anxiety disorders 2

Question 1

what is suitable to treat all types of anxiety disorders?

Answer 1

SSSRIs

Question 2

when should you use benzos in anxiety?

Answer 2

Benzodiazepines are effective in many anxiety
disorders, but their use should be short term and only
considered beyond this in treatment-resistant cases
because of problems with side effects and
dependence

Question 3

what should be discussed with antidepressants and benzos?

Answer 3

should be specific discussion and monitoring of
adverse effects on stopping the drugs after a week of
treatment (discontinuation symptoms and, with
benzodiazepines, rebound anxiety and
withdrawal/dependence)

Question 4

how do you detect and diagnose GAD?

Answer 4

• Become familiar with the symptoms and signs of GAD
• Assess the level of disability to help determine thethreshold for treatment
• Ask about long-standing anxiety symptoms whenpatients present with depression or unexplainedphysical symptoms

Question 5

what is the acute treatment for GAD?

Answer 5

• Choose an evidence-based acute treatment
• Pharmacological: some SSRIs (escitalopram,paroxetine, sertraline), venlafaxine, somebenzodiazepines (alprazolam, diazepam), imipramine,buspirone, hydroxyzine
• Psychological: cognitive-behaviour therapy

Question 6

how long of a trial period is needed before a result may be seen with GAD treatment?

Answer 6

up to 12 weeks

Question 7

when should long term treatment of GAD be initiated?

Answer 7

• Continue drug treatment for a further six months in

patients who are responding at 12 weeks

Question 8

what should be given in long term GAD?

Answer 8

• The best evidence is for SSRIs (escitalopram,
paroxetine)
• Consider cognitive-behaviour therapy as it may
reduce relapse rates better than drug treatment
• Monitor efficacy and tolerability regularly during
long term treatment

Question 9

what should you do when GAD treatment fails?

Answer 9

• Consider switching to another evidence-based
treatment after non-response to initial treatment
• Consider switching to venlafaxine or imipramine in
non-responders to acute treatment with an SSRI
• Consider use of benzodiazepines after non-response
to SSRI and SNRI treatment

Question 10

how do you detect and diagnose panic disorder?

Answer 10

• Assess the level of agoraphobic avoidance to help judge the severity of
the condition
• Ask about panic attacks and agoraphobia when patients present with
depression or medically unexplained physical symptoms such as chest
pain or shortness of breath

Question 11

what is the acute treatment for panic disorder?

Answer 11

• pharmacological: all SSRIs, some TCAs (clomipramine, imipramine), some
benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam),
venlafaxine, reboxetine
• psychological: cognitive-behaviour therapy
• Consider increasing the dose if there is insufficient response, but there is
only limited evidence for a dose response relationship with SSRIs
• Initial side-effects can be minimized by slowly increasing the dose

Question 12

what should be given in long-term treatment for panic disorder?

Answer 12

In longer-term drug treatment use an approach known to be efficacious
in preventing relapse: first line drug choice is an SSRI , imipramine is a
second-line choice

Question 13

what do you have to rememver when stopping treatment for panic disorder?

Answer 13

• When stopping treatment, reduce the dose gradually over an extended
period to avoid discontinuation and rebound symptoms.
• In the absence of evidence a minimum of three months is recommended
for this taper period

Question 14

what happens when initial treatment for panic disorder fails?

Answer 14

• Consider switching to another evidence-based treatment after non-
response at 12 weeks
• Consider combining evidence-based treatments only when there are no
contraindications
• Consider adding paroxetine or buspirone to psychological treatments
after partial response
• Consider adding paroxetine, whilst continuing with CBT, after initial non-
response
• Consider adding group-CBT in non-responders to pharmacological
approaches
• Consider referral to regional or national specialist services in refractory
patients

Question 15

how do you detect and diagnose social phobia?

Answer 15

• Assess the level of disability to help distinguish social phobia from shyness
• Ask about social anxiety symptoms when patients present with depression, panic
attacks restricted to social situations, or alcohol misuse

Question 16

what is the acute treatment for social phobia?

Answer 16

• pharmacological: most SSRIs (escitalopram, fluoxetine, fluvoxamine, paroxetine,
sertraline), venlafaxine, phenelzine, moclobemide, some benzodiazepines
(bromazepam, clonazepam) and anticonvulsants (gabapentin, pregabalin) and
olanzapine
• psychological: cognitive-behaviour therapy

Question 17

when may someone benefit from an inc dose of SSRI?

Answer 17

• Routine prescription of higher doses of SSRIs is not recommended , but individual
patients may benefit from higher doses

Question 18

how should social phobia be treated in the long term?

Answer 18

• In longer-term treatment use an approach known to be efficacious in preventing
relapse : consider an SSRI or CBT first-line : clonazepam may be considered as a
second-line choice

Question 19

what should be done when initial treatment of social phobia fails?

Answer 19

Consider switching to venlafaxine after non-response to acute treatment with an
SSRI
• Consider adding buspirone after partial response to an SSRI
• Consider benzodiazepines in patients who have not responded to other
approaches
• Consider combining evidence-based treatments only when there are no
contraindications
• Consider combining drug treatment and CBT

Question 20

how do you detect and diagnose simple phobia?

Answer 20

• Assess the number of fears, impairment andcomorbidity to judge severity
• Ask about anxiety symptoms when patients presentwith specific fears or phobias

Question 21

how do you treat simple phobia?

