Anxiety Flashcards by Kirsten Gust

1st line for GAD

–> offer CBT or meds (routine combo not supported)

Venlafaxine
Escitalopram
Sertraline
Paroxetine
Pregabalin
Duloxetine
Agomelatine

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2nd line meds for GAD

Benzos (ABLD)
Bupropion
Buspirone
Quetiapine
Hydroxyzine
Imipramine
Vortioxetine

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Adjuncts for GAD

Pregabalin - 2nd line

Antipsychotics (QORA) - 3rd line

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Not recommended for GAD

Beta-blockers (propranolol)

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1st line for Social Anxiety D/O

–> offer CBT or meds (unclear if combo is better)

Venlafaxine
Escitalopram
Sertraline
Paroxetine
Pregabalin
Fluvoxamine

**Maintenance Rx shown to reduce risk of relapse vs. placebo; but CBT has more enduring benefits

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2nd line meds for Social Anxiety D/O

Benzos (ABC)
Phenelzine
Gabapentin
Citalopram

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Adjuncts for Social Anxiety D/O

Antipsychotics (R+A) - 3rd line
Buspirone
Paroxetine

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Not recommended for Social Anxiety D/O

Beta-blockers (propanolol, atenolol)
Buspirone monotx
Imipramine
Quetiapine

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First line for Panic D/O

–> offer CBT + meds or CBT alone

All SSRIs
Venlafaxine

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2nd line meds for Panic D/O

Benzos (ACDL) --> taper over 4-7 months
Mirtazapine
Imipramine
Clomipramine
Reboxetine

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Adjuncts for Panic D/O

Benzos (AC) - 2nd line **only time benzos are adjuncts
Antipsychotics (ORA) - 3rd line
VPA
Pindolol

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Not recommended for Panic D/O

Beta-blockers (propranolol)
Buspirone
Trazodone

**Do not combine benzos with exposure therapy

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1st line for OCD

–> offer CBT (ERP) + meds, or CBT alone

All SSRIs, except citalopram

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2nd line meds for OCD

Citalopram, Clomipramine

Venlafaxine, Mirtazapine

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Adjuncts for OCD

Antipsychotics (R+A) - 1st line
Memantine, topiramate, seroquel - 2nd line

Olanzapine, haldol, ziprasidone - 3rd line
Pregabalin, mirtazapine, citalopram, ondansetron - 3rd line

**OCD can be difficult to treat so early adjuncts may be important, instead of switching (to preserve any benefits of current tx)

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Not recommended for OCD

Benzos!
Clonidine
Desipramine (NA&raquo_space;» 5-HT)
ECT

1st line meds for PTSD

–> offer meds +/- therapy if trauma-focused option available (unclear if combo is better)

Venlafaxine
Fluoxetine
Sertraline
Paroxetine

**Prazosin has good Level 1 evidence for nightmares and sleep quality

2nd line meds for PTSD

Fluvoxamine
Mirtazapine
Phenelzine

Adjuncts for PTSD

Antipsychotics (O+R) - 2nd line, (Q+A) - 3rd line

Eszopiclone, Clonidine, Pregabalin/Gabapentin, Reboxetine

Not recommended for PTSD

Benzos! - early benzo use can increase risk for PTSD!
Citalopram
Desipramine
Olanzapine
VPA

Psychotherapy for GAD

CBT 1st line = meds; routine combo NOT supported

Individual = group (but worry and depression get better faster with individual)
Internet/computer-based also effective
CBT adapted to GAD targets cognitive distortions about utility of worry, ability to cope vs. looming vulnerability, intolerance of uncertainty(Applied relaxation - limited efficacy (GAD ppl can’t learn to relax…))
(Psychodynamic - unclear)

Psychotherapy for SAD

CBT (cognitive restructuring + exposure) 1st line = meds
**Unclear if combo is better (phenelzine + CBT > either alone, but other studies showed CBT + meds = CBT)

Benefits from CBT maintained at 1-5 yrs; more enduring than benefits after tx with meds
Individual = group
Internet or virtual-reality-based also effective

CBT > IPT > waitlist
CBT > Mindfulness-based therapy > waitlist

Psychotherapy for Panic D/O

CBT + meds > CBT 1st line > meds
After tx: CBT alone = CBT + meds > meds alone

Exposure most important for panic (can be in vivo, interoceptive, or with virtual reality)
Interoceptive exposure > relaxation
Combined exposure + cognitive strategies needed for agoraphobia
Homework, follow-up program = better outcomes
Individual + group OK
Internet/self-help-based = face-to-face CBT

(Eye movement not important)

Offering CBT around time of med d/c reduces risk of relapse

Psychotherapy for OCD

CBT (mainly ERP) 1st line = CBT + meds > meds alone
i.e. if meds needed/preferred, also add CBT to improve response and reduce relapse rates

ERP-based or cognitive-based (eg. DIRT) both effective
Individual = group
Stepped-care approach cost effective
Therapist-guided exposure > self-guided > waitlist
Telephone or internet-based OK, but need exposure(ACT, Cognitive therapy, and mindfulness may help)
(EMDR not recommended, insufficient evidence)

Psychotherapy for PTSD

**Unclear if combo therapy + meds > either alone ?Meds > therapy Stress mgmt < TF-CBT = EMDR [EMDR may give faster response than CBT] = prolonged exposure = CPT [cognitive processing + written accounts] - Individual or group TF-CBT is OK - Internet-based/remote-delivered CBT and virtual reality exposure OK - Benefits of adding cognitive restructuring to exposure are conflicting, may be useful for particular sx (eg. guilt, anger) - But, 1/3 to 1/2 of pts still significantly symptomatic s/p CBT; generalizability unclear **DBT also helpful, esp. as pre-tx to improve suitability for further therapy

For which anxiety disorders is there evidence for added benefit of D-CYCLOSERINE in combination with exposure therapy?

SAD Panic, in some studies OCD, in some studies **do not use in PTSD --> may worsen response to therapy

What therapy option would you recommend for Hoarding Disorder?

Group CBT: shown to reduce hoarding + depression sx

What is systematic desensitization?

1) Systematic desensitization involves teaching relaxation strategies prior to graded exposure (reciprocal inhibition) 2) May be a useful strategy for phobias (but not recommended in the Guidelines) and SELECTIVE MUTISM, ?PTSD 3) Not generally recommended for other anxiety d/o since exposure to anxiety is an important part of the tx process; regular ERP > ERP with relaxation

For which anxiety disorders has maintenance tx with medication been shown to reduce the risk of relapse? For which anxiety disorders have the benefits of psychotherapy been shown to be maintained over months to years?

All - GAD, SAD, Panic, OCD, and PTSD

Name a "last-resort" tx for refractory OCD (10% of cases)

Psychosurgery (Level 3 evidence): Capsulotomy or cingulotomy Deep brain stimulation (Level 4 evidence) - allows adjustability and reversibility, response seems just as good as psychosurgery and less a/e rTMS also has some evidence - inhibitory low frequency stimulation of the overactive supplementary motor area **ECT is NOT recommended!!!

What is recommended for debriefing after trauma?

Do NOT offer debriefing to all ppl exposed to trauma (not effective and can be harmful!) - Screen and treat only those with symptoms - Trauma-focused CBT has been shown to reduce risk of chronic PTSD in those with Acute Stress D/O and acute PTSD **Meds have also not been shown to prevent PTSD