Chronic anxiety 

• Psychotherapy 
  • GAD will benefit the most
• Medications 
  • SSRIs and SNRIs
    • Helpful for OCD, PTSD, GAD
    • Impulsive disorders will not respond to SSRIs
    • Risk of serotonin syndrome 

Acute anxiety 

• Will benefit from acute treatment
• Medications - anxiolytics 
  • Rapid-acting benzodiazepines
    • Rapid-acting benzodiazepines 
      • IV Lorazepam 
      • PO Alprezalem
    • Panic disorders will benefit from benzos 
    • Used for acute attack abortion 
    • Chronic use 
      • Avoid to prevent dependence 
      • Can create withdrawal similar to alcohol 
        • 
        • Treat alcohol withdrawal with long-acting benzos 
          • Diazepam 
          • Chlordiazepoxide 
      • Both ethanol and benzos bind to GABA receptors 
  • Non-selective beta-blockers
    • Propranolol 
    • Nadolol 
    • Atenolol 
    • Risks 
      • Decreased HR 
      • Decreased Mood 

Antipsychotics 

Psychosis has both positive and negative symptoms:

• Positive symptoms 
  • Hallucinations 
  • Delusions 
  • Driven by 
    • Mesolimbic D2C receptors driven by dopamine cause these symptoms 
    • Blocking these receptors prevents positive symptoms 
• Negative symptoms 
  • Lack of speech, emotion, interest 
  • Driven by 
    • 5HT1 receptors driven by serotonin 
    • Blocking these receptors will lessen the negative symptoms 

Pharmacology 

• Typical antipsychotics = first-generation antipsychotics 
  • Idea was to reduce positive symptoms by blocking the D2C receptors in the mesolimbic region 
  • These medications blocked all dopaminergic effects 
  • Higher doses caused extrapyramidal side effects 
    • In the nigrostriatal tract, dopamine blockage will cause extrapyramidal side effects 
    • In the tuberoinfundibular tract dopamine blockage will result in gynecomastia and galactorrhea and amenorrhea in males and females respectively 
  • General side effects = cholinergic effects 
    • Urinary retention 
    • Dry mouth 
  • For typical antipsychotics, more effective drugs will have more side effects 
    • Haloperidol - potent with more side effects 
      • Used in the acute setting for sedation 
    • Fluphenazine - potent with more side effects 
    • Thoridiozine - less potent less side effects 
    • Chlorpromazine - less potent less side effects
• Atypical antipsychotics = second-generation antipsychotics 
  • Target 
    • Positive symptoms 
      • By blocking D2C dopamine receptors (selectively) 
      • Fewer extrapyramidal symptoms 
    • Negative symptoms 
      • By blocking serotonin receptors 
  • Examples 
    • Quetiapine 
      • Somnolence is a side effect 
      • Used to treat insomnia 
      • Can also be used to treat bipolar mania (with psychotic features)
    • Olanzapine 
      • Weight gain and diabetes are side effects 
      • Can use a mixture of Olanzapine with Haloperitol for rapid sedation 
    • Risperidone 
      • Highest incidence of extrapyramidal symptoms 
      • Can be used chronically 
    • Aripiprazole 
    • Ziprasidone
  • General side effects
    • Cholinergic side effects 
    • QTC prolongation 
  • Mostly used in compliant patients who will take all of their medications 
• Clozapine - most effective 
  • Class of its own 
  • Best drug and last resort due to the increased risk of mortality from agranulocytosis = lekopenia 
    • 
  • Need to have failed 2 antipsychotic treatment 
  • CBCs weekly and monthly 

Extrapyramidal symptoms

• Commonly seen with typical antipsychotic use 
• 
• Symptoms
  • Akathisia
    • Subjective feeling of restlessness 
    • Treatment 
      • Decrease the dose of the antipsychotic 
      • Use beta-blockers 
      • Anticholinergic medications 
    • 
  • Acute dystonia 
    • Contraction of major muscle groups 
    • Oculogyro crisis 
      • Eyes locked in place looking up 
    • Torticollis 
      • Contraction of the sternocleidomastoids
      • Neck twisted to one side  
      • 
    • Treatment 
      • Anticholinergic medications 
  • Dyskinesia = bradykinesia 
    • Dopamine receptors inhibited in the wrong region 
    • Shuffling gate, cogwheel rigidity 
    • Parkinsonism 
    • Treatment 
      • Anticholinergic medications 
  • Tardive dyskinesia 
    • Irreversible, chronic and lifelong 
    • Facial 
      • Grimaces, moving the jaw
      • 
    • Has no treatment 
    • On medication for greater than 6 months 
    • Antipsychotic medication treatment will make it worse 
    • Management 
      • Stop the antipsychotic treatment at the earliest symptoms