2 γ-unit, 2α units and Benzodiazepine-insensitive target α4, α6,
γ1, or δ. Benzos appear to bind to the region of the receptor b/w the gamma 2 and gamma 3 subunit and the
alpha 1,2, or 3 subunit, one benzo molecule per receptor complex. GABA must be present for the positive
allosteric modulator (the benzo) to work
a. Which GABA-A receptor subunits are important for regulating anxiety?
GABAA – sensitive receptors at the α2 and α3 subunits are for anxiety. Anxiotyic effect due to phasic
postsynaptic inhibition
GABAA – sensitive receptors at the α1 exert a sedative effect due to enhancement of phasic postsynaptic
inhibition
The functions of a GABA A receptor can vary based on the subunits present. GABA A receptors can be
classified by the specific isoform subunits that they contain.
b. What is the difference between BZD-sensitive, vs. BZD-insensitive GABA-A receptors
BZD-sensitive are synaptic ,regulate phasic inhibition(burst), and incluse 2 β-units , 2 γ-unit, 2α units
and
BZD-insensitive are extrasynaptic, regulate tonic inhibition (SET TONE), has a delta subunit instead of a
gamma subunit, and neuroactive steroids bind( b/w the α and δ subunits).
Β = beta, γ=gamma, α = alpha, δ= delta
Benzodiazepine-sensitive GABA Benzodiazepine-INsensitive GABA
To be gaba sensitive - Must have 2 β-units , 2 γ-unit, -to be GABA insensitive - must have 2 β-units , 2 γ-unit,
2 α units 2α units?
-must include: GABA A receptors are those with α4, α6, γ1, or δ
subunits.
2 β-units
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