Answer 21

• Use psychological approaches based on exposuretechniques as first-line treatment
• Consider paroxetine or benzodiazepines whenpatients with distressing and impairing phobias havenot responded to psychological approaches

Question 22

how do you detect and diagnose PTSD?

Answer 22

• Ask about a history of trauma when patients present with psychological
symptoms
• Become familiar with the diagnostic criteria for posttraumatic stress disorder

Question 23

How should you try and prevent post-traumatic symptoms?

Answer 23

• After major trauma, and providing there are no contraindications, consider
preventive treatment of posttraumatic symptoms with propranolol.
• Routine debriefing is not indicated
• Trauma-focused CBT can prevent the emergence of chronic PTSD in individuals
with post-traumatic symptoms lasting one month or longer after a traumatic
event

Question 24

how do you acutely treat chronic PTSD?

Answer 24

• pharmacological: some SSRIs (fluoxetine, paroxetine, sertraline), some TCAs
(amitriptyline, imipramine), phenelzine, mirtazapine, venlafaxine, lamotrigine
• psychological: trauma-focused individual CBT and EMDR

Question 25

how do you treat PTSD in the long term?

Answer 25

In longer-term treatment use an approach known to be efficacious in preventing
relapse: among pharmacological treatments the best evidence is for SSRIs
• Monitor efficacy and tolerability regularly during long term treatment

Question 26

when can antidepressants be used in PTSD?

Answer 26

in patients with coexisting severe depressive

symptoms

Question 27

what should you do when initial treatment for PTSD fails?

Answer 27

Consider switching to other evidence-based treatments, after non-response to
first treatment
• Consider combining evidence-based treatments only when there are no
contraindications
• Consider combining drug and psychological treatment
• Consider augmentation of antidepressants with an atypical antipsychotic after
initial non-response
• Consider referral to regional or national specialist services in refractory patients

Question 28

how should you detect and diagnose OCD?

Answer 28

• Assess the time engaged in obsessive-compulsive behaviour, the associated distress
and impairment, and the degree of attempted resistance to confirm the diagnosis
• Ask about obsessive-compulsive symptoms when patients present with depression

Question 29

how do you treat OCD?

Answer 29

• pharmacological: clomipramine and SSRIs

* psychological: exposure therapy and cognitive-behaviour therapy

Question 30

when should you continue long term treatment for someone with OCD?

Answer 30

Continue drug treatment for a further 12 months in patients who are responding at 12
weeks

Question 31

how do you treat OCD long-term?

Answer 31

In longer-term treatment use an approach known to be efficacious in preventing
relapse : consider SSRIs as first choice as there is best evidence for this group

Question 32

are you able to combine drugs with pyschological treatments for PTSD?

Answer 32

• Routinely combining drug and psychological approaches is not recommended for
initial treatment but consider adding an SSRI or clomipramine to psychological
treatment when efficacy needs to be maximized

Question 33

what should you do when initial treatment fails with PTSD medication?

Answer 33

• Consider increasing the dose of clomipramine or SSRI after initial non-response to
standard doses
• Consider switching between proven treatments after initial non-response
• Consider combining evidence-based treatments only when there are no
contraindications
• Consider combining drug treatment and exposure therapy or CBT
When initial treatments fail (cont.)
• Consider augmentation with antipsychotics or pindolol after initial SSRI non-
response

Question 34

what special considerations are there for children and adolescents?

Answer 34

• Reserve pharmacological treatments for children and
adolescents who have not responded to psychological
treatments, and in whom the potential benefits are likely to
outweigh potential risks
• If drug treatment is considered choose from the same range
of treatments as with adults: SSRIs are a first-line choice
from limited evidence, but avoid benzodiazepines and
tricyclic antidepressants because of potential adverse effects
• Consider dosages carefully in relation to age and size,
starting with low doses
• Carefully monitoring for potential adverse effects, being
aware that children and adolescents may find it difficult to
describe them

Question 35

what special considerations are there for elderly?

Answer 35

• Treat as for patients younger than 65 years being mindful of
the possibility of drug interactions, physical comorbidity, the
need for lower doses due to reduced metabolism, or
increased sensitivity to adverse effects

Question 36

what special considerations are there for cardiac disease and epilepsy?

Answer 36

• Avoid tricyclic antidepressants in cardiac disease
• QT prolongation with venlafaxine, predisposes to cardiac
arrhythmias. Avoided in patients at high risk of arrhythmias
• Avoid antidepressants that lower the seizure threshold in
epilepsy
• Consider pharmacokinetic interactions between
antidepressants and other drugs, e.g. anticonvulsants

Question 37

what special considerations are there for pregnancy and breastfeeding?

Answer 37

• Consider carefully the potential risks and benefits of
pharmacological treatment and alternative evidence based
psychological treatments, avoiding drugs if possible
• Fluoxetine or tricyclic antidepressants are considered first-
line if drug treatment is used in pregnancy, as there is most
evidence with these drugs)
• Consider SSRIs (apart from fluoxetine and citalopram) and
tricyclic antidepressant in breast-feeding mothers as
secretion into breast milk is low

Question 38

when should you refer to secondary care mental health services?

Answer 38

• The primary care practitioner feels insufficiently experienced
to manage the patient’s condition
• Two or more attempts at treatment have not resulted in
sustained improvement
• There are severe coexisting depressive symptoms or a risk of
suicide
• Comorbid physical illness and concomitantly prescribed
treatments could interact with prescribed psychotropic
medication
• Proposed interventions are not available within primary care
